A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

A. Cardiac arrest related to septic shock:

Septic shock can occur in burn patients due to the breakdown of the skin barrier, which allows pathogens to enter the bloodstream and cause systemic infection. However, while septic shock is a serious complication of burn injuries, it is not the primary cause of death in the emergent phase. Septic shock can lead to multiple organ failure and contribute to mortality, but it is often a later complication rather than an immediate cause in the emergent phase.

B. Infection:

Infections are a significant concern in burn patients, especially as the burn wound provides an ideal environment for bacterial growth. However, infections typically contribute more significantly to mortality in the later phases of burn care rather than in the emergent phase. In the emergent phase, hypovolemic shock and other immediate complications have a greater impact on mortality.

C. Adrenal failure:

Adrenal failure, specifically acute adrenal insufficiency or Addisonian crisis, can occur in burn patients due to the stress response and corticosteroid depletion. While adrenal insufficiency is a concern in severe burn cases, it is not the primary cause of death in the emergent phase requiring referral to a burn center.

D. Hypovolemic shock and renal failure:

Hypovolemic shock is a critical concern in the emergent phase of burn trauma because burns can lead to significant fluid loss and electrolyte imbalances. Hypovolemic shock results from insufficient circulating blood volume, leading to inadequate perfusion of organs and tissues, which can be life-threatening. Additionally, renal failure can develop due to hypovolemia, decreased cardiac output, and the release of inflammatory mediators, leading to acute kidney injury (AKI). Hypovolemic shock and subsequent renal failure are major contributors to mortality in the emergent phase of burn trauma, necessitating prompt referral to a burn center for specialized care.

A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:

This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.

B. Remind the client they will return to their room after surgery:

This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.

C. Provide instructions about how to cough and deep breathe effectively:

This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.

D. Notify the client that they will receive a food tray in the recovery room:

While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.