Which of the following is the most appropriate initial nursing intervention for a patient with a first-degree burn on the forearm?

B) Cleanse the burn with saline and apply a sterile, non-adherent dressing

A) Apply ice directly to the burn

B) Cleanse the burn with saline and apply a sterile, non-adherent dressing

C) Apply an antibiotic ointment and cover with a tight bandage

D) Leave the burn exposed to air to promote drying

Which nursing intervention is most appropriate for a patient presenting with a first-degree burn on the forearm?

B) Cleanse the burn with saline and apply a sterile, non-adherent dressing.

A) Apply ice directly to the burn area to reduce swelling.

B) Cleanse the burn with saline and apply a sterile, non-adherent dressing.

C) Cover the burn with a tight bandage to prevent further injury.

D) Leave the burn exposed to air for faster healing.

What is the primary reason for keeping a burn wound clean and dry during the healing process?

A) To prevent the development of blisters

C) To reduce pain and discomfort

What is the most appropriate nursing intervention to support the continued healing of a superficial first-degree burn?

B) Keep the burn area clean and dry, and continue using a sterile, non-adherent dressing

A) Apply ice directly to the burn area to reduce any remaining redness

B) Keep the burn area clean and dry, and continue using a sterile, non-adherent dressing

C) Expose the burn to sunlight to promote faster healing

D) Use an antibiotic ointment on the burn area to prevent infection

What is the primary reason the nurse advises the patient to protect the burn area from excessive sun exposure during the healing process?

B) To avoid skin discoloration and hyperpigmentation

A) To prevent the development of skin cancer

B) To avoid skin discoloration and hyperpigmentation

C) To decrease the risk of infection

D) To improve the absorption of topical medications

What is the most appropriate nursing action to recommend for a patient recovering from a burn with improving skin condition?

C) Use a moisturizer to maintain skin moisture and elasticity

A) Apply ice packs to the affected area

B) Encourage sun exposure to aid in vitamin D synthesis

C) Use a moisturizer to maintain skin moisture and elasticity

D) Cover the area with a tight bandage to protect it

What is the most appropriate nursing action to reinforce during discharge teaching for a patient who has successfully healed from a superficial burn injury?

C) Emphasize the importance of ongoing sun protection

A) Encourage the use of antibiotic ointments daily

B) Advise the patient to avoid any physical activity

C) Emphasize the importance of ongoing sun protection

D) Instruct the patient to avoid moisturizing the area

Which of the following actions by the patient most likely contributed to the successful healing of her skin after a burn injury?

A) Applying moisturizer and protecting the skin from sun exposure

B) Using a new type of soap regularly

C) Wearing tight clothing over the affected area

D) Increasing physical activity immediately after the injury

What is the primary reason for keeping a burn wound covered and protected from external irritants?

B) To reduce the risk of infection

A) To prevent the formation of blisters

B) To reduce the risk of infection

C) To promote faster skin regeneration

What is the primary purpose of applying prescribed topical antibiotics to a superficial partial-thickness burn?

A) To enhance the color of the skin

C) To reduce the size of the blister

D) To eliminate pain completely

Burns - Nursing Case Study

Pathophysiology

• Primary mechanism: Burns cause direct damage to skin and underlying tissues by heat, chemicals, or electricity, leading to cell death and loss of skin integrity, which serves as a critical barrier to infection and fluid loss.

• Secondary mechanism: In response to tissue injury, an inflammatory reaction is triggered, resulting in increased vascular permeability. This allows fluid to escape from blood vessels into surrounding tissues, causing edema and hypovolemia (low blood volume).

• Key complication: Hypovolemia can lead to decreased blood pressure and inadequate perfusion of organs, potentially causing shock if not managed promptly with fluid resuscitation.

Patient Profile

Demographics:

25-year-old female, chef

History:

• Key past medical history: No significant past medical history

• Current medications: None

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Minor burns on right forearm

• Key symptoms: Redness, mild pain, no blistering

• Vital signs: Temperature 98.6°F, Heart rate 78 bpm, Blood pressure 120/80 mmHg, Respiratory rate 16 breaths per minute, Oxygen saturation 99% on room air

Section 1

Initial assessment findings:

Upon initial assessment, the patient's right forearm exhibits first-degree burns characterized by uniform redness and mild swelling. The area is warm to the touch, indicating the inflammatory response is active. The patient rates her pain as a 3 out of 10 on the pain scale, describing it as a persistent, burning sensation. Despite the burn, she maintains full range of motion in her wrist and fingers, and capillary refill time is less than two seconds, suggesting good peripheral circulation.

The patient's vital signs remain stable, with a temperature of 98.6°F, heart rate of 78 bpm, blood pressure of 120/80 mmHg, and respiratory rate of 16 breaths per minute. Oxygen saturation is 99% on room air, confirming adequate oxygenation and ventilation. The absence of blistering suggests the burn has not penetrated deeply into the skin layers, reassuring that this is a superficial injury.

Given these findings, the primary nursing interventions focus on pain management, maintaining skin integrity, and preventing infection. The burn area is gently cleansed with saline to remove any debris, and a sterile, non-adherent dressing is applied to protect the skin. The patient is educated on the importance of keeping the area clean and dry, monitoring for signs of infection, and avoiding sun exposure to the affected area. Follow-up care includes advising the patient to return if she experiences increased pain, blistering, or signs of infection, such as pus, increased redness, or fever. These steps ensure a comprehensive approach to managing her condition while minimizing the risk of complications.

Section 2

Response to Interventions:

After 48 hours, the patient returns for a follow-up appointment to reassess the condition of her burn. Upon examination, the nursing assessment reveals that the redness on her right forearm has begun to fade, indicating a positive healing response. The patient reports that her pain has decreased to a 1 out of 10, describing it as a mild, intermittent discomfort rather than a constant burning sensation. The swelling has noticeably reduced, and there are no signs of blistering, which confirms that the injury remains a superficial first-degree burn.

The sterile, non-adherent dressing was effective in maintaining skin integrity, as there are no signs of infection such as increased redness, warmth, or purulent discharge. The patient adhered to the discharge instructions by keeping the area clean and dry and avoiding sun exposure, contributing to the favorable outcome. Vital signs remain stable with a temperature of 98.6°F, heart rate of 76 bpm, blood pressure of 118/78 mmHg, and respiratory rate of 16 breaths per minute, indicating her systemic condition remains unaffected by the burn.

The nurse reinforces the importance of continuous monitoring for any changes, emphasizing that while the current signs are reassuring, vigilance is essential to prevent any late-onset complications. The patient is advised to continue with her current care regimen, including regular cleaning and dressing changes. The nurse also encourages the patient to hydrate adequately and maintain a balanced diet to support overall skin health and healing. Given the positive response to the initial interventions, the patient is scheduled for another follow-up in one week to ensure the burn continues to heal without complications.

Section 3

A week later, the patient arrives for her scheduled follow-up appointment. The nursing assessment reveals further improvement in the condition of her burn. The skin on her right forearm appears to be nearly back to its normal color, with only a faint pink tint remaining. The patient reports that her discomfort has resolved completely, rating her pain as 0 out of 10. There is no swelling or tenderness, and the skin feels smooth and intact, indicating good epithelialization.

Vital signs are stable, with a temperature of 98.4°F, heart rate of 74 bpm, blood pressure of 116/76 mmHg, and respiratory rate of 14 breaths per minute. These findings confirm that the patient remains in stable condition, and no systemic effects from the burn are present. The nurse performs a thorough check for any signs of delayed infection, such as unusual warmth, increased redness, or discharge, but none are observed.

Given the patient's adherence to the care plan and the positive progression of healing, the nurse advises her to gradually resume normal activities while continuing to protect the area from excessive sun exposure. The patient is reminded about the importance of moisturizing the skin to prevent dryness and promote elasticity as it heals. The nurse schedules a final follow-up in two weeks to ensure complete recovery and to provide an opportunity for the patient to ask any lingering questions. This plan reinforces the importance of ongoing care and monitoring, supporting the patient's journey to full recovery without complications.

Section 4

Two weeks later, the patient arrives for her final follow-up appointment. The nurse conducts a comprehensive assessment and observes that the skin on the patient's right forearm has almost completely returned to its normal color, with only a subtle trace of pinkness. The skin is smooth and supple, indicating excellent healing. The patient reports feeling well and experiencing no discomfort or pain, maintaining a pain score of 0 out of 10. She has been diligently applying moisturizer and protecting her skin from sun exposure, as recommended, contributing to the successful healing process.

Vital signs are checked and remain stable: temperature is 98.6°F, heart rate is 72 bpm, blood pressure is 118/78 mmHg, and respiratory rate is 16 breaths per minute. The nurse pays close attention to the area of the healed burn, checking for any signs of delayed complications such as new redness, swelling, or unusual warmth. There are no signs of infection or scarring, and the skin's elasticity is notably improved. The patient expresses relief and satisfaction with her recovery, crediting her adherence to the care plan and the guidance of her healthcare team.

Encouraged by the positive outcome, the nurse discusses the importance of continued skin protection and monitoring for any changes that might require attention in the future. She reassures the patient about the normalcy of the skin's appearance gradually returning to its pre-injury state. The patient is discharged from follow-up care with instructions to contact the clinic if any concerns arise. The nurse reminds her of the importance of ongoing self-care and advises her to maintain regular skin checks as part of her routine health practices. The patient leaves the clinic with confidence and gratitude for the comprehensive care received, marking a successful resolution to her initial injury.

Section 5

Initial Assessment Findings:

During the final follow-up visit, the nurse takes time to review the initial assessment findings from when the patient first presented with her burn injury. Initially, the patient had sustained a superficial partial-thickness burn on her right forearm from a kitchen accident. At that time, the affected area was red, blistered, and painful, with the patient rating her pain as 6 out of 10. Vital signs were stable, but there was mild swelling and tenderness at the site of injury. The patient was educated on wound care, including gentle cleansing, application of prescribed topical antibiotics, and the importance of keeping the area covered and protected from external irritants.

In the weeks that followed, the patient's diligent adherence to the prescribed care regimen played a crucial role in her recovery. The nurse had noted gradual improvement at each visit, observing the transition from erythema to a more uniform skin tone and the reduction of swelling. The patient had also been instructed on the importance of hydration and nutrition to support skin healing, which she incorporated into her daily routine. Through consistent follow-up and patient education, the initial assessment findings set the stage for a smooth recovery process, allowing the patient to regain full function and confidence in her arm's use.

With the initial assessment findings serving as a baseline, the nurse now emphasizes the significance of continued vigilance in monitoring for any changes, such as unexpected discoloration or textural changes, which could indicate potential complications. The patient's journey underscores the importance of foundational nursing care, patient education, and the collaborative effort between the patient and healthcare providers in achieving optimal outcomes. As the patient departs with a renewed sense of well-being, the nurse feels gratified in knowing that the initial assessment and subsequent care plan were pivotal in guiding the patient toward complete recovery.