Which of the following is the most appropriate initial action for the nurse to take to prevent infection in a patient with a superficial partial-thickness burn?

B) Keep the burn area clean and dry

A) Apply a cold compress to the burn site

B) Keep the burn area clean and dry

C) Cover the burn with a tight bandage

D) Encourage vigorous exercise of the affected limb

Which of the following is the most appropriate initial action for managing a superficial partial-thickness burn on a patient's forearm?

C) Clean the burn with mild soap and water

A) Apply a dry sterile dressing to the burn area

B) Immerse the burn in ice water for 15 minutes

C) Clean the burn with mild soap and water

D) Apply a topical antibiotic ointment directly to the burn

Which of the following is a priority intervention in the initial management of a patient with a burn injury?

B) Ensuring the burn site is kept clean and covered with a sterile dressing

C) Applying silicone gel sheets immediately

D) Encouraging the patient to increase physical activity

Which of the following signs noted during the wound assessment indicates that the healing process is progressing well?

A) Wound edges showing signs of epithelialization

B) Surrounding skin being excessively warm

C) Presence of tenderness and swelling

D) Increased redness around the wound

Which of the following observations indicates that the wound healing process is progressing normally?

A) Epithelialization with healthy, pink tissue

B) Excessively warm surrounding skin

C) Swelling around the wound site

D) Elevated white blood cell count

During the follow-up assessment, what observation indicates that the patient's wound is healing appropriately?

A) The wound shows signs of epithelialization with healthy, pink tissue.

B) The surrounding skin is excessively warm and swollen.

C) The patient's temperature is elevated at 101°F.

D) The patient's white blood cell count is 15,000 cells/mcL.

During a wound assessment, which of the following findings would indicate normal healing?

B) A healthy pink hue of newly formed tissue

A) Excessive warmth and swelling around the wound

B) A healthy pink hue of newly formed tissue

C) Presence of yellow or green discharge

D) Increasing pain and redness extending beyond the wound

Burn - Nursing Case Study

Pathophysiology

• Primary mechanism: Tissue Damage - Burns cause direct injury to the skin and underlying tissues, leading to cell death and loss of protective barriers, which can result in fluid loss and increased risk of infection.

• Secondary mechanism: Inflammatory Response - The body initiates an inflammatory response to repair damaged tissue, which causes swelling, redness, and heat. This can further lead to increased vascular permeability, resulting in fluid shifts and edema.

• Key complication: Fluid Imbalance - Due to the loss of skin integrity and increased capillary permeability, patients may experience fluid and electrolyte imbalances, which can lead to hypovolemia and shock if not properly managed.

Patient Profile

Demographics:

28-year-old male, chef

History:

• Key past medical history: No significant past medical history

• Current medications: None

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Minor burn on left forearm

• Key symptoms: Redness, mild pain, and slight swelling in the affected area

• Vital signs: Temperature 98.6°F, Heart rate 76 bpm, Respiratory rate 16 breaths per minute, Blood pressure 118/72 mmHg

Section 1

Initial Assessment Findings:

Upon initial assessment, the burn on the patient's left forearm is classified as a superficial partial-thickness burn, covering approximately 2% of the total body surface area. The affected skin appears red and blistered, with the patient reporting mild to moderate pain upon palpation. The surrounding area is warm to the touch, consistent with the body's inflammatory response. There is no evidence of deeper tissue involvement, and the patient is able to move his fingers and wrist without difficulty, indicating that motor function is intact.

The patient demonstrates understanding of the burn's care requirements, verbalizing the importance of keeping the area clean and dry to prevent infection. He expresses concern about the possibility of scarring, which provides an opportunity for the nurse to educate him on the benefits of proper wound care and the use of topical ointments to promote healing. The patient's vital signs remain stable, with no indications of systemic involvement or signs of infection, such as fever or increased pain. Routine monitoring of the burn site and overall condition is planned to detect any changes early.

In light of the potential for fluid imbalance, the nursing team will focus on maintaining adequate hydration by encouraging oral fluid intake and monitoring urine output to ensure it remains within normal limits. The patient is advised to avoid activities that may irritate the burn or increase the risk of secondary injury. This initial assessment phase sets the stage for ongoing evaluation and management, emphasizing the prevention of complications and the promotion of optimal healing.

Section 2

Response to Interventions:

As the patient begins the initial stages of treatment, the nursing team implements a care plan focused on wound management and pain control. The burn site is carefully cleaned and dressed with a non-adherent, sterile dressing to protect the area and promote healing. The patient is educated on the importance of maintaining the cleanliness of the dressing and is encouraged to report any signs of increased pain, redness, or discharge, which could indicate an infection.

Over the next 24 hours, the patient shows a positive response to the interventions. He reports a decrease in pain levels, now rating it as mild and manageable with over-the-counter analgesics. The burn site remains clean and shows no signs of infection, such as pus formation or a foul odor. The surrounding skin is less warm to the touch, indicating an appropriate progression of the inflammatory response. Vital signs remain stable, with a blood pressure of 118/76 mmHg, heart rate of 72 bpm, respiratory rate of 16 breaths per minute, and temperature of 98.6°F. The patient continues to drink fluids regularly, and urine output is within normal limits, confirming adequate hydration.

This positive response provides an opportunity for the nursing team to reinforce education on self-care and the use of topical ointments that can aid in minimizing scarring. As the patient is keen on preventing scarring, the nurse discusses the benefits of using silicone gel sheets or creams, which can be introduced once the wound begins to close. The patient is advised on the importance of protecting the burn from sun exposure to prevent further skin damage. As the healing progresses, the nursing team will continue to monitor for any changes and ensure the patient remains comfortable and informed throughout his recovery journey.

Section 3

As the patient continues with the treatment plan, the nursing team conducts a routine follow-up assessment to ensure the wound is healing properly and to identify any potential complications early. During this assessment, the nurse notes that the wound edges are beginning to show signs of epithelialization, a positive indication that the healing process is progressing. The surrounding skin appears slightly pink but not excessively warm, and there is no tenderness, swelling, or increased redness, suggesting that inflammation is under control.

The patient reports feeling slight itching at the site, which the nurse explains is a common sign of healing. The patient is reassured and advised not to scratch the area to avoid disrupting the healing tissue. Education is provided on using a moisturizer around the wound to alleviate the itching, while taking care not to apply it directly on the open burn.

Given the stable clinical presentation, the nursing team decides to perform a basic set of laboratory tests to ensure there are no underlying issues that could impede healing. The results return within normal ranges, with a white blood cell count of 6,500 cells/mcL, indicating no active infection, and normal electrolyte levels, supporting the nurse's assessment of adequate hydration. The patient is encouraged to continue with the current treatment plan, maintaining proper wound care and hydration, with a follow-up appointment scheduled in a week to monitor ongoing progress. This proactive approach aims to minimize the risk of complications and supports the patient's goal of a smooth recovery with minimal scarring.

Section 4

A week later, the patient returns for the scheduled follow-up appointment. During the initial assessment, the nurse observes that the wound continues to show signs of epithelialization, with the newly forming tissue appearing healthy and pink. The surrounding skin remains slightly pink but is neither excessively warm nor swollen, consistent with a controlled inflammatory response. The patient's vital signs are stable, with a temperature of 98.6°F, pulse rate of 72 beats per minute, respiratory rate of 16 breaths per minute, and blood pressure of 118/76 mmHg, indicating no signs of systemic infection or distress.

The patient reports that the itching has reduced significantly, following the nurse's advice to use a moisturizer around the wound. The patient also mentions diligently adhering to the hydration and wound care regimen, which has contributed to the stable healing process. The nurse confirms that the patient has continued to avoid scratching the area, which has helped prevent any disruption of the new tissue. The patient's positive response to these interventions further reassures the nursing team that the current treatment plan is effective.

As part of the follow-up, a repeat set of laboratory tests is conducted. The results show a white blood cell count of 6,300 cells/mcL, consistent with no active infection, and normal electrolyte levels, confirming adequate hydration and nutritional status. These findings support the nursing team's assessment that the patient is on track for recovery. The patient is encouraged to continue the current care plan and is advised to return for another follow-up in two weeks to ensure the wound continues to heal without complications. The focus remains on promoting healing, minimizing scarring, and maintaining overall well-being.

Section 5

Two weeks later, the patient returns for the scheduled check-up, and the nurse conducts another thorough assessment. The wound continues to progress well, with the epithelialization process advancing as expected. The newly formed tissue is now more robust, showing a healthy pink hue with no signs of infection. The surrounding skin remains slightly pink, a normal part of the healing process, and there is no excessive warmth or swelling, indicating that inflammation is under control. The patient’s vital signs remain stable, with a temperature of 98.7°F, a pulse rate of 70 beats per minute, a respiratory rate of 16 breaths per minute, and blood pressure of 120/78 mmHg, further reinforcing the absence of systemic complications.

In discussing the patient's adherence to the care plan, the nurse learns that the patient has consistently applied the recommended moisturizer and maintained adequate hydration, which has effectively managed the itching and supported the skin's recovery. The patient expresses satisfaction with the healing progress and reports no new symptoms or discomfort. The nurse praises the patient's commitment to the care regimen and reiterates the importance of continuing these practices to support complete healing and minimize scarring.

However, the patient mentions a slight tingling sensation around the wound, which prompts the nurse to conduct a more detailed examination. The sensation is determined to be a normal part of nerve regeneration, often experienced during the healing process. To ensure this remains a benign symptom, the nurse decides to monitor this sensation closely over the coming weeks and advises the patient to report any changes in sensation or if the tingling becomes bothersome. The nurse schedules another follow-up in two weeks to continue monitoring the wound's healing trajectory and to address any potential concerns proactively.