What is the most appropriate initial action a nurse should take when caring for a patient with a superficial partial-thickness burn on the forearm?

B) Cover the burn with a non-adherent dressing

A) Apply an ice pack to the burn area to reduce swelling

B) Cover the burn with a non-adherent dressing

C) Encourage the patient to keep the burn area exposed to air

D) Wrap the burn area tightly with a cohesive bandage

A 28-year-old female patient has a superficial partial-thickness burn on her right forearm. Which of the following interventions is MOST appropriate to prevent infection in this type of burn?

B) Keep the burn area clean and dry

A) Apply a tight bandage to the burn area

B) Keep the burn area clean and dry

C) Use an antiseptic solution to scrub the burn

D) Expose the burn to air to promote drying

Which of the following interventions is most important to prevent infection in a patient with a minor burn injury?

B) Keeping the burn area clean and dry

A) Applying cool compresses regularly

B) Keeping the burn area clean and dry

C) Performing range of motion exercises

D) Increasing oral fluid intake

What is the primary purpose of applying a non-adherent dressing to a burn wound?

B) To prevent adherence and protect the wound

A) To provide a cushioning effect

B) To prevent adherence and protect the wound

C) To compress the wound and reduce swelling

What is the primary reason the nurse encourages the patient to perform gentle stretching exercises during the recovery of a burn injury?

B) To maintain skin flexibility and prevent stiffness

A) To increase blood flow to the area

B) To maintain skin flexibility and prevent stiffness

C) To accelerate the re-epithelialization process

D) To prevent systemic infection

Based on the patient's current condition and the nurse's assessment, which nursing action is most appropriate to support the patient's recovery?

A) Encourage the patient to increase physical activity to strengthen the affected area.

B) Advise the patient to discontinue wound care since healing is observed.

D) Recommend the patient to avoid any movement of the affected area until fully healed.

Which of the following observations indicates that the burn wound is healing well at the follow-up appointment?

B) The patient reports a pain level of 7 out of 10 at the burn site.

C) There is increased warmth and redness around the burn area.

D) The patient experiences discomfort during daily activities.

What is the most appropriate nursing intervention to ensure the continued healing of the patient's burn site?

A) Encourage the patient to apply moisturizing lotion regularly

B) Advise the patient to avoid stretching exercises

C) Recommend the patient to keep the burn site covered at all times

D) Suggest the patient to apply antibiotic ointment daily

Which intervention is most appropriate for a patient experiencing mild itchiness at a healing burn site?

A) Apply a fragrance-free moisturizer

B) Use a topical antibiotic ointment

C) Cover the burn with a tight bandage

D) Scrub the area gently with soap and water

A patient contacts the clinic reporting mild itchiness and redness at a burn site. Upon examination, the nurse finds a small, slightly erythematous area that is not warm to the touch. What recommendation should the nurse provide to the patient to aid in the healing process?

B) Use a fragrance-free moisturizer to alleviate itchiness.

A) Apply a steroid cream to the area twice a day.

B) Use a fragrance-free moisturizer to alleviate itchiness.

C) Cover the area with a tight bandage to prevent further irritation.

D) Soak the burn site in warm water to reduce redness.

Burn - Nursing Case Study

Pathophysiology

• Primary mechanism: Burn injuries cause damage to skin layers, leading to loss of the protective barrier. This results in fluid loss, temperature imbalance, and increased risk of infection as the skin is compromised.

• Secondary mechanism: The inflammatory response is triggered, releasing cytokines and other mediators. This can cause local edema, further fluid loss, and can lead to systemic effects like shock if not managed.

• Key complication: Minor burns can lead to infection due to the broken skin barrier, emphasizing the importance of wound care and monitoring for signs of infection.

Patient Profile

Demographics:

28-year-old female, office worker

History:

• Key past medical history: No significant medical history

• Current medications: None

• Allergies: None

Current Presentation:

• Chief complaint: Mild burn on right forearm

• Key symptoms: Redness, minor swelling, tenderness at burn site

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

Section 1

Initial Assessment Findings:

Upon further examination of the 28-year-old female patient, the burn on her right forearm is classified as a superficial partial-thickness burn. The affected area measures approximately 3 inches in diameter. The skin appears erythematous with minimal blister formation, consistent with a first-degree burn. The patient reports pain at the site, rating it as 4 out of 10 on a pain scale. The surrounding skin is warm to the touch, and there is slight edema present. The patient denies any additional pain or discomfort in other areas and does not exhibit any signs of systemic involvement, such as fever or chills.

The nursing assessment also includes a thorough review of the patient's ability to perform activities of daily living. The patient expresses that her ability to type and perform other office tasks is slightly hindered due to discomfort. However, she maintains full range of motion in the affected limb. The patient is educated on the necessity of keeping the burn area clean and dry to prevent infection. She is advised to use a non-adherent dressing and to apply a topical antibiotic ointment as a precautionary measure.

The initial assessment reinforces the stable nature of the burn injury, with no immediate signs of infection or systemic complications. The patient is encouraged to monitor for any changes in symptoms, such as increased redness, swelling, or discharge from the burn site, which could indicate an infection. Follow-up care is scheduled to ensure proper healing and to reassess the need for additional interventions. This stable presentation allows the healthcare team to focus on effective wound management and patient education, setting the stage for recovery and preventing further complications.

Section 2

Response to Interventions:

Two days following the initial assessment, the patient returns for a scheduled follow-up visit. During this appointment, the nurse performs a focused reassessment of the burn site. The erythema has decreased, and the previously noted blister has started to resolve, with the skin appearing less tense. The patient continues to report mild pain, now rating it as 2 out of 10. She indicates that the discomfort is more manageable, especially after adhering to the recommended pain management strategies, including the regular application of cool compresses and over-the-counter analgesics.

Upon examination, the burn area remains free from signs of infection. No new blisters or increased swelling are observed, and the surrounding skin maintains its warmth without excessive heat, which suggests an absence of secondary complications. The patient confirms she has been diligent in keeping the area clean and dry, using the prescribed non-adherent dressing and applying the topical antibiotic ointment as directed. Her ability to perform office tasks has slightly improved, although she still experiences some discomfort while typing for extended periods.

The nurse reinforces the importance of continuing the current wound care regimen and encourages the patient to remain vigilant for any changes, such as increased pain, redness, or drainage, which could signal infection. The patient is advised to gradually increase the use of her affected arm to maintain range of motion, avoiding activities that could strain the healing tissue. The nurse schedules another follow-up visit in a week to monitor healing progress and provides additional educational materials on burn care and prevention strategies to support the patient’s recovery and prevent future incidents.

Section 3

At the next follow-up visit, the patient reports continued adherence to her wound care regimen and notes further improvement in her symptoms. The nurse conducts a thorough reassessment of the affected area, finding that the burn site appears to be healing well. The erythema has almost completely resolved, and the skin has begun to re-epithelialize, indicating healthy tissue regeneration. The patient now rates her pain as 1 out of 10, mentioning that it occurs only occasionally, primarily when she inadvertently bumps the area.

Vital signs remain stable, with the patient's temperature at 98.6°F, blood pressure at 118/72 mmHg, pulse at 72 bpm, and respiratory rate at 16 breaths per minute. These findings support the absence of systemic infection or other complications. The patient’s laboratory results show a white blood cell count within normal range, further corroborating the absence of an infectious process. She reports improved functionality in her daily activities, and her ability to perform work-related tasks has increased significantly, with only minimal discomfort after prolonged computer use.

The nurse praises the patient for her diligent care and encourages her to continue monitoring for any signs of infection. The patient is advised to maintain her current regimen while slowly reintroducing normal activities to prevent overexertion of the healing tissue. To support the ongoing recovery, the nurse suggests gentle stretching exercises to maintain flexibility and prevent stiffness. The patient is scheduled for a final follow-up appointment in two weeks, with instructions to contact the clinic if any concerning symptoms arise in the interim. This approach aims to ensure a complete recovery and empower the patient to manage her care effectively.

Section 4

Two weeks later, the patient returns for her final follow-up appointment. During the visit, the nurse conducts a comprehensive assessment to evaluate the patient's progress. The burn site now shows significant improvement with almost complete re-epithelialization. The skin is smooth and slightly pink, indicating healthy tissue regeneration. There are no signs of infection, such as increased warmth, redness, or drainage. The patient reports that her pain has completely resolved, rating it as 0 out of 10, and she no longer experiences discomfort during daily activities or work-related tasks.

The nurse reviews the patient's vital signs, which remain stable: temperature at 98.6°F, blood pressure at 116/70 mmHg, pulse at 70 bpm, and respiratory rate at 16 breaths per minute. These stable vital signs, along with the normal laboratory results from the previous visit, confirm the absence of systemic complications. The patient mentions she has been following the recommended stretching exercises and has noticed improved flexibility in the affected area.

The patient expresses confidence in managing her recovery and is eager to return to all her normal activities. The nurse reinforces the importance of continuing skin protection measures, such as using sunscreen and wearing protective clothing, to prevent further injury to the newly healed skin. As the patient leaves, she is encouraged to maintain communication with the clinic should any new concerns or symptoms arise. This proactive approach ensures the patient remains empowered and well-informed as she completes her recovery journey.

Section 5

A few days after her final follow-up appointment, the patient experiences a mild change in her condition, prompting her to contact the clinic. During a phone consultation with the nurse, she describes a slight itchiness at the burn site and a small area of redness that has developed. Concerned about the possibility of a minor complication, the nurse advises the patient to come in for an in-person assessment to ensure optimal healing and to rule out any potential issues.

Upon examination, the nurse observes that the burn site remains mostly smooth and pink, with the exception of a small, slightly erythematous area. The nurse measures the affected region, noting it is approximately 2 cm in diameter and not warm to the touch, which suggests that infection is unlikely. The patient's vital signs remain stable, with a temperature of 98.7°F, blood pressure at 118/72 mmHg, pulse at 72 bpm, and respiratory rate at 16 breaths per minute. These findings support the absence of systemic complications.

The nurse reassures the patient that the minor redness and itching are common as healing tissues adapt and suggests applying a fragrance-free moisturizer to help alleviate the itchiness. Additionally, the nurse emphasizes the importance of avoiding scratching to prevent skin breakdown. The patient is advised to monitor the area closely for any changes, such as increased redness, warmth, or swelling, and to return to the clinic if these occur. This careful monitoring and proactive management provide an opportunity for clinical reasoning, allowing the patient to remain engaged in her recovery while minimizing the risk of further complications.