Question

A client has been severely burned in a house fire and admitted to the burn unit. After emergency stabilization, one of the primary nursing goals is to prevent contractures. Which nursing intervention supports achievement of this goal? A. Administration of albumin B. Promoting the intake of protein foods. C. Application of splints to immobilize body parts D. Treating the burns with the open method and not wrapping the burned injury.

Short answer

Application of splints to immobilize body parts (C) is the correct nursing intervention to prevent contractures.

Step-by-step solution

Understanding the concept of contractures

Contractures are the shortening and hardening of muscles, tendons, or other tissue often leading to rigidity and deformity of joints. Contractures are a common complication following burns due to the lack of movement and the nature of scar formation. Preventing contractures is a significant nursing goal in the care of burn patients.

Evaluating the options against the goal of preventing contractures

Evaluate each given option to determine which one directly aids in the prevention of contractures. The administration of albumin (A) is related to fluid balance rather than directly preventing contractures. Promoting the intake of protein foods (B) can help with tissue repair but does not directly prevent contractures. The application of splints to immobilize body parts (C) directly aids in keeping the body in proper alignment and prevents the shortening of muscles and tendons that can lead to contractures. Treating the burns with the open method (D) focuses on the method of burn treatment and not on the prevention of contractures.

Identifying the correct intervention

Identify the best intervention to prevent contractures, which is through maintaining body parts in the proper anatomical position to avoid the shortening of tissues and development of contractures. Therefore, the correct answer is the application of splints (C), as it immobilizes body parts in an extended position, thus preventing contractures.

Key concepts

Nursing Intervention for Burn Care

Caring for patients who have suffered from severe burns requires a multi-faceted approach. Nursing interventions are crucial components in this type of care. For instance, the application of splints is a key intervention to prevent contractures, a condition where the skin, muscles, or tendons shorten and lead to rigidity and deformity, particularly after burns.

Splints help in maintaining the body parts in their proper anatomical position, which is essential to counteract the contractive forces of healing tissues. Other nursing interventions include frequent repositioning of the patient, ensuring adequate nutrition (particularly protein intake for tissue repair), and meticulous wound care to promote healing and prevent infection. Pain management and psychological support are also integral, as they can influence the patient's mobility and engagement with necessary rehabilitation exercises.

A thorough assessment and monitoring routine ensures that nurses are the first to detect any signs of complications, including the development of contractures, and address them promptly. This proactive stance in burn care, rooted in a foundation of evidence-based practice, maximizes patient recovery outcomes and quality of life.

Contracture Management

Contracture management is critical in the rehabilitation of burn patients. It primarily involves interventions to maintain the elasticity of the skin and muscle function. Nurses play a central role in this aspect of patient care.

The use of splints or other orthotic devices is often recommended to keep the affected areas in a functional position and minimize the risk of tissue shortening. In addition to splinting, nurses may also participate in range-of-motion exercises, apply emollients to the skin to maintain its pliability, and work alongside physical therapists for more extensive rehabilitation.

Patient Education

Educating patients and their families about the importance of adhering to the regimen of splinting and exercises is imperative. Understanding the potential for contractures and the rationale behind sometimes uncomfortable or time-consuming interventions motivates compliance and positively impacts outcomes.

Burn Unit Patient Care

In a burn unit, where patients face a unique set of challenges, specialized patient care is pivotal. The multidisciplinary approach in these units ensures that all aspects of a patient's needs are addressed. Nurses act as the central link coordinating this care.

The primary focus of nurses in a burn unit is not only to facilitate wound healing and manage pain but also to prevent complications such as contractures. This includes continuous monitoring of vital signs, careful dressing of wounds, and administrating prescribed medications, which are all integral parts of a burn unit nurse's responsibilities.

Team Collaboration

Nurses collaborate closely with dietitians, physical therapists, and occupational therapists to create comprehensive treatment plans that encompass nutritional support for tissue healing, as well as physical and occupational therapy to maintain and improve range of motion and functional ability. Teamwork is essential in delivering holistic care that gives burn patients the best chance at a full recovery.