Question

A 44-year-old client is admitted to the emergency department with burns to the neck and face received from an explosion while working on a gas pipeline. During the nurse's initial assessment, highest priority should be given to: A. Noting signs of increased intracranial pressure (ICP) B. Monitoring hourly intake and output C. Assessing changes in circumference of the neck D. Replacing fluid loss since based on weight

Short answer

C. Assessing changes in circumference of the neck

Step-by-step solution

Identify the critical aspect of the injury

The client has burns to the neck and face. These areas are critical because they can impact breathing and airway patency.

Determine possible complications

With burns to the neck and face, the swelling or damage can compromise the airway leading to potential respiratory distress or obstruction.

Prioritize care based on immediate threats to life

The highest priority should address the most immediate threat to the client's life, which in this case would be the airway.

Evaluate the options

A. Increased ICP is a concern for head injuries, not burns to the neck and face. B. Monitoring intake/output is related to fluid management but not immediately critical for airway. C. Changes in neck circumference can indicate swelling that might affect the airway. D. Replacing fluids is essential but not the highest priority over airway management.

Choose the highest priority

Given the potential for airway obstruction or compromise due to swelling, the highest priority should be assessing changes in the circumference of the neck.

Key concepts

Airway Management

Burn injuries to the neck and face can be life-threatening due to the possibility of airway obstruction. When assessing a patient with such injuries, ensuring the airway is clear and not compromised is crucial.

If the airway is obstructed, the patient cannot breathe properly, leading to oxygen deprivation and potentially irreversible damage. Therefore, **airway management** in such cases includes:

• Monitoring for signs of respiratory distress
• Looking for swelling in the neck and face
• Ensuring the airway remains open
• Using tools like endotracheal tubes if necessary

Proper airway management interventions help avoid complications like hypoxia and respiratory failure. Remember, **airway patency** should always be the top priority in burn injuries to the neck and face.

Burn Injury Assessment

Assessing burn injuries involves evaluating several factors to guide treatment. Initially, the extent and depth of the burns must be determined to understand the severity.

For burns to the neck and face, close attention to potential swelling is essential. Swelling can increase rapidly, leading to airway closures.

Key factors in burn injury assessment include:

• Determining the total body surface area (TBSA) affected
• Classifying burns as superficial, partial-thickness, or full-thickness
• Monitoring vital signs, including respiratory rate
• Checking the capillary refill in limbs

In the presented case, assessing changes in the circumference of the neck is particularly critical. This helps anticipate and quickly respond to any airway obstruction, ensuring patient safety.

Patient Prioritization

Patient prioritization involves identifying and addressing the most immediate threats to a patient's life. The goal is to provide timely and appropriate care to improve outcomes.

In critical care, this often means addressing issues related to **ABCs** (Airway, Breathing, Circulation) first. Airway issues take precedence since without a patent airway, the patient cannot breathe effectively.

Key skills for effective patient prioritization:

• Conducting a rapid primary survey (ABCs)
• Using triage protocols
• Implementing emergency interventions quickly
• Reassessing and adjusting care priorities as needed

**Example scenario:** For a patient with burns to the neck and face, immediate steps would include: checking for and managing airway obstructions, and monitoring changes in neck circumference. Always address the most life-threatening issues first before moving on to secondary concerns. Effective prioritization saves lives by ensuring critical issues receive immediate attention and care.