When planning care for a person with burn on the upper part of the body involving face & arm, neck. Which of the following nursing diagnosis should take the highest priority?

1. A

   Fluid volume deficit

2. B

   Body image disturbances

3. C

   Ineffective airway clearance

4. D

   Risk of infection

Appeared in: HPSSSB Staff Nurse - 2016

Explanation

• The ABC (Airway, Breathing, Circulation) framework dictates that maintaining a patent airway is the first and most critical priority in all emergency situations.
• Burns to the face and neck are a primary indicator of potential inhalation injury and subsequent airway edema (swelling).
• This swelling can occur rapidly and progress to complete airway obstruction, which is an immediate life-threatening event.
• Therefore, the nursing diagnosis of 'Ineffective airway clearance' addresses the most urgent problem.

Why Other Options Were Wrong

• Option A: While 'Fluid volume deficit' is a critical, life-threatening condition in major burns (the 'C' for Circulation), it is the second priority after securing the airway.
• Option B: This is a psychosocial diagnosis that addresses the long-term emotional and psychological impact of the burns. It is not an immediate physiological priority.
• Option D: Infection is a major cause of mortality in burn patients, but the risk develops over hours to days. It is not the most immediate life threat compared to airway obstruction.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing diagnoses for burn injuries using the ABC framework to guide bedside assessment, documentation, and the next nursing action.
• In any patient with burns to the head, neck, or upper chest, the nurse's first action must be a rapid and continuous assessment of the airway for signs of compromise, such as hoarseness, stridor, or difficulty swallowing.
• Be prepared for prophylactic intubation. The airway can swell shut quickly, and waiting for respiratory distress to become severe can make intubation difficult or impossible.
• What if? If the burn was extensive but located only on the patient's back and legs, 'Fluid volume deficit' would become the highest priority, as the immediate risk to the airway would be significantly lower.

How to Approach the Question

• First, identify that the question is asking for the 'highest priority', which signals a prioritization question.
• Recall the fundamental principle of emergency nursing: the ABCs (Airway, Breathing, Circulation).
• Analyze the clinical scenario for the most immediate life threat. The key information is 'burn on the... face & arm, neck'.
• Connect the clinical data to the ABCs. Burns to the face and neck directly threaten the 'A' for Airway due to the high risk of swelling and obstruction.
• Evaluate each option against this framework: 'Ineffective airway clearance' directly addresses the Airway. 'Fluid volume deficit' addresses Circulation. 'Risk of infection' and 'Body image' are later priorities.
• Conclude that the Airway-related diagnosis is the highest priority.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing diagnoses for burn injuries using the ABC framework.
• Stem keywords: burn, upper part of the body, face, arm, neck, highest priority, nursing diagnosis
• Lead-in keywords: highest priority
• Clinical cues: The location of the burn on the face and neck is the most critical piece of information, as it directly implies a risk to the airway.

Question ID

QML27k0g4eEzicQ2CX8hS7

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 85-87