A 75-year-old woman has been on the unit with a burn to the left elbow caused by a bathrobe that caught fire while the client was cooking
The burn is on the inner aspect of the elbow, and is described as a full-thickness burn, which is now in the third stage of healing. When planning care for this client, the nurse focuses on which of the following as a priority of care? 1. Monitoring the client for wound hemorrhage
2. Monitoring for signs of infection
3. Preventing contractures and immobility
4. Preventing dehiscence
3
Rationale: The elderly client has scar tissue that is less elastic and less flexible, placing the client at risk for a contracture of the elbow. The wound is in the third stage of healing, and is no longer at risk for infection or hemorrhage. Burn wounds are not sutured, so there is no risk of dehiscence.
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