Which of the following would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a third-degree circumferential burn of the right arm?
1. Infection, risk for
2. Altered Tissue Perfusion, risk for
3. Altered Nutrition: Less Than Body Requirements, risk for
4. Impaired Physical Mobility
2
Rationale:
1. When the burn is circumferential, blood flow can become restricted due to edema, and can result in tissue hypoxia; therefore, the priority diagnosis is Altered Tissue Perfusion, risk for to the extremity. Risk of infection would be a secondary priority in this case.
2. Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered tissue perfusion to the extremity is the greatest risk, and therefore the priority diagnosis.
3. Infection, nutrition, and mobility would have secondary priority in this case.
4. Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis Altered Tissue Perfusion, risk for.
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