Which is 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. Risk for infection
2. Risk for altered tissue perfusion
3. Risk for altered nutrition: less than body requirements
4. Impaired physical mobility
2
Rationale:
1. When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is a risk for altered tissue perfusion to the extremity. Risk for infection would have second priority in this case.
2. When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is a risk for altered tissue perfusion to the extremity.
3. When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is a risk for altered tissue perfusion to the extremity. Risk for altered nutrition would have second priority in this case.
4. When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is a risk for altered tissue perfusion to the extremity. Risk for impaired mobility would have second priority in this case.
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