A priority nursing diagnosis for a client with burns during the emergent period would be: 1. Excess fluid volume. 2. Imbalanced nutrition: Less than body requirements. 3. Risk for injury (falling). 4. Risk for infection.
The Correct Answer and Explanation is:
Correct Answer: 4. Risk for infection.
Explanation:
In the emergent phase of burn care—also known as the resuscitative phase—prioritizing nursing diagnoses is crucial for improving outcomes and preventing complications. The primary concern during this phase is maintaining life by managing airway, breathing, and circulation, but a significant nursing priority is preventing infection.
“Risk for infection” is a priority diagnosis because burn injuries compromise the integrity of the skin, which is the body’s first line of defense against microbial invasion. When the skin barrier is lost, the patient becomes highly susceptible to bacterial, viral, and fungal infections. The larger and deeper the burn, the greater the risk. In fact, sepsis from infection is one of the leading causes of morbidity and mortality in burn patients.
Additionally, the immune response in burn patients is altered. The massive inflammatory response triggered by the burn injury can lead to immune system suppression, making it even more difficult for the body to combat invading pathogens. Burn wounds often require invasive interventions such as IV lines, catheters, and intubation, all of which can serve as portals for infection.
While other diagnoses such as excess fluid volume, imbalanced nutrition, or risk for falls are relevant at various stages of burn recovery, they are not as immediately life-threatening in the emergent period. For example, fluid volume deficit (not excess) is typically more relevant early on due to plasma loss, and nutrition becomes more critical during the acute or rehabilitative phases. Similarly, fall risk is more pertinent when mobility is affected, generally after stabilization.
Therefore, given the immediacy and severity of the threat posed by infection following burn injury, “Risk for infection” is the most appropriate and priority nursing diagnosis during the emergent phase.
