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Laboratory Test Result to Report Immediately in Burned Client During Emergent Phase

Laboratory Test Results Present During the Emergent Phase of Burn Recovery

All of the following laboratory test results on a burned client’s blood are present during the emergent phase of burn recovery:

  • Elevated white blood cell count (WBC)
  • Elevated neutrophil count
  • Elevated erythrocyte sedimentation rate (ESR)
  • Elevated C-reactive protein (CRP) level
  • Elevated blood glucose level
  • Elevated potassium level
  • Elevated sodium level
  • Decreased chloride level
  • Decreased bicarbonate level
  • Decreased blood pH

Laboratory Test Result to Report Immediately

The nurse should report the elevated potassium level to the physician immediately. Potassium is an electrolyte that is essential for many bodily functions, including nerve and muscle function. Elevated potassium levels, also known as hyperkalemia, can cause serious complications, such as arrhythmias, cardiac arrest, and death.

Why is Hyperkalemia a Concern in Burn Patients?

Hyperkalemia is a concern in burn patients because burn injuries can cause the release of potassium from the cells into the bloodstream. This is due to a number of factors, including cell death, inflammation, and stress.

Signs and Symptoms of Hyperkalemia

The signs and symptoms of hyperkalemia can vary depending on the severity of the hyperkalemia. Some common signs and symptoms of hyperkalemia include:

  • Muscle weakness
  • Muscle cramps
  • Numbness and tingling
  • Fatigue
  • Arrhythmias
  • Cardiac arrest

Treatment of Hyperkalemia

The treatment of hyperkalemia depends on the severity of the hyperkalemia and the underlying cause. Treatment may include:

  • Restricting dietary potassium intake
  • Administering intravenous fluids
  • Administering medications to promote potassium excretion, such as diuretics
  • Performing dialysis

Conclusion

The nurse should report the elevated potassium level to the physician immediately because hyperkalemia is a serious complication that can lead to death. The physician will assess the client’s condition and develop a treatment plan to manage the hyperkalemia.

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Priority Nursing Diagnosis During the First 24 Hours for Client with Full-Thickness Chemical Burns

Priority Nursing Diagnosis

The priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm is risk for airway compromise.

Why is Airway Compromise a Priority Concern in Clients with Full-Thickness Chemical Burns?

Full-thickness chemical burns can damage the airway, leading to airway compromise. This is because chemical burns can cause inflammation, swelling, and necrosis (death of tissue) of the airway. Airway compromise can be fatal, so it is important to assess the airway and intervene early if necessary.

Other Nursing Diagnoses to Consider

In addition to risk for airway compromise, other nursing diagnoses to consider for a client with full-thickness chemical burns include:

  • Risk for fluid volume deficit: Full-thickness chemical burns can cause fluid loss through evaporation and increased capillary permeability. Fluid loss can lead to dehydration and shock.
  • Risk for infection: Full-thickness chemical burns can create an open wound that is susceptible to infection.
  • Pain: Full-thickness chemical burns can be very painful.
  • Anxiety: Clients with full-thickness chemical burns may experience anxiety due to the pain, disfigurement, and potential for complications.

Nursing Interventions

Nursing interventions for a client with full-thickness chemical burns will focus on preventing and managing complications. Nursing interventions include:

  • Airway assessment: Nurses should assess the client’s airway closely for signs of airway compromise, such as stridor, wheezing, and dyspnea. If airway compromise is detected, nurses should take steps to open the airway, such as intubation.
  • Fluid resuscitation: Nurses should administer fluids to the client to prevent dehydration and shock. The amount of fluid administered will depend on the severity of the burn injury and the client’s individual needs.
  • Infection prevention: Nurses should implement infection prevention measures, such as wound care and isolation.
  • Pain management: Nurses should provide pain management to the client to improve comfort and quality of life. Pain management may include medications, non-pharmacological interventions, or a combination of both.
  • Anxiety reduction: Nurses should provide emotional support to the client and their family to help reduce anxiety.

Conclusion

The priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm is risk for airway compromise. Nurses should assess the client’s airway closely and take steps to open the airway if necessary. Nurses should also implement other nursing interventions, such as fluid resuscitation, infection prevention, pain management, and anxiety reduction.

Additional Information

It is important to note that the burn recovery process is unique to each individual. The timing and severity of complications can vary depending on the severity of the burn injury and the client’s underlying medical conditions. Nurses should work with the healthcare team to develop a personalized treatment plan for each burn patient.

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Clinical Manifestation Indicating the Burned Client is Moving into Fluid Remobelization Phase

Fluid Remobelization Phase of Burn Recovery

The fluid remobilization phase of burn recovery begins 24-48 hours after the burn injury and lasts for several days. During this phase, the fluid that has shifted into the interstitial space (tissue spaces) during the burn injury begins to shift back into the intravascular space (blood vessels).

Clinical Manifestation Indicating the Burned Client is Moving into the Fluid Remobelization Phase

The clinical manifestation that indicates that the burned client is moving into the fluid remobilization phase is increased urine output. This is because the fluid that is shifting back into the intravascular space is excreted by the kidneys.

Other clinical manifestations that may indicate that the burned client is moving into the fluid remobilization phase include:

  • Decreased edema: Edema is swelling caused by fluid accumulation in the tissues. As the fluid shifts back into the intravascular space, edema should decrease.
  • Improved vital signs: The client’s vital signs, such as blood pressure and heart rate, may improve as the fluid shifts back into the intravascular space.
  • Improved mental status: The client’s mental status, such as level of consciousness and orientation, may improve as the fluid shifts back into the intravascular space.

Conclusion

The clinical manifestation that indicates that the burned client is moving into the fluid remobilization phase is increased urine output. Other clinical manifestations that may indicate that the burned client is moving into the fluid remobilization phase include decreased edema, improved vital signs, and improved mental status.

Additional Information

It is important to note that the burn recovery process is unique to each individual. The timing of the fluid remobilization phase may vary depending on the severity of the burn injury and the client’s underlying medical conditions. Nurses should monitor the client closely for signs of fluid remobilization and work with the healthcare team to develop a personalized treatment plan.

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Absent Bowel Sounds in Burn Patient 12 Hours After Burn: Nurse’s Best Action

Nurse’s Best Action

The nurse’s best action when a burn patient has absent bowel sounds in all four abdominal quadrants 12 hours after the burn is to assess the patient’s abdomen thoroughly. This includes assessing the patient’s vital signs, abdominal pain, distention, tenderness, and rebound tenderness. The nurse should also listen to the patient’s bowel sounds in all four abdominal quadrants.

Why are Absent Bowel Sounds a Concern in Burn Patients?

Absent bowel sounds are a concern in burn patients because they may indicate paralytic ileus. Paralytic ileus is a condition in which the peristaltic movements of the intestines are slowed or stopped. Paralytic ileus can be caused by a number of factors, including:

  • Pain: Burn injuries can be very painful, and pain can inhibit peristaltic movements.
  • Inflammation: Burn injuries can cause inflammation throughout the body, including in the intestines. Inflammation can also inhibit peristaltic movements.
  • Electrolyte imbalances: Burn injuries can lead to electrolyte imbalances, such as hypokalemia (low potassium) and hypomagnesemia (low magnesium). Electrolyte imbalances can also disrupt peristaltic movements.

Nursing Interventions for Paralytic Ileus in Burn Patients

The nursing interventions for paralytic ileus in burn patients are focused on preventing and managing complications. Nursing interventions include:

  • Monitoring the patient’s vital signs and abdominal assessment: Nurses should monitor the patient’s vital signs and abdominal assessment closely for any signs of deterioration. This is important because paralytic ileus can lead to complications such as abdominal distention, vomiting, and constipation.
  • Providing pain management: Nurses should provide pain management to the patient to help reduce pain and improve peristaltic movements. Pain management may include medications, non-pharmacological interventions, or a combination of both.
  • Replacing electrolytes: Nurses should replace electrolytes, such as potassium and magnesium, as needed. Electrolyte replacement can help to improve peristaltic movements.
  • Providing nutritional support: Nurses should provide nutritional support to the patient to help prevent malnutrition and promote healing. Nutritional support may include enteral nutrition (feeding through a tube) or parenteral nutrition (feeding through an IV).

Conclusion

The nurse’s best action when a burn patient has absent bowel sounds in all four abdominal quadrants 12 hours after the burn is to assess the patient’s abdomen thoroughly and monitor the patient’s vital signs and abdominal assessment closely. The nurse should also provide pain management, replace electrolytes, and provide nutritional support.

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Hypotension and Tachycardia in Burn Patients: Thermal Injury-Related Response

Thermal Injury-Related Response

The thermal injury-related response is a complex process that begins immediately after a burn injury. The body’s response to a burn injury can be divided into three phases:

  1. Ebb phase: The ebb phase occurs in the first 24-48 hours after a burn injury. During this phase, there is a shift of fluid from the intravascular space (blood vessels) to the interstitial space (tissue spaces). This fluid shift is caused by a number of factors, including vasodilation (widening of the blood vessels) and increased capillary permeability (leaky blood vessels). The fluid shift can lead to hypovolemia (low blood volume) and hypotension (low blood pressure).
  2. Flow phase: The flow phase begins 24-48 hours after a burn injury and lasts for several days. During this phase, fluid begins to return to the intravascular space. However, the fluid shift is often not balanced, and the client may remain hypovolemic and hypotensive.
  3. Anabolic phase: The anabolic phase begins several days after a burn injury and lasts for several weeks. During this phase, the body begins to repair the damage caused by the burn injury. The anabolic phase is characterized by increased protein synthesis and fluid retention.

Hypotension and Tachycardia in Burn Patients

Hypotension and tachycardia are common findings in burn patients, especially in the ebb phase. Hypotension is caused by hypovolemia, which is caused by fluid shift and blood loss. Tachycardia is the body’s attempt to compensate for hypotension by increasing the heart rate and cardiac output.

Nursing Interventions

Nurses play a vital role in managing hypotension and tachycardia in burn patients. Nursing interventions include:

  • Fluid resuscitation: Fluid resuscitation is essential for restoring blood volume and improving hemodynamics. Fluids are typically administered intravenously (IV).
  • Monitoring vital signs: Nurses should monitor the client’s vital signs closely, especially blood pressure and heart rate.
  • Administering medications: Medications such as vasopressors may be used to increase blood pressure.
  • Providing emotional support: Burn injury can be a stressful experience for the client and their family. Nurses can provide emotional support and reassurance to the client and their family.

Conclusion

Hypotension and tachycardia are common findings in burn patients, especially in the ebb phase. These findings are an expected result of the thermal injury-related response. Nurses play a vital role in managing hypotension and tachycardia in burn patients by providing fluid resuscitation, monitoring vital signs, administering medications, and providing emotional support.

Additional Information

It is important to note that the severity of hypotension and tachycardia in burn patients will vary depending on the severity of the burn injury and the client’s underlying medical conditions. Nurses should work with the healthcare team to develop a personalized treatment plan for each burn patient.

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Blood Glucose Level of 90 mg/dL in Client with 50% Burns: Nurse’s Best Action

Nurse’s Best Action

The nurse’s best action when a client with a 50% burn injury has a blood glucose level of 90 mg/dL 10 hours after admission is to continue to monitor the client’s blood glucose level closely. This is because the client is at risk for developing hypoglycemia, especially in the first 24 hours after the burn injury.

Why is Hypoglycemia a Risk in Burn Patients?

Hypoglycemia is a condition in which the blood glucose level is too low. It can occur in burn patients for a number of reasons, including:

  • Stress hyperglycemia: Burn injury is a major stressor, which can cause the body to release hormones that increase blood glucose levels. However, in the first 24 hours after the burn injury, the body’s response to stress can change, and blood glucose levels can drop.
  • Insulin resistance: Burn injury can cause insulin resistance, which makes it more difficult for the body to use insulin to lower blood glucose levels.
  • Glycogen depletion: Glycogen is a stored form of glucose that is released into the bloodstream when blood glucose levels drop. However, burn injury can deplete glycogen stores, which can lead to hypoglycemia.

Symptoms of Hypoglycemia in Burn Patients

The symptoms of hypoglycemia in burn patients can vary depending on the severity of the hypoglycemia. Some common symptoms of hypoglycemia include:

  • Sweating
  • Tremors
  • Hunger
  • Dizziness
  • Confusion
  • Loss of consciousness

Treatment of Hypoglycemia in Burn Patients

The treatment of hypoglycemia in burn patients typically involves providing a source of glucose, such as dextrose. Dextrose can be given orally, intravenously, or through a nasogastric tube.

Nurse’s Role in Preventing and Managing Hypoglycemia in Burn Patients

Nurses play a vital role in preventing and managing hypoglycemia in burn patients. Nurses can help to prevent hypoglycemia by:

  • Monitoring the client’s blood glucose level closely
  • Providing the client with a regular diet and snacks
  • Administering insulin as prescribed by the healthcare team

Nurses can also help to manage hypoglycemia by:

  • Recognizing the signs and symptoms of hypoglycemia
  • Providing the client with a source of glucose, such as dextrose
  • Notifying the healthcare team if the client’s blood glucose level drops below 70 mg/dL

Conclusion

The nurse’s best action when a client with a 50% burn injury has a blood glucose level of 90 mg/dL 10 hours after admission is to continue to monitor the client’s blood glucose level closely. The nurse should also be aware of the signs and symptoms of hypoglycemia and be prepared to provide treatment if necessary.

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Client with Inhalation Injury Wheezing Stops: Nurse’s Best Action

Nurse’s Best Action

The nurse’s best action when a client with an inhalation injury who was wheezing 6 hours ago now has no wheezes is to continue to monitor the client’s respiratory status closely. This is because the client is still at risk for respiratory complications, such as bronchospasm, edema, and atelectasis.

The nurse should monitor the client’s vital signs, respiratory rate, depth, and effort. The nurse should also listen to the client’s breath sounds and look for any signs of respiratory distress, such as dyspnea, cyanosis, and restlessness.

The nurse should also reassess the client’s respiratory status regularly, especially in the first 24 hours after the inhalation injury. The nurse should be alert for any signs of respiratory deterioration, such as:

  • Increased respiratory rate
  • Decreased respiratory depth
  • Increased work of breathing
  • Wheezing
  • Cyanosis
  • Restlessness

If the nurse detects any signs of respiratory deterioration, the nurse should notify the healthcare team immediately.

Other Nursing Interventions

In addition to monitoring the client’s respiratory status, the nurse may also need to implement other nursing interventions, such as:

  • Administering medications: The nurse may need to administer medications to the client to help them breathe, such as bronchodilators or corticosteroids.
  • Providing oxygen therapy: The nurse may need to provide oxygen therapy to the client to help them breathe.
  • Positioning the client: The nurse may need to position the client in a way to promote lung expansion and improve ventilation.
  • Providing humidified air: The nurse may need to provide humidified air to the client to help loosen secretions and make it easier to breathe.

Conclusion

The nurse’s best action when a client with an inhalation injury who was wheezing 6 hours ago now has no wheezes is to continue to monitor the client’s respiratory status closely. The nurse should also reassess the client’s respiratory status regularly and be alert for any signs of respiratory deterioration. The nurse may also need to implement other nursing interventions, such as administering medications, providing oxygen therapy, positioning the client, and providing humidified air.

Additional Information

It is important to note that the client’s wheezing may have stopped due to a number of factors, such as the administration of medications, the passage of time, and the client’s own body’s ability to heal. However, it is important to continue to monitor the client’s respiratory status closely, as the client is still at risk for respiratory complications.

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Best First Action for Client with Respiratory Difficulty Due to Neck Dressing

Nurse’s Best First Action

The nurse’s best first action for a client with respiratory difficulty due to a neck dressing is to assess the airway. This can be done by checking the client’s respiratory rate, depth, and effort. The nurse should also listen to the client’s breath sounds and look for any signs of airway obstruction, such as stridor or wheezing.

If the airway is compromised, the nurse should take steps to open the airway, such as:

  • Loosening the neck dressing: The nurse should loosen the neck dressing to relieve pressure on the airway.
  • Positioning the client: The nurse should position the client in a sitting position with their chin tilted forward to open the airway.
  • Administering oxygen: The nurse may need to administer oxygen to the client to help them breathe.

If the airway is not compromised, the nurse should monitor the client’s respiratory status closely. The nurse should also loosen the neck dressing to relieve pressure and improve circulation.

Other Nursing Interventions

In addition to assessing the airway and loosening the neck dressing, the nurse may also need to implement other nursing interventions, such as:

  • Administering medications: The nurse may need to administer medications to the client to help them breathe, such as bronchodilators or corticosteroids.
  • Providing emotional support: The client may feel anxious or scared due to their respiratory difficulty. The nurse should provide emotional support and reassurance to the client and their family.

Conclusion

The nurse’s best first action for a client with respiratory difficulty due to a neck dressing is to assess the airway. If the airway is compromised, the nurse should take steps to open the airway. If the airway is not compromised, the nurse should monitor the client’s respiratory status closely and loosen the neck dressing. The nurse may also need to implement other nursing interventions, such as administering medications or providing emotional support.

Additional Information

It is important to note that the client’s respiratory difficulty may be due to a number of factors, such as the type of neck dressing, the severity of the injury, and the client’s underlying medical conditions. The nurse should work with the healthcare team to identify the cause of the client’s respiratory difficulty and develop a treatment plan.

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Fluid Resuscitation for Burn Patients in the Emergent Phase: Type of Fluid and Administration

Type of Fluid for Fluid Resuscitation in the Emergent Phase of Burn Recovery

The type of fluid that is typically used for fluid resuscitation in the emergent phase of burn recovery is lactated Ringer’s solution. Lactated Ringer’s solution is a crystalloid solution that contains electrolytes, including sodium, potassium, chloride, and lactate. It is also isotonic, meaning that it has the same osmolality as blood.

Why is Lactated Ringer’s Solution the Preferred Fluid for Fluid Resuscitation in Burn Patients?

Lactated Ringer’s solution is the preferred fluid for fluid resuscitation in burn patients because it:

  • Isotonic, meaning that it will not cause fluid shifts into or out of the cells
  • Contains electrolytes that are lost in burn injuries
  • Has a pH that is close to the pH of blood
  • Is relatively inexpensive and readily available

Administration of Fluid Resuscitation

Fluid resuscitation in burn patients is typically administered intravenously (IV). The amount of fluid that is administered depends on the severity of the burn injury and the patient’s individual needs. However, a general rule of thumb is to administer 4 mL of fluid per kilogram of body weight per percentage of total body surface area (TBSA) burned.

For example: A 70 kg patient with a 20% TBSA burn would receive 4 mL/kg/TBSA burned * 70 kg * 20% TBSA burned = 560 mL of fluid in the first 24 hours.

Conclusion

Lactated Ringer’s solution is the preferred fluid for fluid resuscitation in burn patients in the emergent phase of recovery. It is isotonic, contains electrolytes that are lost in burn injuries, has a pH that is close to the pH of blood, and is relatively inexpensive and readily available. Fluid resuscitation is typically administered intravenously, and the amount of fluid that is administered depends on the severity of the burn injury and the patient’s individual needs.

Additional Information

It is important to monitor the patient closely during fluid resuscitation to prevent complications such as fluid overload and electrolyte imbalances. The nurse should also monitor the patient’s vital signs, urine output, and mental status.

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Additional Laboratory Test for African American Burn Patients: G6PD Activity

Additional Laboratory Test for African American Burn Patients

In addition to the standard laboratory tests that are performed on all burn patients, African American burn patients should also have their G6PD activity tested. G6PD activity is a measure of the activity of the enzyme glucose-6-phosphate dehydrogenase (G6PD). G6PD deficiency is a genetic disorder that can make people more susceptible to hemolytic anemia, a condition in which the red blood cells are destroyed prematurely.

Why is G6PD Activity Important in African American Burn Patients?

African Americans are more likely than people of other races to have G6PD deficiency. G6PD deficiency can be triggered by a number of factors, including infection, certain medications, and stress. Burn injury is a major stressor that can trigger G6PD deficiency in susceptible individuals.

Hemolytic Anemia in Burn Patients

Hemolytic anemia can be a serious complication in burn patients. Burn patients are already at risk for anemia due to blood loss and fluid shifts. Hemolytic anemia can worsen anemia and make it more difficult for the body to heal from the burn injury.

Conclusion

African American burn patients should have their G6PD activity tested to screen for G6PD deficiency. If a burn patient is found to have G6PD deficiency, the healthcare team can take steps to prevent hemolytic anemia, such as avoiding certain medications and providing supportive care.

Additional Information

If you or someone you know is an African American burn patient, it is important to talk to your doctor or nurse about the importance of G6PD testing.

Hemolytic Anemia Prevention Strategies for African American Burn Patients

In addition to having their G6PD activity tested, there are a number of things that African American burn patients can do to prevent hemolytic anemia, such as:

  • Avoiding certain medications, such as aspirin and ibuprofen
  • Staying hydrated
  • Eating a healthy diet
  • Getting enough rest

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