Priority Assessment Data
The priority assessment data to obtain from a client with an electrical injury and entrance site on the left hand and exit site on the left foot on admission are:
- Airway: Assess the client’s airway for patency and signs of respiratory distress. Electrical injuries can cause airway compromise due to laryngeal edema, bronchospasm, and respiratory muscle paralysis.
- Breathing: Assess the client’s respiratory rate, depth, and effort. Listen to the client’s breath sounds for any abnormalities, such as wheezing, stridor, or crackles.
- Circulation: Assess the client’s heart rate, rhythm, and blood pressure. Check the client’s peripheral pulses for strength and symmetry. Electrical injuries can cause cardiac arrhythmias, hypotension, and hypovolemic shock.
- Disability: Assess the client’s level of consciousness and orientation. Also assess the client’s neurological function, including motor strength, sensation, and reflexes. Electrical injuries can cause central nervous system damage, peripheral nerve damage, and muscle paralysis.
- Exposure: Inspect the client’s skin for burns, entry and exit wounds, and other signs of injury. Electrical injuries can cause electrical burns, which are deep burns that can damage the underlying tissues.
Other Important Assessment Data
In addition to the priority assessment data, the nurse should also obtain the following information from the client:
- History of the injury: The nurse should ask the client how the electrical injury occurred, including the type of current, voltage, and amperage. The nurse should also ask the client if they lost consciousness or had any seizures.
- Medical history: The nurse should ask the client about any underlying medical conditions, such as heart disease, lung disease, or diabetes. The nurse should also ask the client about any medications they are taking.
- Social history: The nurse should ask the client about their occupation, hobbies, and lifestyle. The nurse should also ask the client about their social support system.
Electrical injuries can cause a variety of serious complications, including airway compromise, respiratory distress, cardiac arrhythmias, hypotension, hypovolemic shock, central nervous system damage, peripheral nerve damage, muscle paralysis, and electrical burns. It is important for the nurse to obtain the priority assessment data and other important information from the client on admission to identify and manage any potential complications.