Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?
A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.
Correct Answer: B. Document the finding as the only action.
Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.
Option A: The glucose level is not high enough to alert the emergency team. A variety of laboratory tests will be needed within the first 24 hours of a patient’s admission (some during the initial resuscitative period and others after the patient is stabilized).
Option C: A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The secondary assessment shouldn’t begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed.
Option D: Infusion of an IV fluid containing dextrose may further increase the client’s blood glucose. The ideal burn resuscitation is the one that effectively restores plasma volume, with no adverse effects. Isotonic crystalloids, hypertonic solutions, and colloids have been used for this purpose, but every solution has its advantages and disadvantages. None of them is ideal, and none is superior to any of the others.
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