The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse’s best action?
A. Continuing to monitor the client
B. Increasing the temperature in the room
C. Increasing the rate of the intravenous fluids
D. Preparing to do a workup for sepsis
Correct Answer: D. Preparing to do a workup for sepsis.
These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started.
Option A: Continuing just to monitor the situation can lead to septic shock. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.
Option B: Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation.
Option C: Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on the extent of injury, amount of urinary output, and weight.
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