A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
Correct Answer: A. Start intravenous fluids.
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Administration of fluids can treat this problem. For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour.
Option C: Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. A CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately.
Option B: Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action. Carefully check pulses in any extremity with circumferential burns. These burns can act as tourniquets as burn-associated edema begins, leading to compartment syndrome.
Option D: In patients with extensive burns, it is sometimes a challenge to monitor the ECG, because the lack of natural skin and application of protective ointments prevent the adherence of the ECG discs.
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