The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
A. Increased blood pressure
B. Increased hematocrit levels
C. Decreased heart rate
D. Increased urine output
Correct Answer: B. Increased hematocrit levels
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours following the injury. During this phase, there is an elevation of the hematocrit levels due to hemoconcentration from the large fluid shifts
Option A: Blood pressure is decreased due to the shifting of fluids. The acute phase of burns is defined as a period extending from the onset of burns with shock to the time taken for wound epithelialization which normally takes about 12 to 14 days if the management of burns is adequate. The first 48 is the period of shock.
Option C: Pulse rate is higher than normal. If resuscitation is carried out urgently the circulatory shock is not only prevented, none of the complications of shock are allowed to manifest.
Option D: Initially, blood is shunted away from the kidneys, resulting in low urine output. The greatest amount of fluid loss in burn patients is in the first 24 h after injury. For the first 8-12 hours, there is a general shift of fluids from intravascular to interstitial fluid compartments. This means that any fluid given during this time will rapidly leak out from the intravascular compartment.
No comments:
Post a Comment