The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?
A. Nothing, because the findings are normal for clients during the acute phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.
Correct Answer: D. Notify the burn emergency team.
These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues.
Option A: Invasive infection is now the chief reason for death and morbidity after burn injury, with it being responsible for 51% of the deaths. The importance of prevention, surveillance, and sampling for infections in this immunocompromised group has been well established; however, there is a dearth of standard-of-care guidelines and novel approaches.
Option B: Urgent resuscitation measures are required, along with broad-spectrum antimicrobial agents, antifungals, and surgical debridement of the affected area. Specimens of this tissue must undergo histopathologic and microbiologic analysis to assist in the identification of the causative organism(s).
Option C: Assessment of the airway and oxygen saturation would not help in diagnosing a burn infection. Burn wound colonization may be diagnosed when bacteria are present at low concentrations (<105 colony-forming units [CFU]) on the wound’s surface. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.
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