When monitoring initial fluid replacement for the patient with 40 TBSA deep

When monitoring initial fluid replacement for the

This preview shows page 24 - 26 out of 28 pages.

When monitoring initial fluid replacement forthe patient with 40% TBSA deep partial-thickness and full-thickness burns, which findingis of most concern to the nurse? a) Serum K+ of 4.5 mEq/L b) Urine output of 35 mL/hr c) Decreased bowel sounds d) Blood pressure of 86/72 mm Hgd Rationale: Adequacy of fluid replacement isassessed by urine output and cardiac parameters.Urine output should be 0.5 to 1 mL/kg/hr. Meanarterial pressure should be >65 mm Hg, systolic BP>90 mm Hg, and heart rate <120 beats/min. A bloodpressure of 86/72 indicates inadequate fluidreplacement. However, the MAP is calculated at 77mm Hg.
Image of page 24
During the emergent phase of burn injury, the nurseassesses for the presence of hypovolemia. In burnpatients, hypovolemia occurs primarily as a result of d. Capillary permeability with fluid shift to theinterstitium. d A patient is to undergo skin grafting with the use of culturedepithelial autografts full-thickness burns. The nurse explains tothe patient that this treatment involves When assessing a patient who spilled hot oil on theright leg and foot, the nurse notes that the skin is dry,pale, hard skin. The patient states that the burn is notpainful. What term would the nurse use to documentthe burn depth?
Image of page 25
Image of page 26

You've reached the end of your free preview.

Want to read all 28 pages?

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture