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?

Respuesta :

Due to capillary fluid leaks and tissue swelling, extensive burns frequently need substantial quantities of intravenous fluid. In the emergent phase of clients with catastrophic injuries, hypovolemic shock is a common cause of mortality.

Burns are tetanus-prone wounds, and tetanus toxoids should be administered every five years, if not already. The objective of fluid management in large burn injuries is to preserve tissue perfusion during the early stages of burn shock, before hypovolemia develops owing to constant fluid extravasation from the intravascular compartment.

Fluids can help with this issue. An ECG and CBC will be performed to determine if these vital signs are the result of a cardiac or bleeding condition. These are not, however, activities that the nurse would perform right away. Checking pulses indicates peripheral perfusion, although this is not an instant nursing activity.

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