The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy. Which assessment findings would best indicate that fluid resuscitation has been successful?

Question

Quizplus · Accepted Answer

After a burn injury, increased capillary permeability leads to third spacing (fluid shifts to areas where normally minimal or absent), allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues. This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn process. Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion. (Option A) Although stable vital signs (eg, systolic blood pressure ≥90 mm Hg, mean arterial pressure ≥65 mm Hg, heart rate <120/min) indicate client improvement, urine output is the greatest indicator of adequate fluid resuscitation. (Option B) A decrease in serum potassium from 5.7 mEq/L to 5.0 mEq/L (5.7 mmol/L to 5.0 mmol/L) indicates that hyperkalemia is resolving but is not an indicator of tissue perfusion. (Option D) Rapid increase in weight indicates that fluid shifts continue to occur and the kidneys are not eliminating properly. This could be a sign of fluid overload. Educational objective: Aggressive fluid resuscitation is essential to correct hypovolemia in a client with severe burns. Urine output ≥30 mL/hr or 0.5 mL/kg/hr, systolic blood pressure ≥90 mm Hg, and heart rate <120/min indicate adequate perfusion to vital organs.

The Nurse Cares for a Client Admitted with Severe Burns