A triage nurse in the emergency department receives a -year-old client who was rescued from an enclosed structural fire. The client sustained deep partial-thickness and full-thickness burns to the face, anterior chest, and bilateral entire upper extremities.
The nurse assesses the following initial clinical data:
| Parameter | Value |
|---|---|
| Blood Pressure | |
| Heart Rate | |
| Respiratory Rate | |
| on room air | |
| pH | |
| Carboxyhemoglobin () |
Physical assessment reveals a hoarse voice, singed nasal hairs, and carbonaceous sputum.
Which interventions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)
- Prepare equipment for rapid sequence endotracheal intubation.Answer
- BCalculate the -hour intravenous fluid resuscitation volume starting from the time of hospital arrival.
- Initiate continuous oxygen via a tight-fitting non-rebreather mask.Answer
- DAdminister a prescribed intravenous loop diuretic if the hourly urine output falls below .
- EPlace the client in a supine position with the head of the bed flat to manage hypotension.
- Insert an indwelling urinary catheter to continuously monitor hourly urine output.Answer
Answer
The correct interventions are preparing for rapid sequence intubation, administering continuous 100% oxygen via a non-rebreather mask, and inserting an indwelling urinary catheter.
The client is exhibiting classical signs of severe inhalation injury (hoarse voice, singed nasal hairs, carbonaceous sputum, and a history of an enclosed space fire). Prophylactic rapid sequence intubation is required before profound airway edema causes complete obstruction. Furthermore, the client has carbon monoxide poisoning, indicated by a carboxyhemoglobin level of 22%. Because standard pulse oximetry cannot differentiate between oxyhemoglobin and carboxyhemoglobin, the oxygen saturation reading of 98% is falsely reassuring. The standard treatment for carbon monoxide toxicity is the immediate application of 100% oxygen via a non-rebreather mask (prior to intubation) to rapidly decrease the half-life of the carboxyhemoglobin. Lastly, aggressive fluid resuscitation is required to combat hypovolemic burn shock. An indwelling urinary catheter is essential because hourly urine output is the most reliable physiological indicator of adequate tissue perfusion and fluid resuscitation.
Step-by-Step Solution
Key Concept
Burn Shock Resuscitation and Inhalation Injury Management
Estimated Time:3m 0s