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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who sustained deep partial-thickness and full-thickness burns over 45% of their total body surface area (TBSA) 8 hours ago. Based on the physiological adaptations occurring during this emergent (resuscitative) phase, which of the following assessment findings should the nurse expect? Select all that apply.

  1. Hematocrit of 56%Answer
  2. Serum potassium of 6.2 mEq/LAnswer
  3. Heart rate of 118 beats per minuteAnswer
  4. D
    Arterial blood gas pH of 7.47
  5. E
    Widened pulse pressure

Answer

The expected findings during the emergent phase of a severe burn are an elevated hematocrit, hyperkalemia, and tachycardia.
In the emergent phase of a severe burn, increased capillary permeability causes fluid to leak into the interstitial space. This leads to intravascular volume depletion, manifesting as hemoconcentration (elevated hematocrit) and compensatory tachycardia. Additionally, the destruction of cells releases large amounts of intracellular potassium into the bloodstream, causing hyperkalemia.

Step-by-Step Solution

1
Analyze the pathophysiology of the emergent (resuscitative) phase of a major burn injury, which occurs in the first 24 to 72 hours.
Identify that this phase is characterized by a massive shift of fluids out of the intravascular space into the interstitial space, along with extensive cellular destruction.
Understanding the underlying fluid and electrolyte shifts is necessary to predict the expected clinical findings.
2
Evaluate each option against the expected physiological adaptations of burn shock.
Determine that intravascular fluid loss leads to hemoconcentration (elevated hematocrit), compensatory tachycardia, and a narrowing pulse pressure, while cell damage releases potassium (hyperkalemia). Tissue hypoxia leads to metabolic acidosis, not alkalosis.
This process systematically eliminates incorrect expectations and confirms the expected compensatory mechanisms and lab values.

Key Concept

During the emergent phase of severe burn injuries, physiological adaptations include massive third-spacing of fluid causing hemoconcentration and hypovolemic shock, cellular destruction causing hyperkalemia, and tissue hypoxia causing metabolic acidosis.
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Topics

Physiological Adaptation

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