The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

Fluid volume deficit. On the second day after severe burns, the patient is experiencing significant fluid loss through evaporation from open wounds caused by burns as well as third spacing into the tissues. Therefore, the most important patient problem to address this day is fluid volume deficit. Although the patient has respiratory failure, the patient is intubated and mechanically ventilated; this has been addressed. The paralytic ileus is a normal part of the pathophysiology of severe burns; the patient will be maintained on parenteral nutrition for quite some time. Acute pain is an important consideration for nursing care; however, complications from fluid volume deficit can lead to death if not appropriately managed.

The nurse is planning care for a patient who sustained third degr...

Category: Physiological Adaptation
Difficulty: 9

Topics: Acid-Base Assessment Cardiovascular Communication & Documentation Delegation, Prioritization and Leadership Fluid and Electrolytes Gastrointestinal Inflammation Respiratory Tissue Integrity

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