Nursing diagnosis: risk for deficient Fluid Volume
Risk factors may include
Loss of fluid through abnormal routes—burn wounds
Increased need—hypermetabolic state, insufficient intake
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, and moist mucous membranes.
Nursing intervention with rationale:
1. Monitor vital signs and central venous pressure (CVP). Note capillary refill and strength of peripheral pulses.
Rationale: Serves as a guide to fluid replacement needs and assesses cardiovascular response. Note: Invasive monitoring is indicated for clients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an associated increased risk of infection, necessitating careful monitoring and care of insertion site.
2. Monitor urinary output and specific gravity. Observe urine color and Hematest, as indicated.
Rationale: Generally, fluid replacement should be titrated to ensure average urinary output of 30 to 50 mL/hr in the adult. Urine can appear red to black in association with massive muscle destruction because of presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75 to 100 mL/hr to reduce risk of tubular damage and renal failure.
3. Estimate wound drainage and insensible losses.
Rationale: Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24 to 72 hours after burn injury.
4. Maintain cumulative record of amount and types of fluid intake.
Rationale: Massive or rapid replacement with different types of fluids and fluctuations in rate of administration require close tabulation to prevent constituent imbalances or fluid overload.
5. Weigh daily.
Rationale: Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15% to 20% weight gain can be anticipated in the first 72 hours during fluid replacement, with return to preburn weight approximately 10 days after burn.
6. Measure circumference of burned extremities, as indicated.
Rationale: May be helpful in estimating extent of edema and fluid shifts affecting circulating volume and urinary output.
7. Investigate changes in mentation.
Rationale: Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced cerebral perfusion.
8. Observe for gastric distention, hematemesis, and tarry stools. Hematest nasogastric (NG) drainage and stools periodically.
Rationale: Stress (Curling’s) ulcer occurs in up to half of all severely burned clients and can occur as early as the first week. Clients with burns more than 20% of TBSA are at risk for mucosal bleeding in the gastrointestinal (GI) tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.
9. Insert and maintain indwelling urinary catheter.
Rationale: Allows for close observation of renal function and prevents urinary retention. Retention of urine with its by-products of tissue-cell destruction can lead to renal dysfunction and infection.
10. Administer medications, as indicated, such as the following: Diuretics, for example, mannitol (Osmitrol)
Rationale: May be indicated to enhance urinary output and clear tubules of debris to prevent necrosis if acute renal failure (ARF) is present.