A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arteriaI blood gas (ABG) values include:

• pH 7.22
• PaCO2 68 mm Hg
• Base excess -2
• PaO2 78 mm Hg
• Oxygen saturation 80%
• Bicarbonate 28 mEq/L

Which of the following interpretations of the ABG values should the nurse make7

1. A. Measure the depth and width of the wound. Regular assessment and documentation of the wound’s size can help track the progress of healing and effectiveness of the treatment plan.

   B. Educate the client about the need for antibiotics. If an infection is present, antibiotics may be necessary. It’s important for the client to understand the purpose and proper use of these medications.

   C. Consult a nutritionist for a diet plan. Good nutrition is essential for wound healing. Certain nutrients, like protein, vitamin C, and zinc, can promote wound healing.

   D. Remove any non-viable tissue. Debridement, or the removal of dead (non-viable) tissue, can help promote the healing of the wound by reducing the risk of infection and allowing healthy tissue to grow.

A. Blood pressure:

Monitoring blood pressure is a crucial aspect of evaluating fluid resuscitation in burn patients. Adequate fluid resuscitation should help maintain stable blood pressure levels within an acceptable range. Hypotension (low blood pressure) can indicate inadequate fluid resuscitation, leading to poor tissue perfusion and organ function. On the other hand, hypertension (high blood pressure) may suggest fluid overload, which can lead to complications such as pulmonary edema. Therefore, regular monitoring of blood pressure helps assess the effectiveness of fluid resuscitation and guides adjustments in fluid administration rates.

B. Bowel sounds:

While bowel sounds are important indicators of gastrointestinal motility and function, they are not directly used to evaluate the success of fluid resuscitation in burn patients. Bowel sounds may be assessed for other reasons, such as postoperative recovery or gastrointestinal conditions, but they do not provide specific information about fluid resuscitation status or tissue perfusion.

C. Level of consciousness:

Assessing the client's level of consciousness is crucial during fluid resuscitation for burns. Changes in consciousness, such as confusion, lethargy, or altered mental status, can indicate inadequate tissue perfusion and oxygenation. A clear and responsive level of consciousness suggests adequate fluid resuscitation and perfusion to vital organs, while alterations in consciousness may prompt further evaluation and adjustment of fluid resuscitation strategies.

D. Urine output:

Monitoring urine output is a key parameter in evaluating fluid resuscitation in burn patients. Adequate urine output (0.5 to 1 mL/kg/hr in adults) indicates sufficient renal perfusion and function, suggesting effective fluid resuscitation. Decreased urine output or oliguria may indicate inadequate fluid resuscitation, renal impairment, or hypovolemia, requiring reassessment and potential adjustments in fluid administration rates or type of fluids used.

E. Platelet count:

Platelet count is an important component of the complete blood count (CBC) and is used to assess clotting function and risk of bleeding. However, platelet count is not specifically used to evaluate the success of fluid resuscitation in burn patients. While clotting parameters may be monitored in burn patients, including platelet count, they are not direct indicators of fluid resuscitation status or tissue perfusion. Other laboratory parameters, such as hemoglobin, hematocrit, electrolyte levels, and arterial blood gases, may be monitored to assess the effectiveness of fluid resuscitation.