Exhibits

On day 3, the RN consults with the provider, who places an order for an arterial blood gas and serum lactate level. The ABG results are as follows: pH 7.35, pCO2 30, pO2 74, and HCO3 20. Based upon the results, what would the RN's most appropriate action be?

Rationale:

• Initiate IV fluids: The patient is showing signs of dehydration (dry mucous membranes, decreased turgor) and a low blood pressure (96/55 mm Hg). IV fluids are essential to rehydrate and stabilize the patient’s condition.
• Prepare client for surgery: The vomiting of coffee ground emesis suggests upper gastrointestinal bleeding, and surgery may be needed if there is active bleeding or a perforated ulcer. Preparation for surgery is appropriate depending on the clinical findings.
• Initiate continuous ECG monitoring: Given the patient's history of anxiety disorder, hypokalemia and current tachycardia (heart rate of 118/min), continuous ECG monitoring is prudent to assess for any arrhythmias, especially considering the possibility of hypovolemia or other complications.
• Insert a nasogastric tube, attach to low suction: A nasogastric tube can help decompress the stomach, remove accumulated fluids, and prevent further vomiting in a patient with suspected upper gastrointestinal bleeding. It’s often used to manage bleeding or obstruction.
• Administer aspirin for abdominal pain: Aspirin is contraindicated in this scenario, as it can irritate the gastrointestinal tract and exacerbate bleeding. Given the possibility of gastrointestinal bleeding (coffee ground emesis), aspirin should not be given.
• Test stools for occult blood: While testing for occult blood is important for diagnosing gastrointestinal bleeding, this may be unnecessary immediately if the patient is already exhibiting coffee ground emesis, which strongly suggests bleeding. This test is not critical at this time.
• Administer 1 unit of packed red blood cells: The patient's hemoglobin is low (10 g/dL), indicating blood loss, which may require a transfusion to stabilize the patient. Administering blood products may be necessary to correct anemia and improve oxygen delivery.

A. Calcium 8.0 mg/dL: A calcium level of 8.0 mg/dL is slightly below the normal range but is not a strong indicator of massive cell destruction. It may be seen in a variety of conditions, including burns, but it is not as directly concerning as other findings.

B. Glucose 180 mg/dL: Elevated glucose levels can occur due to stress, such as a burn injury, and are not specifically indicative of massive cell destruction. Stress-induced hyperglycemia is common and may resolve with proper management of the burn and stress response.

C. Potassium 6.0 mg/dL: Potassium levels of 6.0 mg/dL or higher can be a strong indicator of massive cell destruction. In burn injuries, the breakdown of cells (especially muscle cells) releases intracellular potassium into the bloodstream, leading to hyperkalemia, which is life-threatening and requires immediate attention.

D. Sodium 130 mEq/L: A sodium level of 130 mEq/L indicates mild hyponatremia. While electrolyte imbalances are common in burn patients, this is not as immediately concerning as hyperkalemia and is typically addressed through fluid management.