After assessing an older adult client with a burn wound, the nurse documents the findings as follows:

Question

Vital Signs
Laboratory Results
Wound Assessment
Heart rate: 110 beats/min
Blood pressure: 112/68 mm Hg
Respiratory rate: 20 breaths/min
Oxygen saturation: 94%
Pain: 3/10
Red blood cell count: 5,000,000/mm3
White blood cell count: 10,000/mm3
Platelet count: 200,000/mm3
Left chest burn wound, 3 cm × 2.5 cm × 0.5 cm, wound bed pale, surrounding tissues with edema present
Based on the documented data, which action should the nurse take next?
a.
Assess the client's skin for signs of adequate perfusion.
b.
Calculate intake and output ratio for the last 24 hours.
c.
Prepare to obtain blood and wound cultures.
d.
Place the client in an isolation room.

Answer 1

ANS: C
Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.