Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?
A) Prevent infection
B) Fluid resuscitation
C) Endotracheal tube placement
D) Strict intake and output
B
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Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
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