The nurse is caring for a patient admitted with thermal burns. Which of the following will the nurse need to monitor the patient for particularly during the next 2 to 3 days?
1. hypervolemia
2. pain
3. burn shock
4. continuation of the burn process below the level of obvious injury
3
Rationale: Thermal burns produce microvascular and inflammatory responses within minutes of the injury however the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state which is frequently referred to as burn shock. It is unlikely that the patient will develop hypervolemia after a thermal burn. The patient will experience pain but it will manifest sooner than 2 to 3 days after the injury. Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn.
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