The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea.
These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;