The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is :
a. Keeping the extremity in a dependent position
b. Active and passive range of motion every hour.
c. Preparing for an escharotomy as a prophylactic measure
d. Splinting the forearm
B
Special attention is given to circumferential (completely surrounding a body part) full thickness
burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation.
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