Escharotomies were performed on the arms of a client because of circumferential burn injuries. The nurse's first priority assessment would be to assess the arms for:
1. Circulation in the extremity distal to the escharotomy.
2. Wound infection in the escharotomy site.
3. The extent of the client's ability to perform range-of-motion exercises.
4. The contracture formation.
Circulation in the extremity distal to the escharotomy.
Rationale: Frequent monitoring of the circulation distal to the escharotomy site is part of the ongoing nursing assessment and includes pulses, tissue color including paleness and cyanosis, sensation, increased pain, capillary refill, and decreased temperature. Often it is necessary to monitor circulation every 15 to 20 minutes. Wound infection would not occur immediately; therefore is not the first priority. Range of motion decreases as the wounds heal, not immediately. Contracture formation occurs later, as the wounds heal.
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