A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician because this patient might be developing:
1. Compartment syndrome
2. Inability to perform ADLs
3. Nosocomial infection
4. A deep vein thrombosis
1
Rationale 1: Circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels.
Rationale 2: The ability to perform ADLs would likely not differ based on the location of the burn.
Rationale 3: All hospitalized patients experiencing burns are at risk for nosocomial infections.
Rationale 4: The symptoms of a deep vein thrombosis are more likely to be swelling, warmth, and pain in the extremity.
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