Escharotomies have been performed on a patient's arms because of circumferential burn injuries. What is the nurse's highest assessment priority?

Question

1. Circulation in the extremity distal to the escharotomy
2. Formation of contractures
3. Wound infection in the escharotomy site
4. Ability to perform range-of-motion exercises

Answer 1

1
Rationale 1: Frequent monitoring of the circulation distal to the escharotomy site is part of ongoing nursing assessment and includes pulses, tissue color, sensation, increased pain, capillary refill, and decreased temperature. Often it is necessary to monitor circulation every 15 to 20 minutes.
Rationale 2: Contracture formation occurs later, as the wounds heal.
Rationale 3: Wound infection would not occur immediately; therefore, it is not the first priority.
Rationale 4: Range of motion decreases as the wounds heal, not immediately.