The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

Frequent radial pulse checks. At 96 hours, the patient with burns is past the acute phase. Eschar formation that hardens may lead to compartment syndrome that damages tissue and leads to the loss of limbs. Performing frequent radial pulse checks will allow the nurse to monitor circulation and determine if intervention is necessary. Although strict aseptic technique is required to prevent infection (which can lead to loss of limb) unnoticed loss of circulation will lead to compartment syndrome. Aggressive fluid resuscitation and hourly intake and output measurements will prevent shock and death in the acute phase.

The patient sustained third degree burns to the entirety of bilat...

Category: Reduction of Risk Potential
Difficulty: 9

Topics: Assessment Cardiovascular Delegation, Prioritization and Leadership Inflammation Tissue Integrity

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