Question

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

a. Weeping serosanguinous fluid from wounds
b. Sloughing tissue around wound edges
c. Change in the quality of peripheral pulses
d. Loss of sensation to the left lower extremity
e. Complaint of increased pain and pressure

Answer 1

Immediate nursing interventions for a patient with full thickness burns to lower extremities are required when there are changes in peripheral pulses, loss of sensation, and complaints of increased pain and pressure, as these can indicate serious complications.

Step-by-step explanation:

When caring for a client with full thickness burns to both lower extremities, certain assessment findings do warrant immediate intervention by the nurse. These findings include:

• Change in the quality of peripheral pulses: Suggests a change in circulation to the extremity which can be indicative of compartment syndrome or a loss of perfusion to the area.
• Loss of sensation to the left lower extremity: May signify nerve damage or compromised blood flow.
• Complaint of increased pain and pressure: These symptoms are also indicative of compartment syndrome, which is a medical emergency.

Weeping serosanguinous fluid from wounds and sloughing tissue around wound edges, while they require management, do not usually require immediate intervention compared to changes in pulses, sensation, and increased pain and pressure, which pose acute risks to the patient's limb and overall health.