The nurse is handling a client who sustained an electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure, the nurse should assess the affected extremity in which of the following?
A. Sensation
B. Color
C. Distal circulation
D. All of the above
Correct Answer: D. All of the above
Following fasciotomy, the nurse should assess pulses, color, sensation, and movement of the affected extremity as well as bleeding. A fasciotomy is an emergency procedure used to treat acute compartment syndrome. Acute compartment syndrome often follows high energy trauma, fractures, circumferential burns, crush injuries, or even a tight plaster cast.
Option A: Loss of sensation can signal compartment syndrome. Classical features of compartment syndrome are those of ischemia, pain out of proportion to the injury, paraesthesia, pallor, paralysis, and pain on passive movement, especially stretch of the concerned compartment.
Option B: Pallor is associated with compartment syndrome. Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achievable by primary wound closure, secondary wound healing, or as needed in approximately 50% of wounds split-thickness skin grafting.
Option C: Distal circulation should be checked to prevent ischemia. Two-point discrimination can be useful for determining nerve ischemia. These signs and symptoms can be challenging to assess depending on the conscious level, sensory state, and ability to communicate.
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