Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?

• A. Normal sensation in the involved limb.
• B. Warm, pink skin distal to burn.
• C. Rapid capillary refill and strong distal pulses.
• D. Slow capillary refill in the digits with absent distal pulse points.

Answer: (D)

When a burn fully encircles a limb, swelling inside a nonelastic eschar can raise tissue pressure and squeeze blood flow, risking vascular compromise. The most concerning finding is evidence of reduced distal perfusion: slow capillary refill in the digits with absent distal pulse points. This combination indicates the circulation to the hand or foot is severely threatened and needs prompt assessment and potential intervention (such as releasing constrictive tissue or surgical means) to prevent ischemia. By contrast, normal sensation, warm pink skin distal to the burn, or rapid capillary refill with strong pulses show preserved perfusion and do not signal an urgent need for intervention.

When a burn fully encircles a limb, swelling inside a nonelastic eschar can raise tissue pressure and squeeze blood flow, risking vascular compromise. The most concerning finding is evidence of reduced distal perfusion: slow capillary refill in the digits with absent distal pulse points. This combination indicates the circulation to the hand or foot is severely threatened and needs prompt assessment and potential intervention (such as releasing constrictive tissue or surgical means) to prevent ischemia. By contrast, normal sensation, warm pink skin distal to the burn, or rapid capillary refill with strong pulses show preserved perfusion and do not signal an urgent need for intervention.