Marilyn Hughes (Fracture arm/leg)

The nurse is aware that a late sign of compartment syndrome is which of the following?

Motor weakness unrelenting pain and burning sensation are early signs. A sluggish capillary refill indicates early there is decreased blood perfusion

Upon initial assessment of the patient's limb in this scenario, the nurse determines the first priority is to do which of following?

Notify provider immediately (so appropriate treatment may be initiated and permanent damage is prevented. The pt was expressing extreme pain w/ no relief from recent morphine injection. This condition is an emergency b/c the sudden decrease in blood flow in compartment syndrome can result in ischemic necrosis if prompt intervention does not occur immediately)

When monitoring for potential complications after surgery, what finding would cause the nurse to suspect that the patient is experiencing postoperative bleeding?

decrease in hemoglobin Decrease in hemoglobin would suggest bleeding. Hematocrit would also decrease. An increase in WBC could indicate infection. Bleeding and decrease in intravascular fluid volume would cause an increase in creatinine from decreased blood volume to the kidneys.

What assessment findings observed by the nurse would demonstrate poor vascular perfusion to a splinted extremity?

decreased pedal pulses pale foot Poor arterial perfusion and venous congestion would cause a decrease in pulses and cold, dusky or blue-tinged discoloration of toes. The blood pressure is within normal range. The oxygen saturation represents the oxygen bound to hemoglobin and not perfusion.

Which of the following can reduce the incidence of fat embolism and shock as complications from a bone fracture?

early surgical fixation stabilization of the fracture with surgical fixation reduces incidence of bleeding and fat emboli. (application of ice packs assists in reduction of edema. Proper nutrition enhances fracture healing. Oxygen therapy is an intervention used when respiratory compromise occurs with the complications)

The nurse understands that surgical fixation of fractures carries a risk of infection. The nurse monitors for which of the following signs and symptoms of infection?

elevated temperature elevated WBC count pain redness swelling sx of infection: tenderness, pain, redness, swelling, local warmth, elevated temperature, increased WBC, purulent drainage. (decreased hemoglobin is a sign of bleeding)

The nurse is aware that if conservative measures do not relieve pain and restore tissue perfusion, the patient will need which of the following emergency treatments to correct compartment syndrome?

fasciotomy to relieve pressure within the muscle compartment and prevent neurovascular damage

Which neurovascular assessment finding would cause nurse to suspect compartment syndrome?

numbness and/or tingling of affected extremity With continued nerve ischemia and edema, the patient experiences sensations of hypoesthesia (diminished sensation followed by complete numbness)

After assessing the patient, the nurse recognizes that the cause of compartment syndrome in the pt's case is most likely related to which of the following?

the restrictive splint dressing (increased pressure in confined space compromises blood flow and low tissue perfusion occurs. Tight casts or constrictive splints are often the cause. In this pt's case, when the splint is loosened, perfusion to the extremity is assessed as improved)

Which of the following are appropriate initial nursing interventions to control discomfort in a fractured extremity stabilized with a splint or cast?

Intermittent cold packs analgesic medication elevation of extremity Pain caused by edema can be reduced in the fractured extremity that has normal neurovascular checks by using intermittent cold packs and elevating the extremity. An analgesic medication is ordered to control pain. Warm compresses and lowering the extremity can increase edema and pain.

The nurse suspects that a patient may be developing compartment syndrome. The nurse knows that, for compartment syndrome, the limb should be maintained in which of the following positions?

at heart level the extremity should be elevated but no higher than heart level to maintain arterial perfusion and prevent further accumulation in the compartment/affected limb

The nurse understands that neurovascular assessments should be performed how frequently during the first 24 hrs following application of an immobilization device to a fractured extremity?

Every hour A major nursing concern following the application of an immobilization device is hourly assessment of the extremity during the first 24 hrs and every 1 to 4 hours thereafter to prevent neurovascular dysfunction or compromise from edema or a constricting immobilization device

T/F: the morphine administered to the pt was not effective in relieving her pain; this is a sign of potential compartment syndrome.

True Pts with compartment syndrome may complain of deep, throbbing, unrelenting pain, which continues to increase despite the administration of opioids and seems out of proportion to the injury

Vital signs received during report on the pt were BP 130/82, HR 88, RR 16. During the initial assessment, vitals were BP 150/90, HR 100, RR 20, SpO2 98%. What is the most likely cause for the elevated vitals?

pain pain increases vitals, bleeding decreases BP and increases HR, opioids decrease BP and RR.

When monitoring for potential complications in the patient with a cast, splint, or brace, the nurse recognizes which of the following is an early hallmark sign of compartment syndrome?

pain that intensifies with passive range of motion (due to accumulation of fluid within the compartmental space)

The nurse understands that which of the following is a hallmark sign of compartment syndrome?

pain that intensifies with passive range of motion clinical manifestations of compartment syndrome: dusky, pale appearance of exposed extremity, cool skin temperature, delayed capillary refill, paresthesia, unrelenting pain not relieved by position changes/ice/analgesia. (Hallmark of pain w/ passive ROM-- pain intensifies w/ dorsiflexion of wrist of the affected extremity)

The nurse understands that assessing neurovascular function in a patient with a brace, splint, or cast is vitally important. Neurovascular assessment findings that indicate neurovascular compromise include which of the following?

paralysis paresthesia pallor The "5 Ps" indicative of symptoms of neurovascular compromise are: PAIN, PALLOR, PULSELESSNESS, PARESTHESIA, PARALYSIS

The nurse is aware that compartment syndrome can occur when which of the following happens?

perfusion pressure falls below tissue pressure distal to an injury (it occurs when increased pressure within a confined space compromises blood flow and low tissue perfusion occurs. Ischemia and potentially irreversible neuromuscular damage can occur if action is not taken)