PNE 105 Clinical Vsims Marilyn Hughes (Fracture arm/leg)

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

Motor weakness. Rationale: Motor weakness may occur as a late sign of nerve ischemia. Unrelenting pain and a burning sensation are early signs. A sluggish capillary refill indicates early there is decreased blood perfusion.

What assessment findings observed by the nurse would demonstrate poor vascular perfusion to a splinted extremity? (Select all that apply.) Pale foot Decreased pedal pulses Oxygen saturation of 93% Warm, reddened toes Blood pressure of 110/70

Decreased pedal pulses Pale foot Rationale: 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 neurovascular assessment finding would cause nurse to suspect compartment syndrome?

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

Which of the following are appropriate initial nursing interventions to control discomfort in a fractured extremity stabilized with a splint or cast? (Select all that apply.) Analgesic medication Lowering of extremity Elevation of extremity Warm compresses Intermittent cold packs

Analgesic medication Elevation of extremity Intermittent cold packs Rationale: 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 of 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. Rationale: The extremity should be elevated but no higher than heart level to maintain arterial perfusion and prevent further fluid accumulation in the compartment/affected limb.

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. Rationale: The decrease in hemoglobin would suggest bleeding. Hematocrit would also decrease. An increase in WBC count indicates infection. Bleeding and decrease in intravascular fluid volume would cause an increase in creatinine from decreased blood volume to the kidneys.

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

Early surgical fixation. Rationale: Stabilization of the fracture with surgical fixation reduces the incidence of bleeding and fat emboli. Application of ice packs assists in the 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 neurovascular assessments should be performed how frequently during the first 24 hrs following application of an immobilization device to a fractured extremity?

Every hour. Rationale: A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive range of motion due to accumulation of fluid within the compartmental space.

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. Rationale: If the initial steps of loosening the cast or splint and elevation of the limb to the level of the heart do not relieve the pressure and pain and restore circulation, then a fasciotomy may be necessary to relieve the pressure within the muscle compartment and prevent neurovascular damage.

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. Rationale: The provider must be notified immediately so appropriate treatment may be initiated and permanent damage prevented. Ms. Hughes was expressing extreme pain with no relief from recent morphine injection. This condition is an emergency because 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 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. Rationale: A hallmark sign of compartment syndrome is pain that occurs or 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. Rationale: Clinical manifestations of compartment syndrome include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. However, a hallmark sign of compartment syndrome is pain that occurs or intensifies with passive range of motion (e.g., pain intensifies with dorsiflexion of the wrist of the affected extremity).

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. Rationale: Pain will cause an increase in vital signs. Bleeding will cause a decrease in blood pressure and increase in pulse. Opioids will decrease blood pressure and respiratory rate. Hypoxemia was not present; the SpO2 was within the normal range.

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? (Select all that apply.) Pronation Paresthesia Proprioception Pallor Paralysis

Paresthesia Pallor Paralysis Rationale: The "5 Ps" indicative of symptoms of neurovascular compromise are pain, pallor, pulselessness, paresthesia, and 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. Rationale: Compartment syndrome 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.

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? (Select all that apply.) Swelling Pain Decreased hemoglobin Elevated white blood cell count Elevated temperature Redness

Swelling Pain Elevated WBC Elevated temperature Redness Rationale: The symptoms of infection include tenderness, pain, redness, swelling, local warmth, elevated temperature, increased white blood cell (WBC) count, and purulent drainage. Decreased hemoglobin is a sign of bleeding.

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. Rationale: Compartment syndrome occurs when increased pressure within a confined space compromises blood flow and low tissue perfusion occurs. Tight casts or constrictive splints are often the cause of this complication. In Ms. Hughes' case, when the splint is loosened, perfusion to the extremity is assessed as improved.

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

True. Rationale: Patients 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.