Maryland Next Gen NCLEX Test Bank Project Case Study Topic: (& standalone trend) Compartment Syndrome

Maryland Next Gen NCLEX Test Bank Project
September 1, 2022
Case Study Topic: (& standalone trend)Compartment Syndrome Author:Dawn Leukhardt, MSN, RN
College of Southern Maryland
LaPlata, Maryland
Case Summary
23-year-old female client is admitted to the Medical-Surgical unit from the Post Anesthesia Care Unit following an open reduction and internal fixation for a compound fracture of the right tibia and fibula with application of a fiberglass cast. The right lower extremity is casted from the knee down, leaving the toes exposed. The client develops neurovascular changes consistent with compartment syndrome.
Objectives 1. Identify the components of a neurovascular assessment.
2. Differentiate between acute and chronic complications related to fracture.
3. Recognize signs of neurovascular compromise related to compartment syndrome.
4. Identify changes in assessment data from trends.
5. Delegate care to the unlicensed assistive personnel appropriately.
6. Evaluate effectiveness of interventions on neurovascular status.
Case Study Link Case Study QR Code
https://umaryland.az1.qualtrics.com/jfe/form/
SV_eX9s0hwdlD6QpBI
Trend QR Code Trend Link
https://umaryland.az1.qualtrics.com/jfe/form/
SV_eIZJdMF4fvnMRPE
Case References
1.Bruner and Suddarth (2022) Textbook of Medical-Surgical Nursing 15th Edition
CJCST Version 2.2 designed by Desirée Hensel, 2022. Permission granted to use and modify template for educational purposes. Case Study Question 1 of 6 The nurse is caring for a 23-year-old female client admitted to the medical-surgical unit following surgery
for a compound fracture of the right tibia and fibula .
Nurses’ Notes
0830: Admitted from Post Anesthesia Care Unit following surgery to repair an open fracture with internal fixation with application of a fiberglass cast. R lower extremity elevated. IV infusing as ordered. Client medicated for pain prior to transport. Vital Signs BP 110/72, HR 90, RR 29, Temp 99F (37.2C).Unable to assess pedal pulse on R lower extremity due to cast. Motion of toes limited by pain and cast. Will monitor for signs of acute complications.
0930: Client resting at this time. Will continue to monitor.
1100: Client reporting pain 10/10 in R lower extremity. Updated neurovascular checks. Neurovascular Flowsheet
Right Lower ExtremityPain Score 0-10/10Motion
F = full
L = limited
N = noneSensation
F = full
P = partial
N = noneCapillary Refill
B = brisk < 3 seconds
S = sluggish > 3 secondsColor
N = normal
P = pale
D = dusky
C = cyanoticWarmth
H = hot
W = warm
T = tepid
C = coldPulse
4+ bounding
3+ increased
2+ normal
1+ weak
0 absent
UTA unable to assessTime: 08303/10LFBNWUTA
09303/10LFBNWUTA
10304/10LFBNWUTA
110010/10NNSPTUTA
Orders
0830: Admission Orders: Bedrest with right leg elevated on 2 pillows
May use bedside commode with assistance, no weight bearing to R lower extremity
Advance to Regular diet as tolerated
VS and neurovascular checks every hour for 4 hours then every 4 hours
The nurse is performing a neurovascular assessment of the right lower extremity. Which findings require immediate follow-up? Select all that apply
□Toes on the affected extremity are cool to the touch*
□Unable to palpate pedal pulses on the right leg
□Right toes have noticeable pallor compared to the left*
□Client describes absent sensation of the right lower leg*
□Capillary refill greater than 3 seconds to right toes*
□Client reports pain of 10/10 to R lower extremity*
Scoring Rule: +/-
Rationale: Primary signs of compartment syndrome include the “5 P’s,” Pain (out of proportion/not relieved with pain medication), Pallor, Pulses (diminished or absent), Paresthesia, Paralysis. Additionally, CJCST Version 2.2 designed by Desirée Hensel, 2022. Permission granted to use and modify template for educational purposes.