During a shift assessment on an orthopedic unit, a practical nurse evaluates a client with a newly applied plaster cast on the lower left leg. The client describes an intense, throbbing pain that has worsened significantly despite receiving a scheduled intravenous analgesic one hour ago. The nurse observes that the client's toes are cool to the touch and the pedal pulse is weak. While the charge nurse is notifying the healthcare provider of these findings, which action should the practical nurse implement?
- Keep the affected extremity resting flat on the bed at the level of the client's heartAnswer
- BProp the affected leg on several pillows to elevate it above the heart to alleviate swelling
- CAdminister a PRN breakthrough pain medication to address the client's primary complaint
- DAssign the unlicensed assistive personnel to perform continuous neurovascular checks
Answer
The nurse should keep the affected extremity resting flat on the bed at the level of the client's heart.
When compartment syndrome is suspected, the affected extremity must be maintained at the level of the heart. Elevating the limb above the heart decreases arterial pressure and further compromises tissue perfusion to the ischemic area. Lowering it below the heart increases venous congestion. Keeping it flat at heart level optimizes the balance of blood flow.
Step-by-Step Solution
Key Concept
Compartment Syndrome Positioning and Basic Care