Following a closed reduction and synthetic cast application for a fractured right tibia, a 35-year-old client is admitted to the orthopedic unit. Several hours into the shift, the client complains of a deep, relentless ache in the right calf that remains severe despite receiving a recent dose of intravenous hydromorphone. Assessment reveals a heart rate of 110 beats/min, blood pressure of 142/88 mm Hg, and sluggish capillary refill in the right toes. Which intervention must the nurse execute promptly to prevent a limb-threatening complication?
- AProp the right leg up on several pillows to maximize venous return and reduce edema.
- BInitiate a rapid intravenous fluid challenge to treat the impending signs of circulatory shock.
- Maintain the affected extremity at the level of the client's heart and alert the provider.Answer
- DObtain an arterial blood gas sample to investigate for early hypoxia associated with fat embolism.
Answer
Maintain the affected extremity at the level of the client's heart and alert the provider.
The clinical findings of deep, unrelenting pain that is out of proportion to the injury and unrelieved by opioids, combined with delayed capillary refill, strongly suggest developing compartment syndrome. This is a surgical emergency where elevated pressure within the myofascial compartment compromises circulation. The correct risk-reduction action is to immediately notify the healthcare provider and maintain the extremity at heart level. Elevating the limb above the heart is strictly contraindicated as it further reduces arterial perfusion to the compromised tissues.
Step-by-Step Solution
Key Concept
Compartment Syndrome Assessment and Positioning