Soft Tissue Trauma and Compartment Syndrome

When caring for a patient with a right leg fracture, the patient reports pain not relieved by analgesic and tingling of the toes. The nurse also notes diminished pedal pulses and swelling above the dressing. Which action should the nurse take?Loosen the dressing Maintain the traction weight Prepare for emergency decompression .Immediately inform the health care provider

Loosen the dressing Diminished pulses and swelling indicates vascular constriction. The nurse should loosen the dressing to reduce the risk of compartment syndrome.

Which signs and symptoms would the nurse find in a patient with compartment syndrome?Erythema Erythema, or redness, is seen with tissue injury, not with compartment syndrome.1+ pulses Warmth at the affected site Pain not relieved by morphineTingling sensation of the fingers

1+ pulses Diminished pulses are seen with compartment syndrome as a result of edema and vascular constriction.Pain not relieved by morphine Pain that is not relieved by analgesic drug and out of proportion to the injury is an early sign of compartment syndrome, which may occur as a result of ischemia to the extremity.Tingling sensation of the fingers Tingling sensations, or paresthesia, are a sign of compartment syndrome resulting from the destruction of muscle and nerve cells.

Which injuries are susceptible to compartment syndrome?Fractured rib Orbital fracture Upper arm fracture Basilar skull fracture Third-degree ankle strain

Upper arm fracture The structure of the upper arm, which is divided into compartments, increases the risk for compartment syndrome with injury.Third-degree ankle strain A third-degree ankle strain would lead to severe lower leg swelling, which increases the risk for compartment syndrome.

A patient with an upper arm fracture is diagnosed with compartment syndrome. After the health care provider cuts the cast, the nurse notes continued swelling, absent radial pulse, pallor, and cool skin. Which initial action should the nurse take?Begin preoperative checklist Raise the fractured arm above the head Obtain samples for urinalysis and serum creatinine Continue doing the neurovascular examination until patient is stable

Begin preoperative checklist Because the patient's condition has not improved with removal of the cast, surgical decompression is necessary. The nurse should initiate the preoperative checklist to prepare the patient for surgery.

While caring for a patient after a third-degree ankle sprain, the nurse notes the patient can bear weight on the affected foot without discomfort. Which actions would the nurse consider?Teach strengthening exercises for the ankle Assess neurovascular status of affected extremityTeach patient to continue applying ice packs at home Check X-ray finding with the patient to see if there is no fracture Perform passive range-of-motion (ROM) exercises on the affected foot

Teach strengthening exercises for the ankle Decreased function can lead to muscle atrophy. The nurse should teach the patient about exercises to regain strength and promote mobility.Assess neurovascular status of affected extremity A third-degree sprain can lead to severe swelling, which increases the risk for compartment syndrome. The nurse should assess the neurovascular status to ensure adequate tissue perfusion.

Which manifestation can be seen in a patient with a third-degree back strain?Mild edema Pain and pallor Active bleeding Complete loss of function

Complete loss of function Complete loss of function would be expected in a third-degree strain because there is a severely torn or ruptured muscle.

A patient presents with bilateral leg pain, abdominal pain, and difficulty breathing after a motor vehicle accident. The nurse notes obvious deformities to the bilateral lower legs, bruising to the chest, and abrasions on the chest, abdomen, and arms. Which actions should the nurse perform while assessing the severity of the patient's injuries?Auscultate lung sounds Assess peripheral pulses Assess capillary refill time Start intravenous (IV) infusion with dextrose in 5% water Prepare patient for computed tomography (CT) scan

Auscultate lung sounds Bruising to the chest and difficulty breathing may indicate potential lung damage. The nurse should assess the lung sounds to identify any abnormalities.Assess peripheral pulses Deformities to the lower legs would indicate the possibility for impaired tissue perfusion. The nurse should palpate the bilateral pedal pulses to check any discrepancies.Assess capillary refill time The nurse should assess any patient with a soft tissue injury for capillary refill, because a result greater than 2 seconds can indicate neurovascular dysfunction.