Question

A nurse is caring for an adolescent

Exhibit 1:
1400:
Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.
Exhibit 2: Vital Signs
1400:
Temperature 37° C (98.6° F)
Weight 54.5 kg (120 lb)
Heart rate 89/min
Respiratory rate 20/min
Blood pressure 124/82 mm Hg
Oxygen saturation 98% on room air
1630:
Temperature 38° C (100.4° F)
Heart rate 94/min
Respiratory rate 20/min
Blood pressure 126/84 mm Hg
Oxygen saturation 98% on room air
Exhibit 3: Provider Prescriptions
1415:
X-ray of right leg
Surgery consult
Morphine 4 mg IV every 2 hr as needed for pain.
Exhibit 4: Nurses' Notes
1430:
Adolescent transported to x-ray.
1445:
Adolescent returned from x-ray and sent to surgery.
1600:
Adolescent returned from surgery following an open reduction internal fixation of the right tibia. Adolescent is resting comfortably, parents at bedside. Capillary refill 1 second. Pedal pulse +2 Extremity cool to the touch. Adolescent rates pain as 0 on a scale of 0 to 10.
1630:
The adolescent reports pain as 10 on a scale of 0 to 10.
1700:
Adolescent still reporting pain as 10 on a scale of 0 to 10 following administration of pain medication. On assessment, right foot is cool and pale. Unable to palpate pedal pulse. Adolescent reports tingling and numbness in right foot.
​1710:
Notified provider regarding assessment findings that might indicate compartment syndrome.Awaiting provider's response.
Exhibit 5: Diagnostic Results
1445:
X-ray reveals an open fracture of the right proximal tibia.
Exhibit 6: MAR
1430:
Morphine 4 mg IV
1630:
Morphine 4 mg IV
The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
a) Pain rated as 0 on a scale of 0 to 10
b) Inability to palpate pedal pulse
c) Capillary refill of 1 second
d) Cool and pale right foot

Answer 1

The nurse must report the inability to palpate the pedal pulse prior to the fasciotomy, as it suggests possible compromised blood flow to the limb, which requires urgent medical attention.

Step-by-step explanation:

The nurse should report the finding of an inability to palpate pedal pulse to the provider prior to surgery. This is a critical sign as it may indicate a lack of adequate blood flow to the affected extremity, which is a concern especially after a procedure such as an open reduction internal fixation and can be an indicative of a potential compartment syndrome or other vascular compromise. Other worrying signs that should be noted, although not part of the multiple-choice options, include the extremity being cool and pale, the reported tingling and numbness, and the extreme pain rated as 10 despite analgesic medication. All these signs require immediate medical attention to prevent further complications.