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
What finding should the nurse report to the provider prior to surgery for the fasciotomy?
a) Cool and pale right foot, inability to palpate pedal pulse, and tingling in the right foot
b) Capillary refill of 1 second and pedal pulse of +2 in the right extremity
c) Adolescent reporting pain as 0 on a scale of 0 to 10 after surgery
d) Awaiting the provider's response regarding compartment syndrome assessment findings.

Answer 1

The nurse should report the findings of a cool and pale right foot, inability to palpate pedal pulse, and tingling in the right foot to the provider, as these symptoms indicate possible compartment syndrome.

Step-by-step explanation:

The nurse should report to the provider the findings of a cool and pale right foot, inability to palpate pedal pulse, and tingling in the right foot. These symptoms indicate possible compartment syndrome, which is a serious condition that occurs when increased pressure within a closed space (such as a muscle compartment) compromises circulation and nerve function. Prompt surgical intervention with a fasciotomy is necessary to relieve the pressure and restore blood flow.