Final answer:
A nurse should monitor the limb in 90-90 traction for signs of compartment syndrome, which include pain, pressure, pallor, paresthesia, paralysis, and pulselessness. Regular checks for changes in circulation, sensation, and movement can facilitate early detection.
Step-by-step explanation:
Assessment for Compartment Syndrome in 90-90 Traction
The nurse should assess for signs of compartment syndrome in the limb that is in traction, which in the case of 90-90 traction, is usually the lower limb. Compartment syndrome is a condition where there is increased pressure within a confined space in the body, typically the muscular compartments of the limb. This increased pressure can compromise circulation and cause damage to the muscles and nerves. The nurse should monitor for six primary symptoms, often referred to as the "six P's": pain, pressure, pallor (paleness), paresthesia (tingling), paralysis, and pulselessness.
Regular monitoring of the circulation, sensation, and movement of the toes or fingers of the affected limb is essential. Checking the capillary refill, the warmth of the skin, and the patient’s report of increasing pain or changes in sensation can help in the early detection of compartment syndrome. It is crucial to identify and address compartment syndrome early, as it is a surgical emergency that requires immediate intervention to prevent permanent damage.