Which nursing intervention is a priority for the patient in traction to ensure the therapy is effective?

Compartment syndrome is a serious condition characterized by inflammation and increased pressure within a muscle compartment (muscles, nerves, and vessels within the fascia). While this condition occurs mostly in the lower extremities, it can develop in any muscle group. 

This condition may be caused by decreased compartment size due to restrictive dressings or casts, excessive traction, or due to edema, inflammation, or bleeding within the compartment.

The inflammatory process can create high pressure in the muscle compartment causing circulatory obstruction and venous occlusion. Ischemia along with muscle and nerve damage will start to occur, reducing oxygenation and causing tissue death.

Delays in the diagnosis and treatment of this condition can cause irreversible damage to muscles and nerves and loss of function of the affected muscle compartment. 

Compartment syndrome can occur immediately due to the body’s initial inflammatory response following an injury or it may be delayed, occurring several days after an injury.  Signs and symptoms of this condition include:

• Pain – Severe pain not relieved by analgesics
• Pressure – characterized as increasing within the muscle compartment
• Paresthesia – numbness or tingling sensation
• Pallor – loss of normal color of the affected body part
• Paralysis – loss of function of the affected extremity
• Pulselessness – decreased or absent peripheral pulses 

This condition may be categorized as acute or chronic. Acute compartment syndrome is considered a surgical emergency and must be treated right away to prevent muscle and nerve damage. Chronic compartment syndrome, on the other hand, happens gradually following repetitive muscle use and resolves after stopping the activity. 

A physical exam, compartment pressure measurement testing, magnetic resonance imaging (MRI), and X-ray can help diagnose compartment syndrome.

The Nursing Process

Since compartment syndrome can lead to poor outcomes and high morbidity, prompt diagnosis and treatment are critical. Early detection and effective treatment of this condition can prevent loss of function and permanent damage to the muscles and nerves. 

Proper assessment is essential for the prompt treatment of compartment syndrome. This condition may occur after the application of a cast or pressure dressing that may impede circulation. The nurse must quickly identify signs and symptoms that are consistent with this condition. Additionally, frequent neurovascular assessments are necessary to monitor progression. 

The nurse is also responsible for administering medications, assisting in fasciotomy, and providing education about the condition, treatment, and possible complications.

Nursing Care Plans Related to Compartment Syndrome

Acute Pain Care Plan

A classic sign of compartment syndrome is severe pain that worsens when the muscles are stretched and is not relieved by analgesia. Accurate evaluation and prompt treatment enable timely intervention and prevent complications for patients suffering from compartment syndrome.

Nursing Diagnosis: Acute Pain

Related to:

• Inflammatory process
• Bleeding within the compartment

As evidenced by:

• Reports of severe, unrelieved pain 
• Guarding behavior
• Facial mask of pain/grimace
• Diaphoresis
• Crying and restlessness
• Tachycardia, hypertension, tachypnea

Expected Outcomes:

• The patient will verbalize pain decreased with prescribed medications
• The patient will display vital signs within normal limits

Acute Pain Assessment

1. Assess and monitor the patient’s vital signs.
Assessment of vital signs is essential to help monitor a patient’s inpatient progress. Increases in blood pressure, pulse, and respirations occur when pain is not controlled.

2. Assess the patient’s pain characteristics.
Pain can be managed and treated effectively once an accurate pain assessment is conducted. It is important to assess the extent of the pain, its characteristics, location, and onset. Pain that is out of proportion to the patient’s level of injury and unrelieved with the use of analgesics is considered a sign of compartment syndrome.

Acute Pain Interventions

1. Evaluate the onset of the pain.
In compartment syndrome, it is essential to determine whether the condition is acute or chronic so proper interventions and treatment can be initiated.

2. Continuously monitor the patient’s condition along with the emerging signs and symptoms.
Consider other signs of discomfort such as tightness, numbness, or tingling that signal compartment syndrome.

3. Administer pain medications as indicated and evaluate pain score 30 minutes to an hour following administration.
Monitoring the effects of pharmacologic interventions can help determine the effectiveness of the medication. If pain is not relieved, compartment syndrome may be considered and the healthcare provider alerted.

4. Do not elevate or apply a cold compress to the affected extremity.
Elevating the affected extremity and applying a cold compress can cause vasoconstriction and may worsen the condition.

5. Prepare the patient for surgery as indicated.
Acute compartment syndrome may require immediate fasciotomy (incision into the fascia) to relieve pressure and prevent further damage to the affected nerves and muscles. Preoperative education prepares the patient for surgery as well as what to expect after the surgery.

Ineffective Peripheral Tissue Perfusion Care Plan 

Ineffective tissue perfusion occurs in compartment syndrome due to increased pressure following an injury, compromising circulation and neuromuscular function. If left untreated, this can cause necrosis to the affected tissues, nerves, and muscles.

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to:

• Decreased peripheral blood flow to the affected body parts
• Inflammatory process 

As evidenced by:

• Absence of or decreased peripheral pulses 
• Altered motor function or paralysis
• Altered skin temperature or pallor
• Inflammation or edema
• Severe pain 
• Paresthesia or numbness 

Expected Outcomes:

• The patient will be able to achieve optimum tissue perfusion in the affected tissues as evidenced by palpable and strong pulses, reduced pain, and regained limb strength. 
• The patient will not experience loss of limb or muscle function

Ineffective Peripheral Tissue Perfusion Assessment

1. Assess and monitor for compartment syndrome after surgery.
Casts and pressure bandages can block circulation following fractures or surgery. The nurse can monitor for this complication by regularly assessing the patient’s feelings of pain, tingling, or tightness.

2. Perform neurovascular assessments frequently.
It is essential to monitor and assess the patient’s neurovascular status following surgery or cast application. The nurse should perform regular assessments of skin color, temperature, and pulse strength.

Ineffective Peripheral Tissue Perfusion Interventions

1. Prepare the patient for surgery as indicated.
Fasciotomy is a surgical procedure that helps relieve pressure and restores blood circulation in the affected area. Fasciotomy may be performed at the bedside in some instances.

2. Discuss interventions to help relieve the pressure.
Patients who have had surgery may develop compartment syndrome due to bulky dressings or tight casts. Bandages may be loosened or casts may be cut to help relieve pressure. These should be performed by the healthcare provider as alerted by the nurse.

3. Administer supplemental oxygen as needed.
Providing supplemental oxygen is essential to ensure adequate oxygenation to peripheral tissues.

4. Ensure adequate hydration through the intravenous route as indicated.
Perfusion to the affected area is significantly improved by providing adequate hydration through IV fluids.

5. Ensure that the limbs are at a neutral level and not elevated.
Elevating the affected extremity can compromise blood flow and worsen compartment syndrome.

Impaired Physical Mobility 

Impaired physical mobility is common in patients suffering from compartment syndrome. Paralysis, one of the complications of compartment syndrome, can result from prolonged nerve compression or muscle damage, rendering the patient unable to actively move limbs.

Nursing Diagnosis: Impaired Physical Mobility

Related to:

• Neuromuscular skeletal impairment or injury
• Pain/discomfort

As evidenced by:

• Expressions of discomfort when moving 
• Inability to move purposefully
• Reluctance in attempting movement
• Decreased muscle strength and control
• Decreased activity tolerance
• Limited range of motion

Expected Outcomes:

• The patient will maintain or regain mobility at the maximum possible level
• The patient will participate in PT to increase the strength or function of the affected body part

Impaired Physical Mobility Assessment

1. Assess the patient’s degree of immobility.
Compare the patient’s current mobility level to their described baseline.

2. Assess the emotional effect on physical abilities.
The loss of physical mobility can be devastating and feelings of depression, frustration, or powerlessness can further delay goals.

Impaired Physical Mobility Interventions

1. Assist with active and passive range of motion exercises as indicated.
Passive range of motion exercises can enhance blood circulation, improve muscle tone, preserve joint mobility, and prevent atrophy.

2. Develop new ways to perform ADLs.
Help the patient remain in control of the situation. They may not be able to perform ADLs as easily as they used to but assist the patient in recognizing how they can still maintain their independence.

3. Obtain assistive devices as needed.
Assistive devices like walkers, canes, wheelchairs, grab bars, trapezes, and crutches can help increase the patient’s mobility.

4. Encourage the patient to participate in diversional activities.
This will provide the opportunity to refocus attention and enhance the patient’s self-esteem and control.

5. Administer medications as indicated.
Analgesic and antispasmodic drugs can be prescribed to lessen the patient’s discomfort as it interferes with mobility.

6. Assist the patient in accepting limitations.
It is vital to let the patient accept limitations and abilities. Safety measures should be implemented to prevent further injuries.

7. Consult with physical or occupational therapists.
Rehabilitation should be implemented following treatment for compartment syndrome to prevent loss of strength and further complications.

References and Sources

1. Compartment Syndrome. Cleveland Clinic. Last reviewed by a Cleveland Clinic medical professional on 02/15/2021. https://my.clevelandclinic.org/health/diseases/15315-compartment-syndrome
2. Compartment Syndrome. OrthoInfo. Copyright ©1995-2021 by the American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases–conditions/compartment-syndrome/
3. Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
4. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
5. Pechar, J., & Lyons, M. M. (2016). Acute Compartment Syndrome of the Lower Leg: A Review. The journal for nurse practitioners: JNP, 12(4), 265–270. https://www.npjournal.org/article/S1555-4155(15)01044-2/fulltext
6. Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/

What are the nursing considerations for a patient in traction?

What is the nurse's role in maintaining effective skeletal traction?

Which one is nursing responsibility before skin traction application?

Which nursing action would have the highest priority for a client with a leg in traction quizlet?