OUR LADY OF FATIMA UNIVERSITY

120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING

In Partial Fulfillment
of the Requirement
for the Clinical Duty

COMPARTMENT SYNDORME WITH SEVERE NECTROTIC TISSUE: INTERVENTION TO

IMPROVE PHYSICAL CAPABILITY OF PATIENT WITH AMBULATORY DISABILITY

Submitted to:
Ms. Maria Teres Gallenero, R.N.
Clinical Instructor

Submitted by:
Remigio, Ferdinand Santiago
Rivera, Anne Micah Las Pinas
Rivera, Patricia Mae Teston
Soria, Alyanna Marie
Santiago, Carl Adrian Delos Reyes
Tabangay, Althea Marie Dalingding
Umlas, Philip Gideon Mercado
Uy Kieng, Gwyneth Isabel Cansilao

MARCH 2023
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING

ACKNOWLEDGEMENT
We, the student nurses are first and foremost, thankful to the Almighty God for setting us up to

complete this case study.

With a sense of appreciation and pleasure, we express our heartfelt and sincere thanks to the

following people who have shown their support, advice, assistance, and encouragement for this case study.

We, the student nurse, would like to express our sincere gratitude to our Clinical Instructor, Ms.

Maria Teres Gallenero, R.N. for her guidance, support, enthusiasm, valuable feedback and encouraging

conversations throughout this case study.

We would also like to express our gratitude to our families for their unwavering moral, emotional,

and financial support.

And lastly, we would like to express our sincerest thanks to the university, Our Lady of Fatima

University and to the College of Nursing for all of the lessons, experience and for the opportunity to create

this case study.

 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
TABLE OF CONTENTS

Title Page i

Acknowledgement ii

Table of Contents iii

Case Scenario iv

Chapter 1 (INTRODUCTION)

Chapter 2 (MEDICAL RECORDS)

Patient Profile
Diagnosis
Medical History
Physical and Neurological Assessment

Chapter 3 (ANATOMY)

Chapter 4 (PATHOPHYSIOLOGY)

Chapter 5 (DRUG STUDY)

Chapter 6 (NURSING CARE PLAN)

Chapter 7 (DISCHARGE PLAN)

References
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CASE SCENARIO

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and
fibula after falling on wet grass. Patient F is transferred to the emergency department, where
the determination is made to take her to the operating room for internal fixation and subsequent
casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is
elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains
of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep.
Forty-five minutes later, she again complains of continued pain. At this point, she receives 3
mg of intravenous morphine. While reviewing the patient's chart and medication orders, the
PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a
"complainer" who is frequently seen in the emergency department or physician's office with
vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued
recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report
to the nurses on the floor, the PACU nurse relays her findings regarding the patient's
complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four
hours. She is medicated as ordered, but within one to two hours after receiving her medications
she calls the nurse for additional narcotics. She continues to complain of pain, stating that she
feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without
peripheral swelling of her leg, and peripheral pulses are present but weak.
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that
the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on
call is contacted, and the decision is made over the telephone to bivalve the patient's cast to
ensure adequate circulation. This is accomplished, and the patient appears more comfortable,
although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved
cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is
accomplished. That evening the patient again complains of pain, this time giving a score report
of 10. The physician is again contacted by telephone, and additional pain medications are
ordered. Throughout the night, the patient continues to complain of pain despite frequent doses
of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to
discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak.
She has continued complaints of pain and does not want to be discharged at this time. At this
point, the surgeon considers the possibility that the patient may be developing a case of
compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor
color. The patient is immediately taken to the operating room, where a fasciotomy was
performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue
that requires debridement. The remaining amount of muscle is minimal. The patient eventually
recovers but with severe disability in her ambulatory capabilities.
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 1
INTRODUCTION

According to the World Health Organization, "fall is defined as an event that results in a person
coming to rest inadvertently on the ground, floor, or other lower level. Globally, falls are a major
public health problem. An estimated 684 000 fatal falls occur each year, making them the second
leading cause of unintentional injury death after road traffic injuries. Over 80% of fall-related
fatalities occur in low- and middle-income countries, with regions of the Western Pacific and South
East Asia accounting for 60% of these deaths. In all regions of the world, death rates are highest
among adults over the age of 60. Approximately 37.3 million falls severe enough to require
medical attention occur each year. Prevention strategies should emphasize education, training,
creating safer environments, prioritizing fall-related research, and establishing effective policies
to reduce risk.

Patient F, a female 80-year-old who had suffered trauma due to a fall, It led to a left tibia and fibula
fracture. She underwent an orthopedic surgery, and after the surgery she was put into a cast to fix
the said injury, but while she is in the cast, she is complaining of this burning sensation on her left
leg and pain reaching 9/10 on the pain scale. The doctors then checked into it and declared it to be
removed due to it being too tight and making the patient suffer compartment syndrome, which can
only be fully recovered from by doing a fasciotomy. Upon opening, they discovered extensive
necrotic tissue, where she underwent eventually a debridement. Now, the patient suffers a severe
disability in ambulatory capabilities.

As a healthcare provider, provide patient-family health teaching that focuses on sensory

information, avoids giving excessive information, and initiates a visiting nurse referral for
necessary follow-up teaching of skilled needs. It includes verbal and written information about the
following: Administration of medication that will reduce the patient's pain is needed. For example,
the administration of analgesics helps by reducing the inflammation at the site of the pain or
swelling. Exercise is also important to prevent the joints from numbing, restore the motion of the
joints, and reduce unnecessary muscle tension. Besides exercise and medication, treatment is also
important to prevent future complications. With the help of non-pharmacological treatments,
future complications can be prevented or at the very least lessened. Health education can help the
patient improve individually throughout the recovery phase by teaching the patient how to use
assistive devices. The patient's increased independence will increase the patient's diet, which is
also important because the foods we eat will influence our recovery. For example, by eating
protein, our body will produce new blood cells to help us recover faster and close up open wounds.
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 2
MEDICAL RECORDS

PATIENT PROFILE
Client’s Name: Patient F
Client’s Age: 47 y.o
Sex: F

DIAGNOSIS
Comminuted fracture in left tibia and fibula

HISTORY OF PAST ILLNESS

The client may develop a tolerance to some drugs over time. A tolerance develops when a
person has been regularly taking a drug and their body begins to adapt itself to the presence of the
chemicals in the drug. While reviewing the patient's chart and medication orders, the PACU nurse
discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is
frequently seen in the emergency department or physician's office with vague complaints of pain and
requests for refills of her narcotics.

STATE OF PRESENT ILLNESS

Patient has a sustained comminuted fracture of left tibia and fibulas after falling on wet grass.
She then underwent internal fixation and subsequent casting. After surgery, Patient numerously
complains of pain and is labelled a “complainer” who is frequently seen in the emergency department
with vague complaints of pain and requests for refill of narcotics. Client continuously complains of
pain even after receiving medications and expressing a burning sensation in her left leg. The patient
may be developing a case of compartment syndrome Upon opening the compartment, it is noted that there
is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The
patient eventually recovers but with severe disability in her ambulatory capabilities.
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
NEUROLOGICAL ASSESSMENT

CRANIAL NERVE NORMAL FINDINGS ACTUAL FINDINGS RESULT

I. OLFACTORY Clients are able to Client was able to describe different smell. NORMAL
identify different smells
with each nostril
separately and with eyes
closed unless such
conditions like colds are
present.

II. OPTIC Client is able to read Client was able to read with each eye and NORMAL
with each eye and both both eyes.
eyes.

III. OCULOMOTOR Client pupil size and Pupils are equally round and reactive to NORMAL
shape must asymmetry light and accommodation.
and pupil are able to
react in light and
accommodation.

IV. TROCHLEAR Client’s eye follows the Both eyes are able to move as necessary. NORMAL
hand of the health
provider as it moves.

V. TRIGEMINAL Client has the ability to Client was able to chew, sensitive to pain NORMAL
chew and the strength to stimuli and distinguish soft from hard.
bite. Should be able to
respond to light and deep
sensation and able to
differentiate soft from
hard.

VI. ABDUCENS Both eyes coordinate, Both eyes move in coordination. NORMAL
move in unison with
parallel alignment.

VII. FACIAL Client is able to smile, Clients performed various facial NORMAL
raise eyebrows, and puff expressions without any difficulty and
out cheeks and close were able to distinguish varied tastes.
eyes without any
difficulty. And can also
distinguish taste.
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COLLEGE OF NURSING
VIII. VESTIBULOCOCHLEAR Clients should be able to Client was able to hear the words and felt NORMAL
hear the spoken words vibration as the tuning fork placed.
through whisper test.

Should feel the vibration

when the weber test is
done.

IX. GLOSSOPHARYNGEAL Clients are able to move Client was able to move their tongue in NORMAL
their tongue in different different directions and elicit gag reflex.
directions and elicits gag
reflex.

X. VAGUS Client is able to swallow Client was able to swallow and speak NORMAL
and speak without any without any difficulty.
difficulty.

XI. ACCESSORY Clients should be able to Client was able to shrug shoulders and turn NORMAL
shrug shoulders and turn their head from one side to another.
their head from side to
side.

XII. HYPOGLOSSAL The client should be able The client was able to move the tongue to NORMAL
to push their tongue to the side and move it out.
the side and stick out.
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
PHYSICAL ASSESSMENT (Head to Toe)
BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS

SKULL Generally round, with prominences in the frontal Generally round, with prominences in the frontal and
and occipital area. occipital area.

No tenderness noted upon palpation. No tenderness noted upon palpation.

SCALP Lighter, in color than the complexion. Lighter, in color than the complexion.
Can be moist or oily Can be moist or oily
No scars noted. No scars noted.
Free from lice, nits, and dandruff. Free from lice, nits, and dandruff.
No lesions noted. No lesions noted.
Not tenderness or masses on palpation. Not tenderness or masses on palpation.

HAIR Evenly distributed, black, and smooth. Evenly distributed, black, and smooth.

Shape may be oval or rounded, Face is Shape may be oval or rounded, Face is symmetrical,
FACE symmetrical, no involuntary muscle movements, no involuntary muscle movements, can move facial
can move facial muscles at will. muscles at will.

Eyeballs are symmetrical in size and position. Eyeballs are symmetrical in size and position.

Hair distribution in eyebrows is in its entire Hair distribution in eyebrows is in its entire length.
EYES length.
The eyeballs are in the same plane as the eyebrow
The eyeballs are in the same plane as the eyebrow and maxilla.
and maxilla.

PERRLA – Pupils equally round react to light PERRLA – Pupils equally round react to light and
Visual Acuity and accommodation. accommodation.

Same color as the skin. Same color as the skin.

Blinks involuntarily and bilaterally up to 20 times Blinks involuntarily and bilaterally up to 20 times
Eyelids per minute. per minute.

Do not cover the pupil, the sclera and lids. Do not cover the pupil, the sclera and lids.

Conjunctiva Transparent with light pink color. Transparent with light pink color.
 OUR LADY OF FATIMA UNIVERSITY
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COLLEGE OF NURSING
Sclera Color is white. Color is white.

Cornea Transparent, shiny. Transparent, shiny.

Pupils Black, constrict briskly. Black, constrict briskly.

Iris Visible. Visible.

EARS

Ear canal opening Free of lesions, discharge of inflammation. Free of lesions, discharge of inflammation.

Canal walls are pink.

Canal walls are pink.

Hearing Acuity Patient normally hears words when whispered. Patient normally hears words when whispered.

NOSE AND
PARANASAL
SINUSES

Shape, size and Smooth, symmetric with the same color as the Smooth, symmetric with the same color as the face.
color face.

Close to midline, thicker anteriorly than Close to midline, thicker anteriorly than posteriorly.
posteriorly.
Nasal septum
Oval, symmetric and without discharge.
Oval, symmetric and without discharge.

Nares

MOUTH
Pink, moist symmetric. Pink, moist symmetric.
Lips

Buccal mucosa Glistening pink, soft, moist. Glistening pink, soft, moist.

Gums Slightly pink color, moist and tightly fit against Slightly pink color, moist and tightly fit against the
the tooth. tooth.
 OUR LADY OF FATIMA UNIVERSITY
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COLLEGE OF NURSING
Tongue Moistly, rough on dorsal surface, medium or dull Moistly, rough on dorsal surface, medium or dull red.
red.

Teeth Firmly set, shiny. Firmly set, shiny.

Hard and soft Hard palate- dome shaped. Hard palate- dome shaped.
palate Soft Palate- Light pink. Soft Palate- Light pink.

NECK

Symmetry of Neck Neck is slightly hyperextended, without masses Neck is slightly hyperextended, without masses or
muscles, alignment or asymmetry. asymmetry
of trachea

Neck ROM Neck moves freely, without discomfort. Neck moves freely, without discomfort.

Thyroid gland Rises freely with swallowing. Rises freely with swallowing

CHEST The chest wall is intact with no tenderness and
masses. There’s a full and symmetric expansion
and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory
excursion.
The chest wall is intact with no tenderness and
masses. There’s a full and symmetric expansion and
the thumbs separate 2-3 cm during deep inspiration
when assessing for the respiratory excursion.

Soft, symmetric, and non-tender without
distention. There are no visible lesions or scars.
ABDOMEN The aorta is midline without bruit or visible
pulsation. Umbilicus is midline without
herniation.
A palpable abdominal mass may be present. There is
an aching pain in the epigastric region and left
hypochondriac region which is the first and second
quadrant.
It rarely crosses the midline.

Both extremes are equal in size. Have the same
contour with prominences of joints, no
involuntary movements. Color is even,
EXTREMITIES Temperature is warm and even, has equal
contraction and even. Can perform complete
range of motion, no crepitus must be noted on
joints, can counteract gravity and resistance on
ROM.
Left leg extremes are not equal in size. Does not have
the same contour with prominences of joints, no
involuntary movements. Color is not even,
Temperature is cool to touch, and peripheral pulses
remain weak. Cannot perform complete range of
motion, no crepitus must be noted on joints, cannot
counteract gravity and resistance on ROM.

SKIN Skin is uniform in color, unblemished and has Skin is uniform in color, unblemished and has no
no presence of any foul odor. presence of any foul odor.
 OUR LADY OF FATIMA UNIVERSITY
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COLLEGE OF NURSING
Has a good skin turgor and skin’s temperature is Has a tense and cool temperature. Skin on left leg
within normal limits. has an incision due to fasciotomy.

GENITAL AREA No yellowish or foul smelling. No yellowish or foul smelling.

 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 3 (ANATOMY)

Tibia and fibula are the two long bones located in the lower leg. The tibia is a larger bone
on the inside, and the fibula is a smaller bone on the outside. The tibia is much thicker than
the fibula. It is the main weight-bearing bone of the two. The fibula supports the tibia and
helps stabilize the ankle and lower leg muscles.
OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 4
PATHOPHYSIOLOGY
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 5
DRUG STUDY
NAME OF DRUG MECHANISM OF INDICATION COMMON NURSING
CONTRAINDICATION
ACTION SIDE EFFECTS CONSIDERATIONS

Generic: Mor-feen It binds to opioid It is used to Hypersensitivity Sedation 1. The patient should be in
receptors in the alleviate pain. to morphine a recumbent position
Brand: Duramorph, CNS, inhibiting Dizziness before receiving
ascending pain Acute or severe medication by
Classification:
pathways. asthma Drowsiness parenteral route.
Pharmacotherapeutic:
Opioid agonist GI obstruction Constipation 2. Check vital signs 5-10
mins after IV
Clinical: Opioid Concurrent use Vomiting administration.
analgesic of MAOIs or
use of MAOIs 3. Evaluate clinical
Dosage and Route: within 14 days improvement and
3mg morphine consult a doctor if over-
intravenously
Severe the-counter pain
respiratory relievers are ineffective.
depression

4. Reassess pain after

morphine
administration.

5. Instruct the patient on

how and when to
request and take pain
medication.

6. Instruct the patient to

notify a health care
professional if
persistent side effects
occur.
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COLLEGE OF NURSING
NAME OF DRUG MECHANISM OF INDICATION COMMON NURSING
CONTRAINDICATION
ACTION SIDE EFFECTS CONSIDERATIONS

Generic: It is an opioid Pain scale of 9 Respiratory 1. Explain the therapeutic

Hydromorphone agonist, which out of 10 depression Drowsiness value of the medication
means that it binds prior to administration.
Brand: Dilaudid to multiple opioid Head injury or Dizziness
receptors. Its increased 2. Observe the patient for
Classification: analgesic intracranial Nausea or any adverse reactions,
pressure vomiting such as respiratory
characteristics are
Pharmacologic: depression,
derived from its
Opioids Hypotension Constipation drowsiness, or
action on mu-opioid confusion.
Therapeutic class: receptors. Gastrointestinal Dry mouth
Opioid analgesics obstruction 3. Dilaudid should be
Headache taken with food or milk.
Route: Hepatic or
Renal Disease 4. Medication should be
Sweating
Intramuscular discontinued gradually
Intravenous Hypothyroidism after prolonged use.
Subcutaneous Weakness
Oral 5. Avoid coadministration
Itching with nonopioid
analgesics because it
Loss of may have additive
appetite analgesic effects and
allow for lower opioid
Fatigue doses.

Document the medication

administration, including
the time, dosage, and any
observations or patient
responses.
OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 6
NURSING CARE PLAN
OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
 OUR LADY OF FATIMA UNIVERSITY
120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 7
DISCHARGE PLAN

M - Medication -In order for the patient to reduce pain, administering medications as prescribed by the
doctor is important. Analgesic works by reducing the inflammation site of the pain or swelling. Patients
should take 2 tablets and not more than 3 tablets per day. It should be best taken after meals.

● In taking opioid analgesics which are used to manage pain caused by a major surgery, educate the
patient about the risks of opioid analgesics, which can lead to addiction and substance use disorder.
As a result, doctors will prescribe the lowest possible dose to effectively manage a person's pain.
They will also carefully monitor the patient and reassess their medications and dosages on a regular
basis.

● Teach the patient and significant others on how to use analgesics. A healthcare professional must
prescribe these medications and will also advise the patient on medication dosage, duration, and
frequency.

● The body may develop a tolerance to some drugs over time. When tolerance occurs the drug no
longer causes the same reaction. Therefore, increasingly larger doses are needed to achieve a
therapeutic effect. Clinically, this situation can be avoided by giving the drug in smaller doses or
in combination with other drugs that may also relieve pain.

E - Environment/Exercise - The patient needs to have the right environment for them to function and some
exercise to help their joints move to keep them from numbing.

● Teach the patient or family how to keep their home safe and away from harm and free of hazards
to avoid further injuries.

● Instruct the patient to use stretching techniques to help restore motion in these joints and reduce
unnecessary muscle tension. Repositioning can help too

● Encourage the patient to have a physical therapist assist her in moving and manipulating muscles
and joints to improve motion and strength. These techniques can target areas that are difficult to
treat on your own.
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COLLEGE OF NURSING
T - Treatment - Besides medication, treatment is also important for the patients to lessen symptoms and
to prevent further complications.

● Activities such as guided imagery like deep breathing exercises, relaxation tapes,
● Acupressure, back rubs and massage to improve recovery.
● Using non-pharmacologic pain management methods, such as music therapy like listening to
soothing music or visual aids such as watching television or movies.

H - Health Teaching - Teaching patients on learning and improving individual skills all throughout the
recovery phase.

● Teach the patient and significant others to perform active and/or passive ROM exercises of adjacent
joints every 8 hours, as needed.

● Teach the patient on how to use assistive devices/ambulatory aids such as crutches, a walker, a
cane, wheelchair other mobility devices.

● Instruct the patient to avoid any friction on the formation of new scars (for example: crossing legs,
tight clothing, pushing objects with legs or using a weight machine that presses into skin over
incision site).

O - Observation/Outpatient - Importance of follow-up care, date of next appointment, and a telephone

number to call if questions or emergencies arise within the recovery phase.

● A follow-up appointment with the healthcare provider 5-10 days after surgery for suture removal;
no drain was used.

● Rehabilitation appointments began 7 days after surgery and continued once every 5 days.

D - Diet - Prior to discharge, instruct family members to create a meal plan for the patient. The following
foods are nutritious, healthy and helps in recovery from post-operative surgery:

Fats (Nuts, Oils, and Fish)

➔ It is essential for boosting your immune system and lowering your risk of infection.

Protein (Lean meats, Poultry, Fish, Tofu, Eggs, Legumes, and Nuts)
➔ These foods help your body produce new blood cells, which are required for wound healing.

Fiber (Fruits, Vegetables, Whole grains, and Legumes)

➔ It improves digestion and can help prevent constipation, which is a typical issue following surgery.
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COLLEGE OF NURSING
REFERENCES

Comerford, K. C., & Durkin, M. T. (2021). Nursing 2021 drug handbook. 41st edition. Philadelphia,
Wolters Kluwer

Swearingen, P. L., & Wright, J. (2018). All-in-one nursing care planning resource (5th ed.).

World Health Organization. (2021). Fall. Retrieved from https://www.who.int/news-room/fact-

sheets/detail/falls