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CUES Subjective: Objective:

-(+) edema - pallor -pain scale of 10/10

NURSING DIAGNOSIS
Risk for peripheral neurovascular dysfunction r/t the effects of edema formation secondary to fracture on left tibia and compression effect of cast

INFERENCE
Improper cast insertion Or too tight cast Increase pressure within muscle Constriction Hypoxia Cellular metabolism Impede blood circulation Release interstitial fluid within interstitial space Muscle spasm that leads to compartment syndrome

PLANNING
After two weeks of nursing intervention the client is able to

INTERVENTIONS
Independent:

RATIONALE

EVALUATION

1. Assess capillary 1. Peripheral return, skin color pulses, capillary and warmth in refill, skin color, Demonstrate the limb at risk and sensation adequate tissue and compare and maybe perfusion as with unaffected normal initially evidenced by extremities. even in the palpable peripheral presence of pulses, warm compartmental extremities, warm color and capillary Syndrome, refill less than 3 because seconds. superficial circulation is usually not compromised. 2. Assess motion and sensation of operated extremity 2. Increasing pain, numbness/tingli ng suggest nerve injury, Compromised circulation requiring immediate intervention.

3. Monitor v/s

3. Tachycardia and falling BP may reflect response to hypovolemia/ blood loss 4. To prevent the presence of increase compartment pressure that will result to impedes arterial flow and decreasing perfusion

4. Maintain elevation of injured extremity unless contraindicated by confirmed presence of compartment syndrome

5. Evaluate for calf tenderness, positive Homans sign and inflammation.

5. Early identification of thrombus development and intervention may prevent embolus formation.

Collaborative:

1. Administer IV fluids, blood /plasma expanders as needed. 2. Monitor laboratory studies ex. HcT

1. To restore the volume of circulating fluids 2. Evaluate presence/ degree of alteration in clotting mechanism and effects of anticoagulant/ antiplatelet agents when used. 3. Anticoagulants/ anti-platelet agents may be used routinely to reduce risk of thrombophlebit is and pulmonary emboli. 4. Ice packs are

3. Administer medication as indicated , e.g.: low molecular weight heparins, enoxaparin(love nox), dalteparin (fragmin), tinzaparin(innoh ep),

4. Apply cold/heat

as indicated

used initially to limit edema/hemato ma formation. Heat maybe used to enhance circulation, facilitating resolution of tissue edema.

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