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.

To prevent the presence of increase compartment pressure that will result to impedes arterial flow and decreasing perfusion 4. 5. Evaluate for calf tenderness. Early identification of thrombus development and intervention may prevent embolus formation. Monitor v/s 3. positive Homan’s sign and inflammation.3. Maintain elevation of injured extremity unless contraindicated by confirmed presence of compartment syndrome 5. Tachycardia and falling BP may reflect response to hypovolemia/ blood loss 4. .

To restore the volume of circulating fluids 2. e. tinzaparin(innoh ep). dalteparin (fragmin). enoxaparin(love nox). 4. Apply cold/heat . 4. Administer IV fluids. Monitor laboratory studies ex.Collaborative: 1. 3.: low molecular weight heparins. Ice packs are 3.g. Administer medication as indicated . 2. HcT 1. Anticoagulants/ anti-platelet agents may be used routinely to reduce risk of thrombophlebit is and pulmonary emboli. Evaluate presence/ degree of alteration in clotting mechanism and effects of anticoagulant/ antiplatelet agents when used. blood /plasma expanders as needed.

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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