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CUES NURSING

DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:

Objective:

-(+) edema

- pallor

-pain scale of 10/10

Risk for

peripheralneurovasculardysfunction r/tthe effects of edemaformationsecondary tofracture on lefttibia andcompressioneffect of cast

Improper cast

insertion

Or too tight cast

Increase pressurewithin muscleConstriction

Hypoxia

Cellularmetabolism

Impede bloodcirculation

Release interstitialfluid within

interstitial space

Muscle spasmthat leads to

compartmentsyndrome

After two weeks of nursing

intervention theclient is able to

Demonstrateadequate tissueperfusion asevidenced bypalpable peripheralpulses, warmextremities, warmcolor and capillaryrefill less than 3seconds.

Independent:

1. Assess capillaryreturn, skin colorand warmth inthe limb at riskand comparewith unaffectedextremities.

2. Assess motionand sensation of operatedextremity

1. Peripheralpulses, capillaryrefill, skin color,and sensationand maybenormal initiallyeven in thepresence of compartmentalSyndrome,becausesuperficialcirculation isusually notcompromised.

2. Increasing pain,numbness/tingling suggest

nerve injury,Compromisedcirculationrequiringimmediateintervention.

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3. Monitor v/s

4. Maintainelevation of injuredextremity unlesscontraindicatedby confirmedpresence of

compartmentsyndrome

5. Evaluate for calf tenderness,positive

Homans signandinflammation.

3. Tachycardiaand falling BPmay reflectresponse to

hypovolemia/blood loss

4. To prevent thepresence of increasecompartmentpressure thatwill result toimpedesarterial flowand decreasingperfusion

5. Earlyidentification of thrombusdevelopmentandinterventionmay preventembolusformation.

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Collaborative:1. Administer IV

fluids, blood/plasma

expanders asneeded.

2. Monitorlaboratorystudies ex. HcT

3. Administermedication asindicated , e.g.:low molecularweight heparins,

enoxaparin(lovenox), dalteparin(fragmin),tinzaparin(innohep),

4. Apply cold/heat

1. To restore thevolume of circulating

fluids

2. Evaluatepresence/degree of alteration inclottingmechanism andeffects of anti-coagulant/ anti-platelet agentswhen used.

3. Anti-coagulants/anti-plateletagents may beused routinely

to reduce riskof thrombophlebitis andpulmonaryemboli.

4. Ice packs are

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as indicated used initially tolimitedema/hematoma formation.

Heat maybeused toenhancecirculation,facilitatingresolution of tissue edema.