- Acute Pain related to inflammatory process and bleeding within the compartment
as evidenced by reports of severe, unrelieved pain and diaphoresis - Impaired physical mobility related to neuromuscular skeletal impairment or injury as evidenced by expressions of discomfort when moving and decreased muscle strength and control
- Ineffective peripheral tissue perfusion related to decreased peripheral blood flow to the affected body parts as evidenced by absence of or decreased peripheral pulses
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to inflammatory process and bleeding within the compartment as evidenced by reports of severe, unrelieved pain and diaphoresis | 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. | 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. | The patient verbalized pain decreased with prescribed medications The patient displayed vital signs within normal limits |
| Subjective Data: Expression of pain and discomfort with movement Refusal to move Objective Data: -Limited range of motion -Uncoordinated movements -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Contractures -Decreased muscle strength | Impaired physical mobility related to neuromuscular skeletal impairment or injury as evidenced by expressions of discomfort when moving and decreased muscle strength and control | 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 | 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 | The patient maintained or regain mobility at the maximum possible level The patient participated in PT to increase the strength or function of the affected body part |
| Subjective Data: -Altered skin sensations -Claudication -Peripheral pain -Numbness and tingling Objective Data: -Weak or absent peripheral pulses -Cool skin temperature -Thickened nails -Skin discoloration: pallor when legs are raised and rubor when dependent -Loss of hair to legs -Edema -Delayed wound healing | Ineffective peripheral tissue perfusion related to decreased peripheral blood flow to the affected body parts as evidenced by absence of or decreased peripheral pulses | 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 | 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. | The patient achieved 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 |