CNA253 AT2 Scenario: Mrs Gwen Boren Assignment 2022

Student number:
CNA253 AT2 Scenario: Mrs Gwen Boren
Interpret:
In the following table, list the data that you consider to be normal/abnormal (not included in word count)
Normal (Subjective & Objective) Abnormal (Subjective & Objective)
SPO2 99%
Temp 37.5 C
Best eye response 4
Best motor response: 6
Pupils ® 3+ (L) 3+
Limb movements left arm (normal power)
Pulses: not accessible because of the backslap applied
Blood loss: nill
Swelling: cannot access because of the backslap
Blood loss: nill
Bp: 170/95 mmHg (normal is between 120/80 mmHg and 140/90 mmHg)
Pulse 108 bpm (normal is 60-100 bpm(Hart, 2015))
RR 21 breaths/min (normal is 12-16 breaths per min in adults (Sankoff, and Richards,
2015.))
Best verbal response: 4 (Normal is 5)
Limb movements right arm and right leg: mild weakness (normal is normal power)
Colour: blanched (normal should be normal)
Warmth: cool(normal should be warm)
Movement: wiggling toes A+ and patient is reluctant (normal active movement without
pain A- and passive movement without pain P-)
Sensation: pins and needles (normal is good and normal sensation)
Pain: 10/10(normal is nill pain)

Capillary refill: 5 seconds (normal <3seconds (Sansone et al. 2017).)
Relate & Infer (550 words):
Compartment syndrome occurs when tissue pressure exceeds venous pressure in an enclosed muscle compartment and therefore leading to ischemia, nerve
damage and even necrosis (McMillan, Gardner, Schmidt and Johnstone 2019). The most commonly affected areas are the area between the knee and the
ankle. These are areas with a group of muscles, nerves and blood vessels covered with thick fascia. These compartments, therefore, do not stretch, and in
cases of oedema and haemorrhage, there is a build-up of pressure. This increase in pressure causes impairment in blood flow and therefore leads to a lack of
oxygenated blood and accumulation of waste products within the tissues. These intern results in symptoms such as pain and decrease in peripheral sensation
caused by irritation of the nerves (Schmidt 2017). The main cause of an increase in pressure is compartment size decrease or increase in intra-compartment
volume, which can be due to oedema or haemorrhage. Acute compartment syndrome usually occurs following a fracture which causes muscles to bleed
increasing pressure and eventually nerve damage due to decreased blood supply. It can also occur from a badly bruised muscle or when blood is re-
established after circulation was blocked. It can also be caused by constricting bandage or a cast that has been fit tightly. Severe pain is due to pressure and
nerve irritation which make the pain to be more than the pain expected from the injury itself. Nerve irritation is caused by the accumulation of waste products
of metabolism (Lawendy et al. 2016). The cool extremities are due to impaired perfusion and blood flow due to the tissues resulting from the pressure. The
blanched colour in the region is due to decreased oxygenation as free circulation is impaired, and there is an accumulation of deoxygenated blood. The site of
compartment syndrome usually feels firm and wooden like on deep palpation. This affects the free range of movement of the ankle joint as the pressure is
high. There is also severe pain on muscle movement that is the reason the patient is experiencing wiggling toes and reluctance in limb movement. The
sensation of pins and needles is due to impaired nervous sensation resulting from Impaired blood supply and nerve irritation. Increased capillary refill time is
due to decreased peripheral perfusion. Normally capillary refill time should be less than 3seconds when pressure is applied. Severe pain activates the

sympathetic autonomic system causing the release of adrenaline and other adrenal hormones (Arbour and Gelinas 2010). This makes the body to act in a fight
and flight mode. Therefore there is an increase in blood pressure, pulse rate and respiratory rate to increase oxygen intake. Mrs Gwen Boren is experiencing
increased blood pressure (170/95 mmHg) increased pulse (108 bpm) and increased respiratory rate of 21 breaths/min due to sympathetic nervous system
activation due to pain. Increased pulse rate can also be due to pre-existing artrifibrilation. Mrs Gwen Boren is currently being treated on cerebrovascular
accident. Cerebrovascular accident causes impaired perfusion of a certain part of the brain due to blockage of a blood vessel by either a clot or emboli. This
causes necrosis and therefore, impairment of functions controlled by this region (Ramakrishna, Kumar and Ramakrishna 2019). The patient is experiencing
weakness on the right arm and right leg due to a previous cerebrovascular accident. Her best verbal response is four which indicate that the patient is
confused. The patient is also not aware of where she was as she asked the nurse where she was. The confusion is related to previous fall that caused fracture
of the ankle.
Predict (150 words):
Acute compartment syndrome is an emergency condition which an immediate action has to be taken in order to preserve function. If the condition is not
intervened quickly, there is a high risk of permanent damage. Long-time of decreased perfusion causes continued accumulation of waste product of
metabolism such as urea and oxygen depletion in the tissues. This causes permanent nerve damage and even necrosis. When nerve dame and tissue necrosis
has occurred, there is a permanent loss of function in the limb. The sensation of the limb is lost, and muscle function such as range of motion is also lost. This
can even lead to amputation of the affected limb.
Develop, Articulate and Prioritize Nursing Diagnoses – at least 3 (not included in word count)