CNA253 AT2: Evaluating Mrs. Boren's Compartment Syndrome Case Study

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Added on 2022/08/25

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This case study analyzes the presentation of Mrs. Gwen Boren, a patient experiencing compartment syndrome following a fall and ankle fracture. The assignment begins with an interpretation of subjective and objective data, differentiating between normal and abnormal findings, with justifications based on established medical literature and normal physiological ranges. The 'Relate & Infer' section delves into the pathophysiology of compartment syndrome, explaining the mechanisms behind the patient's symptoms, such as blanched skin, cool extremities, and the sensation of pins and needles, linking them to the underlying pressure and compromised blood flow within the muscle compartment. The patient's hypertension, potential causes, and relation to the sympathetic nervous system are discussed. The 'Predict' section addresses the urgency of the condition and the potential for permanent damage if not promptly treated. The assignment then articulates three nursing diagnoses: pain related to muscle and nerve irritation, impaired tissue perfusion, and risk of trauma. Finally, the case study presents goals, actions, and evaluation for the two highest priority nursing diagnoses, focusing on pain management and restoring tissue perfusion, including rationales for interventions such as cast removal, medication administration, and limb elevation. The effectiveness of the interventions is evaluated based on the patient's reported pain levels, vital signs, and observed physical changes. The assignment uses multiple in-text references to support the analysis and interventions.

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)

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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)

Diagnosis 1: Pain related to muscle and nerve irritation due to decreased oxygenation as evidenced by pain scale of 10/10 and patient verbalization on her leg
hurting.
Diagnosis 2: Impaired tissue perfusion related to high pressure in the compartment as evidenced by increased capillary refill time of 5 seconds, blanching
colour and cool temperatures on the limb.
Diagnosis 3: Risk of trauma related to the cerebrovascular accident and advanced age, as evidenced by the previous fall that caused her confusion and ankle
injury.
Goals, Actions and Evaluation 2 highest priority diagnoses only (550 words)
Diagnosis 1 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
To alleviate pain to a
scale of 3 within a
period of 1 hour.
Vital signs decreasing
to normal range within
30 minutes.
Inform the orthopaedic
team for removal of the
cast as soon as possible.
Administer morphine
sulphate 2.5 mg.
Administer paracetamol
1000mg.
Elevate the affected leg.
Educate the patient on
The tight-fitting cast is one of the causes of acute
compartment syndrome. It causes an increase in tissue pressure
in the compartment more than the venous pressure, therefore,
impairing blood flow. Removing the cast will, therefore, offer
relief in the compartment pressure. The condition can resolve
if action is taken quickly and if the syndrome was caused by
tight-fitting cast. Normal functioning of the leg is restored
once proper perfusion is achieved. If the condition does not
resolve, then an emergency surgery has to be performed to
Pain has been
assessed using the
0-10 scale. The
patient reports a
pain scale of 3.
The cast has been
removed and
another one placed,
and the patient

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the condition she is
experiencing and
reassure the patient.
relieve the pressure. This occurs especially when the condition
was caused by oedema or haemorrhage. If done as soon as
possible normal functioning is restored so long as necrosis had
not occurred already (Mar, Barrington and McGuirk 2009).
Morphine is an opioid analgesic which is used to treat severe
pain. It acts within 5 minutes and therefore helps to relieve
acute pain like acute compartment syndrome. Morphine acts
directly at the central nervous system targeting receptors in the
brain causing pain relief (Schloss et al. 2019).
Paracetamol is an analgesic drug which inhibits the
prostaglandin synthesis of both COX-1 and COX-2. This is
mediated through activation of serotonin pathways.
Paracetamol has an analgesic effect and also an antipyretic
effect (Gessner, Horn and Lowenberg 2019).
Elevation of the patient leg can help relieve pressure and
promote blood flow avoiding venous blood pooling. This can
help relieve pain as other interventions are being carried out.
Patient education on the condition helps to alleviate anxiety
and consequently, pain. Being there with the patient helps
reports to be
feeling more
comfortable.
Vital signs are
within the normal
range. Blood
pressure 122/84
mmHg, pulse rate
of 80 bpm and
respiratory rate of
18 breaths/min

them feel relieved, especially when in severe pain (Torlincasi
and Waseem 2019).
Diagnosis 2 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
To restore blood flow to
the extremities, achieve
normal colour, warm
extremities and
improved capillary refill
of fewer than 3 seconds
within one hour.
Communicate with the
orthopaedic team to
review and remove the
cast as soon as possible.
Encourage the patient to
exercise extremities such
as the toes if she can.
A tight-fitting cast can cause build-up in pressure in the
compartment. This impairs free blood circulation, especially to
the extremities. Therefore removing the cast will help increase
blood flow. This, in turn, improves tissue oxygenation and
elimination of metabolic waste. Increased blood flow and
oxygenated blood restore the colour, warmth and capillary
refill (Walters, Kottke, Hargens and Ryan 2019).
Exercising extremities promotes tissue perfusion. It helps
increase blood flow to the tissue, especially when the
obstruction is not complete. This increases oxygen supply and
consequently, tissue function.
The patient had a
capillary refill of
<3seconds on the
application of
pressure, warm
extremities and
normal pink colour.
Reference list:
Arbour, C. and Gélinas, C., 2010. Are vital signs valid indicators for the assessment of pain in postoperative cardiac surgery ICU adults?. Intensive and

Critical Care Nursing, 26(2), pp.83-90.
Gessner, D.M., Horn, J.L. and Lowenberg, D.W., 2019. Pain management in the orthopaedic trauma patient: Non-opioid solutions. Injury.
Hart, J., 2015. Normal resting pulse rate ranges. J. Nurs. Educ. Pract, 5(8), pp.95-98.
Lawendy, A.R., Bihari, A., Sanders, D.W., Badhwar, A. and Cepinskas, G., 2016. Compartment syndrome causes systemic inflammation in a rat: the
bone & joint journal, 98(8), pp.1132-1137.
Mar, G.J., Barrington, M.J. and McGuirk, B.R., 2009. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on
diagnosis. British journal of anaesthesia, 102(1), pp.3-11.
McMillan, T.E., Gardner, W.T., Schmidt, A.H. and Johnstone, A.J., 2019. Diagnosing acute compartment syndrome—where have we got to?.
International orthopaedics, pp.1-7.
Ramakrishna, G., Kumar, P.K. and Ramakrishna, R., 2019. PREVALENCE OF METABOLIC SYNDROME IN CORONARY ARTERY DISEASE
AND CEREBROVASCULAR ACCIDENT PATIENTS. Journal of Evolution of Medical and Dental Sciences, 8(4), pp.233-238.
Schloss, M., Weir, T.B., Jauregui, J.J., Jazini, E. and Abzug, J.M., 2019. Increased morphine requirements are predictive of acute compartment syndrome
in adults with tibia fractures. International Orthopaedics, pp.1-10.
Sansone, C.M., Prendin, F., Giordano, G., Casati, P., Destrebecq, A. and Terzoni, S., 2017. Relationship between capillary refill time at triage and
abnormal clinical condition: a prospective study. The open nursing journal, 11, p.84.
Schmidt, A.H., 2017. Acute compartment syndrome. Injury, 48, pp.S22-S25.
Torlincasi, A.M. and Waseem, M., 2019. Acute Compartment Syndrome. In StatPearls [Internet]. StatPearls Publishing.
Walters, T.J., Kottke, M.A., Hargens, A.R. and Ryan, K.L., 2019. Noninvasive diagnostics for extremity compartment syndrome following traumatic