About
Inflammation and vascular congestion due to compression of areas above or below the effected body area.
Assess
Pain, sensation, redness, bruising, swelling; Monitor for cap refill, temperature, vitals, parasthesias ( numbness, tingling); weakened pulses and pallor of tissue requires immediate intervention.
Complications
Immobility; infection; amputation; acute renal failure- early, emergent treatment to prevent complications.
Fasciotomy- may be needed to relieve buildup of pressure.
Diagnosis
- Ineffective tissue perfusion related to pressure, swelling and edema within compartment
- Acute pain related to edema, pressure of compromised body part
- Risk for injury related to changes in limb compromising blood flow and tissue perfusion
Goals
- The client will identify symptoms that require immediate intervention after injury or surgery.
- The client will have no long-term damage from complication.
Interventions
- Assess client frequently for progression of symptoms.
- Initiate interventions to decrease pressure, as indicated- removal of casts, loosening of dressings.
- If pressure is sustained, prepare client for surgery as indicated.
- Monitor all clients with limb injuries or surgeries for s/s of impaired circulation ( pain, pallor, decreased pulses, paralysis, and parasthesias).
- Monitor for s/s of infection to distal areas to injury ( temp, increased WBC's, pain, redness, edema, increased drainage, odor).
- Monitor for signs/ symptoms of complications.
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