Compartment Syndrome Nursing Diagnosis & Care Plan

Compartment syndrome is a serious medical condition that requires prompt recognition and intervention by healthcare professionals, particularly nurses.

Understanding Compartment Syndrome

Compartment syndrome occurs when pressure within a muscle compartment increases to dangerous levels, compromising blood flow and potentially leading to tissue damage. This condition most commonly affects the legs, arms, and abdomen but can occur in any enclosed muscle space.

Causes of Compartment Syndrome

• Trauma (fractures, crush injuries)
• Tight casts or bandages
• Burns
• Prolonged limb compression
• Severe muscle exertion
• Bleeding disorders

Signs and Symptoms

The classic signs and symptoms of compartment syndrome can be remembered using the “6 P’s”:

1. Pain (severe and out of proportion to the injury)
2. Pallor (pale skin)
3. Paresthesia (numbness or tingling)
4. Paralysis (weakness or inability to move the affected limb)
5. Pulselessness (diminished or absent pulse)
6. Pressure (tightness or tension in the affected area)

Early recognition of these symptoms is crucial for preventing long-term complications.

Nursing Process for Compartment Syndrome

The nursing process plays a vital role in the management of compartment syndrome. Here’s an overview of the steps:

1. Assessment: Conduct thorough neurovascular assessments and monitor for signs of compartment syndrome.
2. Diagnosis: Formulate nursing diagnoses based on assessment findings.
3. Planning: Develop a care plan with specific, measurable goals.
4. Implementation: Execute interventions aimed at relieving pressure and preventing complications.
5. Evaluation: Continuously assess the effectiveness of interventions and adjust the care plan as needed.

Nursing Care Plans for Compartment Syndrome

1. Acute Pain

Nursing Diagnosis Statement: Acute Pain related to increased compartment pressure as evidenced by verbal reports of severe pain, facial grimacing, and guarding behavior.

Related factors/causes:

• Increased intracompartmental pressure
• Tissue ischemia
• Nerve compression

Nursing Interventions and Rationales:

1. Assess pain characteristics (location, intensity, quality) using a standardized pain scale.
   Rationale: Provides baseline data and helps monitor pain progression.
2. Administer prescribed analgesics and monitor their effectiveness.
   Rationale: Helps manage pain and allows for early detection if pain is unresponsive to medication.
3. Position the affected limb at the heart level.
   Rationale: Promotes optimal blood flow without compromising perfusion.
4. Avoid applying cold therapy to the affected area.
   Rationale: Cold therapy can mask pain and potentially worsen tissue ischemia.
5. Educate the patient about reporting any changes in pain intensity or character.
   Rationale: Enables prompt intervention if compartment syndrome worsens.

Desired Outcomes:

• The patient reports decreased pain intensity within 30 minutes of intervention.
• The patient demonstrates improved comfort as evidenced by relaxed facial expression and decreased guarding behavior.

2. Risk for Impaired Tissue Perfusion

Nursing Diagnosis Statement: Risk for Impaired Tissue Perfusion related to increased compartment pressure.

Related factors/causes:

• Edema within the muscle compartment
• Vascular compromise
• Tissue inflammation

Nursing Interventions and Rationales:

1. Perform frequent neurovascular assessments (every 1-2 hours or as ordered).
   Rationale: Allows for early detection of circulatory compromise.
2. Monitor compartment pressures as ordered.
   Rationale: Provides objective data on intracompartmental pressure changes.
3. Remove any constrictive dressings or casts as ordered by the physician.
   Rationale: Relieves external pressure that may contribute to compartment syndrome.
4. Elevate the affected limb only if specifically ordered by the physician.
   Rationale: Improper elevation can compromise blood flow in compartment syndrome.
5. Prepare the patient for potential fasciotomy if symptoms worsen.
   Rationale: Fasciotomy is the definitive treatment for severe compartment syndrome.

Desired Outcomes:

• The patient maintains adequate tissue perfusion as evidenced by warm skin, palpable pulses, and normal capillary refill.
• The patient shows no signs of worsening compartment syndrome.

3. Impaired Physical Mobility

Nursing Diagnosis Statement: Impaired Physical Mobility related to pain and potential nerve damage secondary to compartment syndrome as evidenced by the reluctance to move the affected limb.

Related factors/causes:

• Severe pain with movement
• Muscle weakness
• Nerve compression

Nursing Interventions and Rationales:

1. Assess the patient’s level of mobility and compare it to their baseline.
   Rationale: Provides information on the extent of mobility impairment.
2. Assist with gentle range of motion exercises as tolerated and ordered.
   Rationale: Helps maintain joint flexibility and prevents contractures.
3. Provide assistive devices (e.g., walker, crutches) as appropriate.
   Rationale: Promotes safe mobility and prevents falls.
4. Collaborate with physical therapy for a mobility plan.
   Rationale: Ensures a comprehensive approach to maintaining and improving mobility.
5. Educate the patient on the importance of movement within prescribed limits.
   Rationale: Encourages patient participation in recovery while preventing overexertion.

Desired Outcomes:

• The patient demonstrates improved mobility within the limits of the condition.
• The patient uses assistive devices correctly and safely.

4. Anxiety

Nursing Diagnosis Statement: Anxiety related to uncertainty about prognosis and potential for surgical intervention as evidenced by verbalized concerns and increased heart rate.

Related factors/causes:

• Lack of knowledge about the condition
• Fear of potential complications
• Uncertainty about treatment outcomes

Nursing Interventions and Rationales:

1. Provide clear, concise information about compartment syndrome and its treatment.
   Rationale: Knowledge can help reduce anxiety and promote cooperation with treatment.
2. Encourage the patient to express concerns and ask questions.
   Rationale: Allows for clarification of misconceptions and provides emotional support.
3. Teach relaxation techniques such as deep breathing exercises.
   Rationale: Helps manage anxiety and promotes a sense of control.
4. Ensure a calm and quiet environment when possible.
   Rationale: Reduces external stressors that may exacerbate anxiety.
5. Administer anti-anxiety medications as prescribed.
   Rationale: Pharmacological intervention may be necessary to manage severe anxiety.

Desired Outcomes:

• The patient verbalizes understanding of the condition and treatment plan.
• The patient demonstrates reduced anxiety levels as evidenced by normal vital signs and a relaxed demeanor.

5. Risk for Infection

Nursing Diagnosis Statement: Risk for Infection related to potential surgical intervention (fasciotomy) for compartment syndrome.

Related factors/causes:

• Invasive procedures
• Compromised tissue perfusion
• Potential for prolonged wound healing

Nursing Interventions and Rationales:

1. Maintain strict aseptic technique during all procedures.
   Rationale: Reduces the risk of introducing pathogens.
2. Monitor the surgical site (if applicable) for signs of infection (redness, warmth, purulent drainage).
   Rationale: Allows for early detection and treatment of infection.
3. Administer prophylactic antibiotics as ordered.
   Rationale: Helps prevent postoperative infections.
4. Educate the patient on proper wound care and hygiene.
   Rationale: Encourage the patient to participate in infection prevention.
5. Monitor and report abnormal lab values (e.g., elevated white blood cell count).
   Rationale: Provides objective data on potential systemic infection.

Desired Outcomes:

• The patient remains free from signs and symptoms of infection.
• The patient demonstrates proper wound care techniques if applicable.

Conclusion

Effective nursing care is crucial in the management of compartment syndrome. By implementing these nursing diagnoses and care plans, healthcare professionals can significantly improve patient outcomes and prevent long-term complications associated with this condition.

References

1. American Academy of Orthopaedic Surgeons. (2021). Compartment Syndrome. OrthoInfo. https://orthoinfo.aaos.org/en/diseases–conditions/compartment-syndrome/
2. Duckworth, A. D., & McQueen, M. M. (2017). The Diagnosis of Acute Compartment Syndrome: A Review. European Journal of Trauma and Emergency Surgery, 43(4), 441-448.
3. Gyuton, J. L., & Dalley, A. F. (2021). Textbook of Medical Physiology (14th ed.). Elsevier.
4. Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
5. Mabvuure, N. T., Malahias, M., Hindocha, S., Khan, W., & Juma, A. (2012). Acute Compartment Syndrome of the Limbs: Current Concepts and Management. The Open Orthopaedics Journal, 6, 535-543.
6. National Institute for Health and Care Excellence. (2019). Fractures (non-complex): assessment and management. NICE Guideline [NG38]. https://www.nice.org.uk/guidance/ng38
7. Schmidt, A. H. (2017). Acute Compartment Syndrome. Injury, 48, S22-S25.
8. Von Keudell, A. G., Weaver, M. J., Appleton, P. T., Bae, D. S., Dyer, G. S., Heng, M., Jupiter, J. B., & Vrahas, M. S. (2015). Diagnosis and Treatment of Acute Extremity Compartment Syndrome. The Lancet, 386(10000), 1299-1310.