Compartment Syndrome Nursing Diagnosis and Nursing Care Plan

Compartment Syndrome Nursing Care Plans Diagnosis and Interventions

Compartment Syndrome NCLEX Review and Nursing Care Plans

Compartment syndrome is a serious medical condition characterized by the excessive accumulation of pressure in an enclosed muscle space in the body.

It commonly occurs in the leg, thigh, forearm, hand, and buttock, although it can occur in any enclosed muscle space.

The pressure build-up can impede normal blood flow to the tissues hence immediate medical attention is necessary to prevent permanent damage.

Compartments are referred to as groups of muscles or organs which is surrounded by fascia – a web of strong connective tissues.

When an injury occurs, blood or fluid may accumulate in the compartment, however, the fascia will not easily expand causing a rise of pressure inside the compartment.

This may lead to obstruction in the blood flow resulting to loss of function or death to the tissues.

Signs and Symptoms of Compartment Syndrome

Signs and symptoms of acute compartment syndrome typically manifest within hours of injury, although they can appear up to 48 hours after. These include:

  • Severe pain – this subjective clinical manifestation of the condition is a reliable symptom of compartment syndrome. The pain is normally disproportionate to the amount of injury and does not normally improve after initial treatment is given. Pain may be described as getting worse when stretching the muscles surrounding the affected compartment.
  • Paraesthesia – or the feeling of pins and needles distally in the affected part; this may be due to evolving neurological involvement.
  • The compartment may feel “tense” – as compared to the other side of the body.
  • Features of arterial insufficiency – the presence of what is commonly referred to as the 5Ps:
    • Pain
    • Pallor – mottled, non-blanching skin
    • Perishingly cold
    • Paralysis
    • Pulselessness

In chronic compartment syndrome (also known as exertional compartment syndrome), the signs and symptoms appear about 30 minutes after exercising.

The symptoms typically settle with rest and the function will go back to normal.

Chronic compartment syndrome can be confused with shin splints as they may have the same symptoms.

  • Worsening aches
  • Cramping of the affected compartment

Abdominal compartment, on the other hand, can develop in people who were on life support.

Typically, the person himself will not be able to describe their symptoms and healthcare staff or family members are typically the ones who may notice their presence.

  • Tense or distended abdomen
  • Patient may wince when abdomen is pressed
  • Slowing of urine output
  • Low blood pressure

Causes of Compartment Syndrome

            Acute compartment syndrome – this is the most common type of compartment syndrome accounting to about one third of cases.

  • Fracture
  • Crush injuries
  • Burns
  • Overly tight bandaging
  • Prolonged compression of a limb during a period of unconsciousness
  • Surgery to blood vessels of an arm or leg
  • Vigorous exercises
  • Use of anabolic steroids

Chronic compartment syndrome – the most affected parts are lower leg, buttock, and thigh.

  • Regular, vigorous exercise

Abdominal compartment syndrome – this type may develop immediately after a severe injury, surgery, or during a critical illness needing life support.

  • Trauma resulting to shock
  • Abdominal surgery, specifically with liver transplant
  • Burns
  • Sepsis
  • Severe ascites or abdominal bleeding
  • Pelvic fracture
  • Vigorous abdominal exercises such as sit ups on a back extension machine

Complications of Compartment Syndrome

  1. Permanent damage to nerve or blood vessels. The pressure may block or occlude nerves and blood vessels traversing the compartment leading to permanent damage.
  2. Permanent loss of function. Permanent loss of function of the tissues and muscles involved may be possible due to the lack of blood supply.
  3. Rhabdomyolysis. This is a condition where the skeletal muscles break down. It is rarely associated with compartment syndrome and is one of the complications to watch out for.
  4. Kidney failure. This may occur due to the build-up of muscle destruction by-products.
  5. Amputation. Compartment syndrome may lead to amputation if medical treatment is not immediately given.

Diagnosis of Compartment Syndrome

  • Physical examination and medical history – the diagnosis of compartment syndrome is highly dependent on the clinical manifestations. The presence of severe pain incomparable to the injuries incurred is important in supporting the diagnosis.
  • Intra-compartmental pressure monitor – this is the most reliable diagnostic test in compartment syndrome. It measures the pressure in the compartment with the use of a pressure monitor connected to tiny needle or catheter which is then inserted to the compartment. It is typically done when the clinical manifestations are not enough to make a diagnosis.
  • Creatinine-kinase – CK levels can also be measured to identify the presence of the by-products of muscle cell destruction.

Treatments of Compartment Syndrome

  1. Fasciotomy. This is a surgical procedure to relieve swelling and pressure in the compartment. A skin incision is made and is left open for a period until the pressure is relieved.
  2. Positioning. Keeping the limb in neutral level to avoid overwhelming the affected area with too much blood flow.
  3. Oxygen saturation support. Maintain or improve blood oxygen level to help perfuse the compartment with enough oxygen.
  4. Intravenous therapy. Improving perfusion of the limbs through intravenous fluids is often required.
  5. Symptomatic or supportive treatment. This includes as administration of analgesia for pain. No dressings should be kept on the compartment.

Nursing Diagnosis Compartment Syndrome

Compartment Syndrome Nursing Care Plan 1

Nursing Diagnosis: Acute Pain related to compartment syndrome as evidenced by pain score of 10 out of 10, paresthesia, pallor, pulselessness, and cramping on the affected body region

Desired Outcome: The patient will have a pain score of 0 out of 10.

Compartment Syndrome Nursing InterventionsRationales
Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.
Administer analgesics/ pain medications as prescribed.To provide pain relief to the patient.
Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.To assess the effectiveness of treatment.
Provide more analgesics at recommended/prescribed intervals.To promote pain relief and patient comfort without the risk of overdose.
Elevate the head of the bed and encourage the patient to sit in semi Fowler’s position. Encourage pursed lip breathing and deep breathing exercises.To relieve shortness of breath and help in lung expansion. To promote optimal patient comfort and reduce anxiety/ restlessness.
Refer the patient to a pain specialist as required.To enable to patient to receive more information and specialized care in pain management if needed.

Compartment Syndrome Nursing Care Plan 2

Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood flow to the affected area secondary to compartment syndrome, as evidenced by pain, paresthesia, pallor, pulselessness, weakness, and cramping on the affected body region

Desired Outcome: The patient will be able to achieve optimal tissue perfusion in the affected areas as evidenced by having strong and palpable pulses, regained limb strength, and reduced pain.

Compartment Syndrome Nursing InterventionsRationales
Assess the patient’s vital signs at least every 4 hours, or more frequently if there is a change in them.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for compartment syndrome.
Prepare the patient for the surgical procedure (fasciotomy) as indicated. Preparation involves educating the patient, gaining their consent, and accomplishing a pre-operative checklist.Fasciotomy is a surgical procedure to relieve swelling and pressure in the compartment. A skin incision is made and is left open for a period until the pressure is relieved.
Administer analgesics as prescribed.To provide pain relief especially in the affected area.
 Keep the limb in neutral level / at the level of the heart. Do not elevate.To avoid overwhelming the affected area with too much blood flow.
Administer supplemental oxygen as prescribed.To ensure adequate oxygen in the compartment/ affected area.
Ensure adequate hydration. Administer intravenous fluids as prescribed.Increased blood viscosity is a contributory factor to clotting. Adequate hydration helps reduce blood viscosity. Improving perfusion of the limbs through intravenous fluids is often required.

Compartment Syndrome Nursing Care Plan 3

Nursing Diagnosis: Ineffective coping related to compartment syndrome as evidenced by verbalization of helplessness and/or hopelessness, anxiety, inability to meet basic self-care needs

Desired Outcome: The patient will demonstrate effective coping skills during and after recovery phase.

Compartment Syndrome Nursing InterventionsRationale
Assess the anxiety level of the patient, anxiety triggers and symptoms by asking open-ended questions.To establish a baseline observation of the anxiety level of the patient. Open-ended questions can help explore the thoughts and feelings of the patient regarding the situational crisis.
Initially, support the patient by meeting dependency needs if deemed necessary.The patient can become more anxious if the avenues for dependency are suddenly and/or complete eliminated.
Encourage the patient to be independent and provide positive reinforcement for being able to do self-care and other independent behaviors.To enhance the patient’s self-esteem and encourage him/her to repeat desired behaviors.  
Discuss with the patient and significant other/s the available treatments for anxiety.Anxiety is treatable. Psychotherapy involves speaking with a licensed therapist and going through how to gradually cope with the symptoms. Medications such as anxiolytics and antidepressants can help the patient cope with anxiety.  
Support the patient’s efforts to verbalize and explore the meaning behind obsessive thoughts and worries.The patient should first recognize and accept the presence of obsessive thoughts before change can happen.
Teach the patient to perform relaxation techniques such as deep breathing exercises, guided imagery, meditation, and progressive muscle relaxation.To promote relaxation and reduce stress levels.

More Nursing Diagnosis for Compartment Syndrome

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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