Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on an orthopedic unit. Mr. Johnson, 45, is post-op day 1 from an open reduction internal fixation (ORIF) of his right femur. He has a bulky dressing and his leg is in a splint. During your 0800 assessment, he is restless, rates his pain as 9/10 despite receiving hydromorphone 2 hours ago, and says his leg feels "tight and burning." His right foot is pale and cool to the touch compared to the left. Capillary refill is 3 seconds. Pedal pulses are faint but palpable via Doppler.
Nursing Intervention Strategy:- 1Immediate Assessment & Action• Stay calm but act with urgency. Do not leave the patient.
• Use the call light to summon another nurse. Instruct them to immediately page the orthopedic resident/surgeon and the charge nurse to the bedside STAT.
• While waiting, loosen any tight bandages or dressings over the affected area. Do not elevate the leg.
• Perform a focused neurovascular assessment: Re-check CMS (Circulation: color, temperature, capillary refill, pulses; Motion: "Wiggle your toes"; Sensation: "Can you feel me touching your toes?").
- 2CommunicationWhen the physician arrives, give a concise, accurate SBAR report:
• Situation: "Mr. Johnson, post-op femur ORIF, is showing signs of possible compartment syndrome."
• Background: "He sustained a closed femur fracture 48 hours ago, had surgery yesterday."
• Assessment: "He has severe, unrelenting pain (9/10) not relieved by recent hydromorphone. Right foot is pale, cool, capillary refill 3 seconds. Pedal pulses are faint by Doppler. He reports a burning, tight sensation."
• Recommendation: "I've loosened the dressing. I recommend an immediate compartment pressure measurement and your evaluation."
- 3PreparationAnticipate and prepare for emergency transport to the OR for a fasciotomy. Ensure IV access is patent for possible fluid resuscitation or antibiotics.
Patient Safety and Precautions:
• Never dismiss a patient's complaint of severe or increasing pain in a casted or injured limb.
• Never administer additional narcotics without first reassessing for neurovascular compromise when pain is unrelieved.
• Document meticulously: Time of assessment, exact findings (color, temperature, capillary refill time, pulse quality, motor/sensory function, patient's description of pain), time of physician notification, and orders received.
Nursing Procedure & Medication Flow
• Neurovascular Assessment (CMS Checks): Perform q1-2h for the first 24-48 hours post-fracture or post-op, or per protocol. Compare findings to the unaffected limb.
• Pain Management: Assess pain before and after analgesia. If pain is not relieved, reassess for complications (like compartment syndrome) before simply re-dosing.
• Cast Care: Instruct patients to report any "new" numbness, tingling, severe pain, or inability to move fingers/toes. Teach them NOT to insert objects inside the cast.
A Word from Your Senior Nurse
"Compartment syndrome is one of those 'don't-miss' diagnoses in orthopedics. Trust your assessment skills. If something feels off—if the pain story doesn't match, if the limb looks or feels different—escalate it. In clinical practice, you are the eyes and ears for the physician. Catching this early literally saves limbs and livelihoods. When you study, don't just memorize the 6 P's; visualize the patient, feel the urgency. That connection will make you a vigilant nurse who passes the NCLEX and, more importantly, protects your patients from harm."