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
- Permanent damage to nerve or blood vessels. The pressure may block or occlude nerves and blood vessels traversing the compartment leading to permanent damage.
- Permanent loss of function. Permanent loss of function of the tissues and muscles involved may be possible due to the lack of blood supply.
- 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.
- Kidney failure. This may occur due to the build-up of muscle destruction by-products.
- 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
- 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.
- Positioning. Keeping the limb in neutral level to avoid overwhelming the affected area with too much blood flow.
- Oxygen saturation support. Maintain or improve blood oxygen level to help perfuse the compartment with enough oxygen.
- Intravenous therapy. Improving perfusion of the limbs through intravenous fluids is often required.
- 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 Interventions | Rationales |
| 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 Interventions | Rationales |
| 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 Interventions | Rationale |
| 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
- Impaired Physical Mobility
- Risk for Fall/ Injury
- Alteration in Comfort
- Self-Care Deficit
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.
FAQs
What is the nursing diagnosis for compartment syndrome? ›
Ineffective tissue perfusion occurs in compartment syndrome due to increased pressure following an injury, compromising circulation and neuromuscular function. If left untreated, this can cause necrosis to the affected tissues, nerves, and muscles. Nursing Diagnosis: Ineffective Tissue Perfusion.
What are nursing interventions for compartment syndrome? ›Nursing Interventions Include:
perform neurovascular checks (6 P's) keep the extremity AT HEART level (NOT below….remember you want to maintain arterial pressure and elevating it above heart level will cause more ischemia) loosen and remove restrictive items.
Hallmark symptoms of ACS include the 6 P's: pain, poikilothermia, pallor, paresthesia, pulselessness, and paralysis. Suspicion of ACS is confirmed by measurement of intracompartmental pressure of the affected compartment.
What is the priority action for compartment syndrome? ›The treatment of choice for acute compartment syndrome is early decompression. If the tissue pressure remains elevated in a patient with any other signs or symptoms of a compartment syndrome, adequate decompressive fasciotomy must be performed as an emergency procedure.
What is the diagnosis of compartment syndrome? ›DIAGNOSIS Acute compartment syndrome (ACS) of an extremity is diagnosed on the basis of the history, examination findings, and often the measurement of compartment pressures, although this is not required. ACS most often develops soon after significant trauma, particularly involving long bone fractures.
What are the 4 nursing diagnosis? ›NANDA-I recognizes four categories of nursing diagnoses: problem focused diagnosis, risk diagnosis, health promotion diagnosis, and syndrome. Problem focused diagnoses, also known as actual diagnoses, are patient issues or problems that are present and observable during the assessment phase.
What are the 5 nursing interventions? ›These are assessment, diagnosis, planning, implementation, and evaluation.
What are the 3 nursing interventions? ›There are typically three different categories for nursing interventions: independent, dependent and interdependent.
What are the 5 P's of compartment syndrome? ›Common Signs and Symptoms: The "5 P's" are oftentimes associated with compartment syndrome: pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements). Numbness, tingling, or pain may be present in the entire lower leg and foot.
What are interventions for compartment syndrome? ›A surgical procedure called fasciotomy is the most effective treatment of chronic exertional compartment syndrome. It involves cutting open the inflexible tissue encasing each of the affected muscle compartments. This relieves the pressure.
What are the three common causes of compartment syndrome? ›
- Trauma, such as a crush injury or surgery.
- Broken bone.
- Very bruised muscle.
- Severe sprain.
- A cast or bandage that is too tight.
- Loss of blood supply due to the use of a tourniquet or positioning during surgery.
The classic signs of acute compartment syndrome include the 6 'P's': pain, paresthesia, poikilothermia, pallor, paralysis, and pulselessness. Pain is usually the initial complaint and should trigger the workup of acute compartment syndrome.
What is the main concern with compartment syndrome? ›Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.
What is the most common cause of compartment syndrome? ›Acute compartment syndrome can occur without any precipitating trauma but typically occurs after a long bone fracture, with tibial fractures being the most common cause of the condition, followed by distal radius fractures. Seventy-five percent of cases of acute compartment syndrome are associated with fractures.
What are the findings of compartment syndrome? ›Clinical diagnosis
The classic “P's” described in compartment syndrome are pain, paresthesia, paralysis/paresis, pulselessness, and pallor [14].
- Anxiety.
- Constipation.
- Pain.
- Activity Intolerance.
- Impaired Gas Exchange.
- Excessive Fluid Volume.
- Caregiver Role Strain.
- Ineffective Coping.
Nursing diagnoses must include the problem and its definition, the etiology of the problem, and the defining characteristics or risk factors of the problem. The problem statement explains the patient's current health problem and the nursing interventions needed to care for the patient.
What are the examples of NANDA nursing diagnosis? ›According to NANDA, some of the most common nursing diagnoses include pain, risk of infection, constipation, and body temperature imbalance.
What is basic nursing care examples? ›Basic nursing care such as, promoting comfortable positioning, effective pain relief, promoting periods of uninterrupted sleep, controlling noise and lighting , ensuring privacy and effective communication could assist with reducing the stressors the patient experiences in ICU (Hatchett, Langley & Schmollgruber, 2010).
What are the 3 C's in nursing? ›Perspective: Consistency, Continuity, and Coordination—The 3Cs of Seamless Patient Care. Amid our efforts to improve health care quality, we can easily lose sight of the most basic questions. Consider evidence-based clinical guidelines, protocols, and pathways.
What are nursing goals for patients? ›
A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.
What are the three types of nursing diagnosis? ›The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.
What are nursing actions examples? ›Nursing interventions are simply any action a nurse performs to help patients reach expected outcomes. Providing physical treatments, emotional support, and patient education are all examples of nursing interventions.
What is the best example of a nursing intervention? ›An example of a physiological nursing intervention would be providing IV fluids to a patient who is dehydrated. Safety nursing interventions include actions that maintain a patient's safety and prevent injuries.
What are three symptoms of compartment syndrome? ›Compartment Syndrome Symptoms
Pain that seems greater than expected for the severity of the injury. Numbness, pins-and-needles, or electricity-like pain in the limb. Swelling, tightness and bruising.
In cases with impending compartment syndrome, the extremity should not be elevated since this reduces the already impaired blood flow. A diagnosed compartment syndrome needs immediate fasciotomy as an emergency surgical procedure to release pressure from the affected compartment.
What pressure is used for compartment syndrome? ›A measured pressure of more than about 30 mm Hg or within about 30 mm Hg of diastolic blood pressure supports the diagnosis of compartment syndrome and indicates consideration for immediate fasciotomy.
How do you prevent compartment syndrome? ›Complications may include muscle loss, amputation, infection, nerve damage, and kidney failure. Prevention efforts include ice and elevation of the affected extremity. Chronic compartment syndrome usually requires no treatment or surgery.
Does compartment syndrome affect vitals? ›Symptoms of Acute Compartment Syndrome
This condition could damage the vital organs, such as the liver and kidneys, as it restricts blood flow in these organs. A patient with ACS presents with one or multiple symptoms that usually appear immediately after the injury.
A syndrome diagnosis refers to a cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions. Examples of this diagnosis include: Decreased cardiac output. Decreased cardiac tissue perfusion.
What is associated with compartment syndrome? ›
The pain and swelling of chronic compartment syndrome is caused by exercise. People who participate in activities with repetitive motions, such as running or marching, are more likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the exercise, and is usually not dangerous.
Which of the following is most diagnostic for a compartment syndrome? ›Compartment pressure testing
This test, often called compartment pressure measurement, is the gold standard for diagnosing chronic exertional compartment syndrome. The test involves the insertion of a needle or catheter into your muscle before and after exercise to make the measurements.
Examples of three-part nursing diagnosis statements include: Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities. Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!”
What do I write in a nursing diagnosis? ›Nursing diagnoses must include the problem and its definition, the etiology of the problem, and the defining characteristics or risk factors of the problem. The problem statement explains the patient's current health problem and the nursing interventions needed to care for the patient.
How do you write a nursing care plan? ›- Step 1: Data Collection or Assessment. ...
- Step 2: Data Analysis and Organization.
- Step 3: Formulating Your Nursing Diagnoses. ...
- Step 4: Setting Priorities. ...
- Step 5: Establishing Client Goals and Desired Outcomes. ...
- Step 6: Selecting Nursing Interventions. ...
- Step 7: Providing Rationale.
- Step 8: Evaluation.
Your lower leg, for example, has four compartments. Chronic exertional compartment syndrome often occurs in the same compartment of an affected limb on both sides of the body, usually the lower leg. Signs and symptoms can include: Aching, burning or cramping pain in a compartment of the affected limb.
What are the two types of compartment syndrome? ›Two distinct types of compartment syndrome have been recognized. The first type is associated with trauma to the affected compartment, as seen in fractures or muscle injuries. The second form, called exertional compartment syndrome, is associated with repetitive loading or microtrauma related to physical activity.
What pressure is diagnostic of compartment syndrome? ›Any concern for compartment syndrome based on mechanism, or the presence of pain in the affected extremity, should prompt a compartment pressure check. Both absolute compartment pressures above 30 mm Hg and a pressure differential of less than 30 mm Hg are used to make the diagnosis.