Compartment syndrome is a serious condition characterized by inflammation and increased pressure within a muscle compartment (muscles, nerves, and vessels within the fascia). While this condition occurs mostly in the lower extremities, it can develop in any muscle group.
This condition may be caused by decreased compartment size due to restrictive dressings or casts, excessive traction, or due to edema, inflammation, or bleeding within the compartment.
The inflammatory process can create high pressure in the muscle compartment causing circulatory obstruction and venous occlusion. Ischemia along with muscle and nerve damage will start to occur, reducing oxygenation and causing tissue death.
Delays in the diagnosis and treatment of this condition can cause irreversible damage to muscles and nerves and loss of function of the affected muscle compartment.
Compartment syndrome can occur immediately due to the body’s initial inflammatory response following an injury or it may be delayed, occurring several days after an injury. Signs and symptoms of this condition include:
- Pain – Severe pain not relieved by analgesics
- Pressure – characterized as increasing within the muscle compartment
- Paresthesia – numbness or tingling sensation
- Pallor – loss of normal color of the affected body part
- Paralysis – loss of function of the affected extremity
- Pulselessness – decreased or absent peripheral pulses
This condition may be categorized as acute or chronic. Acute compartment syndrome is considered a surgical emergency and must be treated right away to prevent muscle and nerve damage. Chronic compartment syndrome, on the other hand, happens gradually following repetitive muscle use and resolves after stopping the activity.
A physical exam, compartment pressure measurement testing, magnetic resonance imaging (MRI), and X-ray can help diagnose compartment syndrome.
The Nursing Process
Since compartment syndrome can lead to poor outcomes and high morbidity, prompt diagnosis and treatment are critical. Early detection and effective treatment of this condition can prevent loss of function and permanent damage to the muscles and nerves.
Proper assessment is essential for the prompt treatment of compartment syndrome. This condition may occur after the application of a cast or pressure dressing that may impede circulation. The nurse must quickly identify signs and symptoms that are consistent with this condition. Additionally, frequent neurovascular assessments are necessary to monitor progression.
The nurse is also responsible for administering medications, assisting in fasciotomy, and providing education about the condition, treatment, and possible complications.
Acute Pain Care Plan
A classic sign of compartment syndrome is severe pain that worsens when the muscles are stretched and is not relieved by analgesia. Accurate evaluation and prompt treatment enable timely intervention and prevent complications for patients suffering from compartment syndrome.
Nursing Diagnosis: Acute Pain
- Inflammatory process
- Bleeding within the compartment
As evidenced by:
- Reports of severe, unrelieved pain
- Guarding behavior
- Facial mask of pain/grimace
- Crying and restlessness
- Tachycardia, hypertension, tachypnea
- The patient will verbalize pain decreased with prescribed medications
- The patient will display vital signs within normal limits
Acute Pain Assessment
1. Assess and monitor the patient’s vital signs.
Assessment of vital signs is essential to help monitor a patient’s inpatient progress. Increases in blood pressure, pulse, and respirations occur when pain is not controlled.
2. Assess the patient’s pain characteristics.
Pain can be managed and treated effectively once an accurate pain assessment is conducted. It is important to assess the extent of the pain, its characteristics, location, and onset. Pain that is out of proportion to the patient’s level of injury and unrelieved with the use of analgesics is considered a sign of compartment syndrome.
Acute Pain Interventions
1. Evaluate the onset of the pain.
In compartment syndrome, it is essential to determine whether the condition is acute or chronic so proper interventions and treatment can be initiated.
2. Continuously monitor the patient’s condition along with the emerging signs and symptoms.
Consider other signs of discomfort such as tightness, numbness, or tingling that signal compartment syndrome.
3. Administer pain medications as indicated and evaluate pain score 30 minutes to an hour following administration.
Monitoring the effects of pharmacologic interventions can help determine the effectiveness of the medication. If pain is not relieved, compartment syndrome may be considered and the healthcare provider alerted.
4. Do not elevate or apply a cold compress to the affected extremity.
Elevating the affected extremity and applying a cold compress can cause vasoconstriction and may worsen the condition.
5. Prepare the patient for surgery as indicated.
Acute compartment syndrome may require immediate fasciotomy (incision into the fascia) to relieve pressure and prevent further damage to the affected nerves and muscles. Preoperative education prepares the patient for surgery as well as what to expect after the surgery.
Ineffective Peripheral Tissue Perfusion Care Plan
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
- Decreased peripheral blood flow to the affected body parts
- Inflammatory process
As evidenced by:
- Absence of or decreased peripheral pulses
- Altered motor function or paralysis
- Altered skin temperature or pallor
- Inflammation or edema
- Severe pain
- Paresthesia or numbness
- The patient will be able to achieve optimum tissue perfusion in the affected tissues as evidenced by palpable and strong pulses, reduced pain, and regained limb strength.
- The patient will not experience loss of limb or muscle function
Ineffective Peripheral Tissue Perfusion Assessment
1. Assess and monitor for compartment syndrome after surgery.
Casts and pressure bandages can block circulation following fractures or surgery. The nurse can monitor for this complication by regularly assessing the patient’s feelings of pain, tingling, or tightness.
2. Perform neurovascular assessments frequently.
It is essential to monitor and assess the patient’s neurovascular status following surgery or cast application. The nurse should perform regular assessments of skin color, temperature, and pulse strength.
Ineffective Peripheral Tissue Perfusion Interventions
1. Prepare the patient for surgery as indicated.
Fasciotomy is a surgical procedure that helps relieve pressure and restores blood circulation in the affected area. Fasciotomy may be performed at the bedside in some instances.
2. Discuss interventions to help relieve the pressure.
Patients who have had surgery may develop compartment syndrome due to bulky dressings or tight casts. Bandages may be loosened or casts may be cut to help relieve pressure. These should be performed by the healthcare provider as alerted by the nurse.
3. Administer supplemental oxygen as needed.
Providing supplemental oxygen is essential to ensure adequate oxygenation to peripheral tissues.
4. Ensure adequate hydration through the intravenous route as indicated.
Perfusion to the affected area is significantly improved by providing adequate hydration through IV fluids.
5. Ensure that the limbs are at a neutral level and not elevated.
Elevating the affected extremity can compromise blood flow and worsen compartment syndrome.
Impaired Physical Mobility
Impaired physical mobility is common in patients suffering from compartment syndrome. Paralysis, one of the complications of compartment syndrome, can result from prolonged nerve compression or muscle damage, rendering the patient unable to actively move limbs.
Nursing Diagnosis: Impaired Physical Mobility
- Neuromuscular skeletal impairment or injury
As evidenced by:
- Expressions of discomfort when moving
- Inability to move purposefully
- Reluctance in attempting movement
- Decreased muscle strength and control
- Decreased activity tolerance
- Limited range of motion
- The patient will maintain or regain mobility at the maximum possible level
- The patient will participate in PT to increase the strength or function of the affected body part
Impaired Physical Mobility Assessment
1. Assess the patient’s degree of immobility.
Compare the patient’s current mobility level to their described baseline.
2. Assess the emotional effect on physical abilities.
The loss of physical mobility can be devastating and feelings of depression, frustration, or powerlessness can further delay goals.
Impaired Physical Mobility Interventions
1. Assist with active and passive range of motion exercises as indicated.
Passive range of motion exercises can enhance blood circulation, improve muscle tone, preserve joint mobility, and prevent atrophy.
2. Develop new ways to perform ADLs.
Help the patient remain in control of the situation. They may not be able to perform ADLs as easily as they used to but assist the patient in recognizing how they can still maintain their independence.
3. Obtain assistive devices as needed.
Assistive devices like walkers, canes, wheelchairs, grab bars, trapezes, and crutches can help increase the patient’s mobility.
4. Encourage the patient to participate in diversional activities.
This will provide the opportunity to refocus attention and enhance the patient’s self-esteem and control.
5. Administer medications as indicated.
Analgesic and antispasmodic drugs can be prescribed to lessen the patient’s discomfort as it interferes with mobility.
6. Assist the patient in accepting limitations.
It is vital to let the patient accept limitations and abilities. Safety measures should be implemented to prevent further injuries.
7. Consult with physical or occupational therapists.
Rehabilitation should be implemented following treatment for compartment syndrome to prevent loss of strength and further complications.
References and Sources
- Compartment Syndrome. Cleveland Clinic. Last reviewed by a Cleveland Clinic medical professional on 02/15/2021. https://my.clevelandclinic.org/health/diseases/15315-compartment-syndrome
- Compartment Syndrome. OrthoInfo. Copyright ©1995-2021 by the American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases–conditions/compartment-syndrome/
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Pechar, J., & Lyons, M. M. (2016). Acute Compartment Syndrome of the Lower Leg: A Review. The journal for nurse practitioners: JNP, 12(4), 265–270. https://www.npjournal.org/article/S1555-4155(15)01044-2/fulltext
- Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/
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.
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 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 an example of syndrome nursing diagnosis? ›
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 a 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 the 5 nursing interventions? ›
These are assessment, diagnosis, planning, implementation, and evaluation.How do you write a care plan example? ›
- Personal details.
- A discussion around health and well being goals and aspirations.
- A discussion about information needs.
- A discussion about self care and support for self care.
- Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
- Step 1: Assess the Patient.
- Step 2: Sort Out a Diagnosis.
- Step 3: Plan Patient Goals and Desired Outcomes.
- Step 4: Compile an Evaluation.
- Step 5: Write it All Out.
Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).What are the 4 types of 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.
How do you manage patients with compartment syndrome? ›
Acute compartment syndrome must get immediate treatment. A surgeon will perform an operation called a fasciotomy. To relieve pressure, the surgeon makes an incision (cut) through the skin and the fascia (compartment cover). After the swelling and pressure go away, the surgeon will close the incision.What interventions are there for compartment syndrome? ›
Abdominal compartment syndrome treatments include life support measures like mechanical ventilation, medicines to support blood pressure (vasopressors), and kidney replacement therapies (such as dialysis). Surgery to open the abdomen in order to reduce the compartment syndrome pressures may be necessary.What is a syndrome diagnosis? ›
(SIN-drome) A set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.What is nursing diagnosis and related factors? ›
When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient. Related factors is the terminology used for the underlying causes (etiology) of a patient's problem or situation.What best describes a nursing diagnosis? ›
The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.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 6 Ps of compartment syndrome nursing? ›
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.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.
Diagnosis: identification of the problem to be addressed. Planning: determination along with the patient on how to manage the diagnosis. Implementation: carrying out the plan of care.What is a nursing intervention examples? ›
Examples of nursing interventions include administering treatments, procedures and medications to patients. Educating patients or adjusting their resting position is also a nursing intervention.
How do you write a care plan summary? ›
- Assess the patient. The first step to writing a care plan is performing a patient assessment. ...
- Make a diagnosis. ...
- Set goals and outcomes. ...
- Determine nursing interventions. ...
- Evaluate the plan.
- their goals, needs and preferences.
- the services that you will provide or organise.
- who will provide the services.
- when services will be provided, such as frequency, days and times.
- care management arrangements.
- how involved the person will be in managing their package.
The basic care plan includes:
A health assessment (a review of your health condition) that begins on the day you're admitted, and must be completed within 14 days of admission. A health assessment at least every 90 days after your first review, and possibly more often if your medical status changes.
Modify the care plan
To add a problem to the Care Plan, click New Problem. To add a goal to a care plan problem, click New Goal next to the corresponding problem. To add a task to a goal, click New Task next to the corresponding goal.
The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient's health problems, risks, and strengths, and formation of diagnostic statements.What is an example of a 2 part nursing diagnosis? ›
TWO-PART NURSING DIAGNOSIS: Risk Nursing Diagnosis are written in the two-part format. The first part indicates the diagnostic label and the second part indicates the presence of risk factors or confirmation for a risk nursing diagnosis. Example: 'Risk for infection related to compromised immune system''.What is a 3 part nursing diagnosis statement? ›
A nursing diagnosis generally has three components: a diagnosis approved by NANDA-I, a related to statement which defines the cause of the NANDA-I diagnosis, and an as evidenced by statement that uses specific patient data to provide a reason for the NANDA-I diagnosis and related to statement.How do you write a risk nursing diagnosis? ›
Key considerations on how to write a risk for nursing diagnosis entail the different risk factors a community, family, or individual face in relation to a specific health problem. The risk factors are an indication that the patient is predisposed to higher future risk of acquiring the health problem compared to others.Do you elevate extremities for compartment syndrome? ›
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.Which goals are most important when managing and treating abdominal compartment syndrome? ›
Fluid resuscitation and “early goal-directed therapy” are cornerstones of critical care management. Excessive fluid resuscitation is an independent predictor of IAH/ACS and should be avoided. The use of goal-directed hemodynamic monitoring should be considered to achieve appropriate fluid resuscitation.
How is compartment syndrome diagnosed and treated? ›
If symptoms point to chronic compartment syndrome, your doctor performs a compartment pressure test before and after a workout to compare pressure levels. If either or both readings indicate high pressure, you have chronic compartment syndrome. Your doctors may recommend medical treatment or surgery.What are the 7 P's for compartment syndrome? ›
Early suspicion of the disease should invoke an immediate response. 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 an example of a syndrome? ›
For instance, Irritable Bowel Syndrome, Chronic Fatigue Syndrome, or Polycystic Ovary Syndrome, all of which are more common in women, and in the case of Polycystic Ovary Syndrome, only occur in women. Syndromes are defined by a group of signs or symptoms.What are the three types of syndrome? ›
There are three types of Down syndrome: Trisomy 21 (nondisjunction), Mosaicism, and Translocation. Below is a chart that outlines the cell division process of regular cells.When do you use diagnosis and diagnoses? ›
The plural form is diagnoses, pronounced [ dahy-uhg-noh-seez ]. The verb form is diagnose. A doctor can be said to diagnose an illness or a patient but the meaning is the same—to diagnose is to give a diagnosis of what specific condition is affecting the patient.Can nurses explain diagnosis to patients? ›
Nurses should ensure they are not communicating a diagnosis to patients when discussing test results or assessment findings, unless it has been formally delegated by an NP or physician. When appropriate, you can recommend that patients follow up with an NP or their physician to receive the definitive diagnoses.What are the three parts of a patient care plan? ›
Care Plan Fundamentals
- The What: What does the patient suffer from? ...
- The Why: Why does your patient suffer from this? ...
- The How: How can you make this better?
Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated.What are the interventions of compartment syndrome? ›
Acute compartment syndrome must get immediate treatment. A surgeon will perform an operation called a fasciotomy. To relieve pressure, the surgeon makes an incision (cut) through the skin and the fascia (compartment cover). After the swelling and pressure go away, the surgeon will close the incision.What are the 3 nursing interventions? ›
There are typically three different categories for nursing interventions: independent, dependent and interdependent.
What are the 4 P's of compartment syndrome? ›
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.How do you monitor compartment syndrome? ›
If symptoms point to chronic compartment syndrome, your doctor performs a compartment pressure test before and after a workout to compare pressure levels. If either or both readings indicate high pressure, you have chronic compartment syndrome. Your doctors may recommend medical treatment or surgery.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 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 is the nursing diagnosis priority? ›
Nursing diagnoses are ranked in order of importance. Survival needs or imminent life-threatening problems take the highest priority. For example, the needs for air, water, and food are survival needs.