Lancaster General College of Nursing & Health SciencesDivision of Nursing

Nursing 112: Medical-Surgical Clinical Preparation Sheet

1 (Rev. 12/22/10)

Lancaster General College of Nursing & Health SciencesDivision of Nursing

Nursing 112: Medical-Surgical Clinical Preparation Sheet

NUR 112 Pathophysiology Concept Map

The entire Concept Map is about the medical diagnosis; after it is completed, the student must * patient-specific items

2 (Rev. 12/22/10)

Definition:

A condition in which increased pressure within one or more compartments reduces circulation to the area. The most common sites for this problem in patients with musculoskeletal trauma are the compartments in the lower leg and forearm. Intra-abdominal pressure can increase in patients with abdominal injury, especially blunt trauma, and may do so to

Pathophysiology:

Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Most compartments are located in the extremities. Fascia is an inelastic tissue that surrounds groups of muscles, blood vessels, and nerves in the body. The pathophysiologic changes of increased compartment pressure are

Manifestations (signs and symptoms):

Early signs of ACS include the 6 P’s: pain, pressure, paralysis, paresthesias, pallor, and pulselessness. Pain is increased even with passive motion and may seem out of proportion to the degree of injury. Numbness and tingling or paresthesias may be the first signs of a problem. The affected extremity is pale and cool

Diagnostics:

See above.Medical Diagnosis:

Acute Compartment Syndrome

Community Resources:

Nursing Diagnoses:

Acute pain

Nursing Interventions:

Thorough assessment, including pain that exceeds the level of injury.

Assess tightness of adduction pillows, casts, bandages, etc.

Administer pain medications, IV fluids, Kayexalate, diuretics, vasopressors as ordered.

Monitor IAP.

Medical/Surgical Management:

ACS creates an emergency situation when it occurs. Within 4-6 hours after the onset of compartment syndrome, neurovascular and muscle damage irreversible. The limb can become useless in 24 to 48 hours.

In a few cases, compartment pressure may be monitored on a one-time basis with a handheld device with a digital display, or

References/pages:

Iggy 1180 – 1182,

1308-1309