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Compartment Syndrome Nursing Care Plan and Interventions
The early sign of compartment syndrome is pain out of proportion to the injury, especially pain with passive stretch. Loosen dressings or casts, keep the limb at heart level (not above), notify the provider at once and prepare for fasciotomy.
Compartment syndrome nursing care plan
| Nursing problem | Goal | Key interventions |
|---|---|---|
| Risk for peripheral neurovascular dysfunction | Pain, pulses and sensation monitored; changes reported at once. | |
| Acute pain | Pain trend checked against expected course. | |
| Risk for kidney injury (muscle breakdown) | Potassium and urine output monitored. |
Problem wording is plain-language nursing diagnosis style. Your program may require NANDA-I labels and your own assessment data.
What it is
Compartment syndrome: what it is
Swelling inside a closed muscle compartment raises the pressure until blood can't get in. Muscle and nerve start dying within hours. 1,2
Causes: fractures (most often lower leg or forearm), crush injuries, and tight casts or bandages.
Assessment: what you will see
Early sign: pain out of proportion
Worsening pain that is out of proportion to the injury and gets worse when the muscle is passively stretched. 1,2
Gently extend the client's toes or fingers. Sharp pain in the calf or forearm is a red flag.
Late signs: don't wait for them
Numbness or tingling and a tense compartment, then pallor, pulselessness and paralysis. The pulse can stay present while tissue dies. 2,1
Waiting for a lost pulse means waiting too long.
Complications and red flags
Watch potassium and kidneys
Dying muscle can release potassium and a protein that harms the kidneys (rhabdomyolysis). Monitor potassium and urine output. 2
High potassium can trigger dangerous heart rhythms.
Priority: what the nurse does first
First actions
Loosen or remove the cast, splint or dressing. Keep the limb at heart level, not elevated. Notify the provider immediately. 3,4
Raising the limb lowers blood flow to tissue that is already starving.
Nursing interventions and treatment
Fasciotomy
Measuring compartment pressure can confirm it. Treatment is fasciotomy: cutting through the skin and fascia to relieve the pressure. 2,4
Unless pressure and symptoms ease quickly after the cast comes off, fasciotomy is urgent.
Evaluation: is care working?
Monitor the at-risk limb
Frequent neurovascular checks. Measure limb size at the same marked spot each time and compare with the other limb. 1
A cast that feels too tight gets reported right away, not tolerated.
Keep studying compartment syndrome in NurseLingo Pro
Everything for compartment syndrome in one place. A free account gets 5 free opens of any condition; Pro opens all 277.
Test yourself: free med-surg practice questions with answers and rationales.
Frequently asked questions
What are the priority nursing diagnoses for compartment syndrome?
Common nursing problems for compartment syndrome include risk for peripheral neurovascular dysfunction; acute pain; risk for kidney injury (muscle breakdown). Choose the ones your assessment supports and rank airway, breathing and circulation problems first.
What does the nurse do first for compartment syndrome?
Loosen or remove the cast, splint or dressing. Keep the limb at heart level, not elevated. Notify the provider immediately.
Which nursing intervention is essential in caring for a client with compartment syndrome?
Loosen or remove the cast, splint or dressing, keep the limb at heart level (not elevated) and notify the provider right away. Pain out of proportion to the injury, especially with passive stretch, is the early sign. Prepare for a fasciotomy.
What are the 7 P's of compartment syndrome?
A common teaching list is pain, pressure, paresthesia, pallor, paralysis, pulselessness and poikilothermia (a cool limb). Pain out of proportion is the early sign; pallor, paralysis and pulselessness are late, so act before they appear.
More bones, joints & skin
Sources
- OpenStax Clinical Nursing Skills, 25.2
- merckmanuals.com
- pmc.ncbi.nlm.nih.gov
- OpenStax Medical-Surgical Nursing, 13.3
For study only, not medical advice. Follow your program, your facility's policies and the provider's orders.