An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?
a. Assess the pedal pulses.
b. Apply oxygen by nasal cannula. c.
Increase the IV flow rate.
d. Loosen the traction.
ANS: A
These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.
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