The nurse assesses the client in the postanesthesia are unit after the surgical repair of a fractured femur. Which assessment data cues the nurse to assess the client for compartment syndrome? (Select all that apply.)

Question

1. Burning in feet
2. Dressing is tight
3. Feet are edematous
4. Blood pressure low
5. Peripheral pulses 2+
6. Affected leg feels cool

Answer 1

2, 3, 6
2, 3, and 6. The nurse suspects compartment syndrome in the client with a tight dressing after leg surgery. In compartment syndrome, a well-defined area of soft tissue becomes edematous, fills an inflexible space (cast or dressing), and impairs perfusion to, venous return from, and innervation of the extremity, resulting in weak pulses and cool skin, aggravation of edema, and loss of function and sensation. The hallmark sign of compartment syndrome is loss of function.
1, 4, and 5. Burning sensation, hypotension, and normal peripheral pulses are inconsistent with clinical indicators of compartment syndrome; hypotension is a late sign of compartment syndrome resulting from bleeding.