The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first?

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Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast removal), irreversible nerve and muscle injury can occur. (Option B) Immobilization of the extremity in a sling can lead to venous pooling and edema of the hands and fingers if the sling is not applied properly. The nurse should evaluate the elbow and hand positions and perform a neurovascular assessment, but this is not the priority. elbow and hand positions (Option C) Sanguineous (red) wound drainage at 25 mL/hr is expected 1 day postoperative knee replacement. Drains are usually removed in 24 hours unless drainage is excessive (eg, >1500 mL/24 hr). (Option D) Anticoagulant therapy (eg, unfractionated heparin, enoxaparin, fondaparinux) is standard following total hip replacement. Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50% [0.39-.50], 13.2-17.3 g/dL [132-173 g/L], respectively) are expected due to intra- and postoperative blood loss. Educational objective: Compartment syndrome is a medical emergency that requires decompression within 4-6 hours of onset (eg, fasciotomy, cast removal) to prevent irreversible nerve and muscle injury.

The Nurse on the Orthopedic Unit Receives Information During Evening