A patient presents with signs of acute arterial occlusion in the left leg, including pallor, coldness, and absent pulses, with a Doppler ultrasound confirming a thrombus in the femoral artery. What is the priority nursing intervention to prevent further complications while awaiting surgical intervention?

C) Administer prescribed heparin therapy as ordered

A) Elevate the affected leg above heart level

B) Apply warm compresses to the affected leg

C) Administer prescribed heparin therapy as ordered

D) Encourage ambulation to promote circulation

A patient with an acute arterial occlusion in the left leg is being prepared for potential surgical intervention. Which nursing intervention is the most critical to prevent further complications while awaiting surgery?

D) Administer prescribed anticoagulant therapy and monitor for bleeding.

A) Elevate the affected leg above heart level to reduce swelling.

B) Keep the patient NPO and monitor vital signs closely.

C) Apply warm compresses to the affected leg to promote circulation.

D) Administer prescribed anticoagulant therapy and monitor for bleeding.

A patient undergoing anticoagulation therapy with heparin is diagnosed with compartment syndrome and is scheduled for an urgent fasciotomy. Which nursing intervention is most critical to perform before the patient is taken to the operating room?

C) Ensure informed consent is signed and documented

A) Administer a preoperative antibiotic as ordered

B) Apply ice packs to the affected leg to reduce swelling

C) Ensure informed consent is signed and documented

D) Elevate the affected leg to promote venous return

A patient undergoing anticoagulation therapy with heparin presents with signs of compartment syndrome, including severe leg pain, swelling, and a confirmed compartment pressure of 35 mmHg. The patient is scheduled for an urgent fasciotomy. As the nurse prepares the patient for surgery, which of the following is the most critical nursing intervention to perform prior to the procedure?

D) Ensure the availability of emergency equipment and blood products

A) Administer additional heparin to ensure anticoagulation

B) Monitor and document the patient's pain level and vital signs

C) Educate the patient about the fasciotomy procedure and obtain informed consent

D) Ensure the availability of emergency equipment and blood products

A postoperative patient who underwent a fasciotomy is showing signs of reperfusion syndrome, indicated by elevated serum potassium levels. What is the nurse's priority action after administering calcium gluconate and insulin with glucose?

A) Monitor the patient's heart rhythm continuously for arrhythmias

B) Restrict fluid intake to prevent fluid overload

C) Apply warm compresses to the affected limb to promote circulation

D) Administer a diuretic to enhance potassium excretion

A patient who has undergone a fasciotomy is being closely monitored for post-operative complications. After the procedure, the nurse notes a serum potassium level of 5.6 mEq/L. Which of the following interventions should the nurse prioritize to address this condition?

C) Administer calcium gluconate to stabilize cardiac membranes.

A) Administer loop diuretics to promote potassium excretion.

B) Initiate dialysis to rapidly remove excess potassium from the bloodstream.

C) Administer calcium gluconate to stabilize cardiac membranes.

D) Increase dietary potassium intake to balance electrolyte levels.

A patient recovering from a fasciotomy for compartment syndrome presents with a decrease in dorsalis pedis pulse and increased numbness and tingling in the toes. A Doppler ultrasound shows decreased flow velocity in the distal arteries, and lab results indicate a rise in creatinine levels. Which nursing intervention is the most appropriate to address the renal complications?

B) Increase the rate of intravenous fluids as prescribed

A) Encourage the patient to drink more fluids independently

B) Increase the rate of intravenous fluids as prescribed

C) Apply warm compresses to the affected leg to improve circulation

D) Elevate the affected leg above heart level to reduce swelling

A nurse is caring for a patient recovering from a fasciotomy who is showing signs of decreased dorsalis pedis pulse and increased numbness and tingling in the toes. The patient also has a slight rise in creatinine levels. What is the most appropriate initial nursing action to address these findings?

C) Notify the healthcare provider immediately of the findings

A) Elevate the affected leg to reduce swelling

B) Administer pain medication to manage discomfort

C) Notify the healthcare provider immediately of the findings

D) Apply warm compresses to improve circulation

A patient with suspected rhabdomyolysis and signs of hypoperfusion is being monitored for renal function deterioration. Given the recent findings of elevated creatinine and potassium levels, which nursing intervention is the most critical to prioritize in the care plan?

B) Monitor cardiac rhythm continuously for signs of hyperkalemia.

A) Administer prescribed diuretics to manage fluid overload.

B) Monitor cardiac rhythm continuously for signs of hyperkalemia.

C) Encourage oral fluid intake to promote renal clearance.

D) Apply warm compresses to the lower extremities to improve circulation.

A nurse is caring for a patient with suspected rhabdomyolysis and worsening renal function who is also experiencing a downward trend in blood pressure. Which of the following nursing interventions should take priority to address the patient's current condition and prevent further complications?

A) Administer 0.9% normal saline bolus to improve circulating volume

B) Encourage the patient to increase oral fluid intake to enhance hydration

C) Apply warm compresses to the lower extremities to improve peripheral circulation

D) Prepare the patient for hemodialysis to address electrolyte imbalances

acute arterial occlusion - Nursing Case Study

Pathophysiology

• Primary mechanism: Acute arterial occlusion occurs when a blood clot (thrombus) or embolus suddenly blocks an artery, disrupting blood flow and depriving tissues of oxygen and nutrients, leading to ischemia.

• Secondary mechanism: The reduced blood supply triggers a cascade of inflammatory responses, causing endothelial injury and further promoting clot formation, which can exacerbate the blockage and tissue damage.

• Key complication: If untreated, prolonged ischemia can result in tissue necrosis and the potential for limb loss, emphasizing the need for rapid diagnosis and intervention to restore perfusion and prevent irreversible damage.

Patient Profile

Demographics:

58-year-old male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Hyperlipidemia

• Current medications: Lisinopril, Metformin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of severe pain in the left leg

• Key symptoms: Coldness and pallor of the left leg, diminished pulses, numbness and tingling in the foot, difficulty walking

• Vital signs: Blood Pressure 150/95 mmHg, Heart Rate 110 bpm, Respiratory Rate 22 breaths per minute, Temperature 98.6°F, Oxygen Saturation 94% on room air

Section 1

As the healthcare team conducts an initial assessment, further examination of the patient's left leg reveals critical findings. The affected leg is markedly colder to touch compared to the right leg, with a distinct pallor and cyanosis of the toes. Palpation fails to detect the dorsalis pedis and posterior tibial pulses, indicating a severe compromise in blood flow. Capillary refill time is delayed, exceeding four seconds. The patient's pain is escalating, now rating it as a 9 on a scale of 10, and he exhibits increasing anxiety due to the pain and fear of losing his leg. Neurological assessment shows decreased sensation in the lower leg and foot, with the patient reporting a pins-and-needles sensation now spreading further up the calf. These findings suggest a worsening ischemic condition that requires immediate intervention.

In response to these alarming symptoms, the medical team orders an urgent Doppler ultrasound to confirm the presence and extent of arterial occlusion. Additionally, a complete blood count (CBC) and coagulation profile are drawn to evaluate the patient's hematological status. The Doppler ultrasound reveals a significant thrombus in the femoral artery, confirming the suspected diagnosis of acute arterial occlusion. The CBC shows a mild leukocytosis, indicating a possible inflammatory response, while the coagulation panel is within normal limits, ruling out any intrinsic clotting disorder. Despite these results, the situation is critical, and the patient is at high risk for developing compartment syndrome due to increased pressure from the swelling in the ischemic leg tissues.

With the diagnosis confirmed, the vascular surgery team is promptly consulted for potential intervention options, including thrombolysis or surgical thrombectomy, to restore blood flow. The healthcare team prepares to initiate immediate anticoagulation therapy with heparin to prevent further clot propagation while closely monitoring the patient for signs of deterioration, such as worsening pain, changes in skin color, or further loss of sensation. The urgency of the situation underscores the critical need for timely treatment to salvage the limb and prevent irreversible damage.

Section 2

As the medical team implements the anticoagulation therapy with heparin, they remain vigilant for any changes in the patient's status. Within a few hours, there is a noticeable change. The patient's pain, initially localized to the calf, now extends further up the leg, prompting concern for potential compartment syndrome. The leg appears increasingly swollen, and the skin over the affected area feels tense and shiny. Despite the administration of heparin, the patient's anxiety intensifies as he continues to report a severe, unrelenting pain, now rated as a 10 on the pain scale. Vital signs reveal a rising heart rate of 112 beats per minute and a slight increase in respiratory rate to 22 breaths per minute, consistent with his heightened distress.

Recognizing the critical nature of these developments, the team conducts a compartment pressure measurement to assess for compartment syndrome. The pressure reading returns at 35 mmHg, confirming the diagnosis of compartment syndrome, a complication resulting from ischemic swelling in the leg. This new complication necessitates immediate surgical intervention. The vascular surgeon explains to the patient and his family the need for an urgent fasciotomy to relieve pressure and restore circulation, emphasizing the procedure's role in preventing permanent tissue damage or loss of the limb.

As plans for surgery are expedited, the patient's preoperative laboratory work is reviewed. Hemoglobin levels have dropped slightly to 11.2 g/dL, possibly reflecting the stress response or early signs of muscle breakdown due to ischemia. Electrolytes remain stable, but close monitoring is planned, especially for potassium levels, given the risk of reperfusion injury post-surgery. The patient is prepped for the operating room with the hope that swift surgical intervention will mitigate further complications and preserve limb function, setting the stage for the next critical phase of his medical journey.

Section 3

Following the fasciotomy, the patient is transferred to the recovery room, where the healthcare team closely monitors his vital signs and overall condition. Initially, there is a palpable sense of relief as the patient's heart rate gradually decreases to 98 beats per minute and the respiratory rate stabilizes at 18 breaths per minute. His pain level slightly decreases to a 7 on the pain scale, suggesting some alleviation from the procedure. The surgical site is carefully observed, with significant reduction in swelling and the tension in the leg visibly diminished. The patient's skin color over the affected area shows improvement with a return of capillary refill time to less than 3 seconds, indicating partial restoration of blood flow.

However, the team remains vigilant for potential post-operative complications. Within the next few hours, new laboratory results reveal a rise in serum potassium to 5.6 mEq/L, a signal of reperfusion syndrome as ischemic byproducts are released into the bloodstream. The team addresses this with prompt administration of calcium gluconate and insulin with glucose to stabilize potassium levels and prevent cardiac complications. Renal function tests, including blood urea nitrogen (BUN) and creatinine, are monitored closely to assess for acute kidney injury, a known risk in such scenarios. The patient is also started on intravenous fluids to support kidney perfusion and manage potential rhabdomyolysis.

As the patient progresses through the immediate post-operative phase, the clinical team continues to evaluate his response to interventions. Regular neurovascular checks are performed, focusing on any changes in sensation or muscle weakness that could indicate further complications. The healthcare providers remain engaged in a dynamic process of reassessment and intervention, ensuring that any deviations from expected recovery are promptly addressed. This vigilant approach is crucial as the patient transitions into the next phase of care, where the focus will shift towards rehabilitation and optimizing functional recovery of the affected limb.

Section 4

As the patient continues to recover from the fasciotomy, the healthcare team remains attentive to any new developments in his condition. During a routine neurovascular assessment, the nurse notes a slight decrease in the patient's dorsalis pedis pulse on the affected leg, which has become faint compared to previous checks. In addition, the patient reports increased numbness and tingling in his toes, raising concerns about potential compartment syndrome recurrence or other circulatory issues. Recognizing these signs as potentially significant, the nurse promptly informs the attending physician, who orders an immediate Doppler ultrasound to assess blood flow and rule out any new obstructions.

The Doppler ultrasound reveals a decrease in flow velocity in the distal arteries, suggesting that while the fasciotomy initially relieved compartment pressure, there might be lingering issues affecting perfusion. Concurrently, the patient's laboratory results show a slight rise in creatinine to 1.8 mg/dL, indicating that renal function is becoming compromised. The team suspects a mild acute kidney injury, likely exacerbated by ongoing reperfusion injury and possible rhabdomyolysis. In response, the medical team adjusts the patient's fluid therapy, increasing the rate of intravenous fluids to ensure adequate renal perfusion and prevent further kidney damage.

This change in the patient's status prompts the healthcare team to refine their management strategy. The patient is placed on close hemodynamic and renal monitoring, with frequent checks of urine output and additional blood tests scheduled to track electrolyte levels and kidney function. The interdisciplinary team, including a nephrologist, is consulted to provide expertise on managing the developing renal complications. With these steps, the team aims to stabilize the patient's condition, mitigate further complications, and facilitate a smoother transition to the rehabilitation phase, focusing on restoring functionality while preventing long-term damage.

Section 5

As the healthcare team continues to monitor the patient's condition, they notice a change in his status during the night shift. The patient's blood pressure begins to trend downwards, recorded at 90/60 mmHg, and he reports feeling increasingly fatigued and lightheaded. The nurse performs a thorough assessment and notes that the patient's skin is cool and pale, particularly in the lower extremities, with capillary refill time extending beyond 3 seconds. These findings raise concerns about potential hypoperfusion and underscore the importance of reassessing the adequacy of the current fluid therapy.

In response to these changes, the attending physician orders a repeat Doppler ultrasound and additional laboratory tests to evaluate the patient's hemodynamic status and renal function. The ultrasound confirms a further decrease in flow velocity in the distal arteries of the affected leg, suggesting that the initial intervention may not have fully addressed the underlying vascular compromise. Concurrent laboratory results reveal a further increase in creatinine to 2.2 mg/dL and a rise in creatine kinase levels, supporting the suspicion of ongoing rhabdomyolysis. Electrolyte imbalances are also noted, with a potassium level of 5.8 mEq/L, indicating a risk of hyperkalemia.

Given these developments, the interdisciplinary team decides to adjust the patient's treatment plan. The nephrologist recommends the initiation of renal-protective measures and the careful administration of diuretics to manage fluid overload while avoiding exacerbation of kidney injury. Additionally, the vascular surgeon is consulted to explore further surgical interventions to improve arterial flow. The team emphasizes the need for vigilant monitoring of the patient's cardiovascular and renal status, recognizing the critical nature of these complications and the necessity of timely intervention to prevent further deterioration. As the patient progresses through this challenging phase, the healthcare team remains committed to stabilizing his condition and setting the stage for future recovery and rehabilitation.