Bones

The nurse feels behind and below the medial malleolus for the posterior tibial pulse and compares both feet; when a cast covers the ankle, this pulse cannot be felt, so the nurse checks the toes' color, warmth, capillary refill, feeling, and movement instead. Pain out of proportion to the injury, pain when the toes are moved passively, numbness, a cool pale foot, or a pulse that was present and is now gone means the nurse keeps the leg at heart level, loosens any tight dressing, and notifies the provider immediately. Pain comes before pulse loss, and lost blood flow or compartment syndrome can permanently damage nerve and muscle within hours.

Landing on the feet from a height can break one or both heels and, in about 1 in 10 patients, the thoracolumbar spine too, so assess for back pain, check leg sensation and movement, and keep the spine immobilized until it is cleared. Watch the injured foot for compartment syndrome: pain out of proportion to the injury or with passive toe movement, tense swelling, and numbness or tingling. If these appear, keep the foot at heart level instead of raised, remove ice, loosen any tight dressing or splint, and notify the provider immediately, because the trapped pressure cuts off blood flow and fasciotomy is time-critical.

In the first 24 to 72 hours after a femur fracture, fat from the marrow can travel to the lungs and brain. The nurse watches for sudden shortness of breath, a falling oxygen saturation, new confusion or restlessness, and tiny red-purple spots on the chest, armpits, or neck. The nurse raises the head of the bed, gives oxygen, and calls the provider or rapid response team at once.

The nurse checks both feet and compares them after a leg cast or surgery, after a procedure through the groin artery, and in peripheral artery disease, and marks a hard-to-find pulse with a pen. The artery is absent or hard to feel in some healthy people, so a pulse never found is checked with the posterior tibial pulse behind the inner ankle bone and a Doppler. A pulse that was present and then disappears means blood flow may be blocked: the nurse checks the other foot and the groin site for bleeding or swelling, and notifies the provider at once.

The nurse checks the toes for color, warmth, capillary refill under about 3 seconds, sensation, and movement, and compares with the other foot. Early warnings are pain out of proportion to the injury, pain not relieved by the ordered pain medicine, pain that gets worse when the toes are passively stretched, and numbness or tingling. Pale, cool, or pulseless toes, or toes the patient cannot move, are late signs. The nurse keeps the limb at heart level rather than elevated, does not apply ice, loosens any tight dressing, notifies the provider immediately, and prepares for the cast to be split or for a fasciotomy.

The nurse checks the knee jerk (normal is 2+) every hour or per protocol, along with respiratory rate and urine output, because magnesium dampens nerves in order: reflexes fade before breathing slows, and the kidneys are the only way it leaves the body. If the reflex is absent, respirations fall below 12, or urine output drops below 30 mL/hr, the nurse stops the infusion, notifies the provider, and has calcium gluconate, the antidote, ready. With an epidural in place the knee jerk may be blunted, so the nurse tests the biceps or brachioradialis reflex instead.

A brisk 3+ or 4+ knee jerk, especially with ankle clonus (rhythmic beats of the foot after a quick upward flex), means the brain is irritable and an eclamptic seizure may be near. The nurse reports it right away with the blood pressure, headache, visual changes, and upper abdominal pain, and starts seizure precautions per facility policy, with suction and oxygen ready and a quiet, dim room. Magnesium sulfate is given to prevent the seizure, not to lower the blood pressure.

After a tibial fracture, crush injury, or tight cast, pain out of proportion to the injury, pain that gets worse when the nurse gently stretches the toes, pain opioids do not relieve, and new numbness or tingling mean pressure in a muscle compartment is choking off blood flow; a lost pulse is a late sign, and the nurse does not wait for it. The nurse keeps the leg at heart level, not raised, because elevation lowers the blood pressure feeding the compartment, loosens tight dressings or wraps, and notifies the provider at once. A cast is split or bivalved on the provider's order, and the definitive treatment is surgical fasciotomy.

The tibia lies just under the skin, so its fractures often break through it and let bacteria reach the bone. The nurse controls bleeding with direct pressure, covers the wound with a sterile dressing, does not push bone ends back in or try to straighten the leg, splints it as found, and checks pulses, color, warmth, sensation, and movement below the injury before and after splinting. The nurse keeps the patient NPO for surgery and expects IV antibiotics and a tetanus status check.