A nurse is assisting with the care of a client in a PACU

Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

A long leg cast is used to immobilize fractures and promote bone healing, but it can also lead to complications such as compartment syndrome, impaired circulation, and nerve compression. After cast application, ongoing assessment of neurovascular status is essential to detect early signs of compromised perfusion. Pain that worsens rather than improves is a critical warning sign of potential complications requiring immediate intervention. Nurses must differentiate expected discomfort from abnormal findings that indicate tissue ischemia.

Rationale:
A. Increasing pain in the affected extremity is a hallmark early sign of compartment syndrome or impaired circulation under the cast. This type of pain is often severe, unrelieved by analgesics, and may worsen with movement. It indicates rising pressure within the muscle compartments that can compromise blood flow and tissue viability, requiring immediate provider notification.

B. Itching beneath the cast is a common and expected finding during the healing process. It results from skin dryness and tissue regeneration under immobilization. Although uncomfortable, it does not indicate neurovascular compromise and can be managed with safe comfort measures.

C. Warm toes indicate adequate peripheral perfusion and are a normal finding after cast application. This suggests that arterial blood flow to the distal extremity is intact. It is a reassuring sign rather than an abnormal one that requires reporting.

D. Capillary refill of 3 seconds is slightly delayed but may still be within acceptable limits depending on baseline and clinical context. However, it is less urgent than escalating pain. It should be monitored closely, but increasing pain is a more critical early indicator of compromised circulation that requires immediate attention.

Delirium is an acute, fluctuating change in cognition and attention commonly triggered by infection, hospitalization, and underlying medical conditions. The client demonstrates signs of sepsis (fever, hypotension, elevated WBC) and acute mental status changes including confusion, disorientation, and perceptual disturbances. Early recognition of cognitive changes such as altered orientation and hallucinations is essential for prompt intervention and prevention of complications.

Rationale for correct choices:

• Change in orientation: A change in orientation is a hallmark feature of delirium, especially when it develops acutely in hospitalized older adults. The client initially was oriented to person, place, and time but later became disoriented to time and place. This fluctuating confusion reflects acute brain dysfunction rather than a chronic cognitive disorder. Infections, such as postoperative wound infection, are a common precipitating factor for delirium.

• Hallucinations: Hallucinations are a key feature of delirium and indicate severe disturbance in perception and cognition. The client’s report of spiders crawling on them represents a visual and tactile hallucination, which is classic for delirium. These symptoms often fluctuate and are triggered by infection, hypoxia, or metabolic imbalance. The presence of hallucinations signals worsening neurocognitive impairment requiring immediate intervention.

Rationale for incorrect choices:

• Past medical history: Although conditions such as Parkinson’s disease, hearing loss, and visual impairment increase the risk of delirium, past medical history itself is not an active indicator of delirium development. It represents predisposing risk factors rather than current clinical manifestations. Delirium is diagnosed based on acute changes in mental status, not historical conditions. Therefore, this is not a direct identifying sign of delirium.

• Illusions: Illusions are misinterpretations of real external stimuli (e.g., mistaking a coat on a chair for a person). Although they can occur in delirium, they are not the specific finding described in this case. The client is reporting seeing and feeling spiders that are not present, which is more consistent with hallucinations rather than misinterpretation. Therefore, illusions are not the best descriptor for the client’s current symptoms.