A nurse is teaching a group of parents about car seat safety. Which of the following statements should the nurse include in the teaching?

Rationale for correct choices

• Compartment syndrome: The adolescent demonstrates escalating pain despite repeated opioid administration, along with moderate edema, delayed capillary refill, and numbness/tingling in the affected limb. These signs indicate increased pressure within the casted compartment, which can compromise circulation and nerve function.

• Increasing capillary refill times: Capillary refill has lengthened from 3 to 4 seconds, suggesting impaired peripheral perfusion in the affected extremity. This change indicates vascular compromise and aligns with the pathophysiology of compartment syndrome. Monitoring these subtle vascular changes helps identify early ischemia before permanent damage occurs.

Rationale for incorrect choices

• Pneumonia: Shallow respirations and a slightly increased respiratory rate are present but are mild and likely related to pain or anxiety. Breath sounds remain clear, and oxygen saturation is slightly decreased but not critically low. There is no productive cough, fever spikes, or infection in the lungs, making pneumonia less likely.

• Infection: While the adolescent’s temperature has risen slightly, there is no redness, drainage, or local signs at the surgical site. White blood cell counts are not provided, and systemic signs of infection are minimal. The mild fever could be due to stress or inflammation from surgery rather than infection. Current symptoms points toward neurovascular compromise rather than infection.

• Shallow respirations: Although respirations are shallow at times, this finding alone is more consistent with pain or guarding from the femur injury than with a systemic complication. Respiratory assessment does not demonstrate adventitious sounds or significant hypoxia. Shallow breathing is not the primary indicator of compartment syndrome.

• Increasing respiratory rate: The rise in respiratory rate is minor and likely a response to pain, stress, or mild hypoxia, not the early sign of compartment syndrome. Tachypnea without other systemic signs does not reliably indicate limb vascular compromise. While important to monitor, it is not specific to the identified risk.

A. Withhold the medication if the client does not appear to be in pain: Pain is subjective, and nurses must rely on the client’s self-report rather than appearance. Withholding analgesia based solely on observation may lead to undertreatment of pain.

B. Withhold the medication if the client has a fever: Fever is not a contraindication for hydromorphone administration. Pain management should be based on client need and assessment, while fever is monitored and treated separately if necessary.

C. Count the current number of unit doses available in the medication dispensing system: Counting controlled substances like hydromorphone ensures accurate inventory and accountability, which is a legal and safety requirement. This step helps prevent diversion and maintains compliance with regulations.

D. Document administration of the medication upon removal from the medication dispensing system: Documentation should occur after administration to accurately reflect what the client actually received. Recording upon removal can lead to errors if the medication is not given.