[julsywulsy]

Your patient just returned from having a cast set on their left arm. Your patient complains of worsening pain 30 mins after rec'g pain medication. What do you do?

A. Elevate the patients arm with pillows and apply an Icepack.
B. Offer them a cup of hot tea.
C. Call the Doctor and send for the cast-cutter.
D. Divert their attention from the pain with conversation.

How would you answer this question, based only on the information given? Please explain your rationale.

Thanks!

[michigooseBSN]

B and C are totally false.
A is the best answer no matter what the cause of the pain is. The question doesn't say if the pain medication is oral or parenteral. Either way A is where to start.
D should follow A IF circulation apprears impaired (dusky color, poor capillary refill, white waxy color etc), pain med was parenteral with no relief after 30 min., or no improvement with elevation and icing.

Not a very clear question in my opinion. Not enough information

[grannyNan]

Originally Posted by michigooseBSN

B and C are totally false.
A is the best answer no matter what the cause of the pain is. The question doesn't say if the pain medication is oral or parenteral. Either way A is where to start.
D should follow A IF circulation apprears impaired (dusky color, poor capillary refill, white waxy color etc), pain med was parenteral with no relief after 30 min., or no improvement with elevation and icing.

Not a very clear question in my opinion. Not enough information

I think you mean D and C not B and C. The best answer considering the information given is A. Personally I would check the circulation and neuro status of the limb to see if there is any impairment before I called the doc. The doc will ask you if the fingers are warm/pink or cold and waxy. Although compartment syndrome can occur even when the cast is realatively loose.

[julsywulsy]

Thank you for supporting my answer A which I was told was incorrect. As there was no evidence of CS (no symptoms listed other than pain) I thought A was correct.
The Lecturer told us it was to cut the cast off, but didnt really give us her rationale. I guess I am having a hard time "thinking critically". The problem is that most of the exam questions are written this way so its hard to know what exactly they want us to answer....
Thanks for your replies, I thought I was crazy for a minute...

[NYNewGrad]

Originally Posted by julsywulsy

Thank you for supporting my answer A which I was told was incorrect. As there was no evidence of CS (no symptoms listed other than pain) I thought A was correct.
The Lecturer told us it was to cut the cast off, but didnt really give us her rationale. I guess I am having a hard time "thinking critically". The problem is that most of the exam questions are written this way so its hard to know what exactly they want us to answer....
Thanks for your replies, I thought I was crazy for a minute...

Sorry, but as soon as I read the question I thought - ok, CS. You have to answer the question with the info they give you. Here, they're saying - 1) Cast was "just" placed 2) they got pain meds and pain is "worse".

Let's say maybe the pain meds weren't enough, or it was PO and maybe didnt kick in all the way, you'd still have to wonder why the pain is "worse" as opposed to not relieved. The answer may be a little intimidating in that it says "send for the cast cutter" (i.e. making you the authority) as opposed to call MD and if ordered, then call the cast cutter. Either way though, the pt needs to be thoroughly assessed by the MD/PA/NP.
Obviously, if there was a choice to check neuro/circulation I'd do that first. But thats not a choice. All the other choices are simply ignoring the fact that the pain is worse, and no choice says anything about getting medical attention.

[P_RN]

BUT if you're looking at compartment sx then elevating is contraindicated. I'd have to know what time frame the cast was applied......right after the break? After trauma? After surgery?

I believe I'd call the orthopod and have the cc if she/he might need it. Those strykers tend to disappear just when you're looking frantically for one.

And as much as I love a cuppa tea, if there is a complication the pt might need to be NPO.....(said only slightly sarcastically).

[LouisianaNurse2006]

We were told it is not a good idea to cut off the cast without MD permission, unless it is an emergency and you can't get in touch with any MD. A is still the best answer in my opinion. Keep checking Neuro/CMS, check the PRN order to see if you can give more pain medicine. If No Relief from pain and digits become numb/ tingly, then call MD & possibly cut off cast w/ permission from head nurse or unit supervisor.

[FutureNurse35]

I would pick C, simply because the pain is worsening after medications was given.

[augigi]

I agree, given it was recently placed, the pain has WORSENED after the peak relief should have been obtained would lead me to C) call doc.

[zuzi]

Only my response:

• Asses WHEN?

- fracture was happened
- cast was done
- when pain start

01. Asses patient heart- cardiovascular problems: MI, HTA, ischemia

-can be ok..goes to next step..and reasses time by time
-NO-supposed taht is ischemia, MI, asses make differences, implement measures

• Asses neurovascular status of arm!

-Can be Ok…goes to next step 2 ( to find cause of pain)…but reassess time by time for modifications

- Can be bad from two reasons:

a). guy which applied cast doesn’t observe that a neurovascular modification was started before cast was applied (modifications are worst in this case than in case b, because in case a modification started long time ago-asses when )
a1. additionally asses time (when started modification):
- from how long is fracture
- from how long is cast
b) if the leg was before cast Ok neurovascular means that cast was applied too tight…modification only start to be developed

Even is a or b.. call dr.. because will be necessary an emergency decision to release cast and start a medication specific therapy (in better cases) or to apply some surgery procedure in case if neurovascular modification are worst.
Be careful case a is priority from case b!

2. Asses any others problem that can be conjugate with pain in left arm, what can be??? A joint disease? Asses! Implement!Reasses

3. Asses Pain grade how pain was evolutes?
- in the time o fracture process,
- after fracture was done,
- in time when he was casted,
-after casted.
- Additional inf: patient can tell you something that he believe that made and increased his pain?

Responses that you can find: pain can be cardiac, pain can be compression syndrome, pain can be joint disease enhanced, pain results of nerves damages, pain results from movement in focal in cast time, pain result from dislocation(may be?) in cast time or in mobilization time, level of perception is low so pain feeling is high, (anxiety, fear???)

• Asses medication: type, dosage, route, schedule, admin… all are correct?

With all these information you can make a decision.

In case that you present you can’t have much information…sooo if heart asses is Ok neurovascular asses is ok, if dosage is correct my response is Elevate the patients arm with pillows and apply an Icepack and reassess you don’t know when something can be changed…

Only my two cents…kissis guys!