The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
A. capillary refill.
B. radial and ulnar pulse.
C. finger movement.
D. skin integrity.
Correct Answer: D. Skin integrity
Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important. Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.
Option A: Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb. Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing the patient to describe what he felt.
Option B: Report any danger signs to the nursing staff immediately. Danger signs include pale, cold fingers or toes, tingling, numbness, increased pain, pressure spots, odor, or feeling that the cast has become too tight.
Option C: Assess the motor ability of the affected limb by having the patient wiggle his fingers or toes. Lean down and smell the cast to detect odors indicating tissue damage. A musty or moldy odor at the surface of the cast may be the first indication that necrosis from pressure has developed underneath.