A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand.
Which of the following findings should the nurse report immediately to the charge nurse?
A.
The child is not attempting to move her right arm or fingers.
B.
The fingertips of the right hand are swollen and bruised.
C.
The fingers on the right hand have a capillary refill of 4 seconds.
D.
The parent reports the child will not keep the arm elevated on the pillow.
The Correct Answer and Explanation is:
The correct answer is C. The fingers on the right hand have a capillary refill of 4 seconds.
Explanation:
When a toddler undergoes a cast application for fractures, close monitoring is essential to detect complications such as compartment syndrome or impaired circulation. Capillary refill time (CRT) is a critical indicator of peripheral perfusion and circulatory status. In a healthy individual, capillary refill should take less than 2 seconds. A CRT of 4 seconds suggests significant vascular compromise and potentially severe complications.
A. The child is not attempting to move her right arm or fingers.
While a toddler may be reluctant to move a newly casted limb due to discomfort or fear, lack of movement alone does not indicate a critical issue. It’s essential to assess pain levels and developmental expectations.
B. The fingertips of the right hand are swollen and bruised.
Swelling and bruising can occur after a fracture and cast application, especially in the first few hours as the body begins the healing process. While these findings should be monitored, they do not necessarily indicate an emergency.
C. The fingers on the right hand have a capillary refill of 4 seconds.
This finding is alarming. A CRT of 4 seconds indicates poor perfusion, which could signify compartment syndrome—an increase in pressure within the muscle compartments that can lead to tissue ischemia and necrosis. This condition requires immediate intervention to restore circulation and prevent long-term damage.
D. The parent reports the child will not keep the arm elevated on the pillow.
While arm elevation is important to minimize swelling, a child’s inability to comply with this can be attributed to various factors, including discomfort or developmental behavior. It is less critical than the immediate concerns of capillary refill time.
In conclusion, a capillary refill time of 4 seconds is the most pressing concern and should be reported immediately to ensure the child receives prompt assessment and intervention.