Neurovascular Asessment PDF

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neuro care and assessment ...

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NEUROV NEUROVASCUL ASCUL ASCULAR AR ASSES ASSESSMENT SMENT Objectives     

Student will have an understanding for the requirements for neurovascular Observations Understand the terminology when taking neurovascular observations Develop an understanding of the underlying rationale that drives the need for neurovascular assessment Understand the importance of documentation and escalation of care Become familiar with pulse sites

Neurovascular observations Include assessing the peripheral Pulses of the limbs to detect pressure on the nerves or vascular Supply. It involves neurological and vascular integrity of a limb. Often in Acute care you will see Documentation that is abbreviated As C,W C,W,M,S. ,M,S. -

Colour Warmth Movement Sensation

Reasons for Neurovascular observations • Obtain a baseline prior to surgery on a limb • To assess the status of vasculature and nerve supply to a traumatised Limb • To monitor the status over time so permanent damage or complications Are avoided

Why do we undertake neurovascular assessment? • Upper or lower limb fractures • Surgery to the upper or lower limbs, pts may have had internal or external fixations • Restricted Limb movement due to casts or bandages • Restricting movement can cause damage to nerves and blood vessels • This type of damage can cause a deficit in function or a neurovascular deficit

Common neurovascular complication:

Compartment syndrome • • • •

A major complications to the vessels and nerves in a limb that has undergone trauma This is a collection of symptoms that arise as a result of pressure in the muscle compartment leading to compromised tissue perfusion Muscles of the limbs are grouped into compartments divided by thick inelastic tissue (fascia) Each compartment contains the nerves and vessels that supply the limb

Increased pressure in any compartments

Pressu enclosed space such as within a fascial sheet, cast or bandage reduces capillary flow to that space and muscle and nerve damage can occur

Leads to restricted blood flow is and can lead to inadequate tissue perfusion and oxygenation

Compartment syndrome most commonly occurs in fractures of the tibial shaft and of the forearm, when there is soft tissue injury and in trauma case

When to commence Neurovascular assessments ❑Patients with sustained fractures or injuries that put them at risk of Tissue injury ❑After orthopaedic surgery ❑After vascular surgery ❑Limb movement restricted by casts or bandages ❑Patient who have bites on limbs ❑Patients who have circumferential burns

Complete with 2 staff members at handover Compare

Compare the affected limb with the unaffected limb

Nerve Assessment Sensation and Movement

Assess the limb distal to the injury or site of injury/surgery

Vascular assessment includes Colour, Temp, (Warmth), Capillary refill and Pluse

Five P’s

Pain

Pulse -

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Assess for Presence and volume An absence of a pulse may indicate a lack of arterial flow Pulses need to be assessed distal to the affected site Pulses need to be taken on both limbs if they are accessible Is the pulse, strong, palpable, weak or can it only be taken by a Doppler ultrasound it is helpful to mark the pulse area with indelible pen so that consistency can be maintained

Pallor -

Colour should be healthy, well perfused and pink Comparison with the opposite limb is a Prerequisite for care. Skin must be cleaned to remove blood and betadine prior to assessment A pale limb may indicate poor arterial circulation or cyanosis which can suggest venous stasis. May also look like it has a glossy sheen as a result of swelling.

Paresthesia -

Assess for sensation in the distal digits The skin is lightly touched Aske pts. to report any changes in sensation to the affected limb. This may include: decreased sensation, hypersensation, tingling or pins and needles, numbness or loss of sensation Be aware of different types of anaestheticie: nerve block or spinal

Paralysis -

Assess motor function Ask the patient to move their distal joints Nerve damage can be a result of compartment syndrome Compartment syndrome is usually a late symptom as a consequence of prolonged nerve compression If patients have had microsurgery to tendons, arteries or nerves it is contraindicated to assess movement as this can cause sutures to break

P: Provocting factors Q: Quality R: Radiation S: Severity T: Time

C: Characteristic O: On set L: Location D: Duration S: Severity P : Precipitating factors A: Alleviating factor

S: Situation O: Onset C: Character R: Radiation A: Associated factors T: Timing E: Exacerbating factors S: Severity

Non verbal Signs of Pain

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Grimacing > Guarding > Restlessness Hypertension Tachycardia > Diaphoresis (sweating) > Tachypnoea

Pain Assessment Tools

Pulse Sites

Nursing Interventions • Immobilise limbs to decrease oedema • Ensure casts and bandages are not too tight it should be possible to insert 1-2 fingertips between the proximal and distal ends of casts • Complete and document neurovascular observations to identify symptom patterns • Use a neurovascular chart • If it is not documented, it means it was not done. • If a neurovascular deficit is noted then this should be escalated using ISBAR Communication

Adverse Neurovascular Outcomes ❑Compartment Syndrome = Fasciotomy ❑Fasciotomy to decrease tissue pressure, restore blood flow and minimise tissue damage and functional loss....