Neurovascular Assessment Notes PDF

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N203- Neurovascular Assessment 1. Identify the key areas to be included in a neurovascular assessment.

Purpose - To assess for compromise of nerve function and circulation - To prevent damage to tissues of affected area The Six P’s of NV Assessment - Early signs a) Pain  Nerve injury, DVT, edema, ACS  Earliest and most important sing of compartment syndrome  Considered out of proportion to injury  Poorly localized, persistent, progressive pain often not relieved by analgesics and enhanced by passive extension of the affected muscles and also by touch b) Pallor  Disruption of arterial blood flow  Pulses, capillary refill  Absence of pulse may mean lack of arterial flow  Assess pulses distal to the injury and/or cast  Dorsalis pedis on low lowe limb, radian pulse on uppler limb. If dorsalis pedis not felt then posterior tibialis should be palpated (DP congenitally absent in about 12% of population)  Document if pulse is accessible or not (due to cast, etc.) and use cap refill instead  Pallor and temperature  A neurovascularly impaired limb will be pale or dusky in appearance  May have a glossy exterior as

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a result of swelling (ex. Cellulitis)  Temperature of limb should be assessed proximally and distally to limb with back of hand  Any alteration should be noted  A cold or pale limb below the level of injury may indicate arterial insufficiency  A warm limb with a blue-ish tinge could indicate venous statis  Always check findings against the unaffected limb c) Paresthesia  Numbness, tingling  Sensation  Lightly touch the skin proximally and distally to the affected site  Ask patient to report any changes in sensation to the affected limb  May include decreased sensation, hypersensation, tingling, pins and needles  Loss of sensation or numbness Late signs a) Pulselessness  No arterial blood flow b) Paralysis  Nerve compression  Paralysis (movement)  Nurse should undertake an active or passive range of movement in both limbs, first the unaffected limb, then the affected limb  Note any reduced range of movement  Ischemic muscles are sensitive to stretching

 Extension of the joint may cause extreme pain in forearm or calf  If pain remains when fingers or toes held in extension or movement stopped, report c) Polar  Coolness d/t no arterial blood flow

2. Identify situations which require a neurovascular assessment.

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Swelling  Not necessarily a feature of neurovascular impairment  Any limb will swell after undergoing trauma  Document any increase in swelling

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Components of a NV Assessment  CWMS changes: altered perfusion  Peripheral pulses  Capillary refill  Edema  Pain and/or subjective data  Sensory nerve function (ex. Can you feel this on the bottom of your feet?)  Motor nerve function (ex. ROM)  Dermatome levels Post-surgery Vascular damage  Ex) cellulitis, DVT  Why cellulitis because there’s a lot of inflammation and swelling, there’s a great chance for vascular compromise Burns  Severe constriction, especially feet, when there is tissue damage all the way around a limb Complications include COMPARTMENT SYNDROME People that are left in restraints, you would do a neurovascular assessment with anyone that have restrictions

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3. Describe complications of impaired neurovascular function.

When do I do a NV Assessment? - Any compromised limb - Interstitial edema - Trauma - Casts/splints/dressings - Traction/external fixators - Procedures creating risk for thrombosis or emboli - Spinal injury Neurovascular deficit - May be temporary or permanent - Deficits can have a significant effect on patient outcomes and functional ability - Severe cases may be at risk for amputation of limb Acute Compartment Syndrome - Syndrome where there is progressive buildup of pressure in a confined space: muscle compartment - Occurs when tissue pressure within a confined body space becomes elevated - Circulation compromised and diminishes oxygen supply - Lead to altered functioning of muscle in that area - Muscles of limbs groups in compartments divided by fascia (thick inelastic tissue) - Both arms and legs have four compartments - If pressure in any compartment rises, capillary blood flow is compromised - There is a time limit for intervention  If pressure is not relieved within hours, irreversible damage to tissues and nerves occurs  May lead to contractures, paralysis, loss of sensation and in some cases, amputation - Symptoms of compartment syndrome  Onset may occur from as little as 2 hours up to 6 days following injury or surgery

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Nurse plays a vital role in minimizing the risk of deficit and detecting early symptoms of compartment syndrome

4. Discuss the physiological and psychological effects of immobilization. 5. Describe the purposes and principles Purpose of Traction of traction. - Reduce fractures or dislocations - Immobilize and maintain alignment - Prevent or decrease muscle spasm from lower back pain - Prevent or correct deformities - Provide rest and comfort post-op

6. Describe the nursing care for a patient after cast application.

Tractions assessment - Visually check set-up  Picture is useful  All lines/pulleys/weights are free  Ensure clothing/linens don’t interfere with line of pull - Skin assessment  Pain? Burning?  Signs of inflammation/irritation  Remove belt or boot Q8H - Pin Care  Either standardized plan of care or as ordered by surgeon - NV Assessment  Baseline and ongoing  Compare injured side to normal side Skeletal Traction - Directly attached to bone with pins, wires, screws, or tongs - Up to 30 lbs (13.6 kg) - Used when it’s important to control limb rotation Nursing Considerations for Any Type of Traction - GI  constipation - GU  Cystitis/retention - Pulmonary  pneumonia - CVS

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7. Outline a care plan for an immobilized child.

 Thrombophlebitis/ACS Integument  breakdown Musculoskeletal  immobility Psychosocial  Boredom/alteration of time  Perception/sensory deprivation or overload

Casting Materials - Plaster of Paris  Pros  Easily moulded to limb’s contours  Inexpensive and smooth  Universal of any number  Cons  Messy, dries slowly  Bulky and heavy  Weakened by moisture - Synthetic/Fiberglass  Pros  Lightweight or porous  Integrity stable if wet  Dries quickly  Cons  Expensive and rough exterior  Contraindicated when unusual edema or severely displaced Caring for individuals with alteration in skeletal support and movement requires: - Knowledge of traction or immobility restrictor specific nursing care - Thorough and accurate assessment especially neurovascular assessment - Thorough and accurate assessments especially NV assessment - Knowledge of the effect on the patient and family - Preventative interventions...