Neurovascular Assessment Flashcards
What is a neurovascular deficit?
- May be temporary or permanent
- Deficits of MS system in which ther can be a significant effect on patient outcomes and functional ability
- Severe cases may be at risk for amputation of limb
What is Acute Compartment Syndrome?
- Syndrome where there is progressive build up of pressure in a confined space: muscle compartment
- Circulation compromised and diminishes oxygen supply (increased pressure)
- Leads to altered functioning of muscles in that area
What are the different classifications of compartments?
- Muscles of limbs grouped in compartments divided by fascia (thick, inelastic tissue)
- Both arms and legs have four compartments
Why is there a time limit for intervention in compartment syndrome?
- If pressure not relieved within hours, irreversible damage to tissues and nerves occurs.
- May lead to contractures, paralysis, loss of sensation and in some cases, amputation.
Which patients are vulnerable to experiencing compartment syndrome?
- Fractures to tibia, supracondylar fractures of humerus most at risk of developing compartment syndrome.
- Any injured tissue will swell.
- Patients who have undergone orthopedic surgery, sustained crush injuries, or have movement restricted by casts and bandages are at risk
What are the symptoms of compartment syndrome?
Onset may occur from as little as 2 hours up to six days following injury or surgery.
What is the role of the nurse in compartment syndrome?
Nurse plays a vital role in in minimizing the risk of deficit and detecting early symptoms of compartment syndrome.
What is the purpose of neurovascular assessment?
- To assess for compromise of nerve function and circulation
- To prevent damage to tissues of affected area
What are the six P’s of NV assessment?
1) Pain
2) Pallor
3) Paresthesia
4) Pulselessness
5) Paralysis
6) Polar
How is compartment syndrome pain described as?
- The earliest and most important sign
- Out of proportion to injury
- Poorly localized, persistant, progressive pain, often not relieved by analgesics and enhanced by passive extensive of the affected muscles and touch
How do nurses assess for paralysis?
- Nurse should undertake an active or passive range of movements 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.
How do nurses assess 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.
Why is it important to assess pulse and capillary refill? How do we do it?
- Absence of pulse may mean lack of arterial flow.
- Assess pulses distal to the injury and/or cast
- Dorsalis pedis on lower limb, radial pulse on upper limb. If dorsalis pedis not felt then posterior tibialis should be palpated.
- Document if pulse is accessible or not (due to cast etc) and use cap refill instead
How do we assess pallor and temperature?
- A neurovascularly impaired limb will be pale or dusky in appearance
- May have a glossy exterior as a result of swelling.
- Temp of limb should be assessed proximally and distally to limb with back of hand.
- Any alterations should be noted.
- A cold or pale limb below the level of the injury may indicate arterial insufficiency.
- A warm limb with a blueish tinge could indicate venous stasis
- Always check findings against the unaffected limb
How do we assess swelling?
- Not necessarily a feature of neurovascular impairment
- Any limb will swell after undergoing trauma
- Document any increase in swelling
