Neurovascular Assessments/Checks - Department of Nursing ...

Clinical Protocol/Procedure Page 1 of 2Clinical Manual - Nursing Practice ManualJohn Dempsey Hospital – Department of NursingThe University of Connecticut Health CenterPROTOCOL/PROCEDURE FOR: Neurovascular Assessments/ChecksDESIRED PATIENTOUTCOMES: 1. Patient will have neurovascular status consistent with or improvedfrom baseline.POLICY:1. Neurovascular assessments/checks should be performed immediatelypost orthopedic procedure, surgery or trauma, then every 4 hours for24 hours, then every shift, or per specific practitioner orders.2. The neurological components of the adult neurovascular assessmentinclude: Color, Circulation, color, Sensation, and Motion/Movement(CSM) and sensation of the affected extremity.Note: The “five P’s” can be used to remember the assessment: Pain(especially with passive stretch), pallor, pulselessness,Paralysis, paresthesia.3. Deterioration in neurovascular status or no expected improvementwill be reported to the practitioner immediately.PROCEDURE:ACTIONPOINTS OF EMPHASIS1. Inspect the color of the fingers and/ortoes as appropriate. They should bepink.1. If digits are white or bluish andpatient complains of severe pain withoutmovement or with passive stretch,circulation may be reduced orcompartment syndrome may be developing.If compartment syndrome is suspected, doNOT elevate the extremity, and notifythe practitioner immediately.1.2. Pale/white may indicate inadequatearterial supply.3. Blue/cyanotic/ mottled appearanceindicates inadequate venous return.2. Check Circulation:a. Ssimultaneously toucgh the digitswiththe back of the hand onto theaffectedand unaffected extremities andcompare the temperature.2a. Digits of a casted extremity may be coolimmediately after cast application butshould warm up in a few hours.2b. If digits are cold to touch, circulationmay be compromised.2c. An Eextremity in traction may always becool due to air exposure.b. Assess pulses distal to the injuryand/or cast to assess whether bloodflow is reaching past the area of2d. On the lower limb the dorsalis pedis isusually assessed.2e. On the upper limb the radial pulse isused.

Clinical Protocol/Procedure Page 2 of 2Clinical Manual - Nursing Practice ManualJohn Dempsey Hospital – Department of NursingThe University of Connecticut Health CenterPROTOCOL/PROCEDURE FOR: Neurovascular Assessments/Checksinjury/surgery and perfusing theremaining limb effectively. Ifunable to palpate a pulse, use aDoppler (and document the use of aDoppler).c. Check capillary refill by pressingon the tips of the toe nails orfinger nails until they blanch, thenrelease pressure and note how soonnormal color returns.3. Check Sensation: Lightly touch the skinboth proximally and distally to theaffected site. Ask the patient to reportany changes in sensation to the affectedlimb. my touching the fingers and/ortoes and asking the patient how theyfeel. Note any numbness or tingling2f. An absence of pulse may indicate a lackof arterial flow.2g. Normal capillary refill is ≤3 seconds.2h. If circulation is decreased, capillaryreturn may be very sluggish.,2. Changes in sensation may result frompressure on the relevant nerve(s) and mayinclude decreased sensation,hypersensation, tingling, ‘pins andneedles’, numbness or loss of sensation.4. Check Motion/Movement: 5. To testmovement of the digits, asktell patientto fully plantar and dorsi flex andextend the toes of both limbs or volar(palm) and dorsi flex and extend thefingers of both limbs, first theunaffected and then the affected side,noting any reduced range of movement.5. Check Edema: Inspect the limb forswelling and compare with the unaffectedside.5. Although edema is not necessarilycharacteristic of neurovascular deficit,any notable increase should still bedocumented and reported.PATIENT ANDFAMILYTEACHING:Explain all procedures to patient and family and keep patient/familyinformed of plan of care.DOCUMENTATION: Documentation of color, circulation, sensation, motion/movement and useof Doppler and findings (as appropriate) should be in the nursingassessment documentation or progress note. Any other abnormal findingsmust be documented in the nursing note. Notification of the LIP for anyabnormal findings must be included in the nursing progress note.APPROVAL: Nursing Standards CommitteeEFFECTIVEDATE: 1/12