Clinical Guidelines (Nursing)

Neurovascular observations

  • Introduction

    Aim

    Definition of Terms 

    Assessment

    Parent & Family Education

    Discharge Information

    Potential Complications

    Evidence Table

     

    Introduction

    Monitoring neurovascular status is essential in early recognition of neurovascular deterioration or compromise. Delays in recognising neurovascular compromise can lead to permanent deficits, loss of a limb and even death. Recognition of neurovascular deterioration is therefore crucial. Neurovascular deterioration can occur late after trauma, surgery or cast application.

    Aim

    The aim of this clinical practice guideline is to prevent permanent damage to the limb through early recognition of neurovascular compromise.

    Definition of Terms

    • Neurovascular: Is the structure and function of the vascular and nervous systems in combination. 
    • Musculoskeletal: structurally includes a combination of muscles, bones and joints.
    • Capillary refill: Is an assessment of arterial blood supply return and is performed by briefly interrupting blood supply in the capillary system and timing how long it takes for the blood to return. 
    • Disproportionate Pain: Pain that exceeds what is expected post injury/surgery, which is not relieved by analgesia.
    • Muscle compartment: A well-defined space in the body that consists of a group of muscles in a particular segment, the muscle compartment is bound by fascia. For example the lower leg contains four muscles compartments.
    • Fasciotomy: Surgical incision made through the fascia and into a compartment due to increasing pressure. The aim of the procedure is to release pressure to improve peripheral neurovascular status and prevent long term complications. 
    • Compartment syndrome: Increase in pressure of a closed muscle compartment that causes muscle and nerve ischemia. 

    Assessment

    Criteria for neurovascular assessment

    • Patients who require neurovascular assessment include but are not limited to: 
    • Musculoskeletal trauma to the extremities
      • Fracture 
      • Crush injury 
    • Post operative
      • Internal or external fixation or fractures 
      • Orthopaedic surgery 
      • Spinal surgery 
      • Plastic surgery on extremities or phalanges 
      • Cardiac catheterisation
      • Tourniquet applied for long periods 
    • Application of plaster cast
      • Restrictive dressing 
    • Application of traction (skin and skeletal) 
    • Burns patients 
      • Circumferential burns 
    • Signs of infection in the limb

    Frequency of observations

    • 1 hourly for the first 24 hours post injury, surgery or application of cast.
    • Then 4 hourly for a further 48hours 
    • More frequently if any deviations from baseline observations. 
    Ensure affected limb is elevated to minimise the risk of compartment syndrome. Lower extremities can be elevated with pillows or using bed mechanics; upper extremities can be elevated on either a pillow, sling or box sling.

    Neurovascular assessment

    Peripheral Neurological Assessment

    Pain 

    A validated age appropriate pain assessment tool should be used to determine patients pain levels, this same scale should be used throughout the patient hospital stay to enhance reliability of assessment RCH Pain Assessment Tool.

    The most important indicator of neurovascular compromise is pain disproportionate to the injury. Pain associated with compartment syndrome is generally constant however worse with passive movement to extension and is not relieved with opioid analgesia.
    Indication of pain in non-verbal patients includes restlessness, grimacing, guarding, tachycardia, hypotension, tachypnoea or diaphoresis
    If pain is disproportionate to injury notify medical team. See the Pain directory for more information

     

    Neurovascular Ob Peroneal and Tibial Nerve

     

    Neurovascualr obs Radial Median and Ulna Nerve

     

     

    Sensation

    • If neurovascular compromise is present, patients may report decreased sensation, loss of sensation, dysaesthesia, numbness, tingling or pins and needles.
    • Altered sensation may be a result of a nerve block or epidural, this should be documented on the patient neurovascular chart.
    • The medical team should be contacted if the child experiences any deviation from the baseline assessment.

    Motor function

    • Active movement: Ability to voluntarily extend and flex an extremity or digit.
    • Passive movement: Assessor able to extend and flex an extremity or digit. 
    • Note amount of pain on movement of the limb 
    • It is important to compare movement of digits bilaterally and to the baseline observations as some patients may have had limited or no movement previous to injury.
    • Contact medical team if there is any deterioration in neurovascular assessment. 

     

    Peripheral vascular assessment

     

    Peripheral vascular assessment

    * Capillary refill assessment is evaluated by firmly pressing down on the nail bed of fingers or toes, the nail bed will blanch and the colour should return within 2-3 seconds once the pressure is released.  

     

    Documentation

    • A baseline neurovascular assessment of both limbs is essential in recognising neurovascular compromise and should be documented on admission.
    • Neurovascular observations should be conducted and documented hourly for the initial twenty four hours. 
    • Nursing staff should monitor for patterns of neurovascular deterioration.
    • Alterations in neurovascular status should be documented and the leading medical team should be notified immediately. 
    • An example of upper and lower limb charts can be located here (appendix 1 & appendix 2).

    Parent and Family Education

    Age appropriate education should be provided to the patient, including encouragement for the patient to move their digits regularly. Educate parents on the importance of performing neurovascular observations and why it is necessary to disturb the patient when sleeping. If compartment syndrome develops the patient will need to return to theatre, this can occur quickly and be difficult to deal with. Patients or parents may require support from social workers.

    Discharge Information

    For patients at risk of neurovascular compromise education on neurovascular assessment is crucial. Many patients who are at risk of neurovascular compromise leave hospital before the risk of compartment syndrome is over. Parents need to be aware of the signs and symptoms of neurovascular compromise.

    Links Discharge Information

    • Kids health information: plaster care: Plaster Care (RCH, 2012)
    • Kids health information: Plaster Care at Home (RCH, 2012a)
    • RCH upper limb observations
    • RCH upper limb observations
    • RCH Plastic flap/digital re-implantation observation chart 

    Potential Complications

    Compartment syndrome

    Compartment syndrome is a serious complication of musculoskeletal injury. Compartment syndrome results from an increase in pressure inside a compartment which comprises of muscles and nerves and is enclosed by fascia, fascia is inelastic and does not expand to increased volume or pressure. When the compartment pressure increases, nerves and then muscles become compressed resulting in decreased blood flow and tissue perfusion, muscle ischemia and loss or altered sensation. This will progressively deteriorate until pressure is relieved inside the fascia. Compartment syndrome is a surgical emergency to relieve the pressure or reduce volume within the compartment, which will preserves blood supply and tissue function. Early recognition of neurovascular deterioration is crucial in limb salvage or survival.

    Indications of compartment syndrome

    • Pain: The first and most reliable sign of compartment syndrome. Pain out of proportion to injury, extreme pain on passive movement and pain unrelieved with opioid analgesia. 
    • Paralysis: Is generally a late sign of compartment syndrome and results from prolonged nerve compression or muscle damage. Paralysis presents with inability to actively move the limb and increased pain on passive movement that is not relieved in extension. 
    • Paresthesia: Results from nerve compression and generally is indicated by pins and needles, tingling or numbness. 
    • Pallor: Indicates arterial insufficiencies below the level of injury, below the level of injury will appear cold and pale. 
    • Temperature: Coolness of the limb distal to injury indicates decreased arterial supply. 
    • Capillary refill: Indicates limb perfusion, capillary refill more than 3seconds indicates inadequate limb perfusion. 
    • Pulselessness: Absent pulse is a late sign and indicates tissue death. 
    • Swelling and Increased Pressure: Is a result increased intercompartment pressure, skin presents tight and shiny. 

     Management of Neurovascular Compromise

     Neuro Obs Management of Neurovascular Compromise

    Appendix 1

     

    Neuro Obs Appendix 1 Upper Limb Obs Chart

    Appendix 2 

    Neuro Obs Appendix 2 Lower Limb Obs Chart

     

    Evidence Table 

    Click here to view the Evidence Table

     

    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Rachael Sedgwick, Registered Nurse and Stacey Richards, CSN, Platypus Ward. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published January 2015.