Neurovascular Observations

Neurovascular status is assessed to (3)

- Obtain a baseline prior to surgery on both limbs (essential to recognise neurovascular compromise). - Assess the status of the vasculature and nerve supply to a traumatised limb. - Monitor the status over time so permanent damage or complications are avoided.

What is Compartment Syndrome

A collection of symptoms arising because of pressure int he muscle compartment that results in compromised tissue perfusion. Pressure build-up in an enclosed space reduce the capillary blood flow. Tissue perfusion is reduced and muscle and nerve tissue becomes ischaemic. If pressure is not relieved, irreparable damage occurs within 4 hours. Fascia in inelastic and enclose muscles, nerves and blood vessels. When compartment pressure increases nerves and muscle become compressed.

Blood Loss

Assess blood loss. Check the dressing or cast over the injury/surgical site for visible ooze. Check under the cast. Blood ma have trickled down the limb and collected and oozed through the bottom of the cast or dressing. If a wound drainage system is insitu, ensure it is patent and draining the anticipated amount for the surgery performed.

Vascular Assessment (assesses for "4")

Assess for colour, temperature, capillary refill and pulses.

Assessment of Neurovascular (define):

Assess the limb distal to the injury site/site of surgery to determine compromised vascular oor neurological function. Compare the affected limb with the unaffected limb to help determine what is normal and hat is abnormal for the person. Assess the unaffected limb first.

What do neurovascular observations include (PERIPHERAL AND NEUROLOGICAL)

Assessing the peripheral pulses of the limbs and the neurological function of the limbs to detect pressure ont he nerves or vascular supply.

Nerve assessment (what it checks for)

Check for sensation and movement.

Pallor

Compartment syndrome can cause pallor, redness, or cyanosis. - Inadequate arterial supply- pale, white, cyanotic. - Inadequate venous return- dusky, cyanotic, mottled, purple/black.

Assess the person ( Neurovvascular Assessment)

Initial signs of compartment syndrome are subtle and warning signs are only elicited from a conscious person. Physical signs and symptoms of compartment syndrome devlop late. A person who is unable to communicate pain and paraesthesia needs to be closely monitored.

Paraesthesia

Initially affecting two-point discrimination is the earliest sign or neurological compromise (person unable to discriminate between two touches that are close togetehr). Results from nere compression- generally indicated by pins and needles, tingling or numbness. ** sensation is assessed in the distal digits** ASK THE PATIENT TO CLOSE THEIR EYES AND IDENITFY TOUCHES, SHARP-PEN END SOFT COTTON WISP- along different dermatones.

Polar ( Temperature)

Limbs should be warm to touch or be similar to temperature of unaffected limb, If compartment syndrome occurs, affected limb may be cold or hot to touch. - Normal- warm - Inadequate arterial supply- cold - Inadequate venous return- hot.

Paralysis

Muscle weakness or inability to flex or extend digits are lates symptoms of compartment syndrome. Results from prolonged nerve compression or muscle damage. Paralysis presents with inability to actively move the limb and increased pain on passive movment. Assess motor function ( move dstal joints through a full range of motion). - Check peroneal nerve- ability to dorsiflex ankle and toes - Check tibial nerve, ability to plantar flex ankle and toes. Check Radial Nerve- Median and ulna nerve in hands. ** do not asseess movement in joints of anyone who has had microsurgery or repairs to tendons, arteries or nerves as movement vcan cause sutures to rupture.

Equipment needs

Neurovascular assessment chart

Peroneal Nerve (sensation assessment0

Palpate the dorsal surface of the foot.

Pulses (Capillary refill):

Pulses of the affected limb should be the same rate and volume as unaffected limb. Indicates limb perfusion- capillary refill more than 3 seconds indicates inadequate perfusion. - Pulses and capillary refill may be absent or remain normal in compartment syndrome. - Absent pulses is a late sign and indicator of tissue death. - Cap refill <2 sec = normal. - Inadequate arterial supply > 2 secs - Inadequate venous return- rapid

Ulna Nerve (Motor assessment):

The ability to abduct all fingers.

Aim of neurovascular observations

To idenitfy changes or problems early to enable early intervention. The early indentification of decreased peripheral tissue perfusion.

Pressure

Oedema causes tenseness in the distal limb and swlling may be visible. The tissue will feel firm. Patients who have excessive swelling are at increased risk of neurovasvcular compromise. A limb will generally appear tight and shiny if compartment syndrome is present.

6 P's

Pain, Pallor, Pulses, Paralysis, Paraesthesia and Polar (pressure- caused by odema). A person with intense pain, paraesthesia and paralysis of the limb requires intervention within 4 hours to prevent permanent damage.

How often are assessments performed?

Usually 2 hrly for 24 hours on limbs post surgery, post trauma o rwhen a plaster cast or traction is applied. Observations can be more frequent if you are concerned. Plaster cast replacement hourly observation for 4 hours is usually sufficient.

When do we neurovascular observations? (10)

After orthopaedic surgery, trauma, vascular surgery, bites onlimbs, crush injuries, soft tissue injuries, excessive bleeding, tight casts or bandages on a limb, burns with oedema, prolonged limbs compression.

Treatment of Compartment Syndrome- based on relieving the pressure within the enclosed space & nursing interventions.

Bandages are removed. Casts are bivalved/spread and the padding under the cast may need to be loosened or removed. Splints are loosened and if required removed. Drainage sysmetms are checked to ensure they are patent and drainging. Persons may be taken to theatre to have fasciotomy ( incision through the fascia to relive pressure within the fascial compartment). Nursing interventions: - Extremity to be kept at heart level. - Person is gven supplemental o2. - IV therapy commenced (maintain hydration and reduce effects of myoglobin released when skeletal muscle cells break down). Monitor the person for dark, tea coloured urine= myoglobinuria (leads to renal failure).

Pain

Pain si the earliest and most reliable symptom of comparement syndrome. - Passive sttetching of the muscles or distal digits and elevation of the affected limb above heart level intensified pain- is an indicator of circulatory compromise. - Pain disproportionate to the injury is indicator of neurovascular comproimise. -Assess pain levels using PQRST. - If non-verbal assess restlessness, grimacing, guarding, tachycardia, hypotension, tachypnoea or diaphoresis.

Ulna Nerve (Sensation assessment):

Palpate between the little finger and distal ring finger oon palmar and dorsal surface of hand.

Tibial Nerve (Sensation assessment)

Palpate the plantar surface of the foot.

Median Nerve (sensation assessment):

Palpate the webbing space between thumb and index finger, including palmer surface of the hand.

Radial Nerve (sensation assessment):

Palpate webbing space between thumb and index finger, including dorsal surface of the hand.

Nursing interventions to minimise compromise to the peripheral circulation.

Supported elevation of the persons effected limb at the level f heart, enhances venous return and lymph drainage, decreasing peripheral oedema.

Median Nerve (motor assessment):

The ability to bring the thumb and little finger together so they are touching.

Peroneal Nerve (Motor assessment):

The ability to dorsiflex anke and toes.

Radial Nerve (motor assessment):

The ability to extend wrist and fingers at the knuckle joint. If cast is over hand only assess extension of fingers.

Tibial Nerve (motor assessment):

The ability to plantar flex ankle and toes.