Neurovascular Observations For Orthopaedic Patients



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Canberra Hospital

Standard Operating Procedure

|Neurovascular Observations for Orthopaedic Patients |

Purpose

To accurately assess the nerve and vascular supply to a limb thereby identifying any signs and symptoms that has the potential to affect neurovascular function.

Scope

This document pertains to orthopaedic patients that require Neurovascular Observations at the Canberra Hospital.

This document applies to:

• Nurses and Midwives who are working within their scope of practice (Refer to Nursing and Midwifery Continuing Competence Policy)

• Students under direct supervision.

Procedures

Orthopaedic neurovascular observations are prescribed, post injury and following procedures which have the potential to affect neurovascular function.

Attending neurovascular observations regularly and accurately, promotes

• Early detection of any neurovascular deficits

• Early nursing and medical interventions to prevent permanent dysfunction and/or deformity of the affected limb.

|Neurovascular Observation Frequency |

Neurovascular observation should be attended and documented:

• Hourly for 24 hours post surgery, injury or application of Plaster of Paris (POP) or fibre glass cast then, if stable and satisfactory, fourth hourly then once per shift (Refer to Plaster Cast Management)

• 30 minutes and then hourly for 24 hours after traction initially applied

• 30 minutes after traction re-bandaged

• 30 minutes after backslab re-bandaged.

All requirements should be documented in the patient's clinical record and on the Clinical Care Plan.

|Attending Neurovascular Observation |

Prior to physical assessment consult with the medical team and check the clinical record for post operative/injury instructions (movement of the limb may not be allowed or may be restricted).

1. Attend hand hygiene before touching the patient by either hand washing or using alcohol based hand rub (ABHR)

2. Explain the purpose and reason for assessment to the patient

3. Explain and ensure the patient understands the signs and symptoms that need to be reported, including :

o Increased or change in pain

o Pins and needles

o Numbness

4. Ensure patients skin and nails are clear of all skin preparations that may obscure natural skin colour prior to assessment

5. Maintain privacy

6. Carry out vascular and neurological observations of affected limb as per Attachments 1 , 2 or 3, Use a good light source if observing at night time

7. Assess the vascular and sensory status of the limb below the level of injury

8. Compare neurovascular observations with the unaffected limb

9. Use a gentle touch with a finger initially. Increase pressure if sensation not detected. Ask if sensation is normal or decreased.

10. Attend hand hygiene by either hand washing or using ABHR

11. Record all observations on the Neurovascular Observation Chart

12. Immediately report any abnormal neurovascular observations to the medical officer and document in the patients clinical record.

| |

|ALERT 1: If the limb is in a Plaster of Paris (POP)/ fibreglass cast, splinted or otherwise partially covered it may be difficult to |

|carry out a full assessment. In this case, deficits in the other tests, which are possible, should indicate a disruption of nerve or |

|blood supply. |

| |

|ALERT 2: If movement of the joint at or immediately below the injury is prohibited check sensation and vascular status only. Check the |

|movement of the most distal uninvolved joint(s). |

| |

|ALERT 3: The difference of skin tones between light-skinned and dark-skinned people should be taken into account. Any deficits in nerve |

|or blood supply will be noted when compared with the unaffected limb. |

|Neurological Deficits |

If Neurological Deficit Noted In Upper Limb:

1. Check if regional block given and how long since administered

2. Check for swelling or oedema

3. Check all dressings or splinting along the limb to ensure they are not too tight

4. Check position of arm if elevated to ensure shoulder is not externally rotated too far

5. Check for pressure points under the elbow and upper arm especially for radial and ulnar deficits

6. Check position of sling knot around the neck

7. Check technique when using crutches as pressure in the axilla can produce a brachial plexus injury

8. Report all neurological deficits to a medical officer for review

9. Document all findings in the patients’ clinical record.

The source of upper limb neurological deficits may be anywhere along the nerve pathway. The route of the brachial plexus should be checked for pressure being exerted by external forces.

| |

|ALERT: If damage to the nerve or blood supply of any limb is not detected within 6 hours permanent dysfunction and deformity occurs due |

|to muscle necrosis. |

If Neurological Deficit Noted In Lower Limb:

1. Check if regional block given and how long since administered

2. Check for swelling or oedema

3. Check all dressings or splinting along the limb to ensure they are not too tight

4. Check any support used at the knee to prevent external rotation is not causing pressure

5. Check hip is not dislocated

6. Report all neurological deficits to a medical officer for review

7. Document all findings in the patients’ clinical record.

The source of lower limb neurological deficits may be anywhere along the nerve pathway. The route of the lumbosacral plexus should be checked for pressure being exerted by external forces.

Additional Considerations for all Limb observations:

• Take into account environmental factors when assessing skin warmth eg the room temperature, exposure of the limb and use of ice/cold packs to reduce swelling will affect assessment

• If capillary refill is over 3 second, check for possible peripheral vascular disease.

| |

|ALERT: Peripheral pulses may still be present in the initial stages of Compartment Syndrome because the pathology takes place at the |

|micro-vascular level (see Orthopaedic Practice Manual Standard 5.2.2 -Compartment Syndrome). |

Evaluation

Outcome Measures

• The patient will maintain the expected range of neurological functions and vascular status of the affected limb(s)

• The patient demonstrates an awareness of the signs and symptoms to report which are indicative of functional deficits of the affected limb(s).

Method

• All incidents related to neurovascular observations are reported via the Clinical Incident Reporting System Riskman & Staff Accident Incident Reporting (SAIR). Incidents are reviewed and corrective actions are reported via relevant departments in line with continuous quality improvement processes.

Related Legislation and Policies

ACT Health Infection Prevention and Control Policy

Canberra Hospital Infection Control- Personal Protective Equipment Policy

Nursing and Midwifery Continuing Competence Policy

Plaster Cast Management, Plaster of Paris or Fibre Glass SOP

References

5 moments of Hand Washing- Hand Hygiene Australia



Maher A., Salmond S., Pellino, T., (2002) Orthopaedic Nursing, 3rd Edition W B

Saunders, Philadelphia, pp 177-180.

Dutton, M., (2004) Orthopaedic Examination, Evaluation and Intervention, 1st

Edition, McGraw-Hill, Dow.

Joanne Briggs Institute, TCH Manual, Neurovascular Assessment, Evidence Summary, March 2006

Joanna Briggs Institute, TCH Manual, Observations: Neurovascular, Evidence Summary, February 2009

World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare



Disclaimer: This document has been developed by ACT Health, Canberra Hospital specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility whatsoever.

Attachment 1

|Vascular Assessment – All limbs |

Colour

Check skin colour distal to the injury.

• NORMAL- Skin colour should be the same as unaffected limb. Chart as pink.

• ABNORMAL- Skin different colour to unaffected limb. White or pale indicates inadequate arterial supply. Blue indicates inadequate venous return. Chart as red, white or grey (pale) or blue.

Warmth

Check skin warmth distal to the injury:

• NORMAL- Skin warmth should be the same as unaffected limb. Chart as warm or cool

• ABNORMAL- Skin different temperature to unaffected limb. Cold indicates inadequate arterial supply. Hot indicates inadequate venous return. Chart as hot or cold.

Capillary Return

Squeeze the pad of a finger, toe or nail bed for 2 to 3 seconds. Releases pressure and observe time taken for colour to return:

• NORMAL- Colour should return in 2 to 3 seconds. Chart time taken for colour to return

• ABNORMAL- Colour takes longer than 3 seconds to return. Chart time taken for colour to return.

Peripheral Pulse

Check pulse distal to injury:

• NORMAL- Pulse should be the same strength as pulse on unaffected limb. Chart as present

• ABNORMAL- Diminished or no pulse palpable. Pulse may still be present with Compartment Syndrome. Chart as diminished or absent.

Swelling

Compare size of limb with unaffected limb:

• NORMAL- Limb is the same size as unaffected limb. Chart as nil

• ABNORMAL- Limb enlarged compared with unaffected limb. Chart as slight, moderate, gross swelling. If unchanged from previous assessment chart as nil further.

Attachment 2

|Upper Limb Neurological Test – Circumflex, Ulnar, Radial, Median |

CIRCUMFLEX - supplies deltoid muscle. Sensory- touch over the deltoid area:

• Normal (throughout the document it needs to be consistent with italic or no italic)Can feel touch the same as unaffected limb. Chart as normal.

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively abduct arm at the shoulder:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

Musculocutaneous - supplies biceps and brachioradialis muscles. Sensory - touch radial side of the forearm:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively flex arm at the elbow:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

ULNAR - supplies ulnar side flexor muscles and hand's intrinsic muscles. Sensory- touch on pad of little finger:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively abduct (spread) all the fingers:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

RADIAL – supplies extensor muscles of the arm. Sensory- touch on the back of the hand between the thumb and index finger (thenar space):

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal.

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively dorsiflex the hand. If in POP- actively hyperextend the thumb and fingers:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

MEDIAN- supplies the forearm flexor muscles especially to the thumb. Sensory - touch index finger:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal

• ABNORMAL-Decreased or lack of sensation. Chart as decreased or absent.

Motor- oppose (touch) thumb and small finger:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

Attachment 3

|Lower Limb Neurological Test |

SCIATIC - supplies the hamstring muscles and their divisions below the knee. Level at which injury occurs varies symptoms. Sensory:

• Buttock or thigh injury - touch all surfaces of the foot

• Thigh injury- touch all surfaces of the foot

• Tibial injury- touch lateral aspect of the calf, heel and sole of the foot

o NORMAL- Can feel touch the same as unaffected limb. Chart as “normal”

o ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor:

• Buttock or thigh injury - actively move foot and toes

• Thigh injury - actively flex of the knee

• Tibial injury- actively plantarflex the ankle. Actively evert and dorsiflex the foot

o NORMAL- Can perform movements. Chart as normal

o ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

FEMORAL - supplies quadriceps femoris. Sensory - touch medial aspect of foot:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively extends knee:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

PERONEAL - supplies the peroneal and anterior tibial muscles. Sensory - touch in the first webbed space between the big and second toes:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal.

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor- actively dorsiflex ankle. If in POP- actively extend toes at metatarsal and phalangeal joints.

• NORMAL- Can perform movements. Chart as normal.

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

TIBIAL - supplies gastrocnemius and soleus muscles, and the toes' flexors. Sensory- touch on the medial and lateral surface of the sole of the foot:

• NORMAL- Can feel touch the same as unaffected limb. Chart as normal

• ABNORMAL- Decreased or lack of sensation. Chart as decreased or absent.

Motor - actively plantarflex the ankles and toes. If in POP - actively plantar-flex toes:

• NORMAL- Can perform movements. Chart as normal

• ABNORMAL- Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent.

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