Nursing diagnosis: risk for Peripheral Neurovascular Dysfunction
Risk factors may include
Orthopedic surgery, mechanical compression (e.g., dressing, brace, cast), vascular obstruction, immobilization
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Maintain function as evidenced by sensation and movement within normal limits for individual situation.
Demonstrate adequate tissue perfusion as evidenced by palpable pulses, brisk capillary refill, warm or dry skin, and normal color.
Nursing intervention with rationale:
1. Palpate pulses. Evaluate capillary refill and skin color and temperature. Compare with unoperated limb.
Rationale: Diminished or absent pulses, delayed capillary refill time, pallor, blanching, cyanosis, and coldness of skin reflect diminished circulation or perfusion. Comparison with unoperated limb provides clues as to whether neurovascular problem is localized or generalized.
2. Assess motion and sensation of operated extremity.
Rationale: Increasing pain, numbness or tingling, and/or inability to perform expected movements such as flexing foot suggest nerve injury, compromised circulation, or dislocation of prosthesis, requiring immediate intervention.
3. Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between first and second toe, and assess ability to dorsiflex toes after hip or knee replacement.
Rationale: Position and length of peroneal nerve increase risk of direct injury or compression by tissue edema or hematoma.
4. Monitor vital signs.
Rationale: Tachycardia and falling blood pressure (BP) may reflect response to hypovolemia or blood loss or suggest anaphylaxis related to absorption of methylmethacrylate into systemic circulation. Note: This occurs less often because of the advent of prosthetics having a porous layer that fosters ingrowth of bone instead of total reliance on adhesives to internally fix the device.
5. Monitor amount and characteristics of drainage on dressings and from suction device. Note swelling in operative area.
Rationale: May indicate excessive bleeding or hematoma formation, which can potentiate neurovascular compromise. Note: Drainage following hip replacement may reach 1,000 mL in early postoperative period, potentially affecting circulating volume.
6. Ensure that stabilizing devices such as abduction pillow or splint device are in correct position and are not exerting undue pressure on skin and underlying tissue. Avoid use of pillow or bed knee gatch under knees.
Rationale: Reduces risk of pressure on underlying nerves or compromised circulation to extremities.
7. Evaluate for calf tenderness, positive Homans’ sign, and inflammation.
Rationale: Although clinical signs are often not reliable in this population, surveillance should be carried out. Early identification of thrombus development and intervention may prevent embolus formation.
8. Observe for signs of continued bleeding, oozing from puncture sites and mucous membranes, or ecchymosis following minimal trauma.
Rationale: Depression of clotting mechanisms or sensitivity to anticoagulants may result in bleeding episodes that can affect red blood cell (RBC) level and circulating volume.
9. Encourage regular “foot pumps” throughout day.
Rationale: Pushing the foot down, pointing toes, and pulling toes up toward the ceiling causes the calf to tighten and assist venous return to prevent blood pooling and reduce risk of deep vein thrombosis (DVT).
10. Administer medications, as indicated, for example, low-molecular-weight heparins, enoxaparin (Lovenox), dalteparin (Fragmin), or tinzaparin (Innohep).
Rationale: Anticoagulants or antiplatelet agents may be used routinely to reduce risk of thrombophlebitis and pulmonary emboli. Note: Incidence of DVT without prophylaxis is around 50% to 80% in client with knee replacement and 47% to 64% in client with hip replacement. Studies have shown significant decrease in these numbers with prophylaxis.