Nursing diagnosis: risk for Peripheral Neurovascular Dysfunction
Risk factors may include
Reduction or interruption of blood flow
Direct vascular injury, tissue trauma, excessive edema, thrombus formation
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Maintain tissue perfusion as evidenced by palpable pulses; warm, dry skin; normal sensation; usual sensorium; stable vital signs; and adequate urinary output for individual situation.
Nursing intervention with rationale:
1. Remove jewelry from affected limb immediately.
Rationale: May restrict circulation when edema occurs.
2. Evaluate presence and quality of peripheral pulse distal to injury via palpation or Doppler. Compare with uninjured limb.
Rationale: Decreased or absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Be aware that occasionally a pulse may be palpated even though circulation is blocked by a soft clot through which pulsations may be felt. In addition, perfusion through larger arteries may continue after increased compartment pressure has collapsed the arteriole and venule circulation in the muscle.
3. Assess capillary return, skin color, and warmth distal to the fracture.
Rationale: Return of color should be rapid (3–5 seconds). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Note: Peripheral pulses, capillary refill, skin color, and sensation may be normal even in the presence of compartment syndrome because superficial circulation is usually not compromised.
4. Maintain elevation of injured extremity(ies) unless contraindicated by confirmed presence of compartment syndrome.
Rationale: Promotes venous drainage and decreases edema. Note: In presence of increased compartment pressure, elevation of the extremity actually impedes arterial flow, decreasing perfusion. Casts or circumferential dressings can also cause arterial venous insufficiency.
5. Assess entire length of injured extremity for swelling and edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance and spread of hematoma.
Rationale: Increasing circumference of injured extremity may suggest general tissue swelling or edema but may also reflect hemorrhage. Note: A 1-inch increase in an adult thigh can equal approximately 1 unit of sequestered blood.
6. Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia, muscle tension or tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once.
Rationale: Continued bleeding or edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartment syndrome, necessitating emergency interventions to relieve pressure and restore circulation. Note: This condition constitutes a medical emergency and requires immediate intervention.
7. Investigate sudden signs of limb ischemia, such as decreased skin temperature, pallor, and increased pain.
Rationale: Fracture dislocations of joints, especially the knee, may cause damage to adjacent arteries, with resulting loss of distal blood flow.
8. Encourage client to routinely exercise digits or joints distal to injury. Ambulate as soon as possible.
Rationale: Enhances circulation and reduces pooling of blood, especially in the lower extremities.
9. Investigate tenderness, swelling, or pain on dorsiflexion of foot (positive Homans’ sign).
Rationale: There is an increased potential for thrombophlebitis and pulmonary emboli in clients who have been immobile for several days. Note: The absence of a positive Homans’ sign is not a reliable indicator in many people, especially the elderly, because they often have reduced pain sensation.
10. Monitor vital signs. Note signs of general pallor or cyanosis, cool skin, and changes in mentation.
Rationale: Inadequate circulating volume compromises systemic tissue perfusion.