neuro assessment Flashcards
Why are neurovascular observations performed?
-To assess blood flow to the limbs
-The early identification of decreased peripheral tissue perfusion
What type of patients require this assessment
-Trauma patients who have swollen limbs and those with plaster
-Pre and post vascular and orthopaedic surgery
What do you do when you enter the room?
-Introduce yourself
-Perform hand hygiene
-Tell the patient that you will be checking the pusles and sensation in your left lower limb, is that okay which is going to assess the blood flow to your limb because you’ve had knee reconstructive surgery
-Please tell me if you’ve had any extra strong pain, tingling or numbness
-Use the neurovascular assessment chart to perform the assessment to look for color, warmth, movement, sensation and to palpate the pulse and check capillary refill
-Perform hand hygiene
-Inspect the affected sight, looking for ooze on the wound and if there is a drain tube and the amount of drain in the drain
-If a cast has been applied observe for swelling and blood leakage
-Ask the patient about pain at the affected sight
-Moderate pain is normal but severe or untreatable pain needs to be reported to the treating doctor immediately as it may be compartment syndrome
-Inspect peripheral color, looking for pink skin which is well perfused and the same color as the opposite limb
-Assess the temperature of the limb which should be warm to touch and as warm as the opposite limb, if there is inadequate limb supply the limb will be cold
-Compare pulses, touching the dorsal pedal pulse on the top of each foot. They should have equal rates and volumes. A thready pulse would indicate poor blood supply
-Check capillary refill. Press the nail bed on the foot until it blanches and then let go. The capillary refill should be less than 3 seconds
-Assess sensation and ask the patient to close their eyes to evaluate sharp and soft touch on the distal digits. Use the end of a pen to touch their foot lightly in a square shape across the top of the foot
-Assess movement by asking the patient to move their foot by flexing and pointing and then move them in circles
-Then assess this movement against resistance by asking the patient to push their feet against your hands
-Loss of motor strength is a late symptom of compartment syndrome
-Perform hand hygiene and document findings
If the patient complains assessment or pain is suspected perform a pain assessment
-Then ask the PQRST
-Provokes- what makes your pain worse and what brings the pain on? Does anything help the pain, what has helped in the past?
-Quality- what does the pain feel like, can you describe it?
-Region and Radiates- where is the pain and does your pain radiate anywhere?
-Severity- can you rate the pain on a scale of 1-10?
-Time- when did the pain start, is it constant, how long does it last?
-Take a set of vital signs
-Document dindings
-Suggest non-pharmacological nursing interventions
-Suggest repositioning, elevation with pillows, ice or heat therapy, music, breathing exercises, distractions such as books or movies
What nursing actions could be performed to help relieve pain?
-Suggest repositioning, elevation with pillows, ice or heat therapy, music, breathing exercises, distractions such as books or movies
-Check medication chart and review when the patient is due for medication if there are any PRN medications
-Notify medical officer if pain persists at a high level so that stronger pain relief may be administered
Outline a pain assessment
Ask the PQRST
Provokes- what makes your pain worse and what brings the pain on? Does anything help the pain, what has helped in the past?
Quality- what does the pain feel like, can you describe it?
Region and Radiates- where is the pain and does your pain radiate anywhere?
Severity- can you rate the pain on a scale of 1-10?
Time- when did the pain start, is it constant, how long does it last?
Take a set of vital signs
Document findings
Outline a lower limb neurovascular assessment
-Tell the patient that you will be checking the pusles and sensation in your left lower limb, is that okay which is going to assess the blood flow to your limb because you’ve had knee reconstructive surgery
-Please tell me if you’ve had any extra strong pain, tingling or numbness
-Use the neurovascular assessment chart to perform the assessment to look for color, warmth, movement, sensation and to palpate the pulse and check capillary refill
-Perform hand hygiene
-Inspect the affected sight, looking for ooze on the wound and if there is a drain tube and the amount of drain in the drain
-If a cast has been applied observe for swelling and blood leakage
-Ask the patient about pain at the affected sight
-Moderate pain is normal but severe or untreatable pain needs to be reported to the treating doctor immediately as it may be compartment syndrome
-Inspect peripheral color, looking for pink skin which is well perfused and the same color as the opposite limb
-Assess the temperature of the limb which should be warm to touch and as warm as the opposite limb, if there is inadequate limb supply the limb will be cold
-Compare pulses, touching the dorsal pedal pulse on the top of each foot. They should have equal rates and volumes. A thready pulse would indicate poor blood supply
-Check capillary refill. Press the nail bed on the foot until it blanches and then let go. The capillary refill should be less than 3 seconds
-Assess sensation and ask the patient to close their eyes to evaluate sharp and soft touch on the distal digits. Use the end of a pen to touch their foot lightly in a square shape across the top of the foot
-Assess movement by asking the patient to move their foot by flexing and pointing and then move them in circles
-Then assess this movement against resistance by asking the patient to push their feet against your hands
-Loss of motor strength is a late symptom of compartment syndrome
-Perform hand hygiene and document findings
Briefly note the steps in a neurovascular assessment
-Tell the patient what you’ll be doing
-Inspect sight of wound
-Ask patient about the pain at site
-Inspect skin at lower limb
-Assess temperature of the limb
-Compare pulses on top of foot
-Check capillary refill
-Assess sensation
-Assess motor capability
-Assess strength
what would require medical review
Pain not relieved by analgesia
Weak pulse recorded 30 minutes after strong pulse
Pain at rest with a score between 4 and 10
What is the FIRST thing you do when you enter the room
-introduce yourself
-perform hand hygiene
-educate patient
What do you say to educate your patient and gain consent
-Tell the patient that you will be checking the pusles and sensation in your left lower limb, is that okay which is going to assess the blood flow to your limb because you’ve had knee reconstructive surgery
