NURSING DIAGNOSIS: Risk for peripheral neurovascular dysfunction

related to:
  1. trauma to the nerves or blood vessels during surgery;
  2. blood accumulation and inflammation in the surgical area;
  3. dislocation of the bone graft and/or internal fixation devices (if a fusion was performed);
  4. excessive external pressure on the nerves or blood vessels associated with improper fit or application of stabilization device (e.g. cervical collar, back brace, corset).
Desired Outcome
The client will have usual or improved peripheral neurovascular function as evidenced by:
  1. palpable peripheral pulses
  2. capillary refill time less than 3 seconds
  3. extremities warm and usual color
  4. ability to flex and extend feet, toes, hands, and fingers
  5. usual or improved reflexes, muscle tone, and sensation in extremities
  6. no new or increased pain in extremities.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of peripheral neurovascular dysfunction (check upper extremities after surgery on the cervical area and lower extremities after surgery on the lumbar area):
    1. diminished or absent peripheral pulses
    2. capillary refill time greater than 3 seconds
    3. pallor, cyanosis, or coolness of extremities
    4. inability to flex or extend feet, toes, hands, or fingers
    5. diminished or absent reflexes in extremities
    6. development of or increase in muscle weakness, numbness, or tingling in extremities
    7. development of or increase in pain in extremities.
  2. Implement measures to reduce the risk for peripheral neurovascular dysfunction:
    1. perform actions to reduce strain on the surgical area (see Postoperative Diagnosis 2, action b.1) in order to prevent bleeding and subsequent hematoma formation in the surgical area and to reduce the risk for dislocation of the bone graft and/or internal fixation devices (if fusion was performed)
    2. maintain wound suction and patency of wound drain to reduce the accumulation of blood in the surgical area and subsequently prevent increased pressure on nerves and blood vessels
    3. apply stabilization device properly; notify orthotist if it appears to create excessive pressure on any area
    4. administer corticosteroids (e.g. dexamethasone) if ordered to reduce inflammation in the surgical area.
  3. If signs and symptoms of peripheral neurovascular dysfunction occur:
    1. assess for and correct improper body alignment and external cause of excessive pressure (e.g. tight or improperly applied stabilization device)
    2. notify physician if signs and symptoms persist or worsen
    3. prepare client for surgical intervention (e.g. evacuation of hematoma, repositioning of dislocated bone graft and/or internal fixation devices) if planned.