Risk for peripheral neurovascular dysfunction: operative extremity
related to trauma to or excessive pressure on the nerves or blood vessels during surgery, blood accumulation and edema in the surgical area, improper alignment of operative extremity, pressure exerted by balanced suspension device or straps on abductor wedge, and dislocation of the prosthesis(es).
|The client will maintain normal neurovascular function in the operative extremity as evidenced by:|
- palpable pedal pulses
- capillary refill time in toes less than 3 seconds
- extremity warm and usual color
- ability to flex and extend knee, foot, and toes
- absence of numbness and tingling in leg or foot
- no increase in pain in extremity.
|Nursing Actions and Selected Purposes/Rationales|
- Assess for and report signs and symptoms of neurovascular dysfunction in the operative extremity:
- diminished or absent pedal pulses
- capillary refill time in toes greater than 3 seconds
- pallor, cyanosis, or coolness of the extremity
- inability to flex or extend knee, foot, or toes
- numbness or tingling in leg or foot
- increased pain in the extremity.
- Implement measures to prevent neurovascular dysfunction in the operative extremity:
- perform actions to prevent hematoma formation (see Postoperative Diagnosis 8, action B in hematoma formation complication)
- make sure that balanced suspension device and straps on abductor wedge are not exerting pressure on the popliteal space, Achilles tendon, and lateral and medial aspects of the knee and ankle
- maintain extremity in proper alignment
- perform actions to prevent dislocation of the prostheses (see Postoperative Diagnosis 8, action B in dislocation of the prosthesis complication)
- apply ice to operative hip if ordered to reduce edema and bleeding in the surgical area.
- If signs and symptoms of neurovascular dysfunction occur:
- assess for and correct causes of excessive pressure on operative leg (e.g. tight straps on abductor wedge, improper positioning of balanced suspension device)
- notify physician if the signs and symptoms persist
- prepare client for closed reduction (e.g. traction) or surgical intervention (e.g. relocation of prosthesis, hematoma evacuation) if planned.