NURSING DIAGNOSIS: 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 the dressing, knee immobilizer, or CPM machine; or dislocation of the prosthesis(es).

Desired Outcome
The client will maintain normal neurovascular function in the operative extremity as evidenced by:
  1. palpable pedal pulses
  2. capillary refill time in toes less than 3 seconds
  3. extremity warm and usual color
  4. ability to flex and extend foot and toes
  5. absence of numbness and tingling in foot and toes
  6. absence of foot pain during passive movement of toes and foot
  7. no increase in pain in extremity.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of neurovascular dysfunction in the operative extremity:
    1. diminished or absent pedal pulses
    2. capillary refill time in toes greater than 3 seconds
    3. pallor, cyanosis, or coolness of the extremity
    4. inability to flex or extend foot or toes
    5. numbness or tingling in foot or toes
    6. pain in foot during passive motion of toes or foot
    7. increased pain in extremity.
  2. Implement measures to prevent neurovascular dysfunction in the operative extremity:
    1. apply ice packs to operative knee for the first 24-48 hours after surgery if ordered to reduce bleeding and edema in surgical area
    2. maintain patency of wound drainage system (e.g. prevent kinking of tubing, empty collection device as needed, keep collection device below wound level, maintain suction as ordered) to reduce accumulation of fluid in the surgical area
    3. maintain extremity in proper alignment
    4. elevate operative leg on pillow (when not in CPM machine) for the first 48 hours after surgery in order to reduce edema in the surgical area; place pillows so knee flexion is avoided
    5. position leg so that knee immobilizer and CPM machine are not causing excessive pressure on any area
    6. loosen straps of knee immobilizer if it appears to be too tight
    7. notify physician if dressing appears to be too tight
    8. perform actions to prevent dislocation of the prosthesis(es) and stress fracture of the tibia and femur (see Postoperative Diagnosis 7).
  3. If signs and symptoms of neurovascular dysfunction occur:
    1. assess for and correct causes of excessive pressure
    2. notify physician if the signs and symptoms persist.