Nursing assessment skills are integral to every aspect of patient care. To predict patient care needs, the nurse must understand normal body functioning, have keen assessment skills to recognize changes promptly, and use critical thinking to interpret assessment findings and determine the most appropriate interventions (Murphy & O'Connor, 2010). Components of the focused neurovascular assessment and risks and implications of neurovascular compromise are explored. Show Neurovascular Assessment Neurovascular assessment of the extremities is performed to evaluate sensory and motor function (neuro) and peripheral circulation (vascular) (Blair & Clarke, 2013; Turney, Raley Noble, & Kim, 2013). Observations include pulses, capillary refill, skin color and temperature, sensation, and motor function (Blair & Clarke, 2013; Johnston-Walker & Hardcastle, 2011; Murphy & O'Connor, 2010; Turney et al., 2013; Wiseman & Curtis, 2011). Assessment findings of the affected extremity must be compared to those of the unaffected extremity (Daniels & Nicoll, 2012; Johnston-Walker & Hardcastle, 2011). Even subtle changes must be recognized as important, and differences must be communicated to the physician promptly (Daniels & Nicoll, 2012). Pulses Bilateral pulse assessments should be comparable (Johnston-Walker & Hardcastle, 2011; Wiseman & Curtis, 2011). Major peripheral pulse points include brachial, radial, and ulnar arteries in the upper extremities; and femoral, popliteal, posterior tibialis, and dorsalis pedis in the lower limbs (see Figure 1) (Daniels & Nicoll, 2012). While palpating the pulses of each extremity, assess the most distal pulses that are accessible and parallel (Daniels & Nicoll, 2012). With a 0-4 point scale (0=absent and 4=strong/bounding), assess for weak, diminished pulsations or absence of the pulse (Johnston-Walker & Hardcastle, 2011; Wiseman & Curtis, 2011). Inequality at assessment points is an abnormal finding that can indicate poor perfusion (Daniels & Nicoll, 2012; Johnston-Walker & Hardcastle, 2011). Identifying the pulse palpation site with an indelible marker can help other nurses assess the same location consistently (Johnston-Walker & Hardcastle, 2011). A manual Doppler scan can be helpful in assessing a weak or thready pulse (Wiseman & Curtis, 2011). Capillary Refill Assessment of capillary refill is performed by pressing on the nailbeds or skin of an affected extremity. Results aid in evaluation of peripheral vascular perfusion (Wiseman & Curtis, 2011). Capillary refill of 3 seconds or less... Get Full Access Gale offers a variety of resources for education, lifelong learning, and academic research. Log in through your library to get access to full content and features! Which of the following assessments is found in neurovascular compromise?The components of the neurovascular assessment include pulses, capillary refill, skin color, temperature, sensation, and motor function.
What are the things you should assess for neurovascular compromise?The 6 P's of a neurovascular assessment are pain, poikilothermia, paresthesia, paralysis, pulselessness, and pallor. When the clinician is assessing for pain, pain should only be felt at the site of the injury.
What are the 6 P's of neurovascular compromise?The six P's include: (1) Pain, (2) Poikilothermia, (3) Paresthesia, (4) Paralysis, (5) Pulselessness, and (6) Pallor. The earliest indicator of developing ACS is severe pain. Pulselessness, paresthesia, and complete paralysis are found in the late stage of ACS.
What are the symptoms of neurovascular compromise hint identify the 5 P's?The 5 P's acronym is used systematically in a neurovascular assessment to assess compartment syndrome's presence. The P's refer to pain, pallor, pulse, paresthesia, and paralysis. Pain is commonly rated on a 10-point scale and can be disproportionately severe in the case of compartment syndrome.
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