Neurovascular assessment: an essential nursing focus

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Author: Mary L. Schreiber
Date: January-February 2016
From: MedSurg Nursing(Vol. 25, Issue 1)
Publisher: Jannetti Publications, Inc.
Document Type: Article
Length: 1,461 words

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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.

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...

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Source Citation
Schreiber, Mary L. "Neurovascular assessment: an essential nursing focus." MedSurg Nursing, vol. 25, no. 1, 2016, p. 55+. Accessed 22 Jan. 2021.
  

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