Susceptible to disruption in the circulation, sensation, and motion of an extremity

• Difficulty cooperating with instructions
• Inadequate knowledge of modifiable factors
• Inattentive to peripheral neurovascular symptoms
• Prolonged inappropriate positioning of limbs
• Prolonged pressure on peripheral blood vessels
• Prolonged pressure on peripheral nerves
• Unaddressed nerve entrapment

• Atherosclerosis
• Bone fractures
• Diabetes mellitus
• Immobilization
• Infections
• Mechanical compression
• Neoplasms
• Orthopedic fixation devices
• Orthopedic surgery
• Vascular obstruction
• Wounds and injuries

• History of trauma or vascular injuries
• Inspection of extremities, including signs of soft tissue injury, such as abrasions, lacerations, and contusions
• Pain sensation, including characteristics of pain (sharp, dull, constant, or intermittent), precipitating factors, and reaction to passive stretching of affected muscles
• Tactile sensation in areas innervated by major nerves of upper extremities, including deltoid, radial side of forearm, palmar surface of thumb, fingers, palmar surface of little finger, and webbed space between thumb and index finger
• Tactile sensation in lower extremities, including medial side of foot and leg, medial side of thigh, sole of foot, and lateral aspect of leg below the knee
• Motor nerve function of upper extremities, including arm abduction at shoulder, arm flexion at elbow, thumb and little finger opposition, abduction and adduction of fingers, and extension of wrist and fingers
• Motor nerve function of lower extremities, including knee extension, thigh adduction, plantar flexion and dorsiflexion of ankle, and flexion and extension of toes
• Pulses in upper and lower extremities, including radial, ulnar, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis; perform bilateral comparison and rank quality using following scale:
  • 0 = absent
  • 1 = very weak, barely palpable
  • 2 = weak, reduced
  • 3 = slightly weak, easily located
  • 4 = normal, easily located
• Vascular status, including capillary refill time, blanching, skin temperature, and skin color
• Point tenderness, especially over bony prominences
• Edema
• Increased intracompartmental pressure
• Cranial nerves (if patient has halo cast)

• Patient won't experience disability related to peripheral neurovascular dysfunction after injury or treatment.
• Patient will maintain circulation in extremities.
• Patient will feel and move each toe or finger after application of cast, brace, or splint.
• Patient will demonstrate correct body positioning techniques.
• Patient and family members will express understanding of risk of altered neurovascular status and need to report symptoms of impaired circulation.
• Patient will enroll in smoking-cessation program, as appropriate.
• Patient will not exhibit symptoms of neurovascular compromise.

Suggested NOC Outcomes

• Note whether patient will undergo surgery or a procedure that increases risk of peripheral neurovascular dysfunction to anticipate complications.
• Immobilize the joints directly above and below the suspected fracture site, leaving room for pulse assessment to facilitate monitoring of circulatory status.
• As appropriate, assess circulation before the application of the cast, brace, or splint. After application of the cast, brace, or splint, have patient move fingers and toes every 4 hours until discharge to detect signs of impaired circulation.
• Remove the clothing around the suspected fracture site, clean the site, apply sterile dressings to open wounds, and carefully apply a cast, brace, or splint to avoid further infection and trauma.
• Follow facility guidelines for the application of such devices as tourniquets, restraints, and tape to ensure adequate circulation in affected extremity.
• If you suspect nerve compression, assess the position of the extremity that has a cast, brace, or splint. Positioning of the extremity may affect circulation.
• Elevate the limb above heart level after surgery or trauma to reduce the risk of edema. If increased intracompartmental pressure is evident, maintain the affected limb at heart level to reduce pressure.
• If edema appears in the affected extremity, split, bivalve, slit, or cut a window in the cast and padding according to facility protocol to avoid neurovascular impairment.
• Inject prescribed neurotoxic agents (such as penicillin G, hydrocortisone, tetanus toxoid, and diazepam) away from the affected extremity and major nerves to avoid injury.
• Avoid flexing the affected extremity. Flexion may reduce venous circulation, increasing the risk of neurovascular complications.
• If patient smokes, advise enrollment in a smoking-cessation program. Quitting smoking may enhance oxygenation, decreasing the risk of peripheral neurovascular dysfunction.
• Take steps to ease patient's anxiety. Stress may lead to vasoconstriction.
• Administer and monitor the effectiveness of vasodilators, as ordered, to control vasospasm.
• If patient requires a fasciotomy to restore circulation, provide educational material that explains this emergency procedure to reduce patient anxiety.
• Instruct patient and family members in proper positioning when lying in bed and when sitting and in methods of obtaining pressure relief to avoid pooling of blood and pressure ulcers.
• If appropriate, discuss the cause of the injury and safety precautions to avoid further injury. Injuries to upper extremities usually result from industrial accidents; injuries to lower extremities, from automobile accidents.
• Instruct patient and family members in recognizing the symptoms of peripheral neurovascular dysfunction, including numbness, pain, and tingling. Emphasize the need to report these symptoms to a physician to prevent onset of neurovascular damage after discharge.

Suggested NIC Interventions

• Patient doesn't experience disability related to peripheral neurovascular dysfunction.
• Patient maintains circulation in extremities.
• Patient demonstrates ability to move each toe or finger after application of cast, brace, or splint.
• Patient demonstrates correct body positioning techniques.
• Patient and family members express understanding of risk of altered neurovascular status.
• Patient enrolls in smoking-cessation program, as appropriate.
• Patient shows no symptoms of neurovascular compromise.

• Results of neurovascular assessment (baseline and ongoing)
• Nature of injury or treatment
• History of illnesses and surgeries
• Symptoms of neurovascular dysfunction reported by patient and family members
• Patient's turning schedule
• Instructions provided to patient and family members at discharge
• Evaluations for expected outcomes

• Rodrigues, S., Cepeda, F. X., Toschi, D. E., Dutra, M. A. C. B., Carvalho, J. C., Costa, H. V., … Trombetta, I. C. (2017). The role of increased glucose on neurovascular dysfunction in patients with the metabolic syndrome. Journal of Clinical Hypertension, 19(9), 840-847. doi:10.1111/jch.13060
• Shabir, O., Berwick, J., & Francis, S. E. (2018). Neurovascular dysfunction in vascular dementia, Alzheimer's and atherosclerosis. BMC Neuroscience, 19(1), N.PAG. doi:10.1186/s12868-018-0465-5
• Sobol, G., Gibson, P., Patel, P., Koury, K., Sirkin, M., Reilly, M., & Adams, M. (2017). Low incidence of neurovascular complications after placement of proximal tibial traction pins. Orthopedics, 40(6), e1004-e1008. doi:10.3928/01477447-20171012-04