This guideline provides guidance on neurovascular observations at Great Ormond Street Hospital (GOSH).
Introduction
Monitoring and recording of neurovascular observations is essential in all children following any of the following (Rationale 1):
Nerves are not renowned for their healing abilities. Therefore any damage needs to be diagnosed and assessed promptly in order to reduce the risk of further damage (Rationale 2).
Compartment syndrome occurs from two hours to six days post injury/surgery, but normally within 72 hours (Love 1998; Tucker 1998; Swain and Ross 1999).
With a compromised blood supply creating ischemia, irreversible muscle damage occurs within 4-6 hours and functional nerve damage within 12-24 hours. Limb contractures can develop as early as 12 hours post insult (Booth 1996; Love 1998; Altizer 2002; Edwards 2004; Footner 1992).
Neurovascular observations must be analysed in conjunction with knowledge of the injury and other observations as documented. Complications may include:
The observations should be used in reference to each other and not as individual points of concern. Both limbs should be assessed simultaneously, although it is only required that the injured or affected limb be recorded (Rationale 3).
Inform child and family
Explanation appropriate to the child’s age and condition must be given. The family should have the need for the observations explained to them (Rationale 4, 5 and 6).
The child should be encouraged to practice the movements (shown on the chart) regularly (Rationale 7, 8, 9 and 10).
The child should have an appropriate pain scale explained to them and be encouraged to use this each time. This should be done pre-procedure when possible (Rationale 11, 12 and 13).
How to perform neurovascular observations
Document patient details, surgical details and the date and time of performing the observations (Rationale 14 and 15).
Colour, warmth, swelling and ooze
Visually assess the naked foot/hand checking for colour, swelling and ooze. Check for warmth with superficial touch (Rationale 16, 17, 18 and 19).
Pulse and capillary refill
Check foot/hand for presence and magnitude of pulses distal from the injury/affected area and venous return (capillary refill) (Rationale 20 and 21).
Capillary refill should be measured by pressing on the digit for five seconds, then counting the seconds until the digit returns to its usual colour, normally taking less than two seconds (Rationale 22).
Pain score
Pain score should be done in conjunction with movement (Rationale 23, 24 and 25).
Movement when limb is restricted
Where movement is restricted by a cast or orthotic, the digits should still be flexed and extended and the type of cast documented in the comments section (Rationale 26).
Movement while child is asleep
Where the child is asleep, full movement of the limbs should be carried out passively and documented as such (Rationale 27).
Foot movement
The foot should be actively dorsiflexed as far as mechanically possible (Rationale 28). If active movement is not possible due to language or developmental barriers, then full dorsiflexion should be carried out passively (Altizer 2002)(Rationale 29).
The child should then actively plantarflex the foot as far as mechanically possible. Where this is not possible due to language or developmental barriers, this movement should be carried out passively (Altizer 2002)(Rationale 30).
These should all be done actively and can easily be made into a game. But where this is not possible due to language or developmental barriers, this movement should be carried out passively (Altizer 2002)(Rationale 36).
It is imperative that the limb is fully flexed and extended in order to assess for compartment syndrome (Ross 1991; Dykes 1993).
Sensation
All touchable/visible surfaces (including between digits) should be checked for presence and type of sensation. This should preferably be done with the child’s eyes closed/not watching. The neurovascular charts have diagrams of the nerve endings for the foot and hand (Rationale 37, 38, 39, 40 and 41).
Position
The position of the child should be documented as either left, right, supine, prone or sitting (Rationale 42).
Visual disturbances (C spine patients only)
The child should be assessed for any visual abnormalities (Rationale 43).
Actions to take for suspected compartment syndrome
Call child’s medical team for an urgent review, as time equates to muscle and nerve damage and tissue death (Rationale 44).
If the limb has a bandage or plaster cast in situ, completely split the cast and cut the dressing to skin level (Rationale 45).
Elevate the limb to the height of the heart (Rationale 46).
Carry out 15-30 minute neurovascular observations (Rationale 47).
Action to take for suspected nerve compromise
Refer to child’s medical team if condition not previously documented (Rationale 48).
Treatment
If compartment syndrome has been diagnosed then the patient will need to have an emergency fasciotomy in theatre (Rationale 49).
If the team is unsure of the diagnosis, a needle will be inserted into the compartment to check the pressure (Rationale 50).
If the pressure is indicative of compartment syndrome then the patient will need emergency surgery (Rationale 51).
Rationale 1: To detect early complications.
Rationale 2: Neurovascular observations provide information that is essential in the detection of nerve damage and/or compartment syndrome.
Rationale 3: It is essential to record a baseline of both/all limbs as a reference point, as some people for example, have been noted to have absent pulses in their feet (Dykes 1993) or they have changes in movement or sensation from a previous injury.
Rationale 4: To gain informed consent.
Rationale 5: To improve co-operation.
Rationale 6: To reduce fear and provide reassurance.
Rationale 7: To reduce fear of movement.
Rationale 8: To reduce the need for passive movement.
Rationale 9: To promote blood flow and therefore healing.
Rationale 10: To reduce swelling by improved circulation.
Rationale 11: To gain an understanding of pain scales prior to painful experience.
Rationale 12: To provide a consistent pain score.
Rationale 13: To monitor the effectiveness of the analgesia.
Rationale 14: To comply with Trust policy and professional practice standards (NMC 2008).
Rationale 15: For easy reference to surgical procedure and as such frequency of observations required.
Rationale 16: Colour and warmth are provided by a healthy blood supply. A cool pale limb is indicative of a reduced arterial supply, while a dusky, blue or cyanotic limb is likely to be poor venous return. Warmth can also be indicative of poor venous return (Altizer 2002; Kunkler 1999)
Rationale 17: If a chart refers to the colour ‘pink’, remember this is not an accurate colour for all ethnic groups. In these circumstances, please assess for a well-perfused limb.
Rationale 18: Swelling is an indicator for compartment syndrome and essential to observe. It is especially important if the limb is in any type of cast. Tense refers to a tight shiny limb (Love 1998; Kunkler 1999)
Rationale 19: Ooze requires monitoring for wound care and blood loss. It should be marked on a plaster cast for monitoring and documented.
Rationale 20: In recognition of compartment syndrome a pulseless limb is a late and unreliable sign, as arterial flow may continue while the peripheral perfusion is compromised (Love 1998; Altizer 2002; Edwards 2004; Ross 1991).
Rationale 21: An absent pulse is significant however, as it may denote arterial stenosis, whereas an excessively strong pulse can suggest a distal occlusion (Kunkler 1999).
Rationale 22: Capillary refill is a significant observation, as it is assessing the peripheral perfusion and cardiac output (Kunkler 1999).
Rationale 23: The most reliable and consistent sign of compartment syndrome is pain during movement, as ischemic muscles are highly sensitive to stretching (Tucker 1998; Swain and Ross 1999; Footner 1992; Middleton 2003; Kunkler 1999; Kerr 1997).
Rationale 24: Pain that is disproportionate to the injury, increases with passive extension and progressive, is indicative of compartment syndrome (Altizer 2002; Edwards 2004; Dykes 1993).
Rationale 25: This pain can be masked with large doses of opioids (Edwards 2004).
Rationale 26: This still stretches the muscles and demonstrates nerve function, although to a lesser extent.
Rationale 27: Compartment syndrome is as probable in the sleeping child as if they were awake. If the movement is creating significant pain, then either they require analgesia or it is disproportionate from the injury and needs further assessment.
Rationale 28: Active movement demonstrates nerve function (Booth 1996).
Rationale 29: Dorsiflexion assesses the peroneal nerve function.
Rationale 30: Plantarflexion assesses the tibial nerve function.
Rationale 31: To detect early signs of compartment syndrome.
Rationale 32: Active movement demonstrates nerve function (Booth 1996).
Rationale 33: The L shape tests the radial nerve function.
Rationale 34: The OK sign tests the median nerve function.
Rationale 35: The splayed fingers tests the ulnar nerve function.
Rationale 36: To detect early signs of compartment syndrome.
Rationale 37: Absence or complaints of pins and needles/tingling can be indicative of nerve compromise (Booth 1996; Love 1998; Dykes 1993).
Rationale 38: This assesses the peroneal (dorsal) nerve and the tibial (plantar) nerve in the foot.
Rationale 39: This assesses the radial, median and ulnar nerve in the hand.
Rationale 40: Skeletal muscles are innervated by nerves and therefore nerve damage can result in permanent loss of function to the whole or part of the limb (Altizer 2002; Edwards 2004).
Rationale 41: It is more effective and accurate with the child not watching.
Rationale 42: To document changes in position, as those requiring neurovascular observations commonly have reduced mobility and are therefore at a higher risk of pressure sores.
Rationale 43: To check the effect of the C spine deformity on the visual field and acuity.
Rationale 44: To instigate urgent investigation and treatment.
Rationale 45: To relieve pressure.
Rationale 46: If it isn't elevated higher, the vascular pressure will continue to increase and exacerbate the condition by increasing the ischemia.
Rationale 47: To check on the condition of the affected limb.
Rationale 48: To instigate urgent investigation and treatment.
Rationale 49: The damage caused by compartment syndrome can occur extremely quickly and urgent surgery is required to reduce the amount of damage caused.
Rationale 50: 0-10mmHg is considered a normal compartment pressure. Pressure readings are normally taken in conjunction with the patient’s blood pressure and within 30mmHg of the diastolic are considered diagnostic.
Rationale 51: To reduce the amount of damage caused.
Reference 1:
Booth Y (1996). Traction (Ch 42) Mallett J, Bailey C In: Manual of Clinical Nursing Procedures (4th edition). Oxford, Blackwell Science.
Reference 2:
Fort C (2003). How to combat 3 deadly trauma complications. Nursing 33(5): 58-63.
Reference 3:
Love C (1998). A Discussion and Analysis of Nurse Led Assessment for the Early Detection of Compartment Syndrome. Journal of Orthopaedic Nursing 2(3): 160-167.
Reference 4:
Swain R, Ross D (1999). Lower extremity compartment syndrome. When to suspect acute or chronic pressure buildup. Postgrad Med 105(3): 159-62, 165, 168.
Reference 5:
Altizer L (2002). Neurovascular assessment. Orthop Nurs 21(4): 48-50.
Reference 6:
Edwards S (2004). Acute compartment syndrome. Emerg Nurse 12 (3): 32-8.
Reference 7:
Footner A (1992). Orthopaedic Nursing (2nd edition). London, Bailliere Tindall.
Reference 8:
Ross D (1991). Acute compartment syndrome. Orthop Nurs 10(2): 33-8.
Reference 9:
Middleton C (2003). Compartment syndrome: the importance of early diagnosis. Nurs Times 99(21): 30-2.
Reference 10:
Dykes PC (1993). Minding the five Ps of neurovascular assessment. Am J Nurs 93(6): 38-9.
Reference 11:
Nursing and Midwifery Council (NMC) (2008) The NMC Code: standards for performance, conduct and ethic of professional conduct. London, NMC.
Reference 12:
Kunkler CE (1999) Neurovascular assessment. Orthop Nurs 18(3): 63-71.
Reference 13:
Kerr Graham H (1997) Upper limb trauma (ch 22) Broughton, N In: A textbook pf paediatric orthopaedics. Philadelphia, WB Saunders.
Document control information
Lead author(s)
Carol Irwin, Ward Manager, Surgery
Document owner
Nathan Askew, Ward Manager, Surgery
Approved by
Clinical Practice Committee
First introduced: 21 March 2007
Date approved: 7 December 2011
Review schedule: Two years
Next review: 7 December 2013
Document version: 1.1
Replaces version: 1.0
