Question

Which is a priority assessment for a young child with a nursing diagnosis of Risk for peripheral Neurovascular dysfunction related to the presences of cast on the right arm?

Answer 1

Definition:

Probable Disruption in circulation, sensation, or motion of an extremity constitutes the Risk for Peripheral Neurovascular Dysfunction. The risk diagnosis is not evidenced by signs and symptoms, as the problem would not have occurred and nursing interventions are directed at prevention. The Risk factors mainly include; Fractures, Mechanical compression (e.g., tourniquet, cast, brace, dressing, or restraint), Orthopedic surgery; trauma, Immobilization, Burns, Vascular obstruction, etc.

Priority Assessment for a young Child:

      - Assess for individual risk factors: including trauma to extremity that causes internal tissue damage such as high-velocity and penetrating trauma; fractures (especially long-bone fractures) with hemorrhage; or external pressures from burn eschar, Immobility (e.g., long-term bed rest, tight dressings, splints or casting), Presence of conditions affecting peripheral circulation, such as atherosclerosis, Buerger’s disease, Raynaud’s disease, or diabetes mellitus; passive smoking, obese and sedentary individuals, High levels of homocysteine and cholesterol, Use of anticoagulants; and Vigorous exercise that potentiates risk of circulation insufficiency and occlusion.

- Note presence and degree (1 to 4 scale) of peripheral edema. Evaluate entire length of injured extremity. Measure both affected and unaffected extremity and compare to determine degree of impairment and establish baseline to monitor improvement or progression of condition.

- Monitor for tissue bleeding, and spread of hematoma formation that can compress blood vessels and raise compartment pressures.

- Note position/location of casts, braces, and traction apparatus to ascertain potential for pressure on tissues.

- Assess skin for signs of ulceration as can occur when circulation is impaired.

- Review recent/current drug regimen, noting use of anticoagulants and vaso-active agents.

Additionally;

       - Evaluate the client’s pain, noting severity, nature, exact location, source and alleviating and exacerbating factors.

- Access neurovascular status.

- Inspect for and document any skin lesions, discoloration, or no removable foreign material.

- Evaluate the client’s ability to learn essential procedures, such as applying slings correctly, crutch walking, or using a walker.