Components of the Neurovascular Assessment (Schreiber, 2016)

The neurovascular assessment of the extremities is performed to evaluate sensory and motor function (“neuro”) and peripheral circulation (“vascular”). The components of the neurovascular assessment include pulses, capillary refill, skin color, temperature, sensation, and motor function. Pain and edema are also assessed during this examination.

Comparison of assessment findings bilaterally is extremely important. Even subtle changes can have significant implications. Remember to include neurovascular assessment findings of all extremities in your documentation and to notify the appropriate health care provider of any changes.

Pulses

• Assess upper extremity peripheral pulses (brachial, radial, and ulnar) and lower extremity peripheral pulses (femoral, popliteal, posterior tibialis, and dorsalis pedis) bilaterally. Be sure to assess for the presence of pulses distal to any injury.
• Use a 0 to 4 point scale (0=absent and 4=strong/bounding), noting also if the pulse is weak, diminished or absent.
• Use a marker to indicate a pulse palpation site that is difficult to locate; this can help others with their assessment and provide consistency.
• A manual Doppler scan should be utilized if a pulse palpation site is challenging to find or if the pulse is weak.
• If palpable pulses are not assessable due to casting, assess all other parameters.
• Document if a change in the pulse is detected and notify the appropriate health care provider.

• Assess capillary refill by pressing on the nailbeds to evaluate the peripheral vascular perfusion.
• Note how long it takes for the distal capillary bed to regain its color after pressure has been applied to cause blanching (Pickard, Karlen, & Ansermino, 2011).
• Capillary refill time of two seconds or less is normal for an adult; prolonged capillary refill time can indicate abnormal perfusion.
• Capillary refill time can be affected by age, temperature, ambient light, and pressure application (Pickard, Karlen, & Ansermino, 2011).

• Compare the color of the skin bilaterally.
• Consider the patient’s usual skin tone and any skin conditions when performing this assessment; cyanosis can present differently in different skin tones.
• Pallor or cyanosis may indicate inadequate arterial supply; dusky, cyanotic, mottled, or purple black coloration may indicate inadequate venous return.
• Shiny and pale skin, suggesting pressure in the affected area, may be a sign of compartment syndrome, which requires immediate intervention to prevent vascular compromise that can result in muscle and nerve ischemia (Schreiber, 2016).

• Use the back of your hands to assess skin temperature bilaterally.
• Skin should be warm to touch. Cool skin may indicate inadequate arterial supply; warmth may indicate inadequate venous return or infection (Schreiber, 2016).

• Ask the patient about changes in sensation, such as tingling, numbness (paresthesia), pressure, or burning.
• A pressure sensory exam often consists of assessing light touch with a cotton swab and assessing temperature discrimination with warm and cold stimuli; pinprick sensation can be tested using the sharp end of a disposable safety pin.
• If indicated, consider using the 2-point discrimination test.
• Complaints of numbness or tingling in an extremity should be investigated immediately, with the assessment proximal and distal to the site of injury or surgery (if not precluded by a cast or splint).
• Nerve involvement, compromised blood flow, or the use of ice can alter a patient's sensory function.

• Assess range of motion and strength. The patient's ability to perform specific movements is a key indicator of motor function of specific nerves.
• Loss of motor function is often a late sign of neurovascular compromise; thus, frequent assessment and careful attention is required to detect these subtle changes in the patient.

• Complications can be prevented when pain is identified and treated early.
• Pain can be caused by sensory nerve damage and/or diminished blood flow.
• Use a pain assessment tool to assess severity of pain.  A hallmark of neurovascular compromise is pain disproportionate to the injury.
• Note the location, severity, and areas of radiating pain.
• In sedated patients or those who can’t verbalize information, be aware of non-verbal pain cues including grimacing, guarding, tachycardia, and hypotension.

• Edema can result from musculoskeletal injury, contribute to vascular compromise, and cause damage to muscle and nerve tissue.
• Preexisting disease processes (i.e., heart failure, cirrhosis, or kidney disease) can place a patient at increased risk for edema-related complications.
• Elevating the limb, no higher than heart level, can help decrease edema.

Frequency of Assessments

The frequency of performing a neurovascular assessment can vary within health care organizations and across units, providers, diagnosis, or procedure. On average, if there is no change to a patient's condition, neurovascular assessments typically default to every 4 hours. For at risk patients, it is a best practice recommendation for nurses to perform a neurovascular assessment together during handoff or a change in shift.