00086 Risk Of Peripheral Neurovascular Dysfunction

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00086
Nanda label: risk of peripheral neurovascular dysfunction
Diagnostic focus: neurovascular function
Approved 1992 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of peripheral neurovascular dysfunction ” is defined as: susceptible to an alteration in the circulation, sensitivity or mobility of a limb, which can compromise health. P>

Risk factors

  • To develop

Associated problems

  • Bone fractures
  • Burns
  • Immobilization
  • Mechanical compression
  • Orthopedic surgery
  • Trauma
  • Vascular obstruction

Suggestions of use

Use this label for situations in which nursing professionals can achieve prevention by reducing or eliminating causal factors (for example, risk of peripheral neurovascular dysfunction, related to support compression). In situations that require medical treatment (for example, thrombophlebitis), apply a collaboration problem, as a possible complication of thrombophlebitis in the left leg: risk of peripheral neurovascular dysfunction.

Suggested alternative diagnostics

  • Transoperative postural injury, risk of

NOC Results

  • Neurological status: Peripheral: capacity of the peripheral nervous system to transmit impulses to and from the central nervous system.
  • Sensory function: Cutaneous: Degree in which an individual feels correctly the skin stimulation
  • Tissue perfusion: peripheral: adequacy of blood flow through small limb vessels to maintain tissue function

Evaluation objectives and criteria

  • demonstrates tissue perfusion: peripheral, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or without deviation from normal limits):
    • Pain located in a limb
    • Peripheral edema
    • Numbness
    • Capillary filling in fingers of hands and feet
    • Paresthesia
    • Rupture of the skin
    • Skin temperature of the limbs
  • Other examples

    • blood pressure within the normal range
    • Recognize the signs and symptoms of peripheral neurovascular dysfunction
    • Strong pulsations in the limb
    • Avoid lesions caused by compression devices or fasteners
    • Force without compromise in the limb
    • Demonstrates optimal healing and adaptation to the plaster apparatus, to traction or bandage
    • Good muscle tone and limb movements force

    NIC Interventions

    • Circulatory care: Arterial insufficiency: improvement of arterial circulation
    • Circulatory care: venous insufficiency: improvement of venous circulation
    • Syshing apparatus care: Maintenance: care of the plaster apparatus after drying period
    • Pressure management: pressure reduction on body parts
    • Peripheral sensitivity management: prevention or decrease in injuries or discomfort of patients with sensitivity alteration
    • Position: Neurological patient: Achievement of adequate and optimal body alignment in patients suffering or are at risk of spinal cord lesions or vertebral irritation
    • Circulatory prevention: protection of an area located with limited perfusion
    • Surveillance of the lower extremities: collection, analysis and use of patient data to classify risk and prevent lower extremities lesions
    • Neurological surveillance: Patient data collection and analysis to prevent or reduce neurological complications

    Nursing Activities

    Valuations

    • Perform neurovascular assessments every hour during the first 24 hours after the placement of the plaster, injury, traction or clamping. Then, once stabilized, do the following every four hours:
      • Evaluate and inform the presence of progressive pain and increasing when performing passive movements and is not reduced by narcotic medications, which could be the first symptom of compartment syndrome
    • Assess the motor function, movement and strength of the peripheral nerve involved
    • (NIC) Circulatory care (arterial and venous insufficiency): Perform a complete evaluation of peripheral circulation (for example, check the pulses, edema, capillary filling, color and temperature)
    • (NIC) Management of peripheral sensitivity:
      • Monitor the presence of parstesthesia: numbness, tingling, hyperesthesia and hypoesthesia
      • Monitor the difference between hot and cold, and/or pointed and romo
      • Monitor the good adjustment of clamping, prosthesis, footwear and clothing devices
      • Check the presence of wrinkles or foreign objects in footwear, pockets and clothes
      • Monitor thrombophlebitis and deep phlebotromisis

    Patient and family education

    • Instruct the patient and relatives about routine care of the plaster apparatus and measures to avoid complications
    • Teach the patient and relatives the symptoms of a peripheral nerve injury, and the importance of immediate medical care
    • Teach the patient and family members to perform amplitude exercises of passive, assisted or active movements
    • (NIC) Management of peripheral sensitivity:
      • Teach the patient to observe the established time intervals to change position, instead of waiting to feel uncomfortable
      • Teach the patient and relatives to use the thermometer to check the water temperature

    Collaboration activities

    • Collaborate with a physiotherapist to structure and carry out an exercise program

    Others

    • Avoid tight clothes and accessories to prevent ischemia
    • Establish an immediate treatment if the presence of compartment syndrome is suspected: hold the limb at the height of the heart; Notify the doctor, and advance the removal of the plaster apparatus, oppressive bandages and anterior surgical intervention
    • Make sure the patient’s clothes are not adjusted
    • Perform amplitude exercises of passive or assisted movements
    • (NIC) Circulatory care (arterial and venous insufficiency):
      • Raise the limb 20 ° or more above the level of the heart (to improve venous return), as required
      • Place the limb in a lower position (to improve arterial circulation), as required
      • Maintain adequate hydration to avoid the increase in blood viscosity
      • Change the position patient at least every two hours, as required
    • (NIC) Management of peripheral sensitivity:
      • Avoid or carefully monitor heat or cold use, such as electric pads, hot water bottles or ice bags
      • Motivate the patient to use the body not affected by the body to identify the location and texture of the objects
      • Place a protective grid so that the bedding does not touch the affected parts of the body
      • Recommend the patient to wear comfortable, soft and low heeled footwear

    At home

    • Most previous interventions can be applied at home
    • (NIC) Circulatory care (arterial and venous insufficiency):
      • Instruct the patient about proper feet care
      • Instruct the patient about the factors that affect circulation (smoking, tight clothing, cold exposure, and positions that involve crossing the legs and feet)

    Babies and Children

    • Recognize that restlessness, nervousness and crying can be nonverbal indicators of physical suffering in babies, children and adults who have deterioration of verbal communication