Buck’s traction with a 10 lb. weight is securing a patient’s leg while she is waiting for surgery to repair a hip fracture. It is important to check circulation-sensation-movement:
A. Every shift
B. Every day
C. Every 4 hours
D. Every 15 minutes
Correct Answer: C. Every 4 hours
The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.
Option A: If neurovascular status is compromised, patients may report decreased sensation, loss of sensation, dysesthesia, numbness, tingling, or pins and needles. Altered sensation may be a result of a nerve block or epidural, this should be documented in the patient’s neurovascular assessment in the flowsheet in EMR.
Option B: Assessment of neurovascular status is essential for the early recognition of neurovascular deterioration or compromise. Delays in recognizing neurovascular compromise can lead to permanent deficits, loss of a limb, and even death. Neurovascular deterioration can occur late after trauma, surgery, or cast application.
Option D: Observe every hour for the first 24 hours post-injury, surgery, or application of cast. Then 4 hourly for a further 48 hours or as specified by the treating medical team. Capillary refill assessment is evaluated by firmly pressing down on the nail bed of fingers or toes, the nail bed will blanch and the color should return within 2-3 seconds once the pressure is released.