Reference — Musculoskeletal
Neurovascular Assessment Reference
Every fracture, cast, splint, traction setup, and orthopedic surgery carries the same standing question: is the tissue distal to it still perfused and innervated? This is the check that answers it — done bilaterally, on a schedule, and trended.
Educational use only. Assessment frequency and escalation thresholds follow your facility’s orthopedic and post-procedure protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
The 6 Ps — In the Order They Appear
| P | What You Find | Timing & Meaning |
|---|---|---|
| Pain | Out of proportion, unrelieved by analgesia, worse on passive stretch | Earliest and most reliable warning — act on it |
| Paresthesia | Burning, tingling, then numbness distal to injury | Early — nerve ischemia beginning |
| Pallor | Pale or dusky color, sluggish capillary refill (>3 sec) | Arterial inflow compromise developing |
| Poikilothermia | Limb cool compared with the opposite side | Perfusion failing |
| Paralysis | Cannot move digits distal to injury | Late — nerve and muscle damage advancing |
| Pulselessness | Absent distal pulse | Very late — limb viability already threatened |
CMS: The Working Bedside Check
Circulation
Distal pulse (radial/ulnar above, dorsalis pedis/posterior tibial below), capillary refill under 3 seconds, skin color and temperature — always against the other limb as the control.
Motion
Upper limb: spread the fingers, oppose thumb to fingers, extend the wrist. Lower limb: dorsiflex and plantarflex the foot and great toe. Weakness counts as a change, not just absence.
Sensation
Light touch in the key nerve territories: the web space between the great and second toes (peroneal nerve), the sole (tibial), the web between thumb and index finger (radial), the index fingertip (median), and the little finger (ulnar). Numbness in one territory localizes the nerve under pressure.
When to Assess
On admission as a baseline, then per protocol — commonly every hour initially after injury, surgery, casting, or traction, spacing out as findings stay stable. Always reassess immediately after a cast is applied or modified, traction is adjusted, the limb is repositioned, or the patient reports any new symptom. Document both sides, every time, so a trend exists when it matters.
Escalate Now
Provider notification — immediately, not at rounds — for: pain escalating despite appropriate analgesia or pain on passive stretch; new or spreading paresthesia or numbness; pallor, coolness, or capillary refill over 3 seconds; new motor weakness; any absent pulse. While escalating: loosen restrictive dressings per protocol, keep the limb at heart level, and do not ice a limb with suspected compartment syndrome.
NCLEX Pearls
- ✦Pain and paresthesia come first; pulselessness comes last. An exam answer that waits for a lost pulse is wrong.
- ✦Always compare with the unaffected limb and reassess after every cast, traction, or position change.
- ✦Numbness between the great and second toes = peroneal nerve — classic after knee surgery, fibular fracture, or a tight cast edge.
- ✦Capillary refill over 3 seconds, coolness, or pallor distal to a device is a notify-now finding.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Academy of Orthopaedic Surgeons (AAOS) · National Association of Orthopaedic Nurses (NAON). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →