CMS CHECKS (Circulation, Motor, Sensory)

CMS CHECKS (Circulation, Motor, Sensory)
Gather equipment - appropriate charting forms
Wash hands.
Explain procedure to patient
Assess circulation (4 components):
o Assess color of skin by comparing with unaffected extremity.
o Assess temperature by feeling both extremities simultaneously.
o Assess capillary refill by compressing the nail of the thumb or the
large toe for a few seconds until it blanches (turns white). Note the
return of color. Blood return should be immediate, or less than 3
seconds. If nails are thick and don't blanch, press on side of toe.
o Assess peripheral pulse noting presence and strength. Compare
the pulse with the opposite extremity.
Assess motor ability :
o Ask patient to move all of the involved fingers or toes.
o Assess for the presence of pain with the movement.
o If assessing hands, have patient touch each finger to the thumb
(finger opposition).
Assess sensation:
o Ask patient about the presence or absence of sensation (e.g.
numbness, tingling, or inability to feel pain).
o Pinch each finger or toe and ask the patient to identify which one
you are pinching (ask the patient to close his/her eyes for this).
Note degree or swelling if edema present.
Assess pain and pressure areas. If the patient is unable to communicate,
assess behavior changes, such as restlessness in the adult, or fussiness
in the pediatric patient.
Record findings per agency charting policies.