Ineffective Tissue Perfusion Nursing Care Plan

Use this ineffective tissue perfusion nursing care plan guide to help you create nursing interventions for this nursing diagnosis.

Blood is a connective tissue comprised of a liquid extracellular matrix termed blood plasma which dissolves and suspends multiple cells and cell fragments. It carries oxygen from the lungs and nutrients from the gastrointestinal tract. The oxygen and nutrients subsequently diffuse from the blood into the interstitial fluid and then into the body cells. Insufficient arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death.

Nursing care planning and management for ineffective tissue perfusion is directed at removing vasoconstricting factors, improving peripheral blood flow, reducing metabolic demands on the body, patient participation, understanding the disease process and its treatment, and preventing complications.

Goals and Outcomes

The following are the common goals and expected outcomes for this nursing problem:

• The patient identifies factors that improve circulation.
• The patient identifies necessary lifestyle changes.
• The patient exhibits growing tolerance to activity.
• The patient shows no further worsening/repetition of deficits.
• The patient engages in behaviors or actions to improve tissue perfusion.
• The patient maintains maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain.
• The patient verbalizes or demonstrates normal sensations and movement as appropriate.
• The patient states when to contact physician or healthcare professional

Nursing Assessment and Rationales

Regular assessment is required in order to identify possible problems that may have led to ineffective tissue perfusion as well as name any situation that may happen during nursing care. Here are some assessment cues you may need for creating a nursing care plan (NCP) for ineffective tissue perfusion:

1. Assess for signs of decreased tissue perfusion.
Particular clusters of signs and symptoms occur with differing causes. Evaluation of Ineffective Tissue Perfusion defining characteristics provides a baseline for future comparison.

2. Assess for probable contributing factors related to temporarily impaired arterial blood flow. Some examples include compartment syndrome, constricting cast, embolism, indwelling arterial catheters, positioning, thrombus, and vasospasm.
Early detection of the source facilitates quick, effective management.

3. Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ratio, and prothrombin time or partial thromboplastin time) if anticoagulants are utilized for treatment.
Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Irregularities in coagulation may occur as an effect of therapeutic measures.

Cardiopulmonary

4. Check respirations and absence of work of breathing.
Cardiac pump malfunction and/or ischemic pain may result in respiratory distress. Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications.

Cerebral

5. Check rapid changes or continued shifts in mental status.
Electrolyte/acid-base variations, hypoxia, and systemic emboli influence cerebral perfusion. In addition, it is directly related to cardiac output.

6. Evaluate motor reaction to simple commands, noting purposeful and non-purposeful movement. Document limb movement and note right and left sides individually.
Measures overall awareness and capacity to react to external stimuli and best signifies the condition of consciousness in the patient whose eyes are closed due to trauma or who is aphasic. Consciousness and involuntary movement are incorporated if the patient can both take hold of and let go of the tester’s hand or grasp two fingers on command. Purposeful movement can comprise of grimacing or withdrawing from painful stimuli. Other movements (posturing and abnormal flexion of extremities) usually specify disperse cortical damage. The absence of spontaneous movement on one side of the body signifies damage to the motor tracts in the opposite cerebral hemisphere.

7. Evaluate verbal reaction. Observe if the patient is oriented to person, place, and time; or is confused; uses inappropriate words or phrases that make little sense.

Measures appropriateness of speech content and level of consciousness. If minimum damage has taken place in the cerebral cortex, the patient may be stimulated by verbal stimuli but may show drowsy or uncooperative. More broad damage to the cerebral cortex may be manifested by a slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Injury to the midbrain, pons, and medulla is evidenced by a lack of appropriate reactions to stimuli.

8. Record BP readings for orthostatic changes (a drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes).
Stable BP is needed to keep sufficient tissue perfusion. Medication effects such as altered autonomic control, decompensated heart failure, reduced fluid volume, and vasodilation are among many factors potentially jeopardizing optimal BP.

9. Monitor higher functions, as well as speech, if the patient is alert.
Indicators of location or degree of cerebral circulation or perfusion are alterations in cognition and speech content.

Gastrointestinal

10. Examine GI function, noting anorexia, decreased or absent bowel sounds, nausea or vomiting, abdominal distension, and constipation.
Decreased blood flow to mesentery can turn into GI dysfunction and loss of peristalsis, for example. Problems may be potentiated or provoked by the utilization of analgesics, diminished activity, and dietary changes.

Peripheral

11. Use pulse oximetry to monitor oxygen saturation and pulse rate.
Pulse oximetry is a useful tool to detect changes in oxygenation.

12. Check Hgb levels
Low levels reduce the uptake of oxygen at the alveolar-capillary membrane and oxygen delivery to the tissues.

13. Check for pallor, cyanosis, mottling, and cool or clammy skin. Assess the quality of every pulse.
Nonexistence of peripheral pulses must be reported or managed immediately. Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin perfusion and loss of pulses. Therefore, assessment is required for constant comparisons

14. Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet.
Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of feet are seen in patients with arterial insufficiency. If ulcerations are on the side of the leg, they are usually venous

Renal

15. Monitor intake and observe changes in urine output. Record urine-specific gravity as necessary.
Reduced intake or unrelenting nausea may consequence in lowered circulating volume, which negatively affects perfusion and organ function. Hydration status and renal function are revealed by specific gravity measurements.

16. Note urine output.
Reduce renal perfusion may take place due to vascular occlusion.

17. Submit patient to diagnostic testing as indicated.
A variety of tests are available depending on the cause of the impaired tissue perfusion. Angiograms, Doppler flow studies, segmental limb pressure measurements such as ankle-brachial index (ABI), and vascular stress testing are examples of these tests.

18. Observe for signs of deep vein thrombosis, including pain, tenderness, swelling in the calf and thigh, and redness in the involved extremity.
Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain.

19. Note the results of the D-Dimer Test.
High levels of D-Dimer, a fibrin degradation fragment, are found in deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation.

20. Monitor for the development of gangrene, venous ulceration, and symptoms of cellulitis.
Cellulitis often indicates peripheral vascular disease and is related to poor tissue perfusion.

21. Monitor peripheral pulses. Check for loss of pulses with bluish, purple, or black areas and extreme pain.
These are symptoms of arterial obstruction that can result in the loss of a limb if not immediately reversed.

Nursing Interventions and Rationales

The following are the therapeutic nursing interventions for ineffective tissue perfusion:

1. Check for optimal fluid balance. Administer IV fluids as ordered.
Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.

2. Maintain optimal cardiac output.
This ensures adequate perfusion of vital organs.

3. Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue.
These facilitate perfusion when interference to blood flow transpires or when perfusion has gone down to such a serious level leading to ischemic damage.

Ineffective Tissue Perfusion: Cardiovascular

4. Administer nitroglycerin (NTG) sublingually for complaints of angina.
This enhances myocardial perfusion.

5. Maintain oxygen therapy as ordered.
To enhance myocardial perfusion.

Ineffective Tissue Perfusion: Cerebral

6. When patient experiences dizziness due to orthostatic hypotension when getting up, educate methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing.
Orthostatic hypotension results in temporary decreased cerebral perfusion.

7. If ICP is increased, elevate the head of the bed from 30 to 45 degrees.
This promotes venous outflow from the brain and helps reduce pressure.

8. Avoid measures that may trigger increased ICP such as coughing, vomiting, straining at stool, neck in flexion, head flat, or bearing down.
These will further reduce cerebral blood flow.

9. Administer anticonvulsants as needed.
These reduce the risk of seizure which may result from cerebral edema or ischemia.

10. Control environmental temperature as necessary. Perform a tepid sponge bath when fever occurs.
Fever may be a sign of damage to the hypothalamus. Fever and shivering can further increase ICP.

11. Provide rest periods between care activities and prevent the duration of procedures.
Constant activity can further increase ICP by creating a cumulative stimulant effect.

12. Reorient to the environment as needed.
Decreased cerebral blood flow or cerebral edema may result in changes in the LOC.

Ineffective Tissue Perfusion: Peripheral

13. Assist with position changes.
Gently repositioning a patient from a supine to a sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes.

14. Promote active/passive ROM exercises.
Exercise prevents venous stasis and further circulatory compromise.

15. Administer medications as prescribed to treat the underlying problems. Note the response.
These medications facilitate perfusion for most causes of impairment.

• 15.1. Antiplatelets/anticoagulants
  These reduce blood viscosity and coagulation.

• 15.2. Peripheral vasodilators
  These enhance arterial dilation and improve peripheral blood flow.

• 15.3. Antihypertensives
  These reduce systemic vascular resistance and optimize cardiac output and perfusion.

• 15.4. Inotropes
  These improve cardiac output.

16. Provide oxygen therapy as necessary.
This saturates circulating hemoglobin and augments the efficiency of blood that is reaching the ischemic tissues.

17. Position patient properly in a semi-Fowler’s to high-Fowler’s as tolerated.
Upright positioning promotes improved alveolar gas exchange.

Arterial insufficiency

18. Do not elevate the legs above the level of the heart.
With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.

19. For early arterial insufficiency, encourage exercise such as walking or riding an exercise bicycle for 30 to 60 minutes per day.
Exercise enhances the development of collateral circulation, strengthens muscles, and provides a sense of well-being.

20. Keep patient warm, and have patient wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat.
Patients with arterial insufficiency complain of being constantly cold; therefore keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissues.

21. Provide much attention to foot care. Refer to a podiatrist if the patient has a foot or nail abnormality.
Ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury.

Venous insufficiency

22. If the patient is overweight, encourage weight loss to decrease venous disease.
Obesity is a risk factor for the development of chronic venous disease.

23. Discuss lifestyle with the patient to see if the occupation requires prolonged standing or sitting.
These can result in chronic venous disease.

24. If the patient is mostly immobile, consult with the physician regarding the use of a calf-high pneumatic compression device for the prevention of DVT.
Pneumatic compression devices can be effective in preventing deep vein thrombosis in an immobile patient.

25. Elevate edematous legs as ordered and ensure that there is no pressure under the knee.
Elevation improves venous return and helps minimize edema. Pressure under the knee limits venous circulation.

26. Apply support hose as ordered.
Wearing a support hose helps decrease edema.

27. Encourage patient to walk with a support hose on and perform toe-up and point flex exercises.
Exercise helps increase venous return, build up collateral circulation, and strengthen the calf muscle pumps.

28. If DVT is present, observe for symptoms of a pulmonary embolism, especially if there is a history of trauma.
Fatal pulmonary embolisms have been reported in one-third of trauma patients.

29. Discuss with the patient the difference between arterial and venous insufficiency.
Detailed diagnostic information clarifies clinical assessment and allows for more effective care.

30. Educate patient about nutritional status and the importance of paying special attention to obesity, hyperlipidemia, and malnutrition.
Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue.

31. Encourage smoking cessation.
Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction and ineffective tissue perfusion.

32. Provide knowledge on normal tissue perfusion and possible causes of impairment.
Knowledge of causative factors provides a rationale for treatments

33. Encourage change in lifestyle that could improve tissue perfusion (avoiding crossed legs at the knee when sitting, changing positions at frequent intervals, rising slowly from a supine/sitting to standing position, avoiding smoking, reducing risk factors for atherosclerosis [obesity, hypertension, dyslipidemia, inactivity]).
These measures reduce venous compression/venous stasis and arterial vasoconstriction.

34. Explain all procedures and treatments.
Understanding expected events and sensations can help eliminate anxiety associated with the unknown.

35. Teach the patient to recognize the signs and symptoms that need to be reported to the nurse.
Early assessment facilitates immediate treatment.

Recommended Resources

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See also

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