Nursing Diagnosis for Ineffective Tissue Perfusion

Nursing Diagnosis for Ineffective Tissue Perfusion | Definition of Ineffective Tissue Perfusion; Defining Characteristics of Ineffective Tissue Perfusion; Related Factors of Ineffective Tissue Perfusion

Definition of Ineffective Tissue Perfusion

Decrease in blood circulation to the periphery that may compromise health

Defining Characteristics of Ineffective Tissue Perfusion

Altered skin characteristics (e.g., hair, nails, moisture, sensation, temperature, color, elasticity)
Blood pressure changes in extremities
Claudication
Color does not return to leg on lowering the leg
Delayed peripheral wound healing
Diminished pulses
Edema
Extremity pain
Paresthesia
Skin color pale on elevation

Related Factors of Ineffective Tissue Perfusion

Lack of knowledge of disease process (e.g., diabetes, hyperlipidemia)
Lack of knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility)

Assessment Focus | Nursing Diagnosis for Ineffective Tissue Perfusion

Nursing Diagnosis for Ineffective Tissue Perfusion | Assessment Focus; Expected Outcomes; Suggested NOC Outcomes

Assessment Focus of Ineffective Tissue Perfusion (Refer To Comprehensive Assessment Parameters.)

Activity/exercise
Physical regulation
Comfort
Sensation/perception
Self-care
Tissue integrity
Cardiac function

Expected Outcomes | Nursing Diagnosis for Ineffective Tissue Perfusion

The patient will

Understand the need to maintain moderate activity level to promote circulation.
Articulate the need and rationale for smoking cessation.
Not experience ischemic damage to involved extremity.
Experience adequate perfusion to promote prompt wound healing.
Acknowledge the importance of protecting involved extremity from injury.
Recognize reportable changes in skin characteristics to the involved extremity that indicate decreased perfusion.

Suggested NOC Outcomes | Nursing Diagnosis for Ineffective Tissue Perfusion

Activity Tolerance; Tissue Integrity: Skin and Mucous Membranes; Tissue Perfusion: Peripheral

Nursing Interventions of Ineffective Tissue Perfusion | Nursing Diagnosis for Ineffective Tissue Perfusion

Nursing Diagnosis for Ineffective Tissue Perfusion | Nursing Interventions of Ineffective Tissue Perfusion and Rationales; Suggested NIC Interventions

Nursing Interventions of Ineffective Tissue Perfusion and Rationales

Evaluate involved extremity for clinical signs (pain, decreased temperature, pallor, delayed capillary refill, weak or absent pulse, decreased sensation, and decreased pulse oximetry) that are indicators of ineffective peripheral perfusion.
Protect the extremity from injury using sheepskin or bed cradle and position extremity at or lower than level of heart to promote collateral blood flow.
Instruct patient to increase walking activity to promote collateral circulation and improve blood supply to extremity.
Teach patient to avoid crossing legs or keeping legs in a dependent position to avoid constriction of veins.
Encourage patient to protect extremity from injury or extreme hot or cold temperatures. Infection or ulcer formation may develop more easily because of decreased blood supply.
Refer patients who smoke to smoking cessation program because continued smoking will significantly increase risks for further damage.

Suggested NIC Interventions | Nursing Diagnosis for Ineffective Tissue Perfusion

Circulatory Care: Arterial Insufficiency, Exercise Promotion, Positioning, Skin Surveillance

This is a sample of Nursing Diagnosis for Ineffective Tissue Perfusion.