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Nursing Diagnosis for Ineffective Tissue PerfusionNursing 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

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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.

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