Nursing Diagnosis: 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 Care Plan for Ineffective Tissue Perfusion
Nursing Care Plan 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 Care Plan for Ineffective Tissue Perfusion.
