Introduction for Nursing Diagnosis
nursing diagnosis: Ineffective Peripheral Tissue Perfusion identifies the reduction of blood flow to a limb/extremities due to arterial or venous insufficiency. It is also known as abnormal perfusion or impaired perfusion. The intervention for this diagnosis consists of decreasing the risks associated with the symptoms of decreased peripheral tissue perfusion, stabilizing or increasing the perfusion if possible, and preventing complications.
Nursing Diagnosis Definition
Ineffective Peripheral Tissue Perfusion is defined by NANDA International (NANDA-I) as reduced blood flow to a limb/extremity due to arterial or venous insufficiency.
Defining Characteristics
Subjective Data
- Chronic exertional intolence
- Radiologic evidence of emboli
- Apathy
- Cardiac index decreased
- Fever
- Hypertension
- Patient verbalization of restlessness
Objective Data
- Nailbed pallor or cyanosis
- Erythema
- Diminished pulses
- Ulceration
- Calluses
- Cold extremities
- Lack of physical activity
- Autonomic hyperactivity
- Change in tissue turgor
- Arterial insufficiency: Arterial narrowing, embolism, thrombosis, trauma, septic shock and vasculitis.
- Venous Insufficiency: Increasing venous pressure due to chronic heart failure, decrease in vascular tone due to dehydration, venous occlusion such as phlebitis, post-thrombophlebitic syndrome and edema.
- Impaired Tissue Metabolism: Hypoxia, perfusion deficits and other metabolic disturbances.
Risk Population
The risk population for ineffective peripheral tissue perfusion includes individuals with conditions of decreased circulation or impaired metabolism such as those with diabetes, hypertension, obesity, wound infections, or trauma.
Associated Problems
The associated problems of ineffective peripheral tissue perfusion include skin breakdown, tissue necrosis, decreased strength and joint function, weak capillary refill, edema, and impaired sensation.
Suggestions for Use
nursing diagnosis: Ineffective Peripheral Tissue Perfusion can be used to identify a potential problem before it becomes an actual issue and to develop an appropriate plan of care. It can also be used in clinical practice to provide information about the patient’s response to interventions, monitor the effectiveness of treatment, or to evaluate the need for further interventions.
Suggested Alternative Nursing Diagnosis
- Ineffective Activity Planning
- Ineffective Health Maintenance
- Ineffective peripheral neurovascular regulation
- Problematic blood pressure control
- Vascular Trauma
Usage Tips
When implementing nursing diagnosis: Ineffective Peripheral Tissue Perfusion, consider:
- The patient’s medical history and recent diagnoses.
- Any medications the patient is taking.
- The patient’s environment and lifestyle.
- The patient’s level of activity and physical capabilities.
- Lab results or other pertinent diagnostic tests.
NOC Results
- Perfusion Status: A measure of patient’s level of blood supply to the extremities including color, temperature, pulse and capillary refill.
- Skin Integrity: A measure of patient’s skin quality including integrity and moisture.
- Mobility: A measure of patient’s ability to move easily between positions and perform physical activities.
- Tissue Perfusion: A measure of blood flow throughout the body including oxygenation of cells and organs.
NIC Interventions
- Risk Identification: Identify potential risk factors that lead to inadequate tissue perfusion.
- Blood Pressure Management: Monitor patient’s blood pressure to ensure adequate perfusion and prevent damage due to decreased perfusion.
- Skin Care: Provide skin care measures to protect and promote tissue perfusion to the affected areas.
- Nutrition Monitoring: Monitor patient’s nutritional status to assess adequacy of tissue health.
- Exercise Therapy: Provide exercise therapy to improve patient’s strength and joint function.
Conclusion
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion is a useful tool for assessing, monitoring and preventing the risks associated with decreased circulation. This diagnosis can be used to identify potential problems or to monitor a patient’s response to interventions. Implementation of appropriate interventions can help to restore or improve circulation and reduce the potential for tissue damage or other adverse outcomes.
FAQ
- What is nursing diagnosis: Ineffective Peripheral Tissue Perfusion? nursing diagnosis: Ineffective Peripheral Tissue Perfusion identifies the reduction of blood flow to a limb/extremities due to arterial or venous insufficiency.
- What are the associated problems of ineffective peripheral tissue perfusion? The associated problems of ineffective peripheral tissue perfusion include skin breakdown, tissue necrosis, decreased strength and joint function, weak capillary refill, edema, and impaired sensation.
- Are there any tips for using this diagnosis? Yes, when implementing nursing diagnosis: Ineffective Peripheral Tissue Perfusion, consider the patient’s medical history, medications, environment and lifestyle, activity level and physical capabilities, and lab results or other diagnostic tests.
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