Nursing
Diagnosis: Ineffective Tissue perfusion (specify type): cerebral, renal,
cardiopulmonary, GI, peripheral
Betty J. Ackley
NANDA Definition:
Decrease in oxygen resulting in failure to nourish tissues at the capillary
level
Defining Characteristics:
Defining Characteristics:
Renal
Altered blood pressure outside of acceptable parameters;
hematuria; oliguria or anuria; elevation in BUN/creatinine ratio
Gastrointestinal
Hypoactive or absent bowel sounds; nausea; abdominal distention;
abdominal pain or tenderness
Peripheral
Edema; positive Hoeman's sign; altered skin characteristics (hair,
nails, moisture); weak or absent pulses; skin discolorations; skin temperature
changes; altered sensations; diminished arterial pulsations; skin color pale on
elevation, color does not return on lowering the leg; slow healing of lesions;
cold extremities; dependent, blue, or purple skin color
Cerebral
Speech abnormalities; changes in pupillary reactions; extremity
weakness or paralysis; altered mental status; difficult in swallowing; changes
in motor response; behavioral changes
Cardiopulmonary
Altered respiratory rate outside of acceptable parameters; use of
accessory muscles; capillary refill >3 seconds; abnormal arterial blood
gases; chest pain; sense of "impending doom"; bronchospasms; dyspnea;
dysrhythmias; nasal flaring; chest retraction
Related Factors: Hypovolemia; interruption of arterial flow; hypervolemia; exchange problems; interruption of venous flow; mechanical reduction of venous and/or arterial blood flow; hypoventilation; impaired transport of oxygen across alveolar and/or capillary membrane; mismatch of ventilation with blood flow; decreased hemoglobin concentration in blood; enzyme poisoning; altered affinity of hemoglobin for oxygen
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·
Circulation
Status
·
Cardiac
Pump Effectiveness: Tissue Perfusion: Cardiac
·
Tissue
Perfusion: Cerebral
·
Tissue
Perfusion: Peripheral
·
Fluid
Balance
·
Hydration
·
Urinary
Elimination
Client Outcomes
·
Demonstrates
adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and
dry skin, adequate urinary output, and the absence of respiratory distress
·
Verbalizes
knowledge of treatment regimen, including appropriate exercise and medications
and their actions and possible side effects
·
Identifies
changes in lifestyle that are needed to increase tissue perfusion
NIC Interventions (Nursing
Interventions Classification)
Suggested NIC Labels
·
Circulatory
Care: Arterial Insufficiency
Nursing Interventions and
Rationales
Cerebral perfusion
·
If
client experiences dizziness because of orthostatic hypotension when getting
up, teach 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.
·
Monitor
neurological status; do a neurological examination; and if symptoms of a
cerebrovascular accident (CVA) occur (e.g., hemiparesis, hemiplegia, or
dysphasia), call 911 and send to the emergency room. New onset of these neurological
symptoms can signify a stroke. If caused by a thrombus and the client receives
treatment within 3 hours, a stroke can often be reversed.
·
See
care plans for Decreased
Intracranial adaptive capacity, Risk for Injury, and Acute Confusion.
Peripheral perfusion
·
Check
dorsalis pedis and posterior tibial pulses bilaterally. If unable to find them,
use a Doppler stethoscope and notify physician if pulses not present. Diminished or absent peripheral
pulses indicate arterial insufficiency (Harris, Brown-Etris, Troyer-Caudle,
1996).
·
Note
skin color and feel temperature of the skin. Skin
pallor or mottling, cool or cold skin temperature, or an absent pulse can
signal arterial obstruction, which is an emergency that requires immediate
intervention. Rubor (reddish-blue color accompanied by dependency) indicates
dilated or damaged vessels. Brownish discoloration of skin indicates chronic
venous insufficiency (Bright, Georgi, 1992; Feldman, 1998).
·
Check
capillary refill. Nail
beds usually return to a pinkish color within 3 seconds after nail bed
compression (Dykes, 1993).
·
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 clients with arterial insufficiency. If
ulcerations are on the side of the leg, they are usually venous (Bates,
Bickley, Hoekelman, 1998).
·
Note
presence of edema in extremities and rate it on a four-point scale. Measure
circumference of ankles and calf at the same time each day in the early morning
(Cahall, Spence, 1995).
·
Assess
for pain in extremities, noting severity, quality, timing, and exacerbating and
alleviating factors. Differentiate venous from arterial disease. In clients with venous insufficiency
the pain lessens with elevation of the legs and exercise. In clients with
arterial insufficiency the pain increases with elevation of the legs and
exercise (Black, 1995). Some clients have both arterial and venous
insufficiency. Arterial insufficiency is associated with pain when walking
(claudication) that is relieved by rest. Clients with severe arterial disease
have foot pain while at rest, which keeps them awake at night. Venous
insufficiency is associated with aching, cramping, and discomfort (Bright,
Georgi, 1992).
Arterial insufficiency
·
Monitor
peripheral pulses. If new onset of loss of pulses with bluish, purple, or black
areas and extreme pain, notify physician immediately. These are symptoms of arterial
obstruction that can result in loss of a limb if not immediately reversed.
·
Do
not elevate legs above the level of the heart. With arterial insufficiency, leg elevation decreases
arterial blood supply to the legs.
·
For
early arterial insufficiency, encourage exercise such as walking or riding an
exercise bicycle from 30 to 60 minutes per day. Exercise enhances the development of collateral
circulation, strengthens muscles, and provides a sense of well-being (Cahall,
Spence, 1995). Aerobic exercise training can reverse age-related peripheral
circulatory problems in otherwise healthy older men (Beere et al, 1999).
Exercise therapy should be the initial intervention in nondisabling
claudication (Zafar, Farkouh, Cheebro, 2000).
·
Keep
client warm, and have client wear socks and shoes or sheepskin-lined slippers
when mobile. Do not apply heat. Clients
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 (Creamer-Bauer, 1992).
·
Pay
meticulous attention to foot care. Refer to podiatrist if client has a foot or
nail abnormality. Ischemic
feet are very vulnerable to injury; meticulous foot care can prevent further
injury.
·
If
client has ischemic arterial ulcers, see care plan for Impaired Tissue integrity,
but avoid use of occlusive dressings. Occlusive
dressings should be used with caution in clients with arterial ulceration
because of the increased risk for cellulitis (Cahall, Spence, 1995).
Venous insufficiency
·
Elevate
edematous legs as ordered and ensure that there is no pressure under the knee. Elevation increases venous return
and helps decrease edema. Pressure under the knee decreases venous circulation.
·
Apply
support hose as ordered. Wearing
support hose helps to decrease edema. Studies have demonstrated that thigh-high
compression stockings can effectively decrease the incidence of deep vein
thrombosis (DVT) (Brock, 1994).
·
Encourage
client to walk with 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 (Cahall, Spence, 1995).
·
If
client is overweight, encourage weight loss to decrease venous disease. Obesity is a risk factor for
development of chronic venous disease (Kunimoto et al, 2001).
·
Discuss
lifestyle with client to see if occupation requires prolonged standing or
sitting, which can result in chronic venous disease (Kunimoto et al, 2001).
·
If
client is mostly immobile, consult with physician regarding use of calf-high
pneumatic compression device for prevention of DVT. Pneumatic compression devices can be effective in
preventing deep vein thrombosis in the immobile client (Hyers, 1999)
·
Observe
for signs of deep vein thrombosis, including pain, tenderness, swelling in the
calf and thigh, and redness in the involved extremity. Take serial leg
measurements of the thigh and leg circumferences. In some clients there is a
palpable, tender venous cord that can be felt in the popliteal fossa. Do not
rely on Homans' sign. Thrombosis
with clot formation is usually first detected as swelling of the involved leg
and then as pain. Leg measurement discrepancies >2 cm warrant further
investigation. Homans' sign is not reliable (Herzog, 1992; Launius, Graham,
1998). Unfortunately, symptoms of already-developed DVT will not be found in
25% to 50% of clients' exams, even though the thrombus is present (Eftychiou,
1996; Launius, Graham, 1998).
·
Note
results of D-Dimer Test. High
levels of D-Dimer, a febrin degradation fragment, is found in deep vein
thrombosis, pulmonary embolism, and disseminated intravascular coagulation
(Pagana, Pagana, 2001).
·
If
DVT is present, observe for symptoms of a pulmonary embolism, especially if
there is history of trauma. Based
on data from 16 studies, fatal pulmonary embolisms have been reported in one
third of trauma clients (Agency for Healthcare Research and Quality, 2000).
Geriatric
·
Change
positions slowly when getting client out of bed. The elderly commonly have postural hypotension
resulting from age-related losses of cardiovascular reflexes (Matteson,
McConnell, Linton, 1997).
·
Recognize
that if elderly develop a pulmonary embolus, the symptoms often mimic those of
heart failure or pneumonia (Hyers, 1999).
Home Care Interventions
·
Differentiate
between arterial and venous insufficiency. Accurate
diagnostic information clarifies clinical assessment and allows for more
effective care.
·
If
arterial disease is present and client smokes, aggressively encourage smoking
cessation. See Health-seeking
behaviors.
·
Examine
feet carefully at frequent intervals for changes and new ulcerations. Lower
Extremity Amputation Prevention Program (LEAP) documentation forms are
available at www.bphc.hrsa.gov/leap/
(Feldman, 1998).
·
Assess
client nutritional status, paying special attention to obesity, hyperlipidemia,
and malnutrition. Refer to a dietitian if appropriate. 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 (Rolstad, 1990).
·
Monitor
for development of gangrene, venous ulceration, and symptoms of cellulitis
(redness, pain, and increased swelling in an extremity). Cellulitis often accompanies
peripheral vascular disease and is related to poor tissue perfusion (Marrelli,
1994).
Client/Family Teaching
·
Explain
importance of good foot care. Teach client/family to wash and inspect feet
daily. Recommend that diabetic client wear padded socks, special insoles, and
jogging shoes.
·
Teach
diabetic client that he or she should have a comprehensive foot examination at
least annually, including assessment of sensation with the Semmes-Weinstein
monofilaments. If good sensation is not present, refer to a footwear
professional for fitting of therapeutic shoes and inserts, the cost of which is
covered by Medicare. Semmes-Weinstein
monofilaments are effectively diagnostic of impaired sensation, and early
diagnosis enables the nurse to take protective measures to prevent unnecessary
amputations (Winslow, Jacobsen, 1999). Cushioned footwear can decrease pressure
on feet, decrease callus formation, and help save the feet (George, 1993;
Feldman, 1998).
·
For
arterial disease, stress the importance of not smoking, following a weight loss
program (if client is obese), carefully controlling diabetic condition,
controlling hyperlipidemia and hypertension, and reducing stress. All of these risk factors for
atherosclerosis can be modified (Bright, Georgi, 1992).
·
Teach
client to avoid exposure to cold, to limit exposure to brief periods if going
out in cold weather, and to wear warm clothing.
·
For
venous disease, teach the importance of wearing support hose as ordered,
elevating legs at intervals, and watching for skin breakdown on legs.
·
Teach
client to recognize the signs and symptoms that need to be reported to a
physician (e.g., change in skin temperature, color, sensation, or presence of a
new lesion on the foot).
·
NOTE: If client is receiving
anticoagulant therapy, see Ineffective
Protection.
Tidak ada komentar:
Posting Komentar