Nursing Diagnosis of Ineffective Tissue Perfusion
Ineffective tissue perfusion can occur in several body systems--renal, peripheral, cardiopulmonary, gastrointestinal and cerebral. It is defined as reduced blood flow that results in the failure to nourish the capillary tissues. It causes less oxygenation and nutrition at the cellular level. If the decreased perfusion travels, there are few if any effects on the patient's health. But if it's an acute condition, it can be devastating and cause organ or tissue damage or death.
- Difficulty:
- Challenging
Instructions
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Look for defining characteristics. These include peripheral issues such as edema, weak or absent peripheral pulses, clammy skin, pain or numbness; cardiopulmonary affects such as hypotension or angina; and cerebral issues such as lethargy, confusion, restlessness, seizures and decreased reaction to light. There can also be impacts on the renal system such as changed blood pressure and hematuria or gastrointestinal problems including nausea, abdominal pain or decreased or absent bowel sounds.
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See if the patient is suffering from related factors such as spasms, thrombus, pulmonary embolism, intracranial bleeding or cerebral edema.
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Perform an ongoing assessment. Look for signs of decreased tissue perfusion, possible impaired blood flow and blood clotting capabilities. It's also important to monitor the patient's pulse and perform comparisons to make sure peripheral pulses are steady.
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Do therapeutic interventions. Help with diagnostic testing such as angiograms and predict the need for possible vasodilator therapy, embolectomy or heparinization. Make sure there is best possible cardiac output by raising an affected limb or using an anti-embolism device if necessary.
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Know that you may need to do other specific interventions. This may include range of motion exercises, the administration of oxygen, or changing body position.
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