Nursing Diagnosis for Ineffective Tissue Perfusion

NANDA Definition: Decrease resulting in the failure to nourish the tissues at the capillary level

Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Management is directed at removing vasoconstricting factor(s), improving peripheral blood flow, and reducing metabolic demands on the body. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. If the decreased perfusion is acute and protracted, it can have devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. This care plan focuses on problems in hospitalized patients.

Related Factors:
Peripheral:
Indwelling arterial catheters
Constricting cast
Compartment syndrome
Embolism or thrombus
Arterial spasm
Vasoconstriction
Positioning

Cardiopulmonary:
Pulmonary embolism
Low hemoglobin
Myocardial ischemia
Vasospasm
Hypovolemia

Cerebral:
Increased intracranial pressure (ICP)
Vasoconstriction
Intracranial bleeding
Cerebral edema

Renal:
Chemical irritants
Hypovolemia
Reduced arterial flow
Hemolysis

Gastrointestinal:
Hypovolemia
Obstruction
Reduced arterial flow


Defining Characteristics:
Peripheral:
Weak or absent peripheral pulses
Edema
Numbness, pain, ache in extremities
Cool extremities
Dependent rubor
Clammy skin
Mottling
Differences in blood pressure (BP) in opposite extremities
Prolonged capillary refill

Cardiopulmonary:
Tachycardia
Dysrhythmias
Hypotension
Tachypnea
Abnormal arterial blood gases (ABGs)
Angina

Cerebral:
Restlessness
Confusion
Lethargy
Seizure activity
Decreased Glasgow Coma Scale scores
Pupillary changes
Decreased reaction to light

Renal:
Altered blood pressure
Hematuria
Decreased urine output (<30 ml/hr)
Elevated BUN/creatinine ratio

Gastrointestinal:
Decreased or absent bowel sounds
Nausea
Abdominal distention/pain


Expected Outcome:
Patient maintains optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, normal ABGs, alert LOC, and absence of chest pain.


NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

  • Tissue Perfusion: Cardiopulmonary
  • Tissue Perfusion: Cerebral
  • Tissue Perfusion: Abdominal Organs
  • Tissue Perfusion: Peripheral
  • Fluid Balance
  • Electrolyte and Acid/Base Balance

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Circulatory Care
  • Cardiac Care: Acute
  • Cerebral Perfusion Promotion

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