Last updated on May 16th, 2022 at 06:10 pm
Impaired Perfusion Nursing Care Plans Diagnosis and Interventions
Impaired Perfusion NCLEX Review and Nursing Care Plans
Blood is a connective tissue that transports oxygen and nutrients in the body. When arterial/venous blood flow is insufficient (a mechanism also known as perfusion), it might result in decreased nourishment and oxygenation at the cellular level.
Impaired perfusion is a term that refers to the absence of oxygenated blood flow to particular areas of the body, which may result in major medical problems. If impaired perfusion is not addressed promptly, it can result in necrosis or death in non-perfused organs or tissues.
Types of Impaired Perfusion
- Impaired brain perfusion. The leading cause of impaired brain perfusion is the presence of internal trauma, physical blockage (thrombus or embolus formation), intracranial swelling, intracranial hemorrhage, and decreased cardiac output.
- Impaired renal perfusion. Many factors contribute to impaired perfusion in the kidneys; these include a decrease in cardiac output, physical blockage (formation of thrombus), swelling, or hypovolemia.
The early indicator of renal perfusion is having a low urinary output and an increase in serum creatinine (assesses renal function)
Signs and Symptoms of Impaired Perfusion
- Peripheral
- Prolonged healing of wounds
- Peripheral pulses are weak or absent.
- Extended capillary refilling
- When the patient is dependent, there is pallor on elevation.
- Alterations in skin sensations
- Hair loss in the legs
- Changes in skin temperature
- Cold fingers
- Cardiopulmonary
- Chest pain and shortness of breath (dyspnea)
- Arrhythmias
- Capillary refill of more than 3 seconds
- Increase respiration effort
- Abnormal ABGs
- Symptoms of coronary syndrome
- Vomiting
- Diaphoresis
- Bradycardia/Tachycardia
- Increased breathing rate
- Anxiety
- Alterations in the electrocardiogram
- Elevated cardiac markers in the serum
- Blood pressure that is either too high or too low
- Renal
- Renal parameters are abnormally high
- Oliguria or reduced urinary output
- Gastrointestinal
- Patients report abdominal pain
- Abdominal distension
- Imbalance electrolytes
- Changes or absence of bowel sounds
- Vomiting
- Cerebral
- Inability to move
- Nausea
- Vomiting
- Dysphagia
- Changes in the level of consciousness
- EEG readings that are abnormal
Causes of Impaired Perfusion
Impaired perfusion can occur as a result of conditions that impair blood flow. And when blood flow is compromised, tissue death (necrosis), amputation, organ damage, or even death might result. To fully comprehend the body’s trauma response, the nurse must consider all possible causes of decreased perfusion, affecting the coagulation and compensation processes.
- Hypovolemia as a result of internal and external hemorrhage
- Conditions that impair cardiac output such as cardiac arrest, myocardial infarction, cardiac shock
- Inhibition of blood flow as a result of a tight cast (external) and thrombus formation (internal)
- Medications
- Diabetes. If there is an abnormally high glucose level in the bloodstream, blood vessels may become injured or weakened.
- Peripheral artery disease. PAD is a cardiovascular disorder that causes blood vessels and arteries to become obstructed.
- Atherosclerosis. This causes the arteries and blood vessels to harden due to plaque formation.
Risk Factors of Impaired Perfusion
- Cardiovascular
- Surgery
- Diabetes Mellitus
- Risk lifestyle – may include alcohol abuse, drug abuse, sedentary lifestyle, and/or obesity
- Mechanical compression
- Trauma
- Family history of coronary artery disease or CAD
- Gastrointestinal
- Diabetes Mellitus
- Coagulopathies
- Aging
3. Cerebral
- Head trauma
- Tumor
- Mechanical prosthetic valve
Diagnosis of Impaired Perfusion
- Capillary refill assessment. Thrombus formation, poor cardiac output, edema, and hypovolemia are all markers of decreased perfusion experienced by trauma patients. To measure capillary refill in trauma and post-surgical patients, observe the time it takes for blood flow and color in tissue to return after pinching a finger or toe for around 5 seconds.
- Distal pulses. Patients with limb trauma may experience impaired distal perfusion due to swelling and reduced blood circulation. In an emergency situation, palpitation of pulses close to the heart (e.g., carotid, distal to the location) is utilized to assess the presence of a pulse.
- Blood tests (e.g., ABGs). CT perfusion imaging identifies areas of the brain that are inadequately perfused with blood. It also provides detailed information on the distribution of blood or blood flow to the brain. Additionally, it gives specific information about the blood circulation in the brain.
- Nuclear stress test. This is performed to determine if a blockage is serious enough to affect blood flow.
Treatment for Impaired Perfusion
- Prevention of prolonged immobilization. There is a higher risk of pulmonary embolism (causing venous stasis).
- Reduction of risk for trauma
- Smoking cessation. Atherosclerosis (hardening of the arteries) is more likely by chemical damage to the blood vessels.
- Addressing the underlying cause. Impaired perfusion can be caused by a variety of different factors/conditions. For instance, impaired brain perfusion might be caused by hypovolemia, bleeding in the brain, or poor cardiac output. By addressing the low cardiac workload, the patient can minimize the risk of impaired perfusion.
- Medications. This may include the use of thrombolytics.
- Surgical intervention. This may include the following:
- Bypass
- Angioplasty
- Catheter-assisted thrombus removal
- Vena cava filter
Prevention of Impaired Perfusion
- Perform regular exercise
- Wear light clothing such as cotton and wool socks
- Avoid restrictive or tight stockings and garters
- Avoid prolonged dependent positions by constantly changing positions or wriggling fingers and toes
Nursing Considerations for Patients with Impaired Perfusion
- Monitor for any indications or symptoms of bleeding.
- Administer IV lines before thrombolytic therapy
- Advise the patient to follow a low-fat, low-sodium diet.
- Examine possible contributing variables to the temporary impairment of arterial blood flow.
- Apply direct pressure to treat minor bleeding.
- Ensure that the patient receives adequate rest in the semi-fowler position.
- Obtain a full medical history to rule out any comorbidities that may contribute to impaired perfusion.
Impaired Perfusion Nursing Diagnosis
Impaired Perfusion Nursing Care Plan 1
Amputation
Nursing Diagnosis: Impaired Perfusion related to decreased blood flow in the arteries or veins secondary to amputation, as evidenced by hematoma, tissue edema, and hypovolemia.
Desired Outcome: The patient will be able to retain adequate blood flow (perfusion), as evidenced by warm and dry skin, palpable pulses, and rapid wound healing.
| Impaired Perfusion Nursing Interventions | Rationale |
| Examine the vital signs of the patient. Assess the strength and quality of his/her peripheral pulses. | These are markers of the patient’s circulatory state and impairments in his/her tissue perfusion. |
| Evaluate the patient’s drainage device and dressings, then determine the features of his/her drainage. | Additional fluid replacement may be required if blood loss continues. By continuously monitoring the patient’s drainage output, the nurse can detect early signs of a blood coagulation defect. Additionally, it may facilitate surgical intervention in ligate bleeders. |
| Apply direct pressure to the bleeding location in the event of a hemorrhage. Contact the physician immediately. | The nurse can temporarily control bleeding by applying direct pressure to the area. Usually, bulk dressings encased in plastic wrap are required to control the bleeding. |
| Consider the following while evaluating the patient’s neurovascular function: -Mobility -Pulse -Skin tone -Sensation -Temperature | Patients who have hematomas or post-operative tissue edema may have reduced circulation in the amputation stump, which can lead to tissue necrosis. Similarly, restrictive dressings might compromise circulation, requiring an ongoing evaluation to minimize potential complications. |
| Ask whether the patient experiences throbbing pain After the stump has been wrapped/bandaged. If yes, remove the bandage immediately and reapply with care. | A throbbing pain may be an indication of impaired perfusion. |
| Check the patient’s bandage regularly. | Checking the patient’s bandage on a regular basis allows the nurse to detect early indicators of complications (i.e., damage or death of organs or tissues). |
| Investigate the patient’s complaints or reports of unusual and persistent pain in the site. | Postoperatively, a hematoma can form in the muscle pocket, impairing perfusion and causing persistent pain. |
| Assess the patient’s non-operated lower limb for signs of swelling, inflammation, or Homan’s sign. | Patients experiencing diabetic changes and who have a preexisting peripheral vascular disease (e.g., Homan’s sign) he/she is at risk of having increased thrombus formation in the lower extremities. |
| Support the patient with ambulation. | Ambulation activities increase vascular circulation, which helps avoid stasis or impaired perfusion, exacerbating additional complications. At the same time, assisting the patient fosters a sense of compassion and concern for his or her well-being. |
| Examine laboratory reports for hemoglobin and hematocrit concentrations. | If the patient is hypovolemic (dehydrated), laboratory tests such as hematocrit and hemoglobin should be abnormal. When hemoglobin and hematocrit concentrations approach panic levels, they may perpetuate impaired perfusion. |
| Monitor the patient’s hematology results (PT & aPTT). | It recognizes the risk of developing complications such as posttraumatic disseminated intravascular coagulation (DIC). |
| Administer blood products or supplemental fluids to the patient as necessary. | Increases circulation and ensures optimal perfusion. |
| As prescribed by the physician, provide the patient with a low-dose anticoagulant. | Patients with DIC are more likely to have an excessive number of blood clots, resulting in impaired perfusion. However, when anticoagulant medication is administered, it helps to reduce thrombus formation and bleeding tendencies by ensuring adequate perfusion. |
| If necessary, apply anti-embolic devices to the non-operated limb. Anti-embolic medication reduces the risk of developing thrombophlebitis, a condition in which blood clots form in the lower extremities. Additionally, it improves adequate circulation and venous return. |
Impaired Perfusion Nursing Care Plan 2
Abruptio Placentae
Nursing Diagnosis: Impaired Perfusion related to excessive blood loss, secondary to abruptio placentae, as evidenced by blood loss, changes in the level of consciousness, pallor, abnormal fetal heart rate pattern, edema, changes in the temperature of the skin, alteration in pulse rate, altered blood pressure, abdominal rigidity, and severe abdominal pain.
Desired Outcomes:
- The patient’s vital signs will return to normal.
- Patient comprehension of the disease process, risk factors, and treatment plan will be communicated.
| Impaired Perfusion Nursing Interventions | Rationale |
| Determine the patient’s condition by examining their vital signs, skin color, and oxygen saturation. | Since the placenta’s vascular structures are compromised, premature placental separation causes bleeding. By examining the patient’s vital signs, nurses can get baseline data on blood circulation function. |
| Evaluate the patient’s reports on abdominal pain and uterine irritability. | To identify the degree of placental abruption and hemorrhage. |
| Position the patient in the left lateral position with the head bed raised or elevate the patient’s limbs above the heart level. | The goal is to increase the diffusion of placental fluid or improve the patient’s blood circulation. |
| Check the patient for signs of agitation, hunger, anxiety, and changes in her level of consciousness. | These signs and symptoms may indicate a problem with the brain’s blood flow (cerebral perfusion). |
| Monitor the patient’s input and output (I&O) ratio. | To assess the function and perfusion of the kidneys. Additionally, this establishes a baseline for maternal blood loss. |
| Regularly assess the fetal heart rate. Take note of the periodic fluctuations, baseline, and variability. | May reveal worsening of the condition, hypoxia, or fetal distress. |
| Advise the patient, her family, and loved ones to report any indications or symptoms of thrombosis instantly (e.g., unilateral lower extremity edema, paleness, groin, and leg pain). | Recognizing the warning signs and symptoms of thrombosis early on enables immediate intervention and treatment. |
| Examine the patient’s skin temperature, color, moisture, turgor, and capillary refill (CRT). | To evaluate the presence of peripheral tissue perfusion (e.g., hypervolemia) |
| Educate the patient to refrain from applying uterine pressure. | Because uterine blood flow is not regulated, it may fluctuate depending on the pressure. When there is an increase in pressure, venous blood can accumulate in the lower extremities. |
Impaired Perfusion Nursing Care Plan 3
Benight Febrile Convulsions
Nursing Diagnosis: Impaired Perfusion related to reduced Hgb level in the blood, secondary to benign febrile convulsions, as evidenced by skin discoloration, low Hgb count, pallor, and changes in temperature.
Desired Outcomes:
- The patient will exhibit lifestyle modifications that will improve circulation.
- The caregiver of the patient will be able to share their comprehension of the condition.
| Impaired Perfusion Nursing Interventions | Rationale |
| Assess the patient’s underlying condition and determine the variables affecting his/her situation. | To establish a baseline for the condition or to acquire information about it |
| Address the patient’s risk factors. | The patient’s significant others would need access to this information. This would enable them to better support the patient and recognize the possibility of complications developing. |
| Elevate the head of the patient’s bed before he/she sleeps or rest. | To stimulate blood flow and improve perfusion. |
| Explain the significance of exercising and having A balanced diet. | By eating a balanced and healthy diet, the patient can benefit from increased RBC synthesis and hemoglobin count, which results in a faster recovery and enhanced blood flow. On the other hand, Blood circulation is improved with regular exercise. |
Impaired Perfusion Nursing Care Plan 4
Aortic Aneurysm
Nursing Diagnosis: Impaired Perfusion related to conditions that increase artery wall stress and risk of dissection secondary to aortic aneurysm, as evidenced by hypervolemia during pregnancy, vascular wall defects, trauma, and hypertension
Desired Outcomes:
- The patient will maintain adequate tissue perfusion as evidenced by normal bowel sounds, a state of alertness, non-existent abdominal and chest pain, strong, palpable pulse, and greater than or equal to 30 ml/hr. urine output
| Impaired Perfusion Nursing Interventions | Rationale |
| Ask the patient to describe the site of pain (e.g., abdominal, flank, and groin pain) and assess its features. | The location of the pain can be determined by describing the sensation. And since most abdominal aortic aneurysm patients describe a sharp rise in pain or discomfort, subjective reports can help identify which interventions to employ. |
| Evaluate for indications of progressive dissection. | Aortic aneurysms can be caused by trauma, which increases the risk of rupture and blood clots. Signs and symptoms can help determine the location and course of dissection (e.g., poor urine output, poor motor and sensory function in the lower extremities, bloody diarrhea, and stomach pain). At the same time, dissection of the aortic arch is related to altered levels of consciousness and decreased carotid pulses. Using a high index of suspicion can help establish the best course of action/intervention for reducing mortality. |
| For abdominal aneurysms: | |
| Examine the patient’s lower extremities to detect the presence of insufficiency and peripheral ischemia. (Note for signs and symptoms of numbness, pallor, poikilothermia, pain, and discomfort) | The motor and sensory function of the lower extremities can be compromised due to aortic dissection. This is important to consider since a lack of blood supply can result in tissue or organ death. |
| Inquire about any family history of dissection or rupture that might be relevant. | Assessing the patient’s medical history will help rule out occlusive, cardiac, renal, and cerebrovascular conditions. Moreover, the risk of aortic dissection or rupture increases when hypotension is not adequately regulated. |
| Monitor the patient’s urinary output and assess for the presence of abdominal distension, abdominal pain, and diarrhea. | As a result of an aortic aneurysm, the urinary output may be reduced. Depending on the location of the aneurysm, it may not affect urine output; however, the majority of renal artery aneurysms are located below the artery. It is also possible to rule out perfusion/rupture of the abdomen by the presence of a fever, diarrhea, and abdominal distension. |
| For thoracic aneurysm: | |
| Evaluate the quality of the peripheral pulses with the use of a grading system: 0 = absent or nonpalpable 1+ = palpable 2+ = strong | Examines whether the patient’s respiratory function is compromised due to bronchus or trachea compression. |
| Check for a lump or pulsation in the midline of the abdomen. | Upon clinical palpation, a pulsating abdominal mass may reveal the presence of an enlarging AAA (abdominal aortic aneurysm) |
| Assess the patient’s blood pressure for signs of hypertension. | Rupture can occur if the patient has high blood pressure. |
| Employ nonpharmacological pain relief such as relaxation techniques, repositioning, and cold application. | These treatments may aid the patient, although their effectiveness will depend on the severity or extent of the aneurysm. |
| Provide pain medications. | Persistent acute pain is a sign of continuing dissection or rupture. Surgical intervention may be necessary to alleviate the patient’s condition. |
| Check for hemoptysis. | Hemoptysis can be caused by pulmonary artery perfusion, but it can also be caused by the trachea or the lung being compressed. |
Impaired Perfusion Nursing Care Plan 5
Cardiogenic Shock
Nursing Diagnosis: Impaired Perfusion related to a decrease or cessation in normal blood flow secondary to cardiogenic shock, as evidenced by capillary refill >3 seconds, shortness of breath, oliguria, cyanosis, atypical/abnormal arterial blood gases (ABGs), and disturbed mental status.
Desired Outcome: The patient’s perfusion will be increased as indicated by a heart rate of 60 to 100 beats per minute with absent dysrhythmia, palpable peripheral pulses, systolic blood pressure within 20 mm Hg of baseline, and well-balanced input and output (I&O).
| Impaired Perfusion Nursing Interventions | Rationale |
| Perform vital checks on the patient (heart rate, pulse, blood pressure). Continuously monitor his/her invasive blood pressure (BP) if necessary. | The presence of sinus tachycardia and an elevation in cardiovascular signs may indicate the body’s response to an absence of sufficient perfusion of the tissues. In contrast, performing auscultatory BP is frequently inaccurate when it comes to determining the presence of vasoconstriction. |
| Evaluate any changes in the patient’s level of consciousness. | A mismatch between ventilation and perfusion can cause hypoxia, and if the patient exhibits symptoms associated with this condition, such as anxiety and restlessness, it may indicate impaired perfusion. Additionally, if blood oxygenation and circulation are not restored as soon as possible, the patient may exhibit changes in LOC. |
| Monitor the patient’s capillary refill. | CRT may occasionally be slow (more than 2 seconds) in patients with impaired perfusion due to vasoconstriction. Changes in this non-invasive test are frequently indicative of poor perfusion. |
| Administer oxygen therapy if needed. | When administered to patients, oxygen therapy can help to enhance the amount of oxygen taken up by the hemoglobin in the circulatory system. |
| Promote bedrest and limit the patient’s activity as indicated. | Unassisted ambulation can consume oxygen and deplete its levels or the body’s energy reserves. By minimizing the patient’s activity, excessive oxygen consumption is controlled. |
| Provide IV fluids to the patient. | In order to address systolic and diastolic dysfunction, it is necessary to administer sufficient fluid volume to maximize cardiac output. Note: Cardiac output is an indicator of tissue perfusion. |
| Using a pulse oximeter, determine the patient’s oxygen saturation. Ensure that his/her ABGs and oxygen saturation are within normal limits. | The need to continuously check the patient’s oxygen levels is typically a preventative measure to avoid complications. Normal oxygen saturation should be maintained at 90 percent, whereas a saturation of 70 percent requires immediate medical intervention. As the metabolic demand increases, cardiogenic shock may ensue, resulting in decreased or impaired perfusion. Cardiogenic shock can be fatal. If this occurs, the level of carbon dioxide rises as the pH of the arterial blood decreases. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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