Ineffective Tissue Perfusion

Ineffective Tissue Perfusion 5 Nursing Care Plans

5 Nursing Care Plans for Ineffective Tissue Perfusion

The cells are the building blocks of the human body. For them to function, they need oxygen to break down sugar and use it as energy. This mechanism is carried out by the circulatory system in a process known as tissue perfusion. When this mechanism fails due to several causes, the NANDA nursing diagnosis Ineffective Tissue Perfusion may be used.

Ineffective tissue perfusion can cause some mild to serious medical conditions and complications. However, early detection and treatment can improve the outcome and prevent serious complications from happening.

Signs and Symptoms of Ineffective Tissue Perfusion

The following are the early warning signs of reduced tissue perfusion:

  • Renal
    • Oliguria (reduced urine output) or anuria (absence of urine output)
  • Gastrointestinal
    • Nausea
    • Changes in bowel sounds
  • Peripheral
    • Edema
    • Changes in skin characteristics
    • Changes in pulse
  • Cerebral
    • Dizziness
    • Altered level of consciousness
    • Altered pupillary response
    • Speech abnormalities

Causes of Ineffective Tissue Perfusion

Numerous conditions can affect the body’s ability to perfuse oxygen to the cells. The following are the common causes of ineffective tissue perfusion:

Nursing Care Plans for Ineffective Tissue Perfusion

Nursing Care Plan 1

Ischemic Stroke

Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to interruption of blood flow secondary to ischemic stroke as evidenced by an altered level of consciousness

Desired Outcome: The patient will demonstrate no further deterioration.

InterventionRationale
Monitor vital signs and neurological status.Although regular vital signs can measure tissue perfusion, additional assessment and monitoring of the patient’s neurological status are required for neurology cases. Monitoring of the patient’s neurological status may include measurement of GCS, level of consciousness, pupillary reaction, and muscle strength. 
Assess baseline functions such as the ability of the patient to swallow, speak, and move.Sudden changes in the patient’s symptoms can signify a new stroke or worsening of the condition.
Maintain bed rest and promote a quiet and relaxing environment.Measures to prevent increased intracranial pressure should be promoted to prevent further cerebral injury.
Prevent straining such as when passing stool.Valsalva maneuver can increase intracranial pressure and increases the patient’s risk of bleeding.
Prepare and administer oxygen supplementation as needed.Supplemental oxygenation may be required to prevent cerebral vasodilation that can cause increased pressure and edema.
Administer medications as ordered.Certain medications may be prescribed to prevent further damage.

Nursing Care Plan 2

Chronic Anemia

Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related to low levels of cellular components required for oxygen delivery secondary to chronic anemia as evidenced by hemoglobin level of 6.9 g/dL

Desired Outcome: The patient will maintain maximum perfusion of vital organs as evidenced by normal vital signs and balanced intake and output.

InterventionRationale
Obtain baseline vital signs and monitor them regularly.Abnormal vital signs can signify changes in tissue perfusion.
Commence the patient on fluid balance chart. Measurement of the patient’s fluid intake and output is one of the effective ways to evaluate kidney function.
Encourage the patient to rest and encourage relaxation.Reduced activity and stress levels can reduce the body’s oxygen demand and prevent fatigue and poor tissue perfusion.
Encourage the patient to increase oral fluid intake.proper hydration can improve plasma volume and aid in circulation.
Provide oxygen support as needed.Hemoglobin carries oxygen to the cells in the body. Low levels of hemoglobin can affect the level of oxygenation. Supplemental oxygen may be needed if the problem persists.
Monitor hemoglobin level and other blood components. Increasing hemoglobin level will signify the success of treatment. Decreasing levels will help physicians decide whether blood transfusion is needed.
Transfuse blood as ordered.Severely low levels of hemoglobin may require blood transfusion.

Nursing Care Plan 3

Peripheral Arterial Disease (As a Complication of Diabetes)

Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to delayed peripheral wound healing secondary to peripheral arterial disease as evidenced by an open wound on the right big toe

Desired Outcome: The patient will develop an understanding of the importance of protecting the involved extremity from further injury.

InterventionsRationale
Assess for peripheral tissue perfusion through the following:Pulse rate and its qualitySkin texture and hair growthSkin colorOxygen saturation if possiblePeripheral tissue perfusion can be assessed in several ways. Good tissue perfusion is often characterized by the presence of good pulses in the femoral, popliteal, posterior tibial, and dorsalis pedis region. Hair growth often signifies good perfusion while purplish to cyanotic skin is associated with reduced or absent tissue perfusion.
Assess the patient’s wound and take swabs for lab testing.Prolonged wound healing can predispose the broken skin and surrounding area to further infections. A swab sample of the wound can be sent for culture and sensitivity testing to help direct antibiotic management and aid healing.
Encourage regular exercises as tolerated and as advised.Exercise helps circulation and prevents blood clot formation. However, this will need to be approved by the physician as an order for non-weight bearing activities may be required depending on the degree and location of the wound.
Review risk factors with the patient such as hyperglycemia, smoking, hyperlipidemia, obesity, and malnutrition.Delayed wound healing is very common in patients with peripheral vascular disease. A discussion with the patient regarding risk factors may prevent further injury and promote understanding of the importance of lifestyle modifications to prevent this from happening again.
Discuss ways to help improve peripheral tissue perfusion such as maintaining proper hydration, smoking cessation, weight loss, proper nutrition, keeping the wound clean and dry, wearing of proper protective equipment like non-weight bearing boots, and compliance to medications and treatment.There are several ways for the patient to help his/her wound to heal and improve tissue perfusion. Giving patients information on what they can do to help may improve the outcome of treatment and promote independence and encourage compliance to the patient.
Regular cleaning and change of dressing of the wound.Regular dressing change and wound cleaning prevent further injury and infection.

Nursing Care Plan 4

Buerger’s Disease

Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood flow secondary to Buerger’s disease, as evidenced by pale, reddish, or bluish hands or feet, pain on the affected area, Raynaud’s phenomenon (fingers and toes turn pale when exposed to cold), leg numbness and weakness

  Desired Outcome: The patient will be able to achieve optimal tissue perfusion in the affected areas as evidenced by having strong and palpable pulses, regained leg strength, and reduced pain.

InterventionsRationales
Assess the patient’s vital signs at least every 4 hours, or more frequently if there is a change in them.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for Buerger’s disease.
Encourage the patient to cooperate in the smoking cessation program. Administer nicotine patch as prescribed. Manage tobacco withdrawal symptoms as they appear.Although the relationship between tobacco use and Buerger’s disease is unknown, smoking cessation still proves to be the main intervention to manage the disease.  
Prepare the patient for the surgical procedure as indicated. Preparation involves educating the patient, gaining their consent, and accomplishing a pre-operative checklist.Regional sympathetic block or ganglionectomy can be done surgically to promote vasodilation and improve blood flow. In cases of gangrene and/or ulceration, conservative debridement of necrotic tissue is highly recommended.
Administer analgesics as prescribed.To provide pain relief especially in the affected area.
Ensure adequate hydration.Increased blood viscosity is a contributory factor to clotting. Adequate hydration helps reduce blood viscosity.

Nursing Care Plan 5

Chronic Kidney Disease (CKD)

Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related glomerular malfunction to secondary to chronic kidney disease as evidenced by increase in lab results (BUN, creatinine, uric acid, eGFR levels), oliguria or anuria, peripheral edema, hypertension, muscle twitching and cramping, fatigue, and weakness

Desired Outcome: The patient will actively participate in the treatment plan and will be able to demonstrate behaviors that will help prevent complications.

InterventionRationale
Assess and monitor vital signs.To establish baseline data. To monitor the patient’s blood pressure levels as hypertension can worsen kidney damage.
Fever may indicate disease progression or the presence of an infection.
Perform the necessary blood tests as ordered.To monitor renal function.
Monitor blood glucose levels, especially if the patient is diabetic.To reduce the stress on the kidneys.
Weigh the patient daily. Commence strict Input and Output monitoring. Note the characteristics of the urine.To assess the fluid volume status of the patient. To check for signs of worsening renal function and perfusion.
Administer medications as prescribed.CRF or CKD is irreversible; however, treating underlying causes and managing signs and symptoms can improve the patient’s quality of life and prevent further complications.
Encourage the patient to have a low protein diet. Start a food chart.  Reduction of dietary protein means reduction of waste products, giving the kidneys rest and preventing further deterioration of renal perfusion and function. Food charting can help monitor dietary protein and caloric intake.
Refer to the dietitian.To enable to patient to have specialized advice on renal diet while incorporating his/her food preferences.
Encourage the patient to exercise. Refer to the physiotherapy team.To reduce peripheral edema and to manage obesity, hypertension, fatigue, and weakness.
To enable to patient to have specialized advice on exercise.

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. (2017). 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

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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