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Nursing Care Plan
"Ineffective Tissue Perfusion"
Patient Problem ( Actual ) *Nursing diagnosis * Ineffective tissue perfusion related to ( contributing factor according to the patient’s condition) Subjective Data According to the nurse’s observation. Objective Data According to the patient description. Objectives Short term In 2 days, the patient will… Identify factors that improve circulation. Identify necessary lifestyle changes Engage in behaviors or actions to improve tissue perfusion. Long term In 2 weeks, the patient will… Maintain maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain. Verbalize or demonstrates normal sensations and movement as appropriate.
Nursing intervention
Assessment Assess for signs of decreased tissue perfusion.
- Rationale: Particular clusters of signs and symptoms occur with differing causes. Evaluation of Ineffective Tissue Perfusion defining characteristics provides a baseline for future comparison. Assess for probable contributing factors related to temporarily impaired arterial blood flow. Some examples include compartment syndrome, constricting cast, embolism, indwelling arterial catheters, positioning, thrombus, and vasospasm.
- Rationale: Early detection of the source facilitates quick, effective management.
Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ratio, and prothrombin time or partial thromboplastin time) if anticoagulants are utilized for treatment.
- Rationale: Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Irregularities in coagulation may occur as an effect of therapeutic measures. Check respirations and absence of work of breathing.
- Rationale: Cardiac pump malfunction and/or ischemic pain may result in respiratory distress. Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications. Check rapid changes or continued shifts in mental status.
- Rationale: Electrolyte/acid-base variations, hypoxia, and systemic emboli influence cerebral perfusion. In addition, it is directly related to cardiac output. Record BP readings for orthostatic changes (drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes).
- Rationale: Stable BP is needed to keep sufficient tissue perfusion. Medication effects such as altered autonomic control, decompensated heart failure, reduced fluid volume, and vasodilation are among many factors potentially jeopardizing optimal BP. Monitor higher functions, as well as speech, if patient is alert.
- Rationale: Indicators of location or degree of cerebral circulation or perfusion are alteration in cognition and speech content. Examine GI function, noting anorexia, decreased or absent bowel sounds, nausea or vomiting, abdominal distension, and constipation.
- Rationale: Decreased blood flow to mesentery can turn out to GI dysfunction, loss of peristalsis, for example. Problems may be potentiated or provoked by utilization of analgesics, diminished activity, and dietary changes. Use pulse oximetry to monitor oxygen saturation and pulse rate.
- Rationale: Pulse oximetry is a useful tool to detect changes in oxygenation. Check Hemoglobin levels
- Rationale: Low levels reduce the uptake of oxygen at the alveolar- capillary membrane and oxygen delivery to the tissues.
Maintain oxygen therapy as ordered.
- Rationale: To enhance myocardial perfusion. When patient experiences dizziness due to orthostatic hypotension when getting up, educate 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.
- Rationale: Orthostatic hypotension results in temporary decreased cerebral perfusion. Check mental status; perform a neurological examination.
- Rationale: Review trend in level of consciousness (LOC) and possibility for increased ICP and is helpful in deciding location, extent and development/resolution or central nervous system (CNS) damage. If ICP is increased, elevate head of bed 30 to 45 degrees.
- Rationale: This promotes venous outflow from brain and helps reduce pressure. Avoid measures that may trigger increased ICP such as coughing, vomiting, straining at stool, neck in flexion, head flat, or bearing down.
- Rationale: These will further reduce cerebral blood flow. Administer anticonvulsants as needed.
- Rationale: These reduce risk of seizure, which may result from cerebral edema or ischemia. Control environmental temperature as necessary. Perform tepid sponge bath when fever occurs.
- Rationale: Fever may be a sign of damage to hypothalamus. Fever and shivering can further increase ICP. Evaluate motor reaction to simple commands, noting purposeful and no purposeful movement. Document limb movement and note right and left sides individually.
- Rationale: Measures overall awareness and capacity to react to external stimuli, and best signifies condition of consciousness in the patient whose eyes are closed due to trauma or who is aphasic. Consciousness and involuntary movement are incorporated if patient can both take hold of and let go of the tester’s hand or grasp two fingers on command. Purposeful movement can comprise of grimacing or withdrawing from painful stimuli. Other movements (posturing and abnormal flexion of extremities) usually specify disperse cortical damage.
Absence of spontaneous movement on one side of the body signifies damage to the motor tracts in the opposite cerebral hemisphere. Evaluate verbal reaction. Observe if patient is oriented to person, place and time; or is confused; uses inappropriate words or phrases that make little sense.
- Rationale: Measures appropriateness of speech content and level of consciousness. If minimum damage has taken place in the cerebral cortex, patient may be stimulated by verbal stimuli but may show drowsy or uncooperative. More broad damage to the cerebral cortex may be manifested by slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Injury to midbrain, pons, and medulla is evidenced by lack of appropriate reactions to stimuli. Provide rest periods between care activities and prevent duration of procedures.
- Rationale: Constant activity can further increase ICP by creating a cumulative stimulant effect. Assist with position changes.
- Rationale: Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes. Promote active/passive ROM exercises.
- Rationale: Exercise prevents venous stasis and further circulatory compromise. Position patient properly in a semi-Fowler’s to high-Fowler’s as tolerated.
- Rationale: Upright positioning promotes improved alveolar gas exchange. Monitor peripheral pulses. Check for loss of pulses with bluish, purple, or black areas and extreme pain.
- Rationale: 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.
- Rationale: With arterial insufficiency, leg elevation decreases arterial blood supply to the legs. Keep patient warm, and have patient wear socks and shoes or sheepskin- lined slippers when mobile. Do not apply heat.
Evaluation Achieved ( ) Partially achieved ( ) Not achieved ( ) Evidence by: Important Note "We just recommend examples of nursing care plans. There are many references and interventions may change according to patient condition. You should consider this, search, and see more than one reference to reach the best quality for writing the care plan"
