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
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.
* Defining Characteristics: Peripheral:
o Weak or absent peripheral pulses
o Edema
o Numbness, pain, ache in extremities
o Cool extremities
o Dependent rubor
o Clammy skin
o Mottling
o Differences in blood pressure (BP) in opposite extremities
o Prolonged capillary refill
* Cardiopulmonary:
o Tachycardia
o Dysrhythmias
o Hypotension
o Tachypnea
o Abnormal arterial blood gases (ABGs)
o Angina
* Cerebral:
o Restlessness
o Confusion
o Lethargy
o Seizure activity
o Decreased Glasgow Coma Scale scores
o Pupillary changes
o Decreased reaction to light
* Renal:
o Altered blood pressure
o Hematuria
o Decreased urine output (<30 ml/hr)
o Elevated BUN/creatinine ratio
* Gastrointestinal:
o Decreased or absent bowel sounds
o Nausea
o Abdominal distention/pain
* Related Factors: Peripheral:
o Indwelling arterial catheters
o Constricting cast
o Compartment syndrome
o Embolism or thrombus
o Arterial spasm
o Vasoconstriction
o Positioning
* Cardiopulmonary:
o Pulmonary embolism
o Low hemoglobin
o Myocardial ischemia
o Vasospasm
o Hypovolemia
* Cerebral:
o Increased intracranial pressure (ICP)
o Vasoconstriction
o Intracranial bleeding
o Cerebral edema
* Renal:
o Chemical irritants
o Hypovolemia
o Reduced arterial flow
o Hemolysis
* Gastrointestinal:
o Hypovolemia
o Obstruction
o Reduced arterial flow
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.
Ongoing Assessment
* Assess for signs of decreased tissue perfusion (see Defining Characteristics for each category in this care plan).
* Assess for possible causative factors related to temporarily impaired arterial blood flow. Early detection of cause facilitates prompt, effective treatment.
* Monitor international normalized ratio (INR) and prothrombin time/partial thromboplastin time (PT/PTT) if anticoagulants are used for treatment. Blood clotting studies are used to determine or ensure that clotting factors remain within therapeutic levels.
* Monitor quality of all pulses. Assessment is needed for ongoing comparisons; loss of peripheral pulses must be reported or treated immediately.
Therapeutic Interventions
* Maintain optimal cardiac output. This ensures adequate perfusion of vital organs. Support may be required to facilitate peripheral circulation (e.g., elevation of affected limb, antiembolism devices).
* Assist with diagnostic testing as indicated. Doppler flow studies or angiograms may be required for accurate diagnosis.
* Anticipate need for possible embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. These facilitate perfusion when obstruction to blood flow exists or when perfusion has dropped to such a dangerous level that ischemic damage would be inevitable without treatment.
Specific Interventions
* Peripheral Keep cannulated extremity still. Use soft restraints or arm boards as needed. Movement may cause trauma to artery.
* Do passive range-of-motion (ROM) exercises to unaffected extremity every 2 to 4 hours. Exercise prevents venous stasis.
* Anticipate or continue anticoagulation as ordered. Therapy may range from intravenous (IV) heparin, subcutaneous heparin, and oral anticoagulants to antiplatelet drugs.
* Prepare for removal of arterial catheter as needed. Circulation is potentially compromised with a cannula. It should be removed as soon as therapeutically safe.
* If compartment syndrome is suspected, prepare for surgical intervention (e.g., fasciotomy). The facial covering over muscles is relatively unyielding. Blood flow to tissues can become dangerously reduced as tissues swell in response to trauma from the fracture.
* If cast causes altered tissue perfusion, anticipate that physician will bivalve the cast or remove it. This restores perfusion in affected extremity.
* Administer oxygen as needed. This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues.
* Position properly. This promotes optimal lung ventilation and perfusion. The patient will experience optimal lung expansion in upright position.
* Report changes in ABGs (e.g., hypoxemia, metabolic acidosis, hypercapnia). Titrate medications to treat acidosis; administer oxygen as needed. This maintains maximal oxygenation and ion balance and reduces systemic effects of poor perfusion.
* Anticipate and institute anticoagulation as prescribed. This reduces the risk of thrombus.
* Institute continuous pulse oximetry and titrate oxygen administered. This maintains adequate oxygen saturation of arterial blood.
* Cardiovascular Administer nitroglycerin (NTG) sublingually for complaints of angina. This improves myocardial perfusion.
* Administer oxygen as ordered.
* Cerebral Ensure proper functioning of intracranial pressure (ICP) catheter (if present).
* If ICP is increased, elevate head of bed 30 to 45 degrees. This promotes venous outflow from brain and helps reduce pressure.
* Avoid measures that may trigger increased ICP (e.g., straining, strenuous coughing, positioning with neck in flexion, head flat). Increased intracranial pressures will further reduce cerebral blood flow.
* Administer anticonvulsants as needed. These reduce risk of seizure, which may result from cerebral edema or ischemia.
* Reorient to environment as needed. Decreased cerebral blood flow or cerebral edema may result in changes in the LOC.
Education/Continuity of Care
* Explain all procedures and equipment to the patient.
* Instruct the patient to inform the nurse immediately if symptoms of decreased perfusion persist, increase or return (see Defining Characteristics of this care plan).
* Provide information on normal tissue perfusion and possible causes for impairment.
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