Ineffective peripheral tissue perfusion

Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00204
Nanda label: Ineffective peripheral tissue perfusion
Diagnostic focus: Tissue perfusion

Introduction to Nursing Diagnosis Ineffective Peripheral Tissue Perfusion

Nursing diagnosis is the initial step of a nursing process which involves the systematic collection and organization of the clients’ health data. According to the medical professionals, including the American Nurses Association (ANA), a nursing diagnosis is considered a documented statement that helps define a problem through the analysis of data collected during the assessment phase. The nursing diagnosis Ineffective Peripheral Tissue Perfusion is a humanitarian dietitian condition that results from a wide range of problems including inadequate vascular supply or utilization, inadequate oxygen content supply, circulation and metabolic imbalance.

NANDA Nursing Diagnosis Definition

The NANDA nursing diagnosis for Ineffective Peripheral Tissue Perfusion is described as “reduction in oxygen, nutrition, or other essential elements below that necessary for tissue health over a time period”. It can be broken down into different characteristics such as physical, metabolic, neurological, biochemical, or vasomotor. It can also be classified as primary or secondary according to the source of the pathology or the cause of the problem.

Defining Characteristics

Subjectives:

• Pain in the extremities
• Exhaustion/fatigue
• Lack of sensation in peripheral tissue
• Chromoptosis
• Wheezing /breathlessness

Objectives

• Tachycardia
• Unstable blood pressure levels
• Edema
• Weakness
• Discoloration of the skin
• Distended jugular veins
• Decreased muscle tone

Related Factors

The following are some related factors to ineffective peripheral tissue perfusion:

• Presence of obstructive arterial lesions
• Decreased cardiac output
• Reduced blood volume due to fibrosis/trauma
• Decrease in capillary refill time
• Inadequate nutritional status
• Weakening of the vascular walls
• Imbalance between oxygen supply and oxygen demand
• Softening of the vasculature

Each of these related factors can lead to the reduction in oxygen, nutrition, or other essential elements necessary for healthy functioning tissue. This can have severe adverse effects on patient health, especially if left untreated.

Associated Conditions

The most common associated conditions to ineffective peripheral tissue perfusion include coronary artery disease, diabetes mellitus, atherosclerosis, congestive heart failure, arrhythmia, chronic obstructive pulmonary disease, malnutrition, edema, and anemia. Other medical conditions with potential to decrease peripheral perfusion include shock, peripheral vascular disorders, and peripheral neuropathy. All of these medical conditions can significantly reduce the amount of oxygen and nutrients being delivered to the body's tissues, leading to ineffective peripheral tissue perfusion.

Suggestions for Use

This nursing diagnosis is typically used for the assessment and management of the patient with a pre-existing medical condition or post-operative care. It may also be used for the evaluation of potential medical interventions and therapeutic measures that may be implemented. It should be used in close conjunction with other relevant assessments such as physical or laboratory tests.

Suggested Alternative NANDA Nursing Diagnosis

Other alternative NANDA nursing diagnosis that could be used to assess a patient's risk for displaying symptoms of ineffective peripheral tissue perfusion include Impaired Oxygenation, Deficient Knowledge, or Risk for Imbalanced Fluid Volume. All of these primary nursing diagnoses involve the quality of tissue perfusion and the patient's ability to receive adequate oxygen and nutrition.

Usage Tips

When utilizing the nursing diagnosis of ineffective peripheral tissue perfusion, it is important to use both subjective and objective indicators for the assessment. Additionally, safety measures and interventions should be taken to prevent further health risks, as well as to help facilitate the healing process.

NOC Outcomes

The following is a list of suggested NOC outcomes to be used when providing care to a patient displaying symptoms of ineffective peripheral tissue perfusion:

• Tissue Integrity
• Sensory Perception
• Tissue Perfusion
• Activity Intolerance
• Fatigue Level

These outcomes will help assess the patient’s improvement of tissue perfusion and other related symptoms

Explanation of Each

• Tissue Integrity: is the strength of the tissue, or its ability to withstand forces, which is required to resist tissue damage
• Sensory Perception: is the patient’s ability to identify, interpret and respond to stimuli
• Tissue Perfusion: is the amount of oxygen and nutrients delivered to organs
• Activity Intolerance: is the patient’s tolerance for movement
• Fatigue Level: is the patient’s level of exhaustion due to lack of energy.

Evaluation Objectives and Criteria

When evaluating a patient’s effectiveness in response to nursing treatment for ineffective peripheral tissue perfusion, the following criteria should be used:

• The patient’s tissue integrity should remain intact
• The patient’s sensory perception should increase
• The patient’s tissue perfusion should improve
• The patient’s activity intolerance should diminish
• The patient’s fatigue level should decrease

NIC Interventions

The following is a list of suggested NIC interventions to be used when providing care to a patient displaying symptoms of ineffective peripheral tissue perfusion:

• Instruct client/family on proper body mechanics
• Assist with activities only as tolerated
• Provide an appropriate oxygen saturation level
• Administer medications as prescribed
• Monitor for signs and symptoms of tissue hypoperfusion

Explanation of Each

• Instruct client/family on proper body mechanics: This is done to ensure proper positioning and to minimize further occurrences of hypoperfusion.
• Assist with activities only as tolerated: This involves providing assistance only to the point where it is no longer safe or necessary.
• Provide an appropriate oxygen saturation level: This ensures that the tissue gets the appropriate levels of oxygen for proper function.
• Administer medications as prescribed: This involves providing medications to manage pain, inflammation and other symptoms of hypoperfusion.
• Monitor for signs and symptoms of tissue hypoperfusion: This includes monitoring a patient’s vital signs, skin color, pulse oximetry, and blood pressure.

Nursing Activities

Nursing activities related to ineffective peripheral tissue perfusion include assessing the patient’s vital signs, evaluating the patient’s tissue integrity, monitoring tissue perfusion, and providing guidance in lifestyle changes. Additionally, nurses should provide patient and family education regarding signs and symptoms of ineffective perfusion, importance of adherence to prescribed medications, and provision of resources for follow-up care.

Conclusion

In conclusion, nursing diagnosis ineffective peripheral tissue perfusion is a condition that results from inadequate oxygen delivery or reduced tissue perfusion. It is important for nurses to be aware of the symptoms, related factors, and interventions to provide the best possible care for patients at risk of this condition.

5 FAQs

• What is Ineffective Peripheral Tissue Perfusion? Ineffective peripheral tissue perfusion is a condition that results when there is an insufficient supply of oxygen, nutrients, or other essential substances to the body’s cells or tissues and can be caused by various medical conditions.
• What are the signs and symptoms of ineffective peripheral tissue perfusion? Symptoms of ineffective peripheral tissue perfusion include pain in the extremities, exhaustion/fatigue, lack of sensation in peripheral tissue, weak/discolored skin, tachycardia, unstable blood pressure levels, edema, distended jugular veins, and decreased muscle tone.
• What factors contribute to ineffective peripheral tissue perfusion? factors contributing to ineffective peripheral tissue perfusion are inadequate vascular supply or utilization, inadequate oxygen content supply, circulation and metabolic imbalance, presence of obstructive arterial lesions, decreased cardiac output, reduced blood volume due to fibrosis/trauma, decreased capillary refill time, inadequate nutritional status, weakening of the vascular walls, imbalance between oxygen supply and oxygen demand, and softening of the vasculature.
• What interventions should be administered to treat ineffective peripheral tissue perfusion? suggested interventions for treating ineffective peripheral tissue perfusion include proper body mechanics, assist with activities only as tolerated, provide an appropriate oxygen saturation level, administer medications as prescribed, and monitor for signs and symptoms of tissue hypoperfusion.
• How can a nurse evaluate the effectiveness of nursing treatment for Ineffective Peripheral Tissue Perfusion? Evaluation criteria for nursing treatment for Ineffective Peripheral Tissue Perfusion include the patient’s tissue integrity, sensory perception, tissue perfusion, activity intolerance, and fatigue level.

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