Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan


The words ineffective tissue perfusion surrounded by healthcare-related vector images

Related Factors

  • Insufficient blood flow/ Interruption in blood flow to organs and tissues 
  • Deficient amount of hemoglobin to transport oxygen/Blood loss
  • Impaired exchange mechanism at the capillary level 
  • Hypervolemia 

Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)

Peripheral 

  • Numbness, pain, altered sensation in extremities 

Cerebral 

  • Headaches 

Cardiopulmonary 

  • Chest pain 
  • Nausea
  • Shortness of breath
  • A feeling of impending doom/death 
  • Dizziness/ lightheadedness/ fatigue

Gastrointestinal 

  • Sudden sharp abdominal pain 

Renal

  • Altered fluid intake and output 

Objective Data: assessment, diagnostic tests, and lab values. (Signs)

Peripheral

  • Weak/absent peripheral pulses 
  • Cool skin temperature 
  • Prolonged capillary refill 
  • Thickened nails 
  • Loss of hair on legs/ shiny shins 
  • Pallor on elevation/ rubor when dependent 
  • Prolonged wound healing 

Cerebral 

  • LOC changes: restlessness, irritability, agitation 
  • Nausea/ vomiting 
  • Motor weakness 
  • Slurred speech/dysphagia 
  • Fever  
  • Abnormal CT scans 
  • Abnormal EEG results 

Cardiopulmonary 

  • Symptoms associated with coronary syndrome 
  • Dysrhythmia/ Bradycardia/ Tachycardia
  • Vomiting 
  • Diaphoresis 
  • Anxiety
  • ECG changes 
  • Elevated serum cardiac markers 
  • Elevated/low blood pressure
  • Increased respirations/ shallow breathing  

Gastrointestinal 

  • Decreased/absent bowel sounds 
  • Nausea/ vomiting 
  • Electrolyte imbalance
  • Acid-base imbalance 
  • Abdominal distention 

Renal

  • Decreased urine output 
  • Abnormal renal values 

Expected Outcome 

Peripheral

  • The patient will maintain adequate peripheral perfusion, as evidenced by strong peripheral pulses, warm skin temperature with adequate capillary refill, and the absence of ulcers. 

Cerebral 

  • The patient will demonstrate an intact LOC as evidenced by orientation to person, time, place, and situation and follow commands with intact, bilateral motor function. 

Cardiopulmonary 

  • The patient will have optimal coronary circulation as evidenced by maintaining vital signs within normal limits, being free from arrhythmias and chest pain, and skin that is dry and warm. 

Gastrointestinal 

  • The patient will have optimal gastrointestinal perfusion as evidenced by normal blood pressure, tolerating the prescribed diet, having regular bowel movements, and remaining free of abdominal pain and distention. 

Renal 

  • The patient will have proper renal perfusion as evidenced by adequate urine output and appropriate characteristics of urine. 

Assessment 

Nursing Assessment for Ineffective Peripheral Tissue Perfusion

Monitor distal pulses frequently. Check 

Brachial 
Radial 
Dorsalis Pedis 
Posterior tibialis 

If not able to find pulses, a doppler may be used. Pulses are indicative of adequate perfusion to the respective body part. Absent or weak pulses may indicate a compromise in perfusion. 

Monitor the color, temperature, and sensation of all extremities. 

Color of extremities should be usual for ethnicity. Pallor, cyanosis, or mottled skin color indicate a blockage in perfusion to the extremity. 

Assess for predisposing factors that could cause circulatory problems caused by arterial and venous pathology. 

Predisposing factors for peripheral vascular disease (PVD) can vary depending on the cause of pathology. Arterial predisposing factors may be atherosclerosis or age. Predisposing factors for venous insufficiency may be a history of deep vein thrombosis (DVT) or valvular dysfunction.

Assess for signs of decreased tissue perfusion. 

Arterial Insufficiency Assessment 
These are typical signs of patients with peripheral arterial disease (PAD). 

Skin – shiny skin, hair loss, thick nails, no edema
Hair loss and brittle nails decreased blood flow to hair follicles and nails.

Color – pallor when elevated, rubor when dependent 
Elevation pallor occurs because it is difficult for the blood to move against gravity in narrowed arteries from plaque build-up. Rubor is characterized as redness below the affected artery when placed in a dependent position.  Small arteries dilate to increase blood supply as a compensating mechanism but lose the ability to constrict, leading to the red appearance of the affected extremity when placed to gravity. 

Temperature – cool 
Extremities are cool because of decreased perfusion due to ischemia (plaque build-up) in the arteries.

Pulses – decreased, absent 
Weak or absent pulses are due to reduced blood supply. 

Pain – sharp, intermittent claudication, rest pain 
During rest, there is less oxygen demand by the muscles reducing blood supply to these areas. This decrease in perfusion when resting leads to sharp intermittent pain. 

Ulcers – well-defined edges, small but deep and circular, necrotic 
Arterial wound ulcers have a pale or sometimes necrotic wound bed because there is very little blood supply to the wound bed. 
Venous Insufficiency Assessment 
These are signs of patients with venous insufficiency. 

Skin – brown discoloration along the ankles extending up to the calves (stasis dermatitis), edema
Venous hypertension causes pooling of blood that results in valvular damage in the veins. This causes fluid to back up and leak out into surrounding tissues (edema). 

Temperature – warm 
Adequate perfusion and oxygenation of tissues due to intact arterial function.

Pulses – normal 
Pulses will be normal due to intact arterial function and blood flow.

Pain – dull, continuous pain
This is due to venous hypertension, edema, and ulceration. 

Ulcers – superficial, uneven edges
The wound bed appears pink and healthy because the arterial blood supply to the wound from the arterial blood flow is intact; however,  wound edges are macerated due to constant moist environment from leakage because of venous stasis (backup of blood in damaged veins leaking fluid out into surrounding tissues).
Note capillary refill time. 

After the nail bed is compressed, it should not take longer than 3 seconds for nail beds to assume their pinkish color. Pale nail beds are not necessarily indicative of a blood flow occlusion but poor perfusion. 

Note the severity of extremity edema. 

0 None 
+1 Trace 
+2 Mild 
+3 Moderate 
+4 Significant 

The severity of edema shows how far advanced venous stasis is. This assessment and checking extremity circumference should be done daily at the same time to monitor a trend. 

Monitor vital signs closely.

The patient needs to have a stable blood pressure and a mean arterial pressure (MAP) of at least 65 to adequately perfuse organs and other tissues. Oxygen saturation should be at satisfactory levels to ensure adequate oxygenation. 

Identify possible precipitating factors that may cause a compromise in tissue perfusion. 

Medications 
Positioning 
Pathology 
Medical equipment

Medications such as norepinephrine can cause distal ischemia and renal failure. Ill-positioned patients, pathological events, such as a thrombus formation, or medical equipment such as an endotracheal tube or a cast, all may cause decreased perfusion and cause tissue damage if not monitored closely. 

Monitor hemoglobin frequently. 

The lower the oxygen saturation is, the lower is the affinity for hemoglobin, meaning oxygen uptake will be reduced. That results in less oxygen circulating in the body. 

Nursing Assessment for Ineffective Cerebral Tissue Perfusion

Assess the patient’s mental status. 

Any changes in LOC, orientation, GCS score, or other neurological monitoring methods might indicate a decreased cerebral perfusion. 

Monitor the patient’s vital signs. 

Blood pressure within the normal range promotes adequate cerebral perfusion. Hypotension may lead to inadequate perfusion of the brain. 

Monitor the patient’s fluid balance. 

Decreased urine output may be a sign of reduced perfusion of the kidneys. If the kidneys are inadequately perfused, other vital organ perfusion such as cerebral perfusion may be impaired. The patient might receive volume expanders or be fluid restricted to keep intracranial pressure (ICP) optimal.

Nursing Assessment for Ineffective Coronary Tissue Perfusion

Assess the patient for signs and symptoms of coronary events. Consider that women may report atypical symptoms. 

Knowing the signs and symptoms of acute coronary syndrome allows healthcare staff to act fast. Any signs of a STEMI or NSTEMI, such as chest pain radiating to the arms, shortness of breath, or EKG changes, indicate an obstruction in the coronary vessels preventing adequate perfusion of myocardial tissue. Women might have different symptoms such as gastrointestinal symptoms and jaw pain. 

Note the patient’s cardiac rhythm. 

Some patients may have ECG changes such as ST depression, ST elevation, T wave inversion, new onset of left bundle branch block, which all indicate ischemia or cardiac events that block myocardial tissue perfusion. 

Monitor cardiac markers and other lab values at designated intervals. 

Serum cardiac enzymes circulate in the blood after a coronary event. Trending these lab values and looking at other lab values such as BMP and CBC may provide information about the source of the cardiac event. 

Nursing Assessment for Ineffective Gastrointestinal Tissue Perfusion

Monitor vital signs frequently. 

Hypotension and tachycardia are initial signs of low blood volume in the circulatory system. With low blood volume, the body always seeks to perfuse vital organs, such as the brain and the heart, first. Therefore, blood is directed to those organs first, leaving the gastrointestinal tract and the renal system for last to perfuse. Those organs will take the “hit” first and are at the highest risk of inadequate perfusion. 

Monitor serum lactate frequently. 

When there is an insufficient amount of oxygen available in the body, glucose breaks down into lactate which can be used for energy. Therefore, an increase in lactate levels could indicate a deprivation of oxygen in the body. 

Monitor mean arterial pressure (MAP) frequently. 

Mean arterial pressure is the average pressure in the arteries during one complete cycle of a heartbeat. The MAP should be at least greater than 60 mmHg to perfuse all the body’s vital organs adequately. 

Assess for pain and note qualities, such as onset, location, character, duration, and factors that alleviate pain or worsen it. 

Ischemic abdominal pain can be abrupt. Mesenteric ischemia may be taken into consideration with acute onset of abdominal pain. 

Nursing Assessment for Ineffective Renal Tissue Perfusion

Assess intake and output, urine color, and clarity. 

A decrease in urine output or change in color and clarity could indicate a deterioration in renal function, hence decreased renal perfusion. 

Monitor renal lab values frequently. 

Trending lab values, such as BUN and creatine, may help identify changes in renal function earlier than solely monitoring urine output and may provide additional information about renal function. 

Nursing Interventions for Ineffective Tissue Perfusion

Nursing Interventions for Ineffective Peripheral Tissue Perfusion

Interventions for Arterial Insufficiency 
Encourage the patient to elevate the legs at the heart level, never above the level of the heart. 

Raising extremities above the heart level might slow arterial blood flow and therefore diminish perfusion to the feet.

Encourage the patient to exercise and increase gradually at the patient’s tolerance level. 

Frequent exercise helps build collateral circulation. Collateral circulation is the development of smaller vessels that increase circulation in the compromised area that is occluded. 

Provide warm blankets and encourage to keep extremities warm by wearing socks and slippers. 

Cold temperatures cause vasoconstriction, hence restricting blood flow. 

Anticipate invasive intervention in acute situations. Consider the six Ps of ischemia:

Pain 
Pallor
Pulselessness
Paresthesia
Paralysis 
Poikilothermy (coolness) 

If blood flow to peripheral vessels is occluded, interventions such as stenting, thrombolysis, percutaneous transluminal angioplasty,  and other revascularization therapies may be performed.

Interventions for Venous Insufficiency 
Encourage the patient to elevate the legs above the level of the heart several times per day. 

These measures facilitate venous return and help reduce edema. 

Treat venous stasis ulcers per order.

Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Adequate treatment helps reduce the risk of infection. 

Foster active and passive range of motion (ROM) exercises. 

Movement promotes circulation and decreases venous stasis. 

Provide adequate oxygenation as ordered. 

Supplemental oxygen might be required to keep oxygen saturation greater than 90% and ensure adequate gas exchange. 

For the bed-bound patient, turn and position the patient at least every two hours.

Frequent position changes help prevent stasis in the circulatory system.

Nursing Interventions for Ineffective Cerebral Tissue Perfusion

Keep the head of the bed flat or less than 30 degrees. 

This position maximizes cerebral perfusion. Elevating the head of the bed lowers cerebral venous outflow, leading to an increase in intracranial pressure (ICP). 

Administer fluids as ordered. 

Fluids keep a normal circulating volume in the circulatory system, which helps maintain cerebral blood flow. 

Administer medications per order. 

Thrombolytics 
Anticoagulants/ antiplatelets
Antihypertensives 
Osmotic diuretics  

Thrombolytic therapy is used for selected patients that suffered a stroke. This medication is used to dissolve the blood clot in the brain’s vessels, causing ischemia and restoring cerebral perfusion. 
Anticoagulants and antiplatelets do not dissolve an already existing clot but can reduce the process of blood clot formation, hence new clots from forming. 
Hypertension can damage blood vessels over time.
Antihypertensives keep the blood pressure at goal and decrease the risk for damaged blood vessels forming lesions that could impede blood flow. 
Osmotic diuretics decrease intracranial pressure by limiting water and electrolyte reabsorption. 

Nursing Interventions for Ineffective Coronary Tissue Perfusion

Administer medications as ordered.

Nitroglycerin 
Morphine 
Aspirin 

Nitroglycerin increases coronary perfusion by dilating the coronary arteries. This improves blood flow to ischemic areas of the heart, increasing cardiac output. Increased cardiac output reduces myocardial oxygen consumption. 
Morphine has analgesic properties, as well as hemodynamic effects. It can lower blood pressure and heart rate, and therefore lower oxygen demands decreasing ischemia pain. 
Aspirin has anti-clotting properties that slow down clotting action during an ischemic attack. 

Provide adequate oxygenation as ordered. 

Supplemental oxygen might be required to keep oxygen saturation greater than 90% and ensure adequate gas exchange. Increased oxygenation enhances tissue perfusion of the heart. This might reduce ischemia pain. 

Patient Teaching 

Peripheral

Educate the patient about necessary lifestyle changes. These include 

Smoking cessation 
Following dietary guidelines 
Exercising
Maintaining foot care 
Wound care 

These measures help prevent the worsening of blood flow. Tobacco and caffeine cause vasoconstriction and vessel spasms and, therefore, might interfere with adequate perfusion. Exercising helps improve circulation and form new blood vessels increasing perfusion. 

Provide information about risk factors of peripheral vascular disease (PVD).

Smoking DiabetesHypertension ObesityHigh cholesterol Inactive lifestyle 
Knowledge about the disease and its risk factors allows the patient to make conscious decisions and lifestyle changes that help prevent the worsening of the disease. Awareness might increase compliance. 

Teach patients with peripheral vascular disease not to cross their legs and not to keep them in a dependent position. 

Leg crossing can hinder blood flow and therefore decrease perfusion. 

Instruct the patient never to apply heat sources such as heating pads directly to the skin. 

Chronic inadequate blood flow to the limbs affects sensation. Heat sources could cause burns without the patient realizing it. 

Instruct the patient to take medication as prescribed. Drug therapy might include: 

Antiplatelet therapy such as aspirin and/or Plavix. These medications help prevent platelets from sticking together, keeping blood vessels free of occlusion. 
Anticoagulants such as coumadin. This medication interferes with clotting formation in the body by blocking the formation of prothrombin from vitamin K. 
Cholesterol-lowering medications such as statins block the formation of cholesterol and therefore reduce plaque build-up in the vessels. 

Cardiopulmonary 

Teach the patient signs and symptoms of ischemia and when to call 911. 

Recognizing the signs and symptoms of an ischemic attack allows the patient and family members to act quickly and promote the best outcome possible by receiving early treatment. 

Educate the patient about risk lowering measures such as smoking cessation, adopting a heart-healthy diet, exercising, weight loss, and adherence to a prescribed medication regimen. 

Reducing these risk factors helps with the prevention of worsening coronary artery disease. 

More Care Plans

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Ineffective Breathing Pattern Nursing Diagnosis & Care Plan

Impaired Gas Exchange Nursing Diagnosis & Care Plan

Head Injury Nursing Diagnosis & Care Plan

Ineffective Health Maintenance [Care Plan]

Activity Intolerance Nursing Diagnosis & Care Plan

References:

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https://www.stroke.org.uk/what-is-stroke/are-you-at-risk-of-stroke/high-blood-pressure#:~:text=High%20blood%20pressure%20puts%20an,become%20stiffer%20and%20more%20narrow.

https://oxfordmedicine.com/view/10.1093/med/9780199600830.001.0001/med-9780199600830-chapter-138

https://www.metabolics.com/blog/how-does-the-body-produce-energy

https://www.ncbi.nlm.nih.gov/books/NBK538226/

https://www.pennmedicine.org/updates/blogs/heart-and-vascular-blog/2016/february/the-best-workout-to-manage-symptoms-of-peripheral-artery-disease

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