00204 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
Approved 2008 • Revised 2010, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « ineffective peripheral tissue perfusion is defined as: decreased peripheral blood circulation, which can compromise health.

Definite characteristics

  • Absence of peripheral pulses
  • Motor operation alteration
  • Alteration of skin characteristics
  • Ankle-azum index <0.90
  • Capillary filling time> 3 seconds
  • The color does not return to the lower limbs after a minute of leg elevation
  • Decreased blood pressure in the limbs
  • Decrease in painless distances in the walking test for 6 minutes
  • Decrease in peripheral pulses
  • Delay in the healing of peripheral wounds
  • The distance in the walking test for 6 minutes is lower than the average
  • edema
  • Pain in the limbs
  • Femoral breath
  • Intermittent claudication
  • Paresthesia
  • Paleidity of the skin to the elevation of the extremities

Related factors

  • Excessive sodium intake
  • Inappropriate knowledge of the disease process
  • Insufficient knowledge of modifiable factors
  • Sedentary lifestyle
  • smoking

Associated problems

  • Diabetes mellitus
  • Intravascular procedures
  • Hypertension
  • Trauma

Suggestions of use

Because some of the nursing interventions are different, it is usually important to determine whether ineffective peripheral tissue perfusion has an arterial or venous origin.

Suggested alternative diagnostics

  • Peripheral neurovascular dysfunction, risk of
  • Cutaneous integrity, risk of deterioration of
  • Tissue integrity, deterioration of the
  • injury, risk of

NOC Results

  • Circulatory status: Unidirectional blood flow and without obstruction, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Sensory function: Cutaneous: Degree in which an individual feels correctly the skin stimulation
  • Severity of water overload: severity of excess fluids in intracellular and extracellular spaces of the body
  • Tissue integrity: mucous skin and membranes: structural integrity and normal physiological functioning of the skin and mucous membranes
  • Tissue perfusion: peripheral: adequacy of blood flow through small limb vessels to maintain tissue function

Evaluation objectives and criteria

  • Demonstrates circulatory state, which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or without deviation from the normal range):
    • PA02 and PAC02 or partial pressure of oxygen or carbon dioxide in arterial blood
    • Left and right parotid pulses, brachial, radial, femoral and pedio
    • systolic, diastolic, pulse pressure, medium, central venous pressure and wedge pulmonary pressure
  • Demonstrates circulatory state, which is manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Anomalous respiratory sounds, distension of neck veins, edema (pulmonary) or blows in large vessels
    • Fatigue
    • Peripheral edema and ascites
  • demonstrates tissue integrity: skin and mucous membranes, which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Skin temperature, sensitivity, elasticity, hydration, integrity and thickness
    • Tissue perfusion
  • demonstrates tissue perfusion: peripheral, which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Capillary filling (hand and feet fingers)
    • skin coloration
    • Sensitivity
    • Cutaneous integrity
  • Other examples

    The patient will be able to:

    • Show intact autonomous operation
    • Inform that you have enough energy
    • Walk 6 minutes without experiencing pain in the lower extremities

    NIC Interventions

    Note : Interventions vary depending on the etiology. It is not possible to present all the interventions here.

    • Support for smoking cessation: helps another person to stop smoking
    • Teaching: Procedure/Treatment: Preparation of a patient to understand and prepare mentally to receive a prescribed procedure or treatment
    • Promotion of exercise: facilitation of regular physical activity to maintain or raise the level of health and physical form
    • Pressure management: pressure reduction in different areas of the body
    • Peripheral sensitivity management: prevention or decrease in injuries or discomfort of patients with sensitivity alteration
    • Liquid management: Promotion of water balance and the prevention of complications resulting from abnormal or non -desirable concentrations of liquids
    • Management of liquids and electrolytes: regulation and prevention of complications derived from alterations and/or hydroelectrolytic levels
    • Circulatory prevention: protection of an area located with limited perfusion
    • Circulatory surveillance: Arterial insufficiency: promotion of arterial circulation
    • Circulatory surveillance: venous insufficiency: promotion of venous circulation
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of the skin and mucous membranes
    • Surveillance of the lower extremities: collection, analysis and use of patient data, to classify risk and prevent lesions in the lower extremities

    Nursing Activities

    Valuations

    • Evaluate the presence of pressure ulcers and cellulite symptoms (that is, pain, redness and inflammation in the limbs)
    • (NIC) Circulatory surveillance (arterial and venous insufficiency):
      • Perform an exhaustive evaluation of peripheral circulation [for example, verify peripheral pulses, edema, capillary filling, coloration and temperature (of the limb)]
      • Monitor the degree of discomfort or pain with exercise, at night, or during rest (arterial)
      • Monitor the water state, including intake and elimination
      • (NIC) Peripheral sensitivity management:
      • Watch (at the peripheral level) discrimination between acute or romos, cold or hot stimuli
      • Evaluate the presence of parstesthesia: numbness, tingling, hyperesthesia and hypoesthesia
      • Monitor the presence of thrombophlebitis and deep vein thrombosis
      • Evaluate the adjustment of support devices, prostheses, shoes and clothing
    • Monitor coagulation studies (prothrombin time or TP, part -time thromboplastin or TPT and platelet count)
    • Monitor the electrolytic values ??associated with arrhythmias (for example, serum potassium and magnesium)
    • Perform an exhaustive evaluation of peripheral circulation (peripheral pulses, edema, hair filling, coloration and skin temperature)
    • Assess the peripheral integrity of the skin
    • Value muscle tone, movement, march and self -perception
    • Monitor intake and elimination
    • Monitor the state of hydration (for example, moisture of the mucous membranes, the suitability of the pulses and orthostatic pressure), as required
    • Monitor the relevant laboratory results for fluid retention (for example, increased specific density, BUN increase, hematocrit decrease and increased levels of urinary osmolality)
    • Monitor the overload or fluid retention indicators (crepitations, high PVC venous pressure or hair pulmonary pressure in wedge, edema, distension of neck veins and ascites), as required

    Patient and family education

    • Instruct about the benefits of exercise for peripheral circulation
    • Instruct about the importance of alternating exercise with rest, especially when there is arterial insufficiency
    • Instruct about the effects of smoking on peripheral circulation

    Instruct the patient and the family about:

    • Avoid exposure of limbs at extreme temperatures
    • The importance of complying with the diet and the drug regime
    • Identify signs and symptoms that should be informed to the doctor
    • The importance of preventing venous stasis (for example, not crossing your legs, raising your feet without folding your knees and exercising)
    • (NIC) circulatory surveillance (arterial and venous insufficiency): instruct the patient about proper feet care
    • (NIC) Management of peripheral sensitivity:
      • Teach the patient or the family to monitor the position of body parts when the patient is bathing, sitting, lying or changing position
      • Teach the patient or the family to examine the skin daily to detect any alteration in their integrity

    Collaboration activities

    • Administer medications according to prescription or protocols (analgesics, anticoagulants, nitroglycerin, vasodilators, diuretics, as well as positive inotropic medications and for contractility)
    • Notify the doctor if the pain does not yield
    • (NIC) Circulatory surveillance (arterial and venous insufficiency): Manage antiplatelet or anticoagulant medications, as required

    Others

    • Distribute properly in a period of 24 hours the intake of prescribed liquids
    • Respect liquid restrictions and diet (for example, without salt and low amounts of sodium), according to prescription
    • Avoid chemical, mechanical or thermal trauma, in the limb involved
    • Discourage smoking and the use of stimulants
    • (NIC) Circulatory surveillance: arterial insufficiency ’.
      • Place the limb below the level of the heart, as required
    • (NIC) Circulatory surveillance: venous insufficiency:
      • Apply different compression therapy modalities (short or wide elastic bandages), as required
      • Raise the affected member 20 degrees or more above the level of the heart, as required
      • Promote exercises with active or passive movements during bed rest, especially the lower extremities
    • (NIC) Management of peripheral sensitivity:
      • Avoid the use of heat or cold, or monitor it carefully, such as hot pillows, hot water bottles and ice bags
      • Place railings to the bed to avoid the contact of the sheets with the affected areas
      • Analyze or identify the causes of abnormal sensitivity or changes in sensitivity

    At home

    • The above activities can be used or adapted for use at home

    Older people

    • It is important to be especially attentive to the symptoms of pulmonary embolism in the elderly