00204 Ineffective peripheral tissue perfusion

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00204 Ineffective peripheral tissue perfusion

Definition of the NANDA label

Decreased peripheral blood circulation that can compromise health.

Decrease in blood circulation to the periphery, which may compromise health.

Defining characteristics

• Absence of pulses.
• Impaired motor function.
• Alteration of skin characteristics (color, elasticity, hair, nail hydration, sensitivity, temperature).
• Changes in blood pressure in the extremities.
• Claudication.
• The lower extremities do not regain their color when lowered.
• Delayed healing of peripheral wounds.
• Decreased pulses.
• Edema.
• Pain in the extremities.
• Paresthesia.
• Pale skin on elevation.

Related factors

• Poor knowledge about aggravating factors (eg: smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility).
• Poor knowledge about the disease process (eg, diabetes, hyperlipidemia).
• Mellitus diabetes.
• Hypertension.
• Sedentary lifestyle.
• Smoking.

Associated condition

• Diabetes mellitus
• Endovascular procedure
• Hypertension
• Trauma

NOC

• Circulatory state.
• Hydration.
• Sensitive function: cutaneous.
• Tissue integrity: skin and mucous membranes.
• Tissue perfusion: peripheral.
• Urinary elimination.

NIC

• Hemodynamic regulation.
• Circulatory care: venous insufficiency.
• Circulatory care: arterial insufficiency.
• Circulatory precautions.
• Management of vital signs.
• Neurological monitoring.
• Electrolyte management.
• Fluid / electrolyte management.
• Handling of liquids.
• Intravenous (IV) therapy.
• Management of altered peripheral sensitivity.
• Surveillance of the skin.
• Embolism care: peripheral.

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