00024 Ineffective tissue perfusion

image_pdfDownload PDF

00024 Ineffective tissue perfusion

Definition of the NANDA label

Ineffective tissue perfusion is the state in which an individual has a reduction in oxygen concentration and consequently in cellular metabolism, due to a deficit in capillary blood supply.

* THE TYPE MUST BE SPECIFIED: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL.

Defining characteristics

Impaired renal perfusion

  • Severe hypotension or hypertension.
  • Hematuria.
  • Oliguria or anuria.
  • Increased BUN / creatinine ratio.

Impaired cerebral perfusion

  • Mental confusion.
  • Weakness or paralysis of the limbs.
  • Behavior changes.
  • Variations in the responses of the pupils.
  • Speech abnormalities.
  • Dysphagia.
  • Changes in motor responses.

Impaired cardiopulmonary perfusion

  • Chest pain.
  • Feeling of “imminent death”.
  • Severe tachypnea or bradypnea.
  • Thoracic retraction.
  • Dyspnoea, bronchospasm, nasal flaring and use of accessory muscles.
  • Arrhythmias.
  • Anomalous arterial blood gas.
  • Capillary filling greater than three seconds.

Alteration of gastrointestinal perfusion

  • Hypoactive or absent bowel sounds.
  • Nausea.
  • Abdominal pain or tenderness.
  • Abdominal bloating.

Alteration of peripheral perfusion

  • Edema.
  • Positive Homans sign.
  • Weak or absent pulses.
  • Changes in skin color and temperature.
  • Variations in blood pressure in the extremities.
  • Intermittent claudication.
  • Puffs.
  • Slow growing, thick and brittle nails.
  • Alterations in skin sensitivity.
  • Ulcerations and areas with poor healing.
  • Paleness when raising a limb that does not regain color when lowering it.

Related factors

  • Hypervolemia or hypovolemia.
  • Variations in the affinity of hemoglobin for oxygen.
  • Decreased hemoglobin in the blood.
  • Imbalance in the ventilation / perfusion ratio.
  • Hypoventilation.
  • Impaired oxygen transport through the capillary or alveolar membrane.
  • Blood exchange problems.
  • Enzyme saturation.
  • Interruption of arterial or venous flow.
  • Mechanical reduction of venous or arterial flow.

NOC

  • Effectiveness of the heart pump.
  • Circulatory state.
  • Status of vital signs.
  • Tissue perfusion: cardiac.
  • Tissue perfusion: pulmonary.
  • Neurological state.
  • Tissue perfusion: cerebral.
  • Electrolyte and acid-base balance.
  • Water balance.
  • Hydration.
  • Tissue perfusion: abdominal organs.
  • Sensitive function: cutaneous.
  • Tissue integrity: skin and mucous membranes.
  • Tissue perfusion: peripheral.
  • Urinary elimination.

NIC

  • Cardiac care: acute.
  • Management of dysrhythmia.
  • Shock management: cardiac.
  • Hemodynamic regulation.
  • Circulatory care: venous insufficiency.
  • Circulatory care: arterial insufficiency.
  • Circulatory precautions.
  • Management of cerebral perfusion.
  • Management of vital signs.
  • Cardiac care.
  • Embolism care: pulmonary.
  • Acid-base management: respiratory acidosis.
  • Acid-base management: respiratory alkalosis.
  • Improved cerebral perfusion.
  • Monitoring of intracranial pressure (ICP).
  • Neurological monitoring.
  • Electrolyte management.
  • Fluid / electrolyte management.
  • Liquid handling.
  • Peritoneal dialysis therapy.
  • Hemodialysis therapy.
  • Hemofiltration therapy.
  • Management of hypovolemia.
  • Intravenous (IV) therapy.
  • Management of altered peripheral sensation.
  • Skin monitoring.
  • Embolism care: peripheral.
  • Management of urinary elimination.
  • Probing.
image_pdfDownload PDF