Purpose: To validate defining characteristics of ineffective peripheral tissue perfusion using vasomotor function assessment. Show
Methods: Twenty-four patients with hypertensive cardiomiopathy were evaluated for 18 defining characteristics of ineffective peripheral tissue perfusion and underwent vasomotor function assessment with induction of reactive hyperemia, intra-arterial infusion of acetylcholine, and pulse wave velocity measurement. The Student's t test and Kruskall-Wallis test were used to assess the significance of relationships between defining characteristics and vasomotor function data. Findings: Diminished lower extremity pulses were associated with diminished forearm blood flow during acetylcholine infusion; left ventricular overload, intermittent claudication, and diminished skin moisture were associated with elevated pulse wave velocity values. Conclusion: The defining characteristics of ineffective peripheral tissue perfusion were highly associated with vasomotor function data as "gold standards" for that diagnosis. Practice implications: Nurses should be able to accurately assess diminished lower extremity pulses, intermittent claudication, and diminished skin moisture as relevant characteristics of ineffective peripheral tissue perfusion in patients with hypertensive cardiomiopathy.
Ineffective Tissue Perfusion NCLEX Review and Nursing Care Plans The cells are the building blocks of the human body. For them to function, they need oxygen to break down sugar and use it as energy. This mechanism is carried out by the circulatory system in a process known as tissue perfusion. When this mechanism fails due to several causes, the NANDA nursing diagnosis Ineffective Tissue Perfusion may be used. Ineffective tissue perfusion can cause some mild to serious medical conditions and complications. However, early detection and treatment can improve the outcome and prevent serious complications from happening. Signs and Symptoms of Ineffective Tissue PerfusionThe following are the early warning signs of reduced tissue perfusion:
Causes of Ineffective Tissue PerfusionNumerous conditions can affect the body’s ability to perfuse oxygen to the cells. The following are the common causes of ineffective tissue perfusion:
Ineffective Tissue Perfusion Nursing DiagnosisIneffective Tissue Perfusion Nursing Care Plan 1Ischemic Stroke Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to interruption of blood flow secondary to ischemic stroke as evidenced by an altered level of consciousness Desired Outcome: The patient will demonstrate no further deterioration.
Ineffective Tissue Perfusion Nursing Care Plan 2Chronic Anemia Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related to low levels of cellular components required for oxygen delivery secondary to chronic anemia as evidenced by hemoglobin level of 6.9 g/dL Desired Outcome: The patient will maintain maximum perfusion of vital organs as evidenced by normal vital signs and balanced intake and output.
Ineffective Tissue Perfusion Nursing Care Plan 3Peripheral Arterial Disease (As a Complication of Diabetes) Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to delayed peripheral wound healing secondary to peripheral arterial disease as evidenced by an open wound on the right big toe Desired Outcome: The patient will develop an understanding of the importance of protecting the involved extremity from further injury.
Ineffective Tissue Perfusion Nursing Care Plan 4Buerger’s Disease Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood flow secondary to Buerger’s disease, as evidenced by pale, reddish, or bluish hands or feet, pain on the affected area, Raynaud’s phenomenon (fingers and toes turn pale when exposed to cold), leg numbness and weakness Desired Outcome: The patient will be able to achieve optimal tissue perfusion in the affected areas as evidenced by having strong and palpable pulses, regained leg strength, and reduced pain.
Ineffective Tissue Perfusion Nursing Care Plan 5Chronic Kidney Disease (CKD) Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related glomerular malfunction to secondary to chronic kidney disease as evidenced by increase in lab results (BUN, creatinine, uric acid, eGFR levels), oliguria or anuria, peripheral edema, hypertension, muscle twitching and cramping, fatigue, and weakness Desired Outcome: The patient will actively participate in the treatment plan and will be able to demonstrate behaviors that will help prevent complications.
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. |