Discuss lifestyle with client to see if occupation requires prolonged standing or sitting, which can result in chronic venous disease Kunimoto et al, Document limb movement and note right and left sides individually.
Teach client to avoid exposure to cold, to limit exposure to brief periods if going out in cold weather, and to wear warm clothing. Change positions slowly when getting client out of bed. Diposting oleh nic noc di Review laboratory data ABGs, BUN, creatinine, electrolytesinternational normalized ratio, and prothrombin time or partial thromboplastin time if anticoagulants are utilized for treatment.
Check mental status; perform a neurological examination. Measure circumference of ankles and calf at the same time each day in the early morning Cahall, Spence, Exercise enhances the development of collateral circulation, strengthens muscles, and provides a sense of well-being Cahall, Spence, Altered tissue perfusion Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain.
Refer to podiatrist if client has a foot or nail abnormality. Urinary Elimination Client Outcomes Altered tissue perfusion adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distress Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects Identifies changes in lifestyle that are needed to increase tissue perfusion NIC Interventions Nursing Interventions Classification Suggested NIC Labels Nursing Interventions and Rationales Cerebral perfusion 1.
Measures overall awareness and capacity to react to external stimuli, and best signifies condition of consciousness in the patient whose eyes are closed due to trauma or who is aphasic. Cerebral In case the intracranial pressure increases, raising the head off the bed to a 30 or 45 degree angle can help reduce the pressure.
Exercise prevents venous stasis and further circulatory compromise. Blood clotting studies are used to determine or ensure that clotting factors remain within therapeutic levels. The following are the common goals and expected outcomes for Ineffective Tissue Perfusion.
Gastrointestinal Examine GI function, noting anorexia, decreased or absent bowel sounds, nausea or vomiting, abdominal distension, and constipation. It should be removed as soon as therapeutically safe.
Peripheral Assist with position changes.
Since any alterations in perfusion results in reduced oxygen or nutrition to the affected area, it's important to advise patients at risk, about the ways to prevent or reduce the recurrence of the condition.
Pressure under the knee decreases venous circulation. If ICP is increased, elevate head of bed 30 to 45 degrees. Change in rate of respiration Treatment Impaired tissue infusion over a prolonged period can lead to serious complications like organ failure.
Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Some clients have both arterial and venous insufficiency.
Aerobic exercise training can reverse age-related peripheral circulatory problems in otherwise healthy older men Beere et al, Medication effects such as altered autonomic control, decompensated heart failurereduced fluid volume, and vasodilation are among many factors potentially jeopardizing optimal BP.
Venous insufficiency is associated with aching, cramping, and discomfort Bright, Georgi, Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. Explain importance of good foot care.
These medications facilitate perfusion for most causes of impairment. Cardiovascular Administer nitroglycerin NTG sublingually for complaints of angina. Reduce renal perfusion may take place due to vascular occlusion. Perform regular low-intensity exercise, such as walking Avoid extreme fatigue Avoid long periods of non movement, especially during long distance travel Remain sufficiently hydrated Stop smoking With changes in lifestyle and medical care, ineffective tissue perfusion can be tackled before it reaches a critical stage.
Differentiate venous from arterial disease. Teach client to recognize the signs and symptoms that need to be reported to a physician e. Record urine specific gravity as necessary.
Assess for probable contributing factors related to temporarily impaired arterial blood flow. Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level. Blood is a connective tissue comprised of a liquid extracellular matrix termed as blood plasma which dissolves and suspends multiple cells and cell fragments.
Endothelium-Dependent and -Independent Perfusion Reserve and the Effect of l-Arginine on Myocardial Perfusion in Patients With Syndrome X Stuart D. Rosen and Paolo G. Camici. Endothelium-Dependent and -Independent Perfusion Reserve and the Effect of l-arginine on Myocardial Perfusion in Patients With Syndrome X Morten Bøttcher, Hans Erik Bøtker.
Altered Tissue Perfusion study guide by becsaboo includes 33 questions covering vocabulary, terms and more. Quizlet flashcards, activities and games help you improve your grades. Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level.
Blood is a connective tissue comprised of a liquid extracellular matrix termed as blood plasma which dissolves and suspends multiple cells and cell fragments. ineffective tissue perfusion (specify type) (renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as a state in which an individual has a decrease in oxygen resulting in failure to .Altered tissue perfusion