Ineffective Tissue perfusion

Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:

Renal
  • Altered blood pressure outside of acceptable parameters; 
  • hematuria; 
  • oliguria or anuria; 
  • elevation in BUN/creatinine ratio
Gastrointestinal
  • Hypoactive or absent bowel sounds; 
  • nausea; 
  • abdominal distention; 
  • abdominal pain or tenderness
Peripheral
  • Edema; 
  • positive Hoeman's sign; 
  • altered skin characteristics (hair, nails, moisture); 
  • weak or absent pulses; 
  • skin discolorations; 
  • skin temperature changes; 
  • altered sensations; 
  • diminished arterial pulsations; 
  • skin color pale on elevation, color does not return on lowering the leg; 
  • slow healing of lesions; cold extremities; 
  • dependent, blue, or purple skin color
Cerebral
  • Speech abnormalities; 
  • changes in pupillary reactions; 
  • extremity weakness or paralysis; altered mental status; 
  • difficult in swallowing; 
  • changes in motor response; 
  • behavioral changes
Cardiopulmonary
  • Altered respiratory rate outside of acceptable parameters; 
  • use of accessory muscles; 
  • capillary refill >3 seconds; 
  • abnormal arterial blood gases; 
  • chest pain; 
  • sense of "impending doom"; 
  • bronchospasms; 
  • dyspnea; 
  • dysrhythmias; 
  • nasal flaring; 
  • chest retraction

Related Factors:
  • Hypovolemia; 
  • interruption of arterial flow; 
  • hypervolemia; 
  • exchange problems; 
  • interruption of venous flow; 
  • mechanical reduction of venous and/or arterial blood flow; 
  • hypoventilation; 
  • impaired transport of oxygen across alveolar and/or capillary membrane; 
  • mismatch of ventilation with blood flow; 
  • decreased hemoglobin concentration in blood; 
  • enzyme poisoning; 
  • altered affinity of hemoglobin for oxygen

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Circulation Status
  • Cardiac Pump Effectiveness: Tissue Perfusion: Cardiac
  • Tissue Perfusion: Cerebral
  • Tissue Perfusion: Peripheral
  • Fluid Balance
  • Hydration
  • Urinary Elimination
Client Outcomes
  • Demonstrates 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

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