Ineffective Tissue Perfusion: State in which a person experiences or is at risk of experiencing a decrease in nutrition and respiration at the cellular level because of a decrease in capillary blood supply
Tissue perfusion depends on many physiologic factors, both within body systems and at the cellular level. A person’s response to ineffective tissue perfusion can disrupt some or all functional health patterns and can cause physiologic complications. for example, a person with chronic renal failure is at risk for fluid/electrolyte imbalances, acidosis, nutritional problems, edema, fatigue, pruritus, and disturbed self-concept. Does the diagnosis Ineffective Renal Tissue Perfusion describe these varied responses, or does it simply rename renal failure or renal calculi?
The use of any Ineffective Tissue Perfusion diagnosis other than Peripheral merely provides new labels for medical diagnoses, labels that do not describe the nursing focus or accountability. The following represent examples of Ineffective Tissue Perfusion diagnoses with associated goals from the literature:
Ineffective Tissue Perfusion related to hypovolemia secondary to GI bleeding
Goal: Tissue perfusion improves, as evidenced by stabilized vital signs.
Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure
Goal: Intracranial pressure (ICP) is no greater than 15 mm Hg; clinical signs of ICP are decreased.
Ineffective Tissue Perfusion related to vaso-occlusive nature of sickling secondary to sickle cell crisis
Goal: Client demonstrates improved tissue perfusion, as evidenced by adequate urine output, absence of pain, strong peripheral pulses.
All the above outcomes represent criteria that nurses use to assess the client’s status to determine the appropriate nursing and medical interventions indicated. Thus, these situations represent the following collaborative problems, respectively: PC: GI bleeding, PC: Increased ICP, and PC: Sickling crisis.
NANDA approved the diagnosis Ineffective Tissue Perfusion (Renal, Cerebral, Cardiopulmonary, Gastrointestinal) in 1980. It does not conform to the NANDA definition approved in 1990 (refer to Chapter 2). When using these diagnoses, nurses cannot be accountable for prescribing the interventions for outcome achievement. Instead of using Ineffective Tissue Perfusion, the nurse should focus on the nursing diagnoses and collaborative problems applicable because of altered renal, cardiac, cerebral, pulmonary, or gastrointestinal (GI) tissue perfusion.
Ineffective Peripheral Tissue Perfusion can be a clinically useful nursing diagnosis if used to describe chronic arterial or venous insufficiency or potential thrombophlebitis. (In contrast, acute embolism and thrombophlebitis represent collaborative problems.) A nurse focusing on preventing thrombophlebitis in a postoperative client would write the diagnosis Risk for Ineffective Peripheral Tissue Perfusion related to postoperative immobility and dehydration.
ERRORS IN DIAGNOSTIC STATEMENTS
Ineffective GI Tissue Perfusion related to esophageal bleeding varices
Because this diagnosis actually represents a situation that nurses monitor and manage with nursing and medical interventions, the diagnosis should be rewritten as the collaborative problem PC: Esophageal bleeding varices.
Ineffective Cerebral Tissue Perfusion related to cerebral edema secondary to intracranial infections
This diagnosis represents merely a new label for encephalitis, meningitis, or abscess. Instead, the nurse should specify collaborative problems to clearly describe and designate the nursing accountability: PC: Increased intracranial pressure and PC: Septicemia. In addition, certain nursing diagnoses may be indicated (eg, Risk for Infection Transmission, Impaired Comfort).
Ineffective Peripheral Tissue Perfusion related to deep vein thrombosis
Deep vein thrombosis is a medical diagnosis that evokes responses for which nurses are accountable: monitoring for and managing, with physician- and nurse-prescribed interventions, physiologic complications (eg, embolism, venous ulcers). This situation would be represented by collaborative problems such as PC: Embolism. In addition, the nurse would intervene independently to prevent complications of immobility and teach how to prevent recurrence, applying nursing diagnoses such as Disuse Syndrome and Risk for Ineffective Health Maintenance related to insufficient knowledge of risk factors.