Nursing Diagnosis: Application to Clinical Practice
11th Edition

Ineffective Peripheral Tissue Perfusion
DEFINITION
Ineffective Peripheral Tissue Perfusion: State in which a person experiences or is at risk of experiencing a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary blood supply
DEFINING CHARACTERISTICS
Major (Must Be Present, One or More)
Presence of one of the following types (see Key Concepts for definitions):
  • Claudication (arterial)
  • Rest pain (arterial)
  • Aching pain (arterial or venous)
Diminished or absent arterial pulses (arterial)
Skin color changes
  • Pallor (arterial)
  • Cyanosis (venous)
  • Reactive hyperemia (arterial)
Skin temperature changes
  • Cooler (arterial)
  • Warmer (venous)
Decreased blood pressure (arterial)
Capillary refill longer than 3 s (arterial)
Minor (May Be Present)
Edema (venous)
Change in sensory function (arterial)
Change in motor function (arterial)
Trophic tissue changes (arterial)
  • Hard, thick nails
  • Loss of hair
  • Nonhealing wound
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RELATED FACTORS
Pathophysiologic
Related to compromised blood flow secondary to:
Vascular disorders
  • Arteriosclerosis
  • Raynaud’s disease/syndrome
  • Arterial thrombosis
  • Sickle cell crisis
  • Rheumatoid arthritis
  • Leriche’s syndrome
  • Aneurysm
  • Buerger’s disease
  • Collagen vascular disease
  • Alcoholism
  • Venous hypertension
  • Varicosities
  • Deep vein thrombosis
  • Cirrhosis
Diabetes mellitus
Hypotension
Blood dyscrasias
Renal failure
Cancer/tumor
Treatment-Related
Related to immobilization
Related to presence of invasive lines
Related to pressure sites/constriction (elastic compression bandages, stockings, restraints)
Related to blood vessel trauma or compression
Situational (Personal, Environmental)
Related to pressure of enlarging uterus on pelvic vessels
Related to pressure of enlarged abdomen on pelvic vessels
Related to vasoconstricting effects of tobacco
Related to decreased circulating volume secondary to dehydration
Related to dependent venous pooling
Related to hypothermia
Related to pressure of muscle mass secondary to weight lifting
Focus Assessment Criteria
TABLE II.26 Arterial Insufficiency vs Venous Insufficiency: A Comparison of Subjective Data
Symptom Arterial Insufficiency Venous Insufficiency
Pain
Location Feet, muscles of legs, toes Ankles, lower legs
Quality Burning, shocking, prickling, throbbing, cramping, sharp Aching, tightness
Quantity Increase in severity with increased muscle activity or elevation Varies with fluid intake, use of support hose, and decreased muscle activity
Chronology Setting Brought on predictably by exercise
Use of affected muscle groups
Greater in evening than in morning
Increases during course of day with prolonged standing or sitting
Aggravating factors Exercise
Extremity elevation
Immobility
Extremity dependence
Alleviating factors Cessation of exercise
Extremity dependence
Extremity elevation
Compression stockings or Ace wraps
Paresthesia Numbness, tingling, burning, decreased touch sensation No change unless arterial system or nerves are affected
TABLE II.27 Arterial Insufficiency vs Venous Insufficiency: A Comparison of Objective Data
Sign Arterial Insufficiency Venous Insufficiency
Temperature Cool skin Warm skin
Color Pale on elevation, dependent rubor (reactive hyperemia) Flushed, cyanotic
Typical brown discoloration around ankles
Capillary filling >3 seconds Nonapplicable
Pulses Absent or weak Present unless there is concomitant arterial disease, or edema may obscure them
Movement Decreased motor ability with nerve and muscle ischemia Motor ability unchanged unless edema is severe enough to restrict joint mobility
Ulceration Occurs on foot at site of trauma or at tips of toes (most distal to be perfused)
Ulcers are deep with well-defined margins
Surrounding tissue is shiny and taut with thin skin
Occurs around ankle (area of greatest pressure from chronic venous stasis due to valvular incompetence)
Ulcers shallow with irregular edges
Surrounding tissue edematous with engorged veins
Subjective Data
Assess for Defining Characteristics
  • Pain (associated with, time of day)
  • Temperature change
  • Pallor, cyanosis, paresthesias
  • Change in motor function
Assess for Related Factors
Medical history
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Risk factors
Smoking (never, quit, years)
Immobility
History of phlebitis
Sedentary lifestyle
Family history of heart disease, vascular disease, stroke, kidney disease, or diabetes mellitus
Stress
Medications
  • Type
  • Side effects
  • Dosage
Objective Data
Assess for Defining Characteristics
Skin
  • Temperature (cool, warm)
  • Color (pale, dependent rubor, flushed, cyanotic, brown discolorations)
  • Ulcerations (size, location, description of surrounding tissue)
Bilateral pulses (radial, femoral popliteal, posterior tibial, dorsalis pedis)
  • Rate, rhythm
  • Volume
  • Absent, nonpalpable
  • Weak
  • Normal, easily palpable
  • Aneurysmal
Paresthesia (numbness, tingling, burning)
Edema (location, pitting)
Capillary refill (normal less than 3 seconds)
Motor ability (normal, compromised)
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The individual will report a decrease in pain.
Indicators
  • Define peripheral vascular problem in own words.
  • Identify factors that improve peripheral circulation.
  • Identify necessary lifestyle changes.
  • Identify medical regimen, diet, medications, activities that promote vasodilation.
  • Identify factors that inhibit peripheral circulation.
  • State when to contact physician or health care professional.
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General Interventions
Assess Causative and Contributing Factors
  • Underlying disease
  • Inhibited venous blood flow
  • Hypothermia or vasoconstriction
  • Inhibited arterial blood flow
  • Fluid volume excess or deficit
  • Activities related to symptom/sign onset
Promote Factors that Improve Arterial Blood Flow
Keep extremity in a dependent position.
Keep extremity warm (do not use heating pad or hot water bottle, because the person with a peripheral vascular disease may have a disturbance in sensation and will not be able to determine if the temperature is hot enough to damage tissue; the use of external heat also may increase the metabolic demands of the tissue beyond its capacity).
Reduce risk for trauma.
  • Change positions at least every hour.
  • Avoid leg crossing.
  • Reduce external pressure points (inspect shoes daily for rough lining).
  • Avoid sheepskin heel protectors (they increase heel pressure and pressure across dorsum of foot).
  • Encourage range-of-motion exercises.
  • Discuss smoking cessation (see Ineffective Health Maintenance Related to Tobacco Use).
Promote Factors that Improve Venous Blood Flow
Elevate extremity above the level of the heart (may be contraindicated if severe cardiac or respiratory disease is present).
Avoid standing or sitting with legs dependent for long periods.
Consider the use of elastic compression bandages or below-knee elastic stockings to prevent venous pooling.
Reduce or remove external venous compression that impedes venous flow.
  • Avoid pillows behind the knees or Gatch bed, which is elevated at the knees.
  • Avoid leg crossing.
  • Change positions, move extremities, or wiggle fingers and toes every hour.
  • Avoid garters and tight elastic stockings above the knees.
Measure baseline circumference of calves and thighs if person is at risk for deep venous thrombosis, or if it is suspected.
Discuss the Implications of Condition and Choices
Encourage client to share feelings, concerns, and understanding of risk factors, disease process, and effect on life.
Assist client to select lifestyle behaviors that he or she chooses to change (Burch et al., 1991).
  • Avoid multiple changes.
  • Consider personal abilities, resources, and overall health.
  • Be realistic and optimistic.
Plan a Daily Walking Program
Provide reasons for program.
Teach client to avoid fatigue.
Instruct client to avoid increase in exercise until assessed by physician for cardiac problems.
Reassure client that walking does not harm the blood vessels or the muscles; “walking into the pain,” resting, and resuming walking improves the oxidative metabolic capacity of the muscle.
Start slowly.
Emphasize that it is not the speed or distance but the action of walking that is important.
Assist client to set goals and the steps to achieve them.
  • Will walk 10 min daily.
  • Will walk 10 min daily and 20 min three times a week.
  • Will walk 20 min daily.
  • Will walk 30 min three times a week.
Suggest a method to self-monitor progress (eg, graph, checklist).
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Initiate Health Teaching, as Indicated
Teach Client to
Avoid long car or plane rides (get up and walk around at least every hour).
Keep dry skin lubricated (cracked skin eliminates the physical barrier to infection).
Wear warm clothing during cold weather.
Wear cotton or wool socks.
Use gloves or mittens if hands are exposed to cold (including home freezers).
Avoid dehydration in warm weather.
Give special attention to feet and toes.
  • Wash feet and dry well daily.
  • Do not soak feet.
  • Avoid harsh soaps or chemicals (including iodine) on feet.
  • Keep nails trimmed and filed smooth.
Inspect feet and legs daily for injuries and pressure points.
Wear clean socks.
Wear shoes that offer support and fit comfortably.
Inspect the inside of shoes daily for rough lining.
Briefly Explain the Relation of Certain Risk Factors to the Development of Atherosclerosis
Smoking
  • Vasoconstriction
  • Decreased oxygenation of the blood
  • Elevated blood pressure
  • Increased lipidemia
  • Increased platelet aggregation
Hypertension
Constant trauma of pressure causes damage to the vessel lining, which promotes plaque formation and narrowing.
Hyperlipidemia
Promotes atherosclerosis
Sedentary lifestyle
Decreases muscle tone and strength
Decreases circulation
Excess weight (>10% of ideal)
Fatty tissue increases peripheral resistance and claudication.
Fatty tissue is less vascular.
Teach Methods to Relieve Pain
Assume dependent position for ischemic pain.
Elevate extremities for relief of venous aching.
Relieve phantom pain after an amputation by massaging or tapping stump or opposite limb.
Use other nursing measures such as relaxation or distraction to assist in pain relief.
If these methods do not relieve pain, refer to a physician or pain specialist.
Teach symptoms/signs of underlying disease and when to call the physician or health care professional.
Rationales
  • Venous blood flow is enhanced by an elevated position and inhibited by a dependent position (gravity pulls blood downward, away from the heart).
  • Immobility and venous stasis predispose to thrombus and embolus production.
  • The effects of nicotine on the cardiovascular system contribute to coronary artery disease, stroke, hypertension, and peripheral vascular disease (Porth, 2002).
  • Lack of exercise inhibits the pumping action of the muscles, which enhances circulation.
  • Overweight status increases cardiac workload, causing hypertension (Porth, 2002).
  • An older client may have lifestyle patterns of inactivity, smoking, and high-fat diet that are risk factors; he or she should be counseled to change.
  • Attaining short-term goals can foster motivation to continue to change.
  • Daily foot care can reduce tissue damage and help prevent or detect early further injury and infection.
  • Properly fitted shoes help prevent injury to skin and underlying tissue.
  • Tight garments and certain leg positions constrict leg vessels, further reducing circulation.
  • Community resources can assist the client with weight loss, smoking cessation, diet, and exercise programs.