Ineffective tissue perfusion describes the lack of oxygenated blood flow to areas of the body. Proper perfusion is detrimental to the function of organs and body systems, as organs and tissues that are not perfusing will be damaged and could eventually lead to death.
Nurses must understand the causes of inadequate perfusion, assessment, monitoring, and interventions. Ineffective tissue perfusion can be a life-threatening emergency requiring critical thinking and strict monitoring. While some cases of ineffective perfusion are sudden and traumatic (heart attack, gunshot wound), inadequate perfusion can also be caused by chronic diseases. In this case, nurses have the opportunity to instruct patients with chronic diseases and modifiable risk factors on how to improve circulation.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- General Nursing Assessment
- Ineffective Cardiopulmonary Perfusion
- Ineffective Gastrointestinal Perfusion
- Ineffective Renal Perfusion
- Ineffective Cerebral Perfusion
- Ineffective Peripheral Perfusion
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of ineffective tissue perfusion:
- Hypervolemia & hypovolemia (excess fluid & dehydration/blood loss)
- Low hemoglobin
- Insufficient blood flow
- Hypoventilation
- Trauma
- Infection
- Shock
- Cardiac disorders
- Respiratory disorders
- Vascular disorders
Signs and Symptoms (As evidenced by)
The following sections include common signs and symptoms of ineffective tissue perfusion. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Cardiopulmonary
Common signs and symptoms of ineffective cardiopulmonary perfusion include:
Subjective: (patient reports)
- Chest Pain
- Dyspnea
- Sense of impending doom
Objective: (nurse assesses)
- Arrhythmias
- Capillary refill >3 seconds
- Altered respiratory rate
- Use of accessory muscles to breathe
- Abnormal arterial blood gases
- Unstable blood pressure
- Tachycardia or bradycardia
- Cyanosis
Gastrointestinal
Common signs and symptoms of ineffective gastrointestinal perfusion include:
Subjective: (patient reports)
- Nausea
- Abdominal pain
- Bloating
Objective: (nurse assesses)
- Hypoactive or absent bowel sounds
- Distended abdomen
- Vomiting
- Electrolyte imbalance
Renal
Common signs and symptoms of ineffective renal perfusion include:
- High or low blood pressure
- Decreased urine output
- Elevated BUN/creatinine
Cerebral
Common signs and symptoms of ineffective cerebral perfusion include:
Subjective: (patient reports)
- Dizziness
- Visual disturbance
- Fatigue or weakness
Objective: (nurse assesses)
- Altered mental status
- Restlessness
- Changes in speech
- Difficulty swallowing
- Motor weakness
- Changes in pupillary reaction
- Syncope
- Seizure
Peripheral
Common signs and symptoms of ineffective peripheral perfusion include:
Subjective: (patient reports)
- Altered skin sensations
- Claudication
- Peripheral pain
- Numbness and tingling
Objective: (nurse assesses)
- Weak or absent peripheral pulses
- Cool skin temperature
- Thickened nails
- Skin discoloration; pallor when legs are raised and rubor when dependent
- Loss of hair to legs
- Edema
- Delayed wound healing
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for ineffective tissue perfusion:
- Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema.
- Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02.
- Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion.
- Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time.
General Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data.
1. Take a complete health history.
Assess for acute and chronic conditions that affect perfusion: history of blood clots, myocardial infarction, congestive heart failure, diabetes, vascular diseases, organ failure. Consider that certain conditions can affect the perfusion of multiple body systems.
2. Be aware of signs of infection.
If not quickly identified and treated, sepsis can cause poor perfusion and organ failure evidenced by decreased urine output, abrupt mental status change, and mottled skin.
3. Review lab work and test results.
Arterial blood gases, complete blood counts, electrolytes, and CT scans or ultrasounds (doppler) should be reviewed for signs of new or worsening perfusion issues. This information can also be referred to for comparison.
Ineffective Cardiopulmonary Perfusion
In the following section, you will learn more about the nursing assessment and interventions for a patient with ineffective cardiopulmonary perfusion.
Nursing Assessment
1. Assess for sudden changes.
Note the presence of sudden chest pain, diaphoresis, respiratory distress, and hemoptysis, which could signal a pulmonary embolus, myocardial infarction or another acute cardiovascular event.
2. Assess vital signs and EKG.
Closely monitor blood pressure, heart rate, respirations, and changes in cardiac rhythms. Use this data to compare to baseline information to identify changes in condition.
3. Monitor hemoglobin levels.
Hemoglobin is a red blood cell component that carries oxygen through the body. If hemoglobin is decreased, less oxygen will be perfused through the body and tissues.
4. Assess capillary refill.
Capillary refill assesses circulation and peripheral perfusion. If capillary refill time is sluggish, the client may be hypovolemic and lack blood volume to support the circulatory system with adequate oxygenation. Sluggish capillary refill could also indicate shock, peripheral artery disease, heart failure or hypovolemia.
Nursing Interventions
1. Administer medications to improve blood flow as ordered.
Vasodilators open blood vessels to improve blood flow such as nitroglycerin for chest pain, or hydralazine for high blood pressure.
2. Provide oxygen as required.
To support oxygenation and perfusion oxygen may be needed to ensure gas exchange.
3. Surgical Intervention.
Conditions that impede blood flow, such as blockages may require coronary angioplasty or bypass surgeries. The nurse is vital in educating the patient and family on procedures and monitoring for complications post-op.
4. Teach signs of a heart attack.
Symptoms of a heart attack are different for males and females. Males may have direct chest pain while females often have indirect symptoms such as nausea and jaw, back, or arm pain.
Ineffective Gastrointestinal Perfusion
In the following section, you will learn more about the nursing assessment and interventions for a patient with ineffective gastrointestinal perfusion.
Nursing Assessment
1. Assess for the underlying cause of low gastrointestinal perfusion.
The nurse should assess if the cause of low perfusion is systemic or specifically related to the GI system. The underlying cause will determine the treatment course.
2. Assess bowel sounds.
Inadequate blood flow can slow peristalsis and digestion of the intestines. Bowel sounds are likely to be hypoactive or absent.
3. Take note of the location of abdominal pain and its characteristics.
Sudden abdominal pain can signal the rupture of an aortic aneurysm. Other conditions, such as gallstones, pancreatitis, appendicitis, and bowel obstructions cause severe pain in differing abdominal quadrants.
4. Monitor changes in stool.
Constipation can result from delayed digestion. Blood in the stool can signal ischemic colitis which results from reduced blood flow to the large intestine. Bright blood or black stools can signal a GI bleed.
Nursing Interventions
1. Control nausea and vomiting.
Patients who are vomiting may become dehydrated. Administer antiemetics to control vomiting and replace lost fluid and electrolytes through IV fluids if necessary.
2. Encourage small, easily digested meals.
As patients recover from bowel surgeries or other illnesses, start with liquid or bland diets so as not to overwhelm the gastric system.
3. Insert NG tube as needed.
Patients who require bowel rest or decompression may require a nasogastric tube. Monitor gastric output for bowel function, including colour, volume and consistency.
Ineffective Renal Perfusion
In the following section, you will learn more about the nursing assessment and interventions for a patient with ineffective renal perfusion.
Nursing Assessment
1. Evaluate urine output amount and characteristics.
Kidneys that are not perfusing adequately will slow urine production, eventually stopping production altogether if the hypoperfusion is not treated. Monitor for urine output less than 30 ml/hour or very dark, concentrated urine.
2. Review BUN and creatinine ratio.
Kidney markers such as BUN and creatinine measure waste products that are filtered out by the kidneys. These values will increase if the kidneys are not functioning and filtering correctly. A high BUN to creatinine ratio signals poor blood flow to the kidneys. The nurse should also consider reviewing electrolytes if kidney function is a concern.
3. Observe for edema.
Kidneys that are not filtering waste products and fluid through urine will result in retention observed as edema and swollen extremities.
Nursing Interventions
1. Measure intake and output.
Document accurate intake (oral, IV) against output (urine, emesis) to monitor for fluid imbalance.
2. Weigh daily.
Weight monitoring can detect worsening fluid retention caused by poorly functioning kidneys.
3. Teach patients about diet recommendations.
Fluid and salt may be restricted as this can further exacerbate fluid retention. Patients may need to decrease animal protein intake as this can further damage kidneys.
4. Administer therapies to support kidney function.
Depending on the underlying cause of the kidney hypoperfusion, supportive therapies may include blood pressure medications, diuretic medications, fluid resuscitation, or dialysis.
Ineffective Cerebral Perfusion
In the following section, you will learn more about the nursing assessment and interventions for a patient with ineffective cerebral perfusion.
Nursing Assessment
1. Assess level of consciousness (LOC) and mentation.
Poor perfusion to the brain may result in confusion, speech changes, poor motor control, vision loss, changes in sensation, and loss of consciousness. To track LOC the nurse can use a scale such as the Glasgow Coma Scale. Other assessments can include pupillary response and any numbness or tingling.
2. Assess for signs of a stroke.
If blood flow to the brain is impeded by a blood clot or slowed by bleeding, the patient may experience facial drooping, slurred speech, and/or muscle weakness.
3. Review medications for interactions.
Medications such as narcotics, sedatives, or overdoses of antiseizure drugs or antihypertensives may mask symptoms, or symptoms may improve once the medication is discontinued.
Nursing Interventions
1. Perform frequent neurological exams.
Neurological exams will be ordered at specified intervals to assess for progression or worsening of mentation. Those suffering a stroke will be assessed using the NIH stroke scale.
2. Prepare for imaging studies.
If the underlying cause of the change in neurological status is unknown, the the patient will likely be sent for imaging studies such as a CT or MRI to identify the underlying cause.
3. Elevate the head of the bed.
If a patient has intracranial pressure (ICP) the HOB should be elevated to 30 degrees and their neck kept in a neutral position to promote circulation and lower pressure. This improves venous return.
4. Administer medications as ordered.
Sedation may be required to limit movement. Osmotic diuretics will help lower ICP. Corticosteroids can help with inflammation and edema. Thrombolytics will break up a clot, impeding blood flow.
Ineffective Peripheral Perfusion
In the following section, you will learn more about the nursing assessment and interventions for a patient with ineffective peripheral perfusion.
Nursing Assessment
1. Provide a thorough skin assessment.
Take note of edema, wounds or ulcerations, skin color, temperature, hair loss, and thickened nails.
2. Assess peripheral pulses.
Monitor for absent or weak pulses, which indicate poor perfusion.
3. Assess for pain and numbness.
Patients with conditions such as diabetes, PAD or PVD may lack circulation to extremities. They may experience pain or dulled sensations from poor blood flow.
Nursing Interventions
1. Use a Doppler ultrasound if needed to assess blood flow.
If peripheral pulses are difficult to palpate, a doppler can assist in locating a pulse.
2. Apply anti-embolism stockings.
Patients with edema or poor circulation to the lower legs may require compression stockings to increase venous return.
3. Discourage sitting for long periods or crossing ankles.
This impedes blood flow and venous return.
4. Encourage lifestyle behaviors to improve blood flow.
Quitting smoking, diet control to manage diabetes, and proper exercise are necessary to control chronic diseases.
5. Prevent exposure to cold.
Raynaud’s disease results in poor blood flow to smaller arteries, usually in the fingers or toes, in response to cold or stress. Teach patients to stay inside in cold weather, and use gloves or mittens.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for ineffective tissue perfusion.
Care Plan #1
Diagnostic Statement:
Ineffective tissue perfusion related to hypervolemia secondary to renal failure as evidenced by elevated BUN/creatinine and edema.
Expected outcomes:
- Patient will manifest effective tissue perfusion as evidenced by the following:
- Balanced fluid intake and output
- Stable vital signs
- Blood pressure: 90/60 mmHg to 130/90 mmHg.
- Respiratory Rae: 12 to 20 breaths per minute.
- Pulse: 60 to 100 beats per minute.
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C)
- Absence of edema
- Patient will manifest optimal renal function as evidenced by the following:
- Optimal urine output >30 cc/hr.
- BUN at 6 to 24 mg/dL
- Creatinine at 0.74 to 1.35 mg/dL (for adult men) or 0.59 to 1.04 mg/dL (for adult women)
Assessment:
1. Monitor intake and output, noting a urine output of <30 mL/hr.
During the early phases of acute renal failure, patients exhibit oliguria or anuria. Fluid replacement therapy is calculated based on reported fluid losses.
2. Monitor blood and urine laboratory tests as indicated.
- BUN, creatinine: Both BUN and creatinine are elevated in renal failure.
- Hemoglobin/hematocrit: Anemia occurs as a result of insufficient erythropoietin production. The accumulation of nitrogenous wastes decreases the life of circulating red blood cells and contributes to anemia.
- Sodium/Potassium: Hyponatremia is caused by dilutional hypervolemia because of impaired water excretion. Hyperkalemia occurs in acute renal failure due to alterations in filtration and renal excretion.
3. Monitor daily weights with the same scale and preferably at the same time of day with the patient wearing the same clothing.
Changes in daily body weight reflect changes in fluid balance. Sudden weight gain indicates fluid retention in renal failure.
4. Monitor the patient’s HR, BP, and respiratory rate. Inspect the jugular veins.
Fluid volume excess causes increased BP, tachycardia, and tachypnea. Jugular veins will be distended.
Interventions:
1. Administer oral and IV fluids as prescribed.
During the oliguric phase of acute renal failure, fluid restriction is necessary to manage the excess fluid volume. The diuretic phase of renal failure requires fluid replacement and close sodium and potassium levels monitoring.
2. Administer medications (e.g., diuretics) as prescribed.
Diuretic therapy addresses fluid volume excess. Diuretic administration requires close supervision because hypovolemia can aggravate inadequate renal perfusion.
3. In handling a patient with peripheral edema, move the patient gently and reposition often.
Edematous skin is more susceptible to breakdown.
4. Prepare the patient for renal replacement therapy when indicated.
Hemodialysis is an effective renal replacement therapy for renal failure. It removes excess fluid and corrects electrolyte imbalances.
Care Plan #2
Diagnostic statement:
Ineffective tissue perfusion related to compromised blood flow secondary to arteriosclerosis as evidenced by claudication and skin temperature changes.
Expected outcomes:
- Patient will exhibit optimal peripheral tissue perfusion in the affected extremity as evidenced by the following:
- Strong, palpable pulses
- Reduction or absence of claudication
- Adequate capillary refill
- Warm and dry extremities
- Patient will not experience leg ulceration.
Assessment:
1. Assess for pain, numbness, and tingling sensation for causative factors, time of onset, quality, severity, and relieving factors.
Intermittent claudication is the most common symptom of peripheral arterial disease. Pain occurring in the calf muscles and buttocks is caused by physical activity and relieved by rest. Pain that occurs at rest indicates a severe condition that requires immediate attention. Tingling or numbness indicates ineffective peripheral perfusion.
2. Assess segmental limb pressure measurements such as ankle-brachial index (ABI).
Blood pressure readings are usually higher in the lower and upper extremities. A normal ratio of ankle systolic pressure divided by brachial systolic pressure is >0.9. If his ABI ratio for both legs is less than 0.9, he is diagnosed with peripheral arterial disease (PAD). A ratio of 0.4 or greater indicates severe disease.
3. Monitor laboratory or diagnostic results (e.g., pulse volume recordings, vascular stress testing, magnetic resonance angiography, conventional arteriography, and digital subtraction angiography).
These tests are used to determine the location and severity of symptoms. Arteriography is helpful for patients who require surgical intervention. Exercise testing helps reproduce lameness and provides data to assess the effectiveness of treatment. A Doppler ultrasound can also assess blood flow in peripheral arteries.
Interventions:
1. Instruct on how to prevent the progression of the disease:
- Smoking cessation
- Dietary modification
- Hypertension management
Risk factors for atherosclerosis are smoking, hyperlipidemia, hypertension, diabetes, obesity, physical inactivity, and family history of atherosclerosis. Atherosclerosis can also occur in coronary, cerebral, and renal vessels. Changing risk factors in the early stages of the disease can slow the progression of the disease.
2. Provide information on a daily exercise program where appropriate:
- Walk on a flat surface to relieve calf pain.
- Walk about half a block after having intermittent claudication unless contraindicated.
- Stop and rest until all discomfort subsides.
- Repeat the same process 2-3 times a day for 30 minutes.
Exercise is an essential treatment for peripheral artery disease. The accumulation of lactic acid after claudication promotes the improvement of collateral circulation. The pain subsides once the lactic acid is drained from the local blood system.
3. Instruct in the prevention of complications:
- Keep the extremities warm. Wear stockings to bed.
- Keep the house as warm as possible.
- Never apply hot water bottles or electric heating pads to the feet or legs
- Avoid local cold applications and cold temperatures.
- Inspect the feet regularly for any signs of injury or infection
Warmth promotes vasodilation. Cold causes vasoconstriction and reduced blood flow. Poor peripheral circulation can result in tissue damage. Early assessment of potential problems reduces complications.
4. Administer medications as ordered (e.g., antiplatelets (aspirin, clopidogrel), Cilostazol (Pletal), lipid-lowering agents).
These drugs either reduce the progression and damage related to atherosclerosis or provid symptom relief.
References
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