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Friday, November 26, 2010

Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary, Cerebral

Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary, Cerebral

NANDA Definition
Decrease resulting in the failure to nourish the tissues at the capillary level


Discussion of the Problem
Blood is a connective tissue composed of a liquid extracellular matrix called blood plasma that dissolves and suspends various cells and cell fragments. Blood transports oxygen from the lungs and nutrients from the gastrointestinal tract. The oxygen and nutrients subsequently diffuse from the blood into the interstitial fluid and then into the body cells. Carbon dioxide and other wastes move in the reverse direction, from body cells to interstitial fluid to blood. Blood then transports the wastes to various organs—the lungs, kidneys, and skin—for elimination form the body. Circulating blood helps maintain homeostasis of all body fluids. Blood helps adjust body temperature through the heat absorbing and coolant properties of the water in blood plasma and its variable rate of flow through the skin, where excess heat can be lost from the blood to the environment. In addition, blood osmotic pressure influences the water content of cells, mainly through interactions of dissolved ions and proteins. Blood can clot, which protects against its excessive loss from the cardiovascular system after an injury. In addition, its white blood cells protect against disease by carrying on phagocytosis. Several types of blood proteins including antibodies, interferons, and complement, help protect against disease in a variety of ways. However, conditions such as conditions such as amputation, cerebrovascular accident, stroke, crainiocerebral trauma, disk surgery, myocardial infarction, sepsis, thrombophebitis, deep vein thrombosis, upper gastrointestinal bleeding and atherosclerosis causes. Reduction in arterial blood flow that leads to deprived nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. If the decreased perfusion is acute and protracted, it can have devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. Nursing management is directed at following: removing vasoconstricting factor(s), improving peripheral blood flow, reducing metabolic demands on the body, making the patient understand his/her disease process and its treatment, making the patient participate in self-care program, and preventing complications.

Nursing Interventions Classification (NIC)
  • Cardiac Care: Acute
  • Cerebral Perfusion Promotion
  • Circulatory Care: Venous insufficiency
  • Hemodynamic Regulation
  • Embolus care
  • Neurological Monitoring


Nursing Outcomes Classification (NOC)
  • Electrolyte and Acid/Base Balance
  • Fluid Balance
  • Tissue Perfusion: Abdominal Organs
  • Tissue Perfusion: Cardiopulmonary
  • Tissue Perfusion: Cerebral
  • Tissue Perfusion: Peripheral

Goal and Objectives
  • Patient will display growing tolerance to activity.
  • Patient will display no further worsening/repetition of deficits.
  • Patient will engage in behaviors or actions to improve tissue perfusion.
  • Patient will maintain maximum tissue perfusion to vital organs, as manifested by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain.
  • Patient will verbalize or demonstrate normal sensations and movement as appropriate.

Subjective and Objective Data
  • Cardiopulmonary:
Ø  Abnormal arterial blood gases (ABGs)
Ø  Angina, palpitations
Ø  Dysrhythmias
Ø  Hypotension
Ø  Hypovolemia
Ø  Tachycardia
Ø  Tachypnea
  • Cerebral:
Ø  Altered level of consciousness; memory loss
Ø  Changes in motor/sensory responses; restlessness
Ø  Changes in vital signs
Ø  Confusion
Ø  Decreased Glasgow Coma Scale scores
Ø  Decreased reaction to light
Ø  Lethargy
Ø  Pupillary changes; transient visual disturbances
Ø  Restlessness
Ø  Seizure activity
Ø  Sensory, language, intellectual, and emotional deficits
  • Gastrointestinal:
Ø  Abdominal distention/pain
Ø  Decreased or absent bowel sounds
Ø  Nausea
  • Peripheral:
Ø  Clammy skin; cool extremities
Ø  Decreased ROM, muscle strength
Ø  Dependent rubor
Ø  Differences in blood pressure (BP) in opposite extremities
Ø  Diminished/interrupted blood flow (e.g., edema of operative site, hematoma formation)
Ø  General pallor
Ø  Mottling
Ø  Numbness, pain, ache in extremities
Ø  Paresthesia
Ø  Prolonged capillary refill
Ø  Skin color changes (pallor, erythema)
Ø  Tingling in extremities, intermittent claudication, bone pain
Ø  Tissue edema, pain
Ø  Ulcerations of lower extremities, delayed healing
Ø  Weak or absent peripheral pulses
  • Renal:
Ø  Altered blood pressure
Ø  Decreased urine output (<30 ml/hr)
Ø  Elevated BUN/creatinine ratio
Ø  Hematuria

Related Factors
  • Cardiopulmonary:
Ø  Hypovolemia
Ø  Low hemoglobin
Ø  Myocardial damage from small infarcts, iron deposits, and fibrosis
Ø  Myocardial ischemia
Ø  Pulmonary embolism
Ø  Vaso-occlusive nature of sickling, inflammatory response
Ø  Vasospasm
  • Cerebral:
Ø  Cerebral edema
Ø  Increased intracranial pressure (ICP)
Ø  Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vaso­spasm
Ø  Intracranial bleeding
Ø  Vasoconstriction
  • Gastrointestinal:
Ø  Hypovolemia
Ø  Obstruction
Ø  Reduced arterial flow
  • Peripheral:
Ø  Arterial spasm
Ø  Arteriovenous (AV) shunts in both pulmonary and peripheral circulation
Ø  Compartment syndrome
Ø  Constricting cast
Ø  Decreased blood flow/venous stasis (partial or complete venous obstruction)
Ø  Embolism or thrombus
Ø  Indwelling arterial catheters
Ø  Positioning
Ø  Vasoconstriction
  • Renal:
Ø  Chemical irritants
Ø  Hemolysis
Ø  Hypovolemia
Ø  Reduced arterial flow

Assessment (Dx)
  • Examine rapid changes or continued shifts in mentation, for example, anxiety, confusion, lethargy, and stupor. Electrolyte/acid-base variations, hypoxia, and systemic emboli influences cerebral perfusion. In addition, it is directly related to cardiac output.

  • Check for pallor, cyanosis, and mottling, cool or clammy skin. Observe quality of every pulse. Absence of peripheral pulses must be reported or managed promptly. Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin perfusion and loss of pulses. Thus, assessment is necessary for constant comparisons


PERIPHERAL VASCULAR ASSESSMENT
Check for Symmetry

ü  Compare Right to Left
ü  Compare Upper Extremity to Lower Extremity
Palpable Pulses

ü  Temporal
ü  Carotid
ü  Brachial BP, CPR in infant
ü  Radial pulse
ü  Ulnar
ü  Femoral arterial studies
ü  Popliteal
ü  Dorsalis Pedis
ü  Posterior Tibial
History

ü  blood clots
ü  edema of feet or legs
ü  intermittent claudication
ü  leg cramps
ü  leg ulcers
pain on walking
disappears with rest
ü  pallor of fingertips
ü  varicose veins
INSPECTION
(Upper Extremities )
Compare Side to Side
  • Size
  • Symmetry
  • Skin/color
  • Nail Beds / Capillary Refill
Nails
  • Hair Growth
  • Venous Pattern
INSPECTION
(Lower Extremities)
Compare Side to Side
·         Size
·         Symmetry
·         Skin -color, lesions
·         Nail Beds / Capillary Refill
·         Nails
·         Venous Pattern
Hair Growth
PALPATION
(Upper Extremities)


Compare Side to Side
  • Temperature
  • Capillary refill
  • Pulses
    • Radial
    • Brachial
    • Ulnar

CHARACTERISTICS OF PULSES
palpate along LENGTH of artery with finger pads
  • Rate
  • Rhythm
  • Contour/elasticity
  • Strength (Amplitude)
    • +4 = bounding
    • +3 = full, increased
    • +2 = normal
    • +1 = diminished, weak
    • 0 = absent
Rhythm/Pattern
regular
·         irregular (dysrhythmia)
·         if irregular - take apical
apical/radial
PALPATION
( Lower Extremities)










































Compare Side to Side
·         Pulses
·         Femoral
  • Popliteal Pulses
    • Dorsalis Pedis
    • Posterior Tibial
    • Femoral
    • Popliteal
  • Temperature
  • Edema
+1- +4 pitting
  • Sensation

Arterial Insufficiency of Lower Extremities
Pulses
Decreased/Absent
Color
Pale on elevation
      Dusky Rubor on dependency
Temperature
Cool/Cold
Edema
None
Skin
Shiny, thick nails, no hair
     Ulcers on Toes
Sensation
Pain, more with exercise
   Paresthesias

Venous Insufficiency of Lower Extremities
Pulses
Present
Color
Pink to cyanotic Brown pigment at ankles
Temperature
Warm
Edema
Present
Skin
Discolored, scaly
      ulcers on ankles
Sensation
Pain, More with standing or sitting. Relieved with elevation/support hose

  • Check higher functions, as well as speech, if patient is vigilant. Indicators of location or degree of cerebral circulation or perfusion are changes in cognition and speech content.

  • Check respirations and absence of work of breathing. Cardiac pump malfunction and/or ischemic pain may result to respiratory distress. Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications.

  • Monitor intake, observe changes in urine output. Record urine specific gravity as necessary. Reduced intake or unrelenting nausea may consequence in lowered circulating volume, which negatively affects perfusion and organ function. Hydration status and renal function are revealed by specific gravity measurements.

  • Review GI function, noting anorexia, decreased or absent bowel sounds, nausea or vomiting, abdominal distension and constipation. Diminished blood flow to mesentery can turn out to GI dysfunction, loss of peristalsis, for example. Problems may be potentiated or provoked by utilization of analgesics, diminished activity, and dietary changes.

  • Assess for probable contributing factors related to temporarily impaired arterial blood flow. Early detection of the source facilitates quick, effective management.        

CARDIOVASCULAR  ASSESSMENT
History

Risk factors/Lifestyle
ü  "heart trouble"
ü  cholesterol
ü  diabetes
ü  diet
ü  dyspnea/PND
ü  edema
ü  exercise
ü  fatigue - relationship to exercise
ü  gender
ü  heart murmur
ü  HTN
ü  hypertension
ü  orthopnea
ü  palpitations
ü  stress
ü  chest pain
v  Location substernal?
v  Radiate precordial?
v  Quality crushing?
v  Associated N/V
v  Related to activity?
ü  Any medications?
v  type
v  dose
v  side effects
v  expected effects
v  take as prescribed?
ü  Does the client have a pacemaker?
v  Type
v  battery check
ü  Presence of AID
v  automated internal defibrillator
ü  Congenital heart defect
ü  Cyanosis, dyspnea
ü  Decreased exercise tolerance
ü  Delayed development
Past Health History

ü  CAD
ü  congenital heart defect
ü  Dependent edema
ü  Diabetes
ü  Most recent EKG, stress EKG
ü  Rheumatic fever
ü  Other diagnostics
Family History

ü  Angina
ü  DM
ü  Heart disease
ü  Hyperlipidemia
ü  MI
ü  Stroke
ü  Sudden death age?
Physical exam

Inspect
3 techniques, 3 positions, 5 sites
  1. Use IPA
  2. sitting, then supine, then L lateral recumbent (prn)
  3. IPA sites (more on this later)
1)     Aortic 2 R ICS RSB
2)     Pulmonic 2 L ICS LSB
3)     Tricuspid 5 L ICS LSB
4)     Mitral 5 L ICS MCL
5)     Erb’s point 3 L ICS LSB
6)     be systematic: APTM or MTPA

ü  Precordium
v  Right side
v  tangential light - subtle movements
v  inspect 5 sites for
            Lifts
            indicates enlargement or increased cardiac
            workload          
            Pulsations
            apical impulse 5 ICS LMCL

Palpate
ü  Precordium
v  palpate 5 sites for
            Heave (with palmer surface) ;
                        thrust
            Thrill (with base of finger of heel of hand (bony part))
                        palpable murmur » cat purring
                         
Auscultate
ü  Systematic
ü  S1 and S2
ü  interval between S1 and S2 should be silent
ü  heart sounds not heard best directly over valve
      which produces it, but in direction of blood flow
ü  there are specific sites where each valve sound is
            best heard
ü  Auscultation sites
1)     Aortic 2 R ICS RSB
2)     Pulmonic 2 L ICS LSB
3)     Tricuspid 5 L ICS LSB
4)     Mitral 5 L ICS MCL
5)     Erb’s point 3 L ICS LSB
ü  S1 is loudest at tricuspid and mitral sites
v  LUB-dub
ü  S2 is loudest at pulmonic and aortic sites
v  lub-DUB
ü  To accentuate sound ask client to exhale and hold breath
v  hold yours at same time  
ü  Use diaphragm and bell
v  start with diaphragm
§  (S1 and S2 relatively high pitched)
v  use bell to listen for S3 and S4
ü  Assess
v  heart sounds - S1 and S2
v  rate
v  rhythm - regular (NSR, NRR)
v  (irregularly irregular warrants investigation)
extra sounds
ü  want to hear crisp, distinct S1 and S2
S1 > at apex
S2 > at base
Extra Heart Sounds

Split S2

ü  can be physiologic, pronounced during inspiration, should disappear during exhalation
S3

ü  best heard at apex with bell
ü  during L ventricular filling
ü  physiologic in children and young adults, pregnancy
ü  after age 40 suggests ventricular or valve problem
S4

ü  best heard L lateral recumbent position with bell
ü  seldom heard in young adults unless well conditioned
ü  in older people can be OK or indicate heart disease
ü  indicates resistance to ventricular filling
Murmur

ü  sound superimposed on S1 and S2
ü  blowing, whooshing hum
ü  describe as during systole or diastole
ü  continuous sound caused by turbulent blood flow (~ bruit 20 increased blood flow)
ü  Describe findings in terms of
    • location (ICS, MCL, etc)
    • timing (systole, diastole)




  • Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ratio, and prothrombin time or partial thromboplastin time) if anticoagulants are utilized for treatment. Blood clotting studies are being utilize to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Aberrations in coagulation may occur as an effect of therapeutic measures.


Therapeutic Interventions (Tx)
  • Check sufficient fluid intake. Watch urine output. Dehydration not only results to hypovolemia but adds to sickling and occlusion of capillaries. Lowered renal  perfusion/failure may take place due to vascular occlusion

  • Foresee need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. These help out in perfusion when obstruction to blood flow occurs or when perfusion has gone down to such a dangerous level that ischemic damage would be inevitable without management.

  • Help out with diagnostic testing as indicated. Doppler flow studies or angiograms may be necessary for precise diagnosis.

  • Sustain optimal cardiac output. This guarantees sufficient perfusion of vital organs. Assistance may be necessary to help peripheral circulation.  

Specific Interventions
  • Peripheral
Ø  Foresee or maintain anticoagulation as ordered. Therapy may vary from intravenous (IV) heparin, subcutaneous heparin, and oral anticoagulants to antiplatelet drugs.

Ø  Get ready for removal of arterial catheter as necessary. Circulation is potentially altered with a cannula. It should be detached once therapeutically safe.

Ø  Give oxygen as necessary. This saturates circulating hemoglobin and augments the efficiency of blood that is reaching the ischemic tissues.

Ø  If cast roots altered tissue perfusion, foresee that the physician will bivalve the cast or take it out. This brings back perfusion in affected extremity.

Ø  If compartment syndrome is alleged, arrange for surgical interventions, fasciotomy, for example. The facial covering above muscles is relatively firm. Blood flow to tissues can become dangerously lowered as tissues swell up in reaction to trauma from the fracture.

Ø  Look forward to and introduce anticoagulation as prescribed. This lowers the risk of thrombus.

Ø  Maintain cannulated extremity still. Use supple restraints or arm boards as necessary. Movement may result to trauma to the arteries.

Ø  Perform passive range-of-motion (ROM) exercises to unaffected extremity every two to four hours. Exercise averts venous stasis.

Ø  Position properly. This upholds maximum lung ventilation and perfusion. The patient will experience maximal lung expansion in vertical or upright  position.

Ø  Report changes in ABGs like the following: hypoxemia, metabolic acidosis, hypercapnia. Titrate medications to manage acidosis; give oxygen as necessary. This sustains maximal oxygenation and ion balance and lowers systemic effects of poor perfusion.

Ø  Set up continuous pulse oximetry and titrate oxygen administered. This maintains sufficient oxygen saturation of arterial blood.

  • Cardiovascular
Ø  Give nitroglycerin (NTG) sublingually for complaints of angina. This promotes myocardial perfusion.

Ø  Give oxygen as ordered.

  • Cerebral
Ø  Assist patient to avoid or minimize coughing, vomiting, straining at stool or bearing down when possible. Move patient gradually; avoid patient from bending knees and pushing heels against mattress to move up in bed. These actions add to intrathoracic and intra-abdominal pressures, which can augment ICP.

Ø  Check eye opening. Establishes arousal ability or level of consciousness.

Ø  Check or document neurological status regularly and compare with baseline, for example, Glassgow Coma Scale during first 48 hours. Review trend in level of consciousness (LOC) and possibility for increased ICP and is helpful in deciding location, extent and development/resolution or central nervous system (CNS) damage. Note: Secondary brain injury can take place as a consequence of various factors, including the following: hypoxemia, hypercapnia, hypocapnia, the rate of cerebral metabolism, and presence of cerebral edema/hypotension impairing cerebral perfusion.

Ø  Check temperature and control environmental temperature as necessary. Avoid use of blankets.  Give tepid sponge bath in incidence of fever. Cover extremities in blankets when hypothermia blankets are utilized. Fever may be a sign of damage to hypothalamus. Greater than before metabolic needs of oxygen utilization occur (in particular with fever and shivering), which can further augment ICP.

Ø  Evaluate motor reaction to simple commands, noting purposeful and nonpurposeful) movement. Document limb movement and note right and left sides individually. 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. Consciousness and involuntary movement are incorporated if patient can both take hold of and let go of the tester’s hand or grasp two fingers on command. Purposeful movement can comprise of grimacing or withdrawing from painful stimuli. Other movements (posturing and abnormal flexion of extremities) usually specify disperse cortical damage. Absence of spontaneous movement on one side of the body signifies damage to the motor tracts in the opposite cerebral hemisphere.

Ø  Evaluate verbal reaction. Observe whether patient is alert: oriented to person, place and time; or is confused; uses inappropriate works or phrases that make little sense. Measures aptness of speech content and level of consciousness. If minimum damage has taken place in the cerebral cortex, patient may be stimulated by verbal stimuli but may show drowsy or uncooperative. More broad damage to the cerebral cortex may be manifested by slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Injury to midbrain , pons, and medulla is evidenced by lack of appropriate reactions to stimuli.

Ø  Give anticonvulsants as ordered. These lower the risk of seizure, which may root from cerebral edema or ischemia.

Ø  Give rest periods between care activities and prevent duration of procedures. Constant activity can add to ICP by creating a cumulative stimulant effect.

Ø  If ICP is elevated, raise head of bed thirty to forty-five degrees. This improves venous outflow from brain and helps lower pressure.

Ø  If intracranial pressure (ICP) catheter is present. Guarantee proper functioning.

Ø  Keep head/neck in midline of neutral position, maintain with small towel rolls and pillows. Shun placing head on large pillows. Once in a while check position or fit of cervical collar or tracheostomy ties when utilized. Rotating head to one side compresses the jugular veins and holds back cerebral venous mobilization, thus increasing ICP. Tight fitting collar or ties can also holds back jugular venous mobilization.

Ø  Prevent measures that may sets off increased ICP such as the following: straining, strenuous coughing, positioning with neck in flexion, and head flat. Increased intracranial pressures will more lower cerebral blood flow.

Ø  Reorient to environment as necessary. Lowered cerebral blood flow or cerebral edema may effect in changes in the LOC.

Educative (Edx)     
·         Coach patient in application or intermittent removal of antiembolic hose when utilized. Prevents venous stasis, promotes venous return, and lowers risk of thrombophlebitis in patient who is restricted in activity.

·         Give details about all actions and equipment to the patient.

·         Offer information on normal tissue perfusion and possible causes for injury.

·         Persuade active or passive leg exercises, aversion of isometric exercises. Improves venous return, lowers venous stasis, and lowers risk of thrombophlebitis; conversely, isometric exercises can adversely affect cardiac output by escalating myocardial work and oxygen consumption.

·         Persuade significant other to converse to patient. Recognizable voices of family or significant other show to have a relaxing effect on numerous comatose patients, which can lessen ICP.

·         Teach the patient to notify the nurse promptly if symptoms of reduced perfusion continue, increase or come back.

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