NURSING DIAGNOSIS: Altered tissue perfusion

related to:
  1. hypovolemia associated with fluid loss and decreased fluid intake;
  2. peripheral pooling of blood associated with decreased activity and diminished vasomotor responses resulting from the effects of anesthesia and some medications (e.g. narcotic [opioid] analgesics
Desired Outcome
The client will maintain adequate tissue perfusion as evidenced by:
  1. B/P within normal range for client and stable with position change
  2. usual mental status
  3. extremities warm with absence of pallor and cyanosis
  4. palpable peripheral pulses
  5. capillary refill time less than 3 seconds
  6. urine output at least 30 ml/hour
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of diminished tissue perfusion (e.g. significant decrease in B/P, postural hypotension, dizziness or lightheadedness when changing to an upright position, restlessness, confusion, cool extremities, pallor or cyanosis of extremities, diminished or absent peripheral pulses, slow capillary refill, oliguria).
  2. Implement measures to maintain adequate tissue perfusion:
    1. maintain a minimum fluid intake of 2500 ml/day unless contraindicated; if oral intake is inadequate or contraindicated, maintain intravenous fluid therapy as ordered
    2. administer blood and blood products as ordered
    3. instruct client to change from a supine to an upright position slowly in order to allow time for autoregulatory mechanisms to adjust to the change in the distribution of blood associated with an upright position
    4. perform actions to prevent peripheral pooling of blood and increase venous return:
      1. instruct and assist client to perform active foot and leg exercises every 1-2 hours while awake
      2. encourage and assist with ambulation as soon as allowed and tolerated (client should be instructed to pick up feet instead of shuffling in order to promote contractions of the leg muscles)
      3. discourage positions that compromise blood flow in lower extremities (e.g. crossing legs, pillows under knees, sitting for long periods)
      4. consult physician about an order for antiembolism stockings or an intermittent pneumatic compression device if prolonged activity restriction is expected
    5. perform actions to prevent vasoconstriction:
      1. implement measures to reduce stress (e.g. explain procedures, reduce discomfort, maintain calm environment)
      2. discourage smoking
      3. implement measures to keep client from getting cold (e.g. maintain a comfortable room temperature, provide adequate clothing and blankets).
  3. Consult physician if signs and symptoms of diminished tissue perfusion persist or worsen.