NURSING DIAGNOSIS: Altered tissue perfusion

related to:
  1. maldistribution of circulating blood volume associated with the vasodilation, increased capillary permeability, and selective vasoconstriction that occur in response to many of the inflammatory mediators (e.g. cytokines, complement, histamine, kinins) that are released in a serious infection;
  2. hypovolemia associated with fluid volume deficit resulting from decreased fluid intake and excessive loss of fluid (can occur with diaphoresis, hyperventilation, vomiting, and/or diarrhea if present);
  3. decreased cardiac output (occurs late in severe sepsis and shock) associated with the depressant effect of acidosis, myocardial depressant factor, and some inflammatory mediators (e.g. cytokines) on myocardial contractility.
Desired Outcome
The client will maintain adequate tissue perfusion as evidenced by:
  1. B/P within normal range for client
  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. absence of edema
  7. 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. decreased blood pressure, restlessness, confusion, cool extremities, pallor or cyanosis of extremities, diminished or absent peripheral pulses, slow capillary refill, edema, oliguria).
  2. Implement measures to maintain adequate tissue perfusion:
    1. administer intravenous fluids (e.g. crystalloids, colloids) as ordered
    2. perform actions to prevent or treat fluid volume deficit (see Diagnosis 2, action b)
    3. administer antimicrobial agents as ordered to treat the infection and subsequently decrease the release of inflammatory mediators
    4. administer vasopressors (e.g. dopamine, norepinephrine) and positive inotropic agents (e.g. dobutamine) if ordered to maintain adequate perfusion pressure and cardiac output.
  3. Consult physician if signs and symptoms of diminished tissue perfusion persist or worsen.