Altered Tissue Perfusion: A Comprehensive Nursing Diagnosis Guide

Ineffective tissue perfusion, clinically referred to as altered tissue perfusion, is a critical nursing diagnosis that indicates a reduction in oxygenated blood flow to the body’s tissues. This diminished blood supply compromises the function of organs and systems, potentially leading to tissue damage, organ dysfunction, and even death if not promptly addressed.

For nurses, a thorough understanding of altered tissue perfusion is paramount. This encompasses recognizing the diverse causes, conducting meticulous assessments, implementing vigilant monitoring, and initiating timely interventions. While some instances of altered tissue perfusion manifest acutely due to traumatic events like myocardial infarction or severe injuries, chronic conditions can also progressively impair perfusion. In these chronic cases, nurses play a vital role in educating patients about modifiable risk factors and lifestyle adjustments to enhance circulation and prevent further complications.

In this in-depth guide, we will explore the multifaceted aspects of altered tissue perfusion, equipping nurses with the knowledge and skills necessary for optimal patient care.

Delving into the Etiology: Causes of Altered Tissue Perfusion

Altered tissue perfusion arises from a variety of underlying conditions that impede effective blood flow. Understanding these causes is crucial for targeted nursing interventions. Common contributing factors include:

• Fluid Volume Imbalances: Both hypervolemia (excess fluid volume) and hypovolemia (fluid volume deficit, including dehydration and blood loss) can disrupt optimal blood viscosity and volume, thereby impairing tissue perfusion.
• Reduced Hemoglobin Levels: Insufficient hemoglobin, the oxygen-carrying component of red blood cells, directly limits the oxygen delivery to tissues, resulting in hypoperfusion.
• Compromised Blood Flow Dynamics: Conditions that directly obstruct or impede blood flow, such as thrombi, emboli, or vasoconstriction, directly lead to altered tissue perfusion in the affected areas.
• Hypoventilation: Inadequate respiration and hypoventilation lead to decreased oxygen levels in the blood, consequently reducing the oxygen content available for tissue perfusion.
• Trauma: Physical trauma, including injuries causing blood loss, tissue damage, and shock, can severely compromise tissue perfusion.
• Infection: Systemic infections and sepsis can trigger inflammatory responses and circulatory dysfunction, leading to widespread altered tissue perfusion and organ damage.
• Shock: Various forms of shock, including hypovolemic, cardiogenic, and septic shock, are characterized by inadequate tissue perfusion due to circulatory failure.
• Cardiac Disorders: Conditions like heart failure, arrhythmias, and myocardial infarction directly impact the heart’s pumping efficiency, resulting in reduced cardiac output and subsequent altered tissue perfusion.
• Respiratory Disorders: Chronic obstructive pulmonary disease (COPD), pneumonia, and other respiratory disorders can impair oxygenation and contribute to ineffective tissue perfusion.
• Vascular Disorders: Peripheral artery disease (PAD), venous insufficiency, and other vascular disorders directly obstruct or impair blood flow within blood vessels, leading to localized or systemic altered tissue perfusion.

Recognizing the Signs: Signs and Symptoms of Altered Tissue Perfusion

Identifying altered tissue perfusion involves recognizing a range of signs and symptoms, which can be broadly categorized into subjective (patient-reported) and objective (nurse-assessed) data. These manifestations vary depending on the affected body system.

Cardiopulmonary Perfusion Deficit

Ineffective cardiopulmonary perfusion affects the heart and lungs, leading to critical oxygenation and circulation issues.

Subjective Symptoms:

• Chest Pain (Angina): Discomfort or pain in the chest, often described as pressure, tightness, or squeezing, indicating myocardial ischemia.
• Dyspnea: Shortness of breath or difficulty breathing, reflecting inadequate oxygen supply to the lungs and tissues.
• Sense of Impending Doom: A feeling of anxiety, apprehension, or fear that something terrible is about to happen, often associated with acute cardiopulmonary events.

Objective Signs:

• Arrhythmias: Irregular heart rhythms, indicating electrical conduction disturbances and potential perfusion compromise.
• Capillary Refill >3 Seconds: Delayed return of color to the nailbeds after blanching, suggesting poor peripheral circulation.
• Altered Respiratory Rate: Abnormally fast (tachypnea) or slow (bradypnea) breathing rate, indicating respiratory distress or compensation.
• Use of Accessory Muscles to Breathe: Visible use of neck and shoulder muscles to assist breathing, signifying increased respiratory effort and distress.
• Abnormal Arterial Blood Gases (ABGs): Deviations in blood pH, PaCO2, PaO2, and HCO3 levels, indicating impaired gas exchange and oxygenation.
• Unstable Blood Pressure: Hypotension (low blood pressure) or hypertension (high blood pressure) can both indicate perfusion problems.
• Tachycardia or Bradycardia: Abnormally fast or slow heart rate, reflecting the heart’s attempt to compensate for perfusion deficits.
• Cyanosis: Bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia and poor oxygen perfusion.

Gastrointestinal Perfusion Deficit

Reduced blood flow to the gastrointestinal system can disrupt digestive function and cause a range of symptoms.

Subjective Symptoms:

• Nausea: Feeling of sickness and urge to vomit, often associated with reduced GI motility and perfusion.
• Abdominal Pain: Discomfort or pain in the abdomen, which can be localized or generalized, indicating potential GI ischemia or dysfunction.
• Bloating: Feeling of fullness and distention in the abdomen, possibly due to impaired digestion and gas accumulation.

Objective Signs:

• Hypoactive or Absent Bowel Sounds: Decreased or absent bowel sounds upon auscultation, indicating reduced peristalsis and GI motility due to hypoperfusion.
• Distended Abdomen: Visible swelling or enlargement of the abdomen, potentially caused by fluid accumulation or bowel obstruction related to poor perfusion.
• Vomiting: Expelling stomach contents, which can be a symptom of GI distress and impaired perfusion.
• Electrolyte Imbalance: Abnormal levels of electrolytes like sodium, potassium, and chloride, which can result from GI dysfunction and fluid shifts related to poor perfusion.

Renal Perfusion Deficit

Inadequate blood flow to the kidneys impairs their function in filtering waste and regulating fluid balance.

• High or Low Blood Pressure: Dysregulation of blood pressure, either hypertension or hypotension, can be both a cause and a symptom of renal perfusion issues.
• Decreased Urine Output (Oliguria): Reduced urine production, typically less than 30 ml/hour, indicating impaired kidney filtration due to hypoperfusion.
• Elevated BUN/Creatinine: Increased blood urea nitrogen (BUN) and creatinine levels in blood tests, signifying impaired kidney function and waste product accumulation due to poor perfusion.

Cerebral Perfusion Deficit

Reduced blood flow to the brain can lead to neurological dysfunction and altered mental status.

Subjective Symptoms:

• Dizziness: Feeling lightheaded, unsteady, or faint, indicating reduced blood flow to the brain.
• Visual Disturbance: Blurred vision, double vision, or other visual changes, suggesting compromised cerebral perfusion affecting visual pathways.
• Fatigue or Weakness: Unusual tiredness or lack of strength, which can be a general symptom of reduced oxygen and nutrient delivery to the brain.

Objective Signs:

• Altered Mental Status: Changes in alertness, orientation, cognition, or consciousness, ranging from confusion to coma, indicating significant cerebral hypoperfusion.
• Restlessness: Increased agitation, anxiety, or inability to stay still, often an early sign of cerebral hypoxia.
• Changes in Speech: Slurred speech, difficulty finding words (aphasia), or incoherent speech, indicating neurological impairment due to hypoperfusion.
• Difficulty Swallowing (Dysphagia): Problems swallowing, potentially due to neurological deficits affecting muscles involved in swallowing.
• Motor Weakness: Weakness or paralysis on one side of the body (hemiparesis/hemiplegia), suggesting stroke or localized cerebral hypoperfusion.
• Changes in Pupillary Reaction: Unequal pupils, sluggish pupillary response to light, or fixed and dilated pupils, indicating neurological damage and potential cerebral hypoperfusion.
• Syncope: Fainting or loss of consciousness due to temporary reduction in blood flow to the brain.
• Seizure: Uncontrolled electrical activity in the brain, which can be triggered by cerebral hypoperfusion and hypoxia.

Peripheral Perfusion Deficit

Ineffective peripheral perfusion affects blood flow to the extremities, particularly the legs and feet.

Subjective Symptoms:

• Altered Skin Sensations: Numbness, tingling, or burning sensations in the extremities (paresthesia), indicating nerve ischemia due to poor perfusion.
• Claudication: Pain, cramping, or fatigue in the legs or buttocks during exercise, relieved by rest, a hallmark symptom of peripheral artery disease.
• Peripheral Pain: Persistent pain in the extremities, even at rest, indicating severe peripheral ischemia.
• Numbness and Tingling: Loss of sensation or abnormal tingling in the fingers and toes, reflecting nerve damage from chronic hypoperfusion.

Objective Signs:

• Weak or Absent Peripheral Pulses: Diminished or non-palpable pulses in the feet and ankles (dorsalis pedis, posterior tibial), indicating arterial blockage and reduced blood flow.
• Cool Skin Temperature: Coldness to the touch in the extremities, especially compared to proximal areas, suggesting reduced arterial blood supply.
• Thickened Nails: Thickened and brittle toenails, a chronic sign of poor peripheral circulation and reduced nail bed perfusion.
• Skin Discoloration: Pallor (paleness) when legs are elevated and rubor (redness) when dependent, indicating arterial insufficiency and reactive hyperemia.
• Loss of Hair to Legs: Smooth, shiny skin and hair loss on the lower legs and feet, a trophic change indicating chronic peripheral hypoperfusion.
• Edema: Swelling in the ankles and feet, which can be present in both arterial and venous insufficiency, although the underlying mechanisms differ.
• Delayed Wound Healing: Slow or non-healing sores or ulcers on the feet and legs, a serious complication of peripheral artery disease due to impaired tissue oxygenation and nutrient supply.

Desired Outcomes: Expected Outcomes for Effective Tissue Perfusion

Nursing care plans for altered tissue perfusion aim to achieve specific, measurable outcomes that reflect improved perfusion and patient well-being. Common goals include:

• Maintaining Adequate Peripheral Perfusion: Evidenced by strong peripheral pulses (pedal pulses), warm skin temperature, intact skin integrity without edema, and adequate capillary refill.
• Maintaining Cardiopulmonary Perfusion: Demonstrated by a normal sinus heart rhythm, heart rate within normal limits, absence of shortness of breath, and normal oxygen saturation (SaO2).
• Adopting Lifestyle Modifications: Patient actively engages in lifestyle changes that support adequate tissue perfusion, such as smoking cessation, dietary adjustments, and regular exercise.
• Improving Cerebral Perfusion: Achieved when the patient exhibits intact orientation to person, place, and time, clear speech, and stable neurological function.

Comprehensive Nursing Assessment for Altered Tissue Perfusion

A thorough nursing assessment is the cornerstone of managing altered tissue perfusion. It involves gathering comprehensive data to identify perfusion deficits and their underlying causes.

1. Comprehensive Health History: Obtain a detailed history, focusing on acute and chronic conditions that impact perfusion. This includes:

• History of blood clots (deep vein thrombosis, pulmonary embolism)
• Myocardial infarction (heart attack)
• Congestive heart failure
• Diabetes mellitus
• Vascular diseases (peripheral artery disease, venous insufficiency)
• Organ failure (renal failure, liver failure)
• Risk factors: Smoking, hypertension, hyperlipidemia, sedentary lifestyle, family history of cardiovascular disease.
  Recognize that certain conditions, like heart failure or diabetes, can affect perfusion across multiple body systems.

2. Vigilance for Signs of Infection: Be alert to signs of infection, as untreated infections can progress to sepsis, a life-threatening condition causing widespread poor perfusion and organ failure. Key indicators include:

• Decreased urine output
• Abrupt changes in mental status (confusion, lethargy)
• Mottled skin (patchy, discolored skin)
• Fever, tachycardia, tachypnea

3. Review of Laboratory and Diagnostic Results: Scrutinize relevant lab values and test results for indicators of perfusion issues:

• Arterial blood gases (ABGs): Assess oxygenation and acid-base balance.
• Complete blood count (CBC): Evaluate hemoglobin and hematocrit levels (oxygen-carrying capacity).
• Electrolytes: Monitor for imbalances that can affect cardiac function and fluid balance.
• Coagulation studies (PT/INR, PTT): Assess clotting status, relevant in conditions affecting blood flow.
• Renal function tests (BUN, creatinine): Evaluate kidney function and perfusion.
• Cardiac enzymes (troponin): Assess for myocardial damage.
• Imaging studies (CT scans, Doppler ultrasound): Visualize blood vessels and assess blood flow.
  Compare current results to baseline values to identify new or worsening perfusion problems.

Nursing Care Strategies: Interventions for Altered Tissue Perfusion

Nursing interventions for altered tissue perfusion are tailored to the underlying cause and affected body system. Here’s a breakdown of interventions based on the area of perfusion deficit.

Ineffective Cardiopulmonary Perfusion: Nursing Interventions

Nursing Assessment Focus:

1. Sudden Changes: Immediately assess for sudden onset of chest pain, diaphoresis (sweating), respiratory distress, and hemoptysis (coughing up blood), which may indicate acute events like pulmonary embolism or myocardial infarction.
2. Vital Signs and EKG: Closely monitor blood pressure, heart rate, respiratory rate, and cardiac rhythm via EKG for any deviations from baseline.
3. Hemoglobin Levels: Monitor hemoglobin levels to ensure adequate oxygen-carrying capacity. Low hemoglobin directly reduces oxygen delivery to tissues.
4. Capillary Refill: Assess capillary refill time as an indicator of peripheral perfusion and circulatory status. Prolonged refill (>3 seconds) can suggest hypovolemia, shock, peripheral artery disease, or heart failure.

Nursing Interventions:

1. Medication Administration: Administer prescribed medications to improve blood flow.
   • Vasodilators (e.g., nitroglycerin for chest pain, hydralazine for hypertension) dilate blood vessels, enhancing blood flow.
   • Antiarrhythmics manage abnormal heart rhythms to optimize cardiac output.
   • Inotropes (e.g., dobutamine) strengthen heart contractions to improve cardiac output.
2. Oxygen Therapy: Provide supplemental oxygen as needed to increase blood oxygen saturation and support tissue oxygenation. Oxygen delivery methods range from nasal cannula to mechanical ventilation, depending on the severity of hypoxemia.
3. Surgical Interventions: Prepare patients for potential surgical procedures to restore blood flow in cases of blockages.
   • Coronary angioplasty and stent placement to open blocked coronary arteries.
   • Coronary artery bypass grafting (CABG) to bypass blocked arteries.
   • Embolectomy or thrombectomy to remove blood clots.
     Provide pre- and post-operative education and monitoring for complications.
4. Patient Education: Heart Attack Recognition: Educate patients on the signs and symptoms of a heart attack, emphasizing gender differences. While men often present with classic chest pain, women may experience more atypical symptoms like nausea, jaw pain, back pain, or arm pain. Early recognition and prompt medical attention are crucial.

Ineffective Gastrointestinal Perfusion: Nursing Interventions

Nursing Assessment Focus:

1. Underlying Cause: Determine if GI hypoperfusion is systemic (e.g., shock) or localized to the GI system (e.g., mesenteric ischemia). The underlying cause guides treatment strategies.
2. Bowel Sounds: Auscultate bowel sounds to assess GI motility. Hypoactive or absent bowel sounds suggest reduced peristalsis due to hypoperfusion.
3. Abdominal Pain: Assess the location, character, and onset of abdominal pain. Sudden, severe abdominal pain can signal a ruptured aortic aneurysm or other acute abdominal emergencies. Differentiate pain characteristics associated with various GI conditions (gallstones, pancreatitis, appendicitis, bowel obstruction).
4. Stool Changes: Monitor stool for changes in frequency, consistency, and presence of blood. Constipation can result from slowed digestion. Blood in stool (bright red or black, tarry) can indicate ischemic colitis or GI bleeding.

Nursing Interventions:

1. Nausea and Vomiting Management: Control nausea and vomiting to prevent dehydration and electrolyte imbalances.
   • Administer antiemetics as prescribed.
   • Replace fluid and electrolytes intravenously as needed.
2. Dietary Management: Encourage small, easily digestible meals as the patient recovers. Start with clear liquids and progress to bland diets to avoid overwhelming the GI system.
3. Nasogastric (NG) Tube Insertion: Prepare for NG tube insertion as needed for bowel rest or decompression in cases of severe GI hypoperfusion, obstruction, or ileus. Monitor NG output for color, volume, and consistency to assess bowel function.

Ineffective Renal Perfusion: Nursing Interventions

Nursing Assessment Focus:

1. Urine Output: Closely monitor urine output amount and characteristics. Reduced urine output (<30 ml/hour) or dark, concentrated urine are indicators of impaired renal perfusion. Anuria (absence of urine output) is a critical sign.
2. BUN and Creatinine Ratio: Review BUN and creatinine levels and their ratio. Elevated BUN and creatinine indicate impaired kidney function. A high BUN-to-creatinine ratio suggests poor blood flow to the kidneys. Also monitor electrolyte levels (sodium, potassium, calcium, phosphate).
3. Edema Assessment: Observe for edema (swelling), particularly in the extremities. Edema indicates fluid retention due to impaired kidney filtration.

Nursing Interventions:

1. Intake and Output Monitoring: Accurately measure and document fluid intake (oral, IV) and output (urine, emesis, drainage) to monitor fluid balance.
2. Daily Weight Monitoring: Weigh the patient daily at the same time, using the same scale, and with similar clothing to detect fluid retention changes. Sudden weight gain indicates fluid overload.
3. Dietary Education: Educate patients about diet recommendations.
   • Fluid restriction may be necessary to manage fluid overload.
   • Sodium restriction to minimize fluid retention.
   • Potassium restriction if hyperkalemia is present.
   • Reduced animal protein intake to minimize kidney workload in chronic kidney disease.
4. Renal Support Therapies: Administer therapies to support kidney function based on the underlying cause.
   • Blood pressure medications to optimize renal perfusion pressure.
   • Diuretics to promote fluid excretion.
   • Intravenous fluid resuscitation for hypovolemia.
   • Dialysis (hemodialysis or peritoneal dialysis) for severe renal failure to remove waste products and excess fluid.

Ineffective Cerebral Perfusion: Nursing Interventions

Nursing Assessment Focus:

1. Level of Consciousness (LOC) and Mentation: Assess LOC using tools like the Glasgow Coma Scale (GCS). Evaluate mentation for confusion, disorientation, lethargy, or coma. Assess for speech changes, motor control deficits, vision changes, and sensory alterations.
2. Stroke Signs: Assess for signs of stroke (cerebrovascular accident), including facial drooping, slurred speech, and unilateral muscle weakness. Use stroke assessment tools like the NIH Stroke Scale (NIHSS).
3. Medication Review: Review the patient’s medication list for potential interactions or medications that could mask neurological symptoms (e.g., narcotics, sedatives, antiseizure drugs, antihypertensives). Consider medication side effects or overdoses.

Nursing Interventions:

1. Frequent Neurological Exams: Perform neurological assessments at prescribed intervals to monitor for changes in LOC, pupillary response, motor function, and sensory function. Use standardized scales like the NIHSS for stroke patients.
2. Prepare for Imaging Studies: Prepare the patient for brain imaging studies (CT scan, MRI) to identify the underlying cause of altered cerebral perfusion, such as stroke, hemorrhage, or tumor.
3. Head of Bed Elevation: Elevate the head of the bed to 30 degrees (unless contraindicated) to promote venous return from the brain and reduce intracranial pressure (ICP). Maintain a neutral neck position to optimize cerebral blood flow.
4. Medication Administration: Administer medications as prescribed.
   • Sedatives to manage agitation and reduce metabolic demand on the brain.
   • Osmotic diuretics (e.g., mannitol) to reduce ICP.
   • Corticosteroids to reduce brain inflammation and edema.
   • Thrombolytics (e.g., tPA) to dissolve blood clots in ischemic stroke (within a specific time window).
   • Antihypertensives to manage blood pressure and prevent further cerebral damage.

Ineffective Peripheral Perfusion: Nursing Interventions

Nursing Assessment Focus:

1. Thorough Skin Assessment: Conduct a comprehensive skin assessment of the extremities, noting:
   • Skin color (pallor, cyanosis, rubor)
   • Temperature (coolness)
   • Edema (location, severity)
   • Wounds, ulcers, or lesions (location, size, characteristics)
   • Hair loss on legs
   • Thickened nails
2. Peripheral Pulses: Palpate peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral, radial, brachial) and grade their strength (0-4+ scale). Document absent or weak pulses.
3. Pain and Numbness: Assess for pain, numbness, tingling, or claudication in the extremities, noting location, quality, and aggravating/relieving factors.

Nursing Interventions:

1. Doppler Ultrasound: Use a Doppler ultrasound device to assess blood flow if peripheral pulses are weak or non-palpable. Doppler can detect blood flow even when pulses are not easily felt.
2. Anti-embolism Stockings: Apply anti-embolism stockings (compression stockings) to improve venous return and reduce edema in patients with venous insufficiency or edema. Ensure proper fit.
3. Positioning and Activity:
   • Discourage prolonged sitting or crossing legs, as these impede blood flow.
   • Encourage regular leg exercises (ankle pumps, toe raises) to promote circulation.
   • Elevate legs when sitting to improve venous return (for venous insufficiency).
   • For arterial insufficiency, sometimes dependent positioning (legs slightly below heart level) can improve arterial flow, but this should be individualized and carefully assessed.
4. Lifestyle Modifications: Educate patients on lifestyle changes to improve peripheral blood flow:
   • Smoking cessation: Smoking is a major risk factor for peripheral artery disease.
   • Diabetes management: Strict blood sugar control is crucial for preventing vascular complications of diabetes.
   • Dietary modifications: Low-fat, low-cholesterol diet to manage hyperlipidemia.
   • Regular exercise: Walking, cycling, and other forms of exercise improve peripheral circulation.
5. Cold Avoidance: Advise patients with Raynaud’s disease or peripheral artery disease to avoid exposure to cold temperatures, which can exacerbate vasoconstriction and reduce blood flow. Recommend wearing warm clothing, gloves, and socks in cold environments.

Nursing Care Plan Examples for Altered Tissue Perfusion

Care Plan #1: Ineffective Tissue Perfusion Related to Hypervolemia (Renal Failure)

Diagnostic Statement: Ineffective tissue perfusion related to hypervolemia secondary to renal failure as evidenced by elevated BUN/creatinine and edema.

Expected Outcomes:

• Patient will demonstrate effective tissue perfusion, indicated by balanced fluid intake and output, stable vital signs (BP 90/60-130/90 mmHg, RR 12-20 breaths/min, HR 60-100 bpm, Temp 97.8-99.1°F), and absence of edema.
• Patient will exhibit optimal renal function, evidenced by urine output >30 cc/hr, BUN 6-24 mg/dL, and creatinine 0.74-1.35 mg/dL (male) or 0.59-1.04 mg/dL (female).

Assessments:

1. Monitor intake and output, noting oliguria or anuria in early renal failure phases. Fluid replacement is based on fluid losses.
2. Monitor BUN, creatinine (elevated in renal failure), hemoglobin/hematocrit (anemia common), and electrolytes (sodium, potassium imbalances).
3. Monitor daily weights for fluid balance changes. Sudden weight gain indicates fluid retention.
4. Monitor HR, BP, respiratory rate, and jugular veins for fluid volume excess signs (increased BP, tachycardia, tachypnea, jugular vein distention).

Interventions:

1. Administer oral and IV fluids as prescribed, considering fluid restriction in oliguric phase and fluid replacement in diuretic phase of renal failure.
2. Administer diuretics to manage fluid volume excess, with close monitoring for hypovolemia, which can worsen renal perfusion.
3. Handle patients with edema gently and reposition frequently to prevent skin breakdown.
4. Prepare patient for renal replacement therapy (hemodialysis) as indicated to remove excess fluid and correct electrolyte imbalances.

Care Plan #2: Ineffective Tissue Perfusion Related to Arteriosclerosis

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, indicated by strong, palpable pulses, reduced or absent claudication, adequate capillary refill, and warm, dry extremities.
• Patient will not develop leg ulceration.

Assessments:

1. Assess pain, numbness, and tingling: onset, quality, severity, relieving factors. Intermittent claudication is common in PAD; pain at rest indicates severe disease.
2. Assess ankle-brachial index (ABI). Normal ABI >0.9. ABI <0.9 indicates PAD; <0.4 severe disease.
3. Monitor diagnostic results: pulse volume recordings, vascular stress testing, MRA, arteriography, Doppler ultrasound to assess location and severity of PAD.

Interventions:

1. Educate on disease progression prevention: smoking cessation, dietary modification, hypertension management, hyperlipidemia management, diabetes management, weight management, exercise.
2. Provide information on daily exercise program: walking program to improve collateral circulation.
3. Instruct on complication prevention: keep extremities warm (stockings), avoid cold, inspect feet regularly for injury.
4. Administer medications: antiplatelets (aspirin, clopidogrel), cilostazol, lipid-lowering agents to slow atherosclerosis progression and relieve symptoms.

Care Plan #3: Ineffective Tissue Perfusion Related to Venous Pooling

Diagnostic statement: Ineffective tissue perfusion related to dependent venous pooling as evidenced by varicose veins and thick nails.

Expected Outcomes:

• Patient will demonstrate palpable peripheral pulses and warm, dry skin.
• Patient will demonstrate strategies to prevent venous pooling.

Assessments:

1. Note skin color and temperature. Reddish-blue discoloration indicates venous congestion. Brownish discoloration on tibia indicates chronic venous insufficiency.
2. Assess extremity pain: severity, quality, timing, exacerbating/alleviating factors. Venous insufficiency pain lessens with leg elevation and exercise.
3. Assess skin texture, ulcerations, hair distribution, ulcers, gangrene on legs/feet. Venous ulcers are typically on the side of the leg.

Interventions:

1. Elevate edematous legs as ordered, avoiding pressure under knees and heels to prevent pressure ulcers.
2. Apply graduated compression stockings, ensuring proper fit, to improve venous return and prevent blood pooling.
3. Encourage walking with compression stockings and toe-up/point-flex exercises to increase venous return and strengthen calf muscles.
4. Discuss lifestyle modifications: avoid prolonged standing/sitting, wear compression socks at work if job requires prolonged standing, increase activity, avoid tight clothing and high heels.

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