Altered Peripheral Tissue Perfusion - Nanda Nursing Diagnosis

Definition

Circumstances where an individual experiencing or at risk of a decline in nutrition and respiration at the cellular level, a decrease in peripheral capillary blood supply.

Related Factor:
Ppathophysiological
Related to the weakening of blood flow
(Vascular disorders)
Arteriosclerosis
Hypertension
Aneurysms
Arterial thrombosis
Of deep venous thrombosis
Collagen vascular disease
Rheumatoid arthritis
Diabetes mellitus
Diskariasis blood (platelet disorders)
Renal failure
Cancer / tumor
Varicose veins
Burger's Disease
Sickle cell crisis
Cirrhosis alcoholism
Action
Related to immobilization
Related to the flow of invasive
Related to the pressure on place / constriction (bandages, stockings)
Related to vascular trauma
Situational (Personal, environmental)
Related to the pressure of the enlarged uterus on the peripheral circulation
Related to the pressure of the enlarged abdomen in the pelvic and peripheral circulation
Related to the collection hanging venosa
Related to hypothermia
Related to vasoconstriction effects of tobacco
Related to a decrease in circulating volume: dehydration

Major Data

Decrease or absence of a pulse
Changes in skin color
Pale (arterial)
Cyanosis (Vena)
Reactive hyperemia (arterial)
Changes in skin temperature
Cooler (arterial)
Warmer (venous)

Expected outcomes

Individuals will:
1. Identifying factors that increase peripheral circulation faktro
2. Identify the necessary lifestyle changes
3. Identify how medical, diet, medication, activity increases vasodilation
4. Reported a decrease in pain
5. Describes when to call the doctor / health

Intervention

1. Teach individuals to
a. Maintain the limb in a dependent position
b. Maintaining extremities warm (do not use heating pads or hot botolair, because individuals with peripheral vascular disease may experience disturbances of sensation and not be able to determine if heat damage tissue, the use of external heating can also increase the metabolic needs of the tissues through its capacity limit.
c. Reduce the risk of trauma
- Change position at least every hour
- Avoid crossing legs
- Reduce the external pressure (eg, narrow shoes)
- Avoid skin pelundung of Tumut
- Encourage range of motion exercises
2. Plan a program runs every day
a. Instruct individuals in the reasons for the program
b. Teach individuals to avoid fatigue
c. Instruct to avoid an increase in the exercise to be assessed by a doctor for heart problems
d. Make sure the running back does not hurt individual vein or muscle.
3. Teach the factors that increase the flow of venous blood
a. Elevate the extremity above the heart, unless there are contraindications eg, heart disease, respiratory disorders.
b. Avoid standing or sitting with feet hanging for a long time.
c. Consider the use of bandages or elastic stockings below the knee to prevent static vein.
d. Reduce or remove the external vein compression disrupting the flow of the vein.
- Avoid pillows behind the knee or knee brace bed.
- Avoid crossing of the lower leg
- Change the position, move the limb or finger shaking legs every hour
- Avoid the use of garter and stocking thin above the knee.
4. Measure the base circle of the calves and thighs, if the individual risk of deep venous thrombosis or if it is suspected
5. Teach individuals to
a. Avoid long trips by car or plane, when the inevitable up and running at least every hour.
b. Keep the skin dry lubricated (broken skin eliminating physical barriers to infection)
c. Use warm clothing during cold weather
d. Use cotton or wool socks
e. Avoid dehydration in hot weather
f. Give special attention to the feet and toes.
- Wash and dry feet thoroughly every day
- Not merandam both feet
- Avoid harsh soaps or chemicals including iodine on foot
- Keep your nails cut and refined in a state
g. Observe the feet and lower legs against injury and suppression
h. Use clean socks
i. Use shoes that support, fit and comfortable
j. Observe the inside of shoes every day for rough lines.
6. Teach about the modification of risk factors
a. Diet:
- Avoid foods high in cholesterol
- Modify the input of sodium to control hypertension
- Refer to a dietitian
b. Relaxation techniques to reduce the effects of strs
c. Stop smoking
d. Exercise program