Evidence-Based Nursing Practice Guidelines for Tissue Perfusion: Periphery in the ICU - Systematic Review of the Literature
Evidence-based nursing practice on tissue perfusion: periphery in the ICU - Systematized Literature Review
Karyne Monteiro Bachie.Nurse. Student of the Intensive Care Nursing Specialization Course / Fluminense Federal University (UFF).firstname.lastname@example.org
prof. Doctor Isabel Cruz.Head of the UFF.email@example.com
Abstract:Ineffective peripheral tissue perfusion is a NANDA nursing diagnosis; the definition of which means a reduction in blood circulation to the periphery that can endanger health. Such a diagnosis is associated with diabetes mellitus and hypertension. Peripheral arterial obstructive disease (PAD) is characterized by hardening of the arterial wall and narrowing of its lumen, often occurring in the lower extremities, causing a chronic atherosclerotic process. Based on the literature, there is a strong association between the clinical manifestation of PAD and diabetes mellitus (DM) and systemic arterial hypertension (SAH), given the systemic features of both. Thus, the aim of the present study was to review evidence-based nursing guidelines that will assist critical care nurses in identifying diagnoses and nursing care prescriptions to achieve tissue perfusion: peripheral outcome. The descriptive research was conducted through a systematic review of the literature and was based on secondary works published between 2011 and 2018.
Keywords:peripheral arterial disease; nursing care; intensive care unit
Resume:Ineffective peripheral tissue perfusion is a NANDA nursing diagnosis, defined as decreased blood flow to the periphery that can compromise health. This diagnosis has diabetes mellitus and arterial hypertension as associated conditions. Peripheral obstructive arterial disease (PAOD) is characterized by hardening of the arterial walls and narrowing of their lumen, which often occurs in the lower extremities, causing a chronic atherosclerotic process. Based on the literature, there is evidence of a strong association between the clinical manifestation of ODPA and diabetes mellitus (DM) and systemic arterial hypertension (SAH), given the systemic features of both. Thus, the aim of the present study was to review evidence-based nursing guidelines that will assist critical care nurses in identifying diagnoses and nursing care prescriptions to achieve the outcome of tissue perfusion: peripheral. The descriptive research was conducted through a systematic review of the literature and was based on secondary works published between 2011 and 2018.
Keywords:peripheral arterial disease; nursing care; intensive care unit
Intensive care nursing care is complex and challenging as professionals are exposed to difficult clinical situations that require increased attention and control, in addition to requiring technological innovations that must be integrated into the nursing system in a consistent, correct, safe and humane manner. at the bedside.(1). In their care practice, the nurse carries out administrative and care work in conjunction. The Systematization of Nursing Care (SAE) is an essential tool to implement interventions and manage this care.(2).
The nursing diagnosis is a clinical judgment that forms the basis for the elaboration of the nursing plan, which is an action plan and provides direction for the care of the patient. The implementation of care is called implementation and the evaluation is the recording of the findings, including the interventions prescribed on a case-by-case basis.(3). Ineffective peripheral tissue perfusion is a NANDA nursing diagnosis(North American Association for Nursing Diagnosis), the definition of which means a reduction in blood circulation to the periphery that can endanger health. This diagnosis is associated with diabetes mellitus and arterial hypertension.(4).
Based on the literature, there is evidence of a strong association between the clinical manifestation of peripheral arterial disease (PAOD) and diabetes mellitus (DM) and systemic arterial hypertension (SAH), given the systemic features of both.(5). Patients with type 2 diabetes mellitus have dyslipidemia, an increase in the levels of lipids and lipoproteins in the bloodstream, which subsequently cause cardiovascular disease. Dyslipidemia is usually present at the time of diagnosis of hyperglycemia in people with diabetes.(6).
PAOD is characterized by the hardening of the walls of the arteries and the narrowing of their lumen, which often occurs in the lower extremities, causing a chronic atherosclerotic process.(7). One of the most common symptoms is intermittent claudication, which results from decreased blood flow to the lower extremities during exercise. Claudication is characterized by pain or discomfort when walking that resolves after rest.(8).
People with diabetes and PAOD are at high risk for complications such as ischemic ulcers, gangrene, and amputation. Ankle Brachial Index (ABI) is a simple and non-invasive method for the early detection of PAOD(9). The ABI is calculated by dividing the highest systolic pressure in the ankle arteries by the systolic pressure in the brachial artery, measured with the person in the supine position, using a sphygmomanometer and a portable continuous wave ultrasound machine.(8).
The paucity of information about the practice based on scientific evidence and its guidelines to achieve the outcome of nursing tissue perfusion: peripheral for the highly complex patient in intensive care in a maximum of 7 days of hospitalization.
Table 1: Description of the components of the PICOT strategy, Niterói, 2019.
Practice question component
Adult or elderly patient at risk of tissue perfusion: peripheral, ineffective
Take care of the circulatory system: arterial/venous insufficiency
check or compare
Monitoring of the lower extremities; Mechanical circulatory support equipment.
Nursing Outcome (NOC)
peripheral tissue perfusion: adequacy of blood flow through the small vessels of the extremities to maintain tissue function
Up to 7 days of hospitalization in the ICU or High Complexity Unit
Critical path: 7 days
Review the evidence-based nursing guidelines that assist the critical care nurse in identifying diagnoses and nursing care prescriptions to achieve tissue perfusion outcome: peripheral, in 7 days.
Based on the evidence, how can nursing care be optimized so that the highly complex patient achieves the result of tissue perfusion: peripheral in a maximum of 7 days of hospitalization?
Material and method
The descriptive research was conducted through a systematic review of the literature and based on secondary works published in the period from 2011 to 2018. It was conducted between the months of May and October 2019. The research was conducted in a virtual environment in the Virtual Health Library (VHL), in the Electronic Databases: Online Medical Literature Analysis and Retrieval System (MEDLINE), Nursing Database (BDENF), Online Electronic Scientific Library (SCIELO), and Latin American Literature and the Caribbean in Health Sciences (LILACS). The articles identified in the search had to meet the inclusion criteria: Portuguese and English and were published between 2011 and 2019. Repetitive articles, with incomplete text and articles deviating from the proposed theme, were excluded. The descriptors were chosen according to the PICOT strategy, using:peripheral arterial disease AND nursing care AND intensive care. Ten articles were selected as results for further discussion, meeting all inclusion criteria.
Authors, year and country
Purpose of the investigation
Kind of study
level of evidence
Tamires Gomes dos Santos, Fernanda Silva Santos, Marcia Tasso Dal Poggetto, Fernanda Bonato Zuffi, 2016, Brazilië(11)
Report the case of care to a diabetes user with PAOD and display the nursing diagnoses and interventions listed for this case.
1 diabetes patient withobstructive arterial disease
Needa systematized nursing care, which should not be done empirically, but should be based on evidence and science, constituting comprehensive and quality care for the patient
Luan Barbosa Furtado, Artur Acelino Francisco Luz Nunes Queiroz, Álvaro Francisco Lopes de Sousa, Giovanna de Oliveira Libório Dourado, Moisés Lopes Carvalho, 2015, Brazilië(12)
To present a case report of the nursing care of a patient with a medical diagnosis of peripheral arterial obstructive disease.
1 patient with PAOD
The need for rapprochement between nursing and patient is reinforced
Cristiane Baldessar Mendez1
Nadia Chiodelli Salum2
Lucia Nazareth lover
Carlos Mauricio Lopes Mendez, 2019, Brazil(13)
Describe the development of an educational mobile application for nursing monitoring of people diagnosed with peripheral arterial disease, aiming to modify behavioral risk factors, such as inadequate nutrition, sedentary lifestyle, smoking, overweight and non-compliance with medication prescriptions.
Development of educational mobile applications
Technological production of the prototype type
Need to measure the impact of the applicationFollow upfor peripheral arterial disease in the health of Brazilians, as well as the cost comparison when using mobile technology in follow-up and traditional consultations
Daniela Luisa Maggi, Leyla Regina Dal Piva de Quadros, Karina Oliveira Azzolin,
Silvia Goldmeier, 2014, Brazil(14)
Demonstrate that the Ankle Brachial Index (ABI) and the Edinburgh Claudication Questionnaire are tools that can be used by nurses in the prevention of cardiovascular disease (CVD)
Encouraging use of the ankle-brachial index associated with the Edinburgh Claudication Questionnaire outcome by nurses given its low cost and potential for the prevention of cardiovascular events
José Aderval Aragão, et al., 2018, Brazilië(15)
To evaluate quality of life in patients with peripheral arterial disease admitted to the vascular surgery department of a charity hospital on the third floor.
Exploratory cross-sectional study
It is imperative that people with peripheral arterial disease, health professionals, and social and family organizations work together to address the factors that negatively impact the quality of life of these people.
Caroline Shihara de Assis, Letícia de Carvalho Batista, Nelson Woloske, Antonio Eduardo Zerati, Rita de Cassia Gengo e Silva, 2015, Brazilië(sixteen)
To evaluate the functional independence of patients with intermittent claudication and verify the association of functional independence with sociodemographic and clinical variables, with the ability to walk and with the level of physical activity.
Descriptive, exploratory, transversal, with a quantitative approach
It is suggested that other studies be conducted to confirm our results.
David Brito, Henrique Correia, Ana Vaz Ferreira, Susana Jorge, Hernâni Caniço, 2017, Brazilië(17)
To determine the prevalence of peripheral arterial disease manifestations in patients with diabetes in primary care.
Observational, analytical and transversal
The complementarity of diagnostic methods can
contribute to greater detection of cases of peripheral arterial disease,
would be expected given the limitations in sensitivity
of the methods used (IPTB, lameness and pulses)
Luz Marina Alfonso Dutra, Maria Rita Carvalho Garbi Novaes, Manuela Costa Melo,
Danyelle Lorrane Carneiro Veloso, Dayane Leticia Faustino, Leila Maria Sales Sousa. 2017, Brazilie(18)
Identify risk factors for foot ulcers by screening for diabetic peripheral neuropathy and disease.
Peripheral arterial disease in type I and II diabetics
Ttransversal and analytical
The implementation of the protocol provides assistance
integral quality of the individual, which must be strengthened
through systematized actions that imply targeted behavior
in the nursing process
Tatiana Martins, Nádia Chiodelli Salum, Melissa Orlandi Honório Lock,
Lucia Nazareth Amante, Juliana Balbinot Reis Girondi, Luciara Fabiane Sebold, 2019, Brazilië(19)
of hospitalized patients for obstructive arterial disease
periphery and their home care needs
exploratory descriptive approach
of better planning
for hospital discharge of patients with peripheral arterial occlusive disease,
so that the health education process permeates
for all stages of hospitalization,
with its beginning in the reception of the patient and his
finiteness by counter-reference
Anne Caroline Santos Ramos, Maria Lucila Hernández-Macedo, Jorge A. López, 2016, Brazilië(20)
clarify what it is
diabetes, its pathophysiology and mechanisms
Causes of peripheral arterial disease of the lower extremities.
18 secondary works
Maintenance of homeostasis in diabetics throughsimple measures, such as a balanced diet,
administering medication, exercising
physical activities, elimination of risk factors and
regular visits to the endocrinologist and
The function of the circulatory system is to transport blood throughout the body to meet the need for nutrients, oxygen and various other substances, in addition to removing metabolites excreted through the urinary tract, to maintain the body's homeostasis. One of the metabolites transported through the blood is glucose, which is the main source of energy in the human body. Diabetes Mellitus is an endocrinological disease and/or a chronic metabolic disorder characterized by hyperglycemic indexes.(20). Hyperglycaemia causes long-term organic damage, such as neuropathies, retinopathies, nephropathies and cardiovascular diseases.(21).
As for cardiovascular diseases, they can be micro or macrovascular and affect small or large blood vessels respectively. This occurs in the form of atherosclerosis, increasing the incidence of cerebrovascular accident (ACV), heart attacks and necrosis of the extremities.(22).
Peripheral arterial disease is caused by macrovascular changes due to advanced atherosclerosis, accentuated by dyslipidemia, which reduces blood flow to the body's lower extremities during exercise and routine activities, due to narrowing of the lumen of the blood vessels.(23). The prevalence of peripheral arterial disease in the diabetic population is higher than in the general population and tends to increase with age and additional risk factors. It is estimated to be more than 20% in patients with diabetes and about 50% of these with lower extremity ulcers, which is associated with cardiovascular morbidity and mortality.(17).
Research related to the evaluation of the risk of ulceration in diabetic patients highlights the importance of early screening for peripheral arterial disease as a common complication in diabetics as it enables nurses to reduce the need for referral to a specialist professional for diagnosis, follow-up identify and treat and thus reduce the risk of ulceration(18). In this way, it is necessary to take increasingly faster and more effective diagnostic and intervention measures.minimize the increase in cardiovascular morbidity and mortality(24).
A measure of great importance to assess cardiovascular deficits is the ankle brachial index (ABI), an important indicator of peripheral arterial occlusive disease (PAOD) in the asymptomatic phase. Patients with PAOD are five to seven times more likely to have an acute myocardial infarction (AMI) and a cerebrovascular accident (CVA), compared to a person who does not have cardiovascular disease (CVD).(25).
Using the ABI associated with the Edinburgh Claudication Questionnaire, which performs sensitivity and specificity analyzes for intermittent claudication (IC), showed that bothtools that provide important information about the risk of cardiovascular disease and aid in the early detection of asymptomatic cases. In addition, they are easy-to-use tools in clinical evaluation. Another important aspect in this study was the relationship between the ABI associated withEdinburgh Claudication Questionnairewith the risk factors studied (sedentary lifestyle, smoking, dyslipidaemia, diabetes and hypertension), qualifying it as a tool of great importance for clinical practice. Information on subclinical atherosclerotic disease, a predictor of cardiovascular events, should be considered prior to use. It is a non-invasive method, easy to use by nurses, that should be promoted given its low cost and potential for the prevention of cardiovascular events. (14).
Quality of life is a measure that has become increasingly important to assess the deterioration of daily life due to interventions and vascular diseases such as DTAE, that is, from a variety of conditions that can affect the life of the individual.(26). A study evaluated the quality of life of patients diagnosed with PAOD and found that several conditions can affect the lives of these people, such associal isolation, shame, sense of discrimination by society andfamily(15). The patient living with chronic non-communicable diseases faces various limitations in their lifestyle and interaction with the environment, sometimes denying them pleasurable activities and neglecting their self-care(11-12).It is therefore necessary for people with these types of diseases, health professionals and social and family organizations to work together to address the factors that negatively affect the quality of life of these people. Another issue addressed relates to education, where a better understanding of the information allows for a better understanding of the disease and, consequently, greater adherence to treatment.(15).
The recommendations found suggest that patients with intermittent claudication should be encouraged to the recommended level of physical activity as a way to maintain their functional independence to perform motor and cognitive functions in daily life. Functional independence is associated with a higher level of physical activity and a greater ability to walk(sixteen).
Peripheral arterial disease can lead to disfigurement and death in advanced stages; however, if diagnosed in time, it can be treated clinically without surgical intervention. For this, it is necessary that the patient orients himself to his problem, with the aim of clarifying the disease, its evolution and the proposed therapy. One of the main objectives of the health education process in the hospital environment is to prepare the patient for the return home, to make him the main person responsible for his recovery and the maintenance of his well-being, as health education aims to improve people's quality of life to increase. autonomy and the ability to intervene in one's own life This requires the multidisciplinary team to experience discharge from the hospital as a delicate moment, in which a complex transition from professional care to home care takes place(19).
The development of an educational mobile application andFollow upfor patients with peripheral arterial disease, it was one of the forms of health education that proved capable of promoting greater knowledge about the disease and a consequent increase in adherence to therapy. the strategy ofFollow upIt makes it possible, by following the evolution of the wound healing process and possible complications, to clarify doubts and promote continuity of treatment. It is a strategy that has the potential to make a significant contribution to improving access to quality services and reducing costs.(13).
The treatment of peripheral arterial disease and the resulting ineffective peripheral tissue perfusion is necessary from systematic nursing care, based on scientific evidence, and constitutes a comprehensive and quality care for the patient. The use of the Systematization of Nursing Care (SAE) in the ICU is fundamental as it organizes and plans the actions performed by the nursing team in accordance with the care needs to provide qualified assistance to the client. In this environment, it is the nurse's responsibility to provide specialized nursing care, planning and organizing the care of the critically ill patient, linking their technical-scientific knowledge to the needs of pathology, devices and equipment, and fundamental human needs for the patient and his family.
The viability of comprehensive and qualified nursing care is necessary for this profession to gain more and more scientific knowledge and professional support, producing evidence-based knowledge.
With regard to peripheral arterial disease, although it is a common pathology, it requires attention and sensitivity on the part of the health professional as the patient living with chronic non-communicable diseases faces various limitations in their lifestyle and interaction with the environment.
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2. Hausmann M, Peduzzi M. Articulation between the management and care dimensions of the nursing work process. Text context Enferm, Florianópolis, April-June 2009; 18(2): 258-65.
3. Ralph, SS.; Taylor, C. M.; Manual Nursing Diagnostics [technical review CRUZ, I.C.F.; FIGUEREIDO, JEF] - Rio de Janeiro: Guanabara Koogan, 2009.
4. Herdman, TH, Kamitsuru S. NANDA-I nursing diagnoses: definitions and classification 2018-2020.11e druk. Porto Alegre: Artmed; 2017.
5. Hennion DR, Siano KA. Diagnosis and treatment of peripheral arterial disease.American physician. 2013; 88(5): 306–10.
6. Pereira, R. The relationship between dyslipidemia and diabetes mellitus type 2. Cadernos UniFOA. Round turn. 2011; year VI, no. 17.
7. Men AL, Farah BQ, Ritti-Dias RM. Muscle function in subjects with peripheral arterial occlusive disease: a systematic review. motor skills 2012, 8(1): 86-96.
8. Standing Committee on Healthcare Protocols of the SES-DF – CPPAS. Organization of assistance to patients with peripheral obstructive arterial disease. Care protocols. 2017
9. Caldeira M, Mina F. Peripheral obstructive arterial disease in people with diabetes. Portuguese Journal of Diabetes. 2017; 12(3): 107-111
10. Oxford Center for Evidence-Based Medicine.CEBM. [Online].; 2009 [cited August 1, 2018. Available at:<https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/>.
11. Santos, TG Two, Santos FS, Poggetto MTD, Zuffi FB. Nursing care for peripheral arterial disease: experience report. Rev Enferm Healthcare [online]. August/December 2016; 5(2):103-109
12 Furtado LB, Queiroz AAFLN, Sousa AFL et al. Nursing care for a patient with peripheral arterial disease: case report. Rev. Pre. Infection and health. 2015(1):82-88
13. Mendez CB, Salum NC, Junkes C, Amante LN, Mendez CML.Educational mobile application for monitoring patients with peripheral arterial disease.Eerwaarde Latino-Am. Nursing. 2019;27:e3122.
14. Maggi DL, Quadros LRDP de, Azzolin KO. Ankle-brachial index: nurses' strategy to identify cardiovascular disease risk factors. Rev Esc Enferm USP 2014; 48(2):223-7
[PubMed] 15. Aragao JA, Santos RM, Neves OMG, Aragao ICS, et al. Quality of life in patients with peripheral arterial disease. J Vasc Bras. April-June 2018; 17(2):117-121
16. Assis CS, Batista LC, Wolosker N, Zerati AE, Silva RCG. Measure of functional independence in patients with intermittent claudication. Rev Esc Enferm USP 2015; 49(5):756-761
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18. Dutra LMA, Novaes MRCG, Melo MC, Veloso DLC, Faustino DL, Sousa LMS.Evaluation of the risk of ulceration in diabetics. Rev Bras Enferm [Internet].2018;71(supplement 2):733-9.
19. Martins, T., Salum, N.C., Lock, M.O.H., Amante, L.Z., Girondi, J.B.R. and Sebold, L.F. (2019). Knowledge of patients with peripheral arterial obstructive disease: a qualitative study. Journal of Psychology, Diversity and Health, 8(3), 267-281.
20. Ramos ACS, Hernández-Macedo ML, López JÁ. Physiopathological aspects of peripheral arterial disease of the lower extremities in diabetic patients. Tiradentes University/Biomedicine/Aracaju, SE ISSN: 1807-2518
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- Check for optimal fluid balance. Administer IV fluids as ordered. ...
- Maintain optimal cardiac output. ...
- Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue.
ineffective Tissue Perfusion (specify) may be related to hypovolemia and vascular pooling (vasodilation), and is possibly evidenced by diminished pulse, pallor or cyanosis, hypotension, and changes in mentation.What are the interventions for tissue perfusion? ›
The best treatment for a patient with inadequate tissue perfusion is to relax, rest, reduce stress, and increase fluid intake. Increasing fluid intake will provide more fluid in the blood cells to aid circulation. Rest, relaxing, and stress relief reduce the oxygen demand.What is ineffective tissue perfusion Nanda? ›
Ineffective tissue perfusion describes the lack of oxygenated blood flow to areas of the body. Proper perfusion is detrimental to the function of organs and body systems as organs and tissues that are not perfusing will die.What improves tissue perfusion? ›
Catecholamines are used to increase cardiac output and blood pressure, aiming ultimately at restoring/improving tissue perfusion.How do you demonstrate adequate tissue perfusion? ›
Evaluation of tissue perfusion can be done by considering gum or lip mucous membrane colour, the capillary refill time, and the blood pressure. High mean arterial pressure does not guarantee adequate tissue perfusion.What causes poor peripheral perfusion? ›
The main cause is atherosclerosis, which is the build-up of fatty deposits that narrow a blood vessel, usually an artery. The narrowed blood vessel reduces the circulation of blood to the associated body part. Peripheral vascular disease mainly affects blood vessels of the legs and kidneys and, less commonly, the arms.Which finding should the nurse interpret as indicating decreased tissue perfusion? ›
A low volume pulse could be indicative of inadequate tissue perfusion; this can be a crucial indicator of indirect prediction of the systolic blood pressure of the patient.What clinical signs are assessed to determine whether tissue perfusion is adequate? ›
Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.How do you manage poor perfusion? ›
- Increase cardiovascular exercise. ...
- If you smoke, quit. ...
- Drink black or green tea. ...
- If you are anemic, take iron supplements or eat iron-rich food. ...
- Dry brush your body. ...
- Decrease stress. ...
- Include more omega-3 fatty acids in your diet. ...
- Wear compression socks and elevate your legs.
- Pump – the heart. The average adult heart contracts between 60 and 100 times per minute. ...
- Pipes – the blood vessels. Normal blood pressure equals good perfusion (even though there are numerous debates as to what “normal” is). ...
- Plasma – the blood. ...
- About the Author.
Lactate is the most frequently used marker of tissue perfusion .What is peripheral tissue perfusion? ›
Peripheral perfusion index is defined as the difference between the pulsatile and non-pulsatile portion of pulse wave, measured by plethysmography. Peripheral perfusion index (PPI) gives information on peripheral vascular tonus by the pulsatility, decreasing in vasoconstriction and raising in vasodilation .What is the Nanda nursing diagnosis ineffective protection? ›
NANDA-I diagnosis: Ineffective Protection (00043)
Definition: Decrease in the ability to guard self from internal or external threats such as illness or injury.
- Tissue conditioning (cytokine therapy, thermal conditioning, hypoxia conditioning, extracorporeal shockwave therapy)
- Management of associated chronic medical conditions (diabetes, hypertension)
- Lifestyle modifications (exercise, smoking cessation)
- Cigarette smoking.
- Vascular disease.
- Other disease.
Oxygen plays a critical role in the formation of collagen, the growth of new capillaries, and the control of infection. Perfusion and delivery of O2 to tissue are closely related.What is evidence of adequate perfusion? ›
Adequate perfusion is defined as adequate circulation of blood through organs and tissues, manifested by normal pulse, tissue color, level of consciousness and blood pressure.What suggests poor perfusion? ›
A CRT longer than 2 seconds suggests poor perfusion due to peripheral vasoconstriction. Peripheral vasoconstriction is an appropriate response to low circulating blood volume and reduced oxygen delivery to vital tissues.How do you assess peripheral perfusion? ›
Recent findings: Clinical assessment of peripheral circulation includes physical examination by inspecting the skin for pallor or mottling, and measuring capillary refill time on finger or knee.
Peripheral perfusion index values depend on the blood flow in the peripheral circulation and the vascular tone; thus, it reflects two main determinants, which are the cardiac output and the balance between the sympathetic and the parasympathetic nervous systems.Which assessment finding indicates impaired tissue perfusion? ›
Capillary Refill: Impaired Tissue Perfusion Assessment
Assess capillary refill by pinching the finger or toe at the nailbed for 5 seconds and then observing the time it takes for the blood flow and color to return to the tissue. Normal capillary refill time in adults should be less than 3 seconds (4).
Dehydration also causes hypovolemia and hemoconcentration with inadequate tissue perfusion.What are the 6 perfusion parameters? ›
These “perfusion parameters” are: mentation, heart rate, pulse quality, mucous membrane color, capillary refill time, and extremity temperature (Table 1). Heart rate is often the first parameter to change.What are the markers of poor peripheral perfusion? ›
Discussion: Clinical signs of poor peripheral perfusion consist of a cold, pale, clammy, and mottled skin, associated with an increase in capillary refill time.What is a good peripheral perfusion index? ›
The normal perfusion index (PI) ranges from 0.02% to 20%. If the perfusion index is at or below 0.4% showing weak pulse strength, then the oximeter reading can be unreliable. Peripheral artery diseases, diabetes, obesity, blood clots, etc. are the reasons for poor perfusion.What does poor peripheral perfusion mean? ›
Inadequate perfusion to the extremities refers to decreased arterial blood flow to the extremities. This can be due to a sudden embolic event obstructing arterial flow, or a chronic obstructive process leading to decreased arterial flow to the extremities.What are the three 3 components of a NANDA nursing diagnosis? ›
A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis).What is an example of a NANDA risk diagnosis? ›
Risk-related diagnoses only contain a NANDA-I diagnosis and an as evidenced by statement because it is describing a vulnerability, not a cause. For example, a nurse may use a nursing diagnosis such as "risk for pressure ulcer as evidenced by lack of movement, poor nutrition, and hydration."What are the 3 major types classifications of NANDA-I nursing diagnoses? ›
NANDA-I recognizes four categories of nursing diagnoses: problem focused diagnosis, risk diagnosis, health promotion diagnosis, and syndrome.
Clean, dry, and moisturize skin, particularly bony prominences, twice daily or as indicated by incontinence or sweating. Avoid hot water. If a powder is desirable, use medical-grade cornstarch; avoid talc.What nursing interventions should the nurse perform? ›
Providing physical treatments, emotional support, and patient education are all examples of nursing interventions. Nurses typically perform these actions as part of a nursing care plan to monitor and improve their patient's comfort and health.What is the nursing intervention for soft tissue injury? ›
The initial treatment for soft tissue injuries is based on the principles of 'RICE' (rest, ice, compression and elevation) and 'Avoid HARM' (see below). These are most important in the 48–72 hours following the injury and can speed up recovery. Rest and avoid activities that cause significant pain.What are the top 5 nursing interventions that need to be considered with a patient with a heart failure? ›
- Relieving fluid overload symptoms.
- Relieving symptoms of anxiety and fatigue.
- Promoting physical activity.
- Increasing medication compliance.
- Decreasing adverse effects of treatment.
- Teaching patients about dietary restrictions.
- Teaching patient about self-monitoring of symptoms.
Nursing interventions that are required in postoperative care include prompt pain control, assessment of the surgical site and drainage tubes, monitoring the rate and patency of IV fluids and IV access, and assessing the patient's level of sensation, circulation, and safety.What are three 3 nursing interventions to protect skin integrity for an immobile? ›
As previously discussed skin integrity can be maintained and skin breakdown can be prevented with a number of different interventions such as turning and repositioning the client at least every two hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing.What are the 7 nursing interventions? ›
Based on the medical needs they cater to, nursing interventions are further classified into seven important categories: community, family, behavioral, physiological basic, physiological complex, safety, and health system.What are 3 nursing interventions the nurse would need to implement with a patient who has HTN? ›
- Monitor blood pressure frequently. ...
- Administer antihypertensive medications as prescribed.
- Have two large-bore IVs.
- Provide oxygen f the saturations are low (less than 94%)
- Limit fluid intake if the patient is in heart failure.
- Assess ECG to ensure the patient is not having a heart attack.
The five priorities focus on: recognising that someone is dying; communicating sensitively with them and their family; involving them in decisions; supporting them and their family; and creating an individual plan of care that includes adequate nutrition and hydration.What are the 4 things that should be avoided after sustaining a soft tissue injury and why? ›
Avoid hot baths, showers, saunas, heat packs, and heat rubs. Alcohol – Similar to heat, alcohol has an effect of dilating blood vessels, which in turn will increase the flow of blood to the area. Alcohol can also mask pain and the severity of the injury, which may put you at greater risk for re-injury 7.
- Rest. Take a break from the activity that caused the injury. ...
- Ice. Use cold packs for 20 minutes at a time, several times a day. ...
- Compression. To prevent additional swelling and blood loss, wear an elastic compression bandage.
The rest, ice, compression and elevation (RICE) method is the best way to treat acute soft tissue injuries, such as bruises and sprains. Advanced treatment options for more serious soft tissue damage may include injections, splinting and physical therapy.What are the 3 types of nursing interventions? ›
Classification of Nursing Interventions. There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 for an image of a nurse collaborating with the health care team when planning interventions.)What is one of the most essential interventions that a nurse performs? ›
The role of educating others is one of the most essential interventions that a nurse performs. She/he must both identify the information of learners need and consider their readiness to learn and their styles of learning.What are the five aims of interventions with patients? ›
According to the theory, the five goals of nursing intervention are to build trust, promote the patient's positive orientation, promote the patient's control, affirm and promote the patient's strengths, and set mutual, health-directed goals.