Tissue perfusion is often confused with blood flow, but is actually a measure of the volume of blood that flows

through the capillaries in a tissue. Tissue perfusion is generally measured in milliliters of blood per 100 grams of tissue. This measurement is carried out to understand the health of a particular tissue, since impaired or reduced tissue perfusion can indicate a medical condition which requires care. Ineffective tissue perfusion can be mainly renal, cerebral, gastrointestinal or cardiac in nature. In layman's terms, ineffective tissue perfusion means that the blood flow in the affected region is insufficient. When blood flow to a particular region decreases, it causes reduced nutritional supply to the cells in this region, which can be problematic if continued over a prolonged period. Altered tissue perfusion can also cause a reduction in oxygen supply to the affected region. Ineffective tissue perfusion sometimes takes place for a short period of time, without serious consequences, but can result in death or damage of a tissue if left untreated or undetected. When there are fluctuations in blood circulation or flow, causing altered tissue perfusion, there are different symptoms that will manifest in various ways, depending on the region affected. Some of the possible symptoms that may be seen are as follows: Ineffective Tissue Perfusion: Symptoms Peripheral:

Water retention (edema) Weak peripheral pulse Numbness in extremities Damp, cold skin Changes in temperature

Cerebral:

Renal:

Mood swings and irritability Confusion Lethargy Altered speech pattern Slow or reduced pupil reaction to light

Low urine output Fluctuations in blood pressure High levels of blood urea nitrogen/creatinine ratio

Gastrointestinal:

Nausea Abdominal pain Distended abdomen

Reduction in bowel sounds

Cardiac: Chest pain Abnormal arterial blood gases Hypotension Change in rate of respiration

Ineffective Tissue Perfusion: Treatment Impaired tissue infusion over a prolonged period can lead to serious complications like organ failure. Depending on the affected region, the care plan for the patient will change. The care plan for each category is listed below: Peripheral: Keep the patient still. Any movement may cause further trauma. Demonstrate, and aid in practicing passive range of motion exercises after frequent intervals. Monitor pulses regularly. Do not elevate limbs. Keep hands and feet warm.

Cerebral: In case intercranial pressure increases, raising the head of the bed to a 30 or 45 degree angle can help reduce pressure. Avoid any strenuous action that may cause further increase in intercranial pressure. Treatments may include the administration of anticonvulsants to counter the possibility of seizures.

Cardiac: Administer oxygen if needed. Administer nitroglycerin for complaints of angina.

The aim behind the treatment for ineffective tissue perfusion is for the patient to regain optimum tissue perfusion as a result of the care plan. Since any alterations in tissue perfusion results in reduced oxygen or nutrition to the affected area, it's important to advise patients at risk about ways to prevent or reduce recurrence. Some of these ways discussed below can be incorporated into a home care plan that can be implemented through simple lifestyle changes: Regular low intensity exercise, such as walking Avoiding extreme fatigue Avoiding long periods of non movement, especially during long distance travel Sufficient hydration Cessation of smoking

With changes in lifestyle and medical care, ineffective tissue perfusion can be tackled before it reaches a critical stage. Always consult a medical practitioner for a correct diagnosis, and proper medical treatment.

Nursing Diagnosis Long Term Goal: Imbalanced Nutrition: Less than body requirements r/t special diet Patient will ingest enough modifications, NPO status, increased caloric needs calories to meet metabolic

demands Short Term Goals / Outcomes: Patient will maintain weight Patient will demonstrate normal lab values (albumin, prealbumin, etc) Patient will demonstrate timely wound healing Intervention Rationale Evaluation

Obtain admission During aggressive nutritional support patients Admission weight 100kg weight and weigh daily. weight should remain stable or gain to Current weight 101kg pound daily Obtain a nutritional history and prior etiological factors for reduced nutrition. To ensure proper nutrition it is essential that the nurse obtain a history. The history should include weight loss, food allergies, use of nutritional supplements, swallowing difficulties, nausea or vomiting, constipation or diarrhea, alcohol consumption and any special diet the patient was following. Patients history negative for nutritional deficiency. Follows regular diet.

Monitor lab values that indicate nutritional status: Albumin indicates the degree of protein depletion. 2.5 g/dl indicates severe depletion. albumin / Prealbumin is a more immediate indicator of prealbumin protein adequacy. Transferrin is important for iron transfer and typically depletes as serum protein decreases. RBC and WBC are usually decreased in malnutrition, indicating anemia and decreased resistance to infection. Potassium is typically increased and sodium is typically decreased in malnutrition.
Electrolytes

Albumin 3.0 g/dl. All other labs within normal range.

Transferrin

RBC and WBC counts

Consult with As the stress of a critical illness mounts, the nutritionist to calculate patient requires increased calories and as patients caloric, much as 1.5 to 2 g/kg/day of protein.

Patient requires 25 kcal/Kg/day and 1 gram

protein and fluid requirements.

Normally a patient will require about 1ml of fluid per calorie.

protein.

Consult with Indirect calorimetry uses a metabolic care to nutritionist to calculate calculate basal energy expenditure. This will energy demand by guide how best to feed the patient. using indirect calorimetry. If enteral feedings are being used:
start at slow rate and increase as tolerated check residual every two to four hours

Calculated by nutritionist.

Continuous feeds and starting slow cause less gastro-intestinal upset

Enteral feedings being used. Placement checked with aspirate of 4.5.

To prevent aspiration, residuals should be checked and feedings stopped if the residual is 10ml residual obtained. No twice the amount of the hourly rate. signs of aspiration noted. A motility agent to aid with high residuals No diarrhea present.

administer metoclopramide as ordered check placement of the feeding tube

Visualization by x-ray should occur with insertion. The best method to check placement is by obtaining aspirate from the tube with a pH less than five To prevent aspiration of tube feeding contents and ventilator assisted pneumonia

keep head of bed elevated between 30 and 45 degrees

To prevent bacterial colonization of the stomach

change feeding system set-up every 24 hours monitor for and prevent diarrhea

Diarrhea is common with enteral feedings. If patient is receiving bolus feeds switching to continuous may decrease the occurrences. If patient is lactose intolerant, switch to a feed that does not contain lactose. Adequately diluting liquid medication with water may also help.

If parenteral nutrition is being used:

full barrier precautions are used during insertion of the catheter use a dedicated line for the infusion

To prevent catheter related sepsis

The line should be a virgin port and nothing else administered through it to decrease the risk of precipitation forming in the catheter. To prevent catheter related sepsis

Parenteral nutrition infusion via left subclavian catheter. No signs of infection noted. Blood glucose within normal limits.

change the solution bag and tubing every 24 hours

Due to the high concentration of glucose and lipids overfeeding can occur. Lipids should not be administered if the patient is receiving another lipid based medication Due to the high glucose contents rapid shifts in glucose can occur with rate adjustments.

monitor for overfeeding

monitor blood glucose frequently

Nursing diagnosis: deficient Fluid Volume related to Fluid shifts from extracellular, intravascular, and interstitial compartments into intestines and/or peritoneal space, Vomiting; medically restricted intake; nasogastric (NG) or intestinal aspiration, Fever, hypermetabolic state Possibly evidenced by Dry mucous membranes, poor skin turgor, delayed capillary refill, weak peripheral pulses Diminished urinary output; dark, concentrated urine Hypotension; tachycardia Desired Outcomes/Evaluation CriteriaClient Will Fluid Balance Demonstrate improved fluid balance as evidenced by adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and weight within acceptable range. Nursing intervention with rationale: 1. Monitor vital signs, noting presence of hypotension (including postural changes), tachycardia, tachypnea, and fever. Measure central venous pressure (CVP) if available. Rationale: Aids in evaluating degree of fluid deficit, effectiveness of fluid replacement therapy, and response to medications. 2. Maintain accurate intake and output (I&O) and correlate with daily weights. Include measured and

estimated losses, such as with gastric suction, drains, dressings, Hemovacs, diaphoresis, and abdominal girth for third spacing of fluid. Rationale: Reflects overall hydration status. Urine output may be diminished because of hypovolemia and decreased renal perfusion, but weight may still increase, reflecting tissue edema or ascites accumulation (third spacing). Gastric suction losses may be large, and a great deal of fluid can be sequestered in the bowel and peritoneal space (ascites). 3. Measure urine specific gravity. Rationale: Reflects hydration status and changes in renal function, which may warn of developing acute renal failure in response to hypovolemia and effect of toxins. Note: Many antibiotics also have nephrotoxic effects that may further affect kidney function and urine output. 4. Observe skin and mucous membrane dryness and turgor. Note peripheral and sacral edema. Rationale: Hypovolemia, fluid shifts, and nutritional deficits contribute to poor skin turgor and taut edematous tissues. 5. Eliminate noxious sights or smells from environment. Limit intake of ice chips. Rationale: Reduces gastric stimulation and vomiting response. Note: Excessive use of ice chips during gastric aspiration can increase gastric washout of electrolytes. 6. Change position frequently, provide frequent skin care, and maintain dry, wrinkle-free bedding. Rationale: Edematous tissue with compromised circulation is prone to breakdown. 7. Monitor laboratory studies: Hgb/Hct, electrolytes, protein, albumin, BUN, and creatinine (Cr). Rationale: Provides information about hydration and organ function. Significant consequences to systemic function are possible mas a result of fluid shifts, hypovolemia, hypoxemia, circulating toxins, and necrotic tissue products. 8. Administer plasma, blood, fluids, electrolytes, and diuretics, as indicated. Rationale: Replenishes and maintains circulating volume and electrolyte balance. Colloids, such as plasma or blood, help move water back into intravascular compartment by increasing osmotic pressure gradient. Diuretics may be used to assist in excretion of toxins and to enhance renal function. 9. Maintain NPO status with NG or intestinal aspiration. Rationale: Reduces vomiting caused by hyperactivity of bowel; manages stomach and intestinal fluids.

Nursing Care Plans For Activity Intolerance Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities Limitation Characteristics Activity Intolerance: Response not from normal blood pressure on the activity Response does not dati normal heart rate for activities EKG shows changes aritmia EKG showed ischemia changes inconvenience during activities Dyspnea at beraktifitas Reporting of fatigue

 Reporting of weaknes Related factors Nursing Diagnosis Activity Intolerance: Bedrest complete exhaustion imbalance between oxygen supply and demand immobility Lifestyle Defining Characteristics Activity Intolerance Subjective: Verbal report of fatigue/weakness Exertional discomfort/dyspnea Objective: Abnormal heart rate/blood pressure response to activity Electrocardiographic changes reflecting arrhythmias/or ischemia Sample Clinical Applications Nursing Diagnosis Activity Intolerance Anemias, Angina, Tuberculosis, Uterine Bleeding Aortic Stenosis, Bronchitis, Emphysema, Diabetes Mellitus, Peripheral Vascular Disease, Rheumatic Fever, Dysmenorrhea, Heart Failure, Human Immunodeficiency Virus/Acquired Immunodeficiency Disease (HIV/AIDS), Labor/Preterm Labor, Leukemias, Mitral Stenosis, Obesity, Pain, Pericarditis, Thrombocytopenia. Nursing Outcomes Nursing Diagnosis Activity Intolerance Patien will Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible. Patien will Use identified techniques to enhance activity tolerance. Patien will Participate in necessary/desired activities. Patien will Report measurable increase in activity tolerance. Patien will Demonstrate a decrease in physiological signs of intolerance

Nursing Assist client To

Priority Nursing Identify to deal with promote

Care contributing wellness

Plans For Activity causative/precipitating factors and manage activities within (patient teaching/discharge

Intolerance factors individual limits considerations)