Care plan help for: Alteration in tissue perfusion: peripheral

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my patient is an 88yo female, type 11 diabetes, anemic, paraplegic, stage IV pressure ulcer on R ischium (present for 5 years) and severly demented. I already have one care plan done for a diagnosis related to impaired skin integrity. My second Diagnosis is: Altered(or Ineffective) tissue perfusion:peripheral r/t interuption of arterial flow and decreased hemoglobin concentration in the blood aeb weak pedal pulses, slow healing of stage IV debubitis ulcer on right ischium. Is this correct?

Also I'm am stuck with client goals. Because she is severly demented, I will not be able to use any goals related to "client will verbalize, identify, describe, etc." The only goal I can come up with is Client will demonstrate adequate tissue perfusion aeb palpable peripheral pulses, warm and dry skin and cap refil

Also, I am having a very difficult time finding nursing interventions. We are required to have ~7 interv. per client centered goal. I've have searched a million journal articles, and the only things I can find are based on assessments (pulses, skin color/temp, cap refill, skin texture, and edema)

The client does not have any medication orders related to this issue. Would glycemic control and insulin therapy have anything to do with peripheral tissue perfusion?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

let me understand. . .you are asking for help with organizing and writing goals and nursing interventions for this patient related to the nursing diagnosis of ineffective tissue perfusion, peripheral. is that right?

i am looking at the defining characteristics that you have listed to support this diagnosis (weak pedal pulses, slow healing of stage iv decubitus ulcer on right ischium). the weak pedal pulses definitely fit the definition of this diagnosis ("decrease in oxygen resulting in the failure to nourish the tissues at the capillary level"). however, i disagree with the way you have worded the second item "slow healing" as being a good descriptor. yes, delayed healing is a defining characteristic of this nursing diagnosis, but i think you can be more specific in a description of this particular problem. how long has it taken to heal? also, how has the skin in and around this pressure ulcer changed after 5 years? is there any edema present in the tissues around the ulcer? what about the coloring and description of the wound? is this wound truly due to poor circulation? or is it a problem of the patient not being cooperative with positioning and other interventions since she is severely demented. the reason i'm bringing this up is because your nursing interventions must directly relate back and treat these symptoms, so it is important that you choose and write your symptoms so that you are going to have something to compare and contrast with any advancement that is made in potential wound healing.

some suggestions for goals related to this diagnosis are:

  • maintain, or increase, cognitive status, skin temperature, skin color urinary output.
  • decrease peripheral edema.
  • maintain or increase skin temperature, skin sensation, elasticity, hydration, skin intactness.
  • decrease or improvement in skin flaking, skin scaling, erythema, and/or blanching.
  • maintain or increase capillary refill fingers/toes, skin color, skin integrity, skin temperature of extremities, femoral pulse rate, pedal pulse rate, blood pressure.
  • decrease or improvement in localized pain, peripheral edema and/or necrosis of tissue.

some goals related to the actual wound revolve around the extent of regeneration of cells and tissues:

  • expect to see the appearance of scar formation.
  • decrease or improvement in (purulent, serous, sanguineous, serosanguineous) drainage, skin erythema, surrounding skin bruising, periwound edema, skin temperature elevation, foul wound odor, wound inflammation, macerated skin, necrosis, sloughing, tunneling, undermining, and/or sinus tract formation

these are all taken from nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson, and meridean maas, specifically from listings under the following outcome headings: circulation status, tissue integrity: skin & mucous membranes, tissue perfusion: peripheral, wound healing: primary intention and secondary intention. you will need to write the appropriate language for your care plan for any of the above you might decide to use as goals or outcomes. i listed them primarily to give you some ideas of where you can go with goals, and subsequently, interventions with this particular diagnosis.

nursing interventions can take four forms:

  1. evaluation of the patient condition along a continuum
  2. the performance of actual hands-on nursing care
  3. education of the patient or caregivers
  4. management of the care on behalf of the patient

if one of your goals is to get some healing going in this wound, then your nursing interventions must be directed toward that goal. while the patient may not be able to understand and comply with a teaching plan, her primary caregivers should be able to. so, don't be scared off a teaching plan just because the patient is confused. diabetic and colostomy teaching nurses do this all the time. they give instructions on the care of wounds and colostomies to the people who are going to be primarily responsible for carrying out the care. this is how specialized dressing changes or customized plans get put together and put into action. so, don't be discouraged from developing a plan of wound care thinking that it is going to fall on deaf ears. assuming that this patient is going back, to let's say a snf, any wound care plan can be communicated to the nurses of the snf upon her discharge. this falls within the care management function of the rn.

so, after all that, what i am saying is that you are on the right tract with your nursing diagnosis. here are some resources you might find helpful:

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php

http://www.nursing.uiowa.edu/sites/chronicwound/ - chronic wound healing. a tutorial that includes definitions, descriptions of wounds, assessment, debridement, cleansing, maintaining a moist environment, supporting the wound surfaces and nutrition. has photographs to help show and explain concepts. by professor rita frantz at the university of iowa college of nursing.

http://www.worldwidewounds.com/ - world wide wounds. an online resource for dressing materials and practical wound management information. has links at the bottom of the opening page to acute wounds, dressings and bandages, maggot therapy, miscellaneous, veterinary, diabetic feet, infected wounds, leg ulcers and pressure ulcers.

http://www.thinairproductions.ca/tcoywpreview.htm - "taking care of your wound" video

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Thank you so much, that is a big help. You questioned whether or not the wound was related to tissue perfusion or dementia and noncompliance. I believe the cause of the wound as well as its delayed healing is related to the altered tissue perfusion in addition to her inability to change positions(demented and paraplegic), and the loation (being that she is bedridden and in an area vulnerable to contamination with urine and fecal matter).

A question/concern with goals and interventions directed at the pressure ulcer is that they direct more towards the diagnosis of impaired skin integrity. Is it still ok to include this goal and interventions for wound care if my diagnosis is altered tissue perfusion?

Also, I forgot to mention that my client is a resident in a nursing home, and she doesn't have family that come to visit. I see what you mean about the teaching interventions though in relation to the primary care giver.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I pulled the ideas for the goals from the reference I cited above. I guess that wound healing and tissue integrity are things that must be included in the diagnosis of Ineffective Tissue Perfusion or they would not have listed them under this particular diagnosis--and they are the experts. I was particularly looking at the goals pertaining to ineffective peripheral tissue perfusion. So, I would say the answer to your question about it being OK to include these goals and interventions for wound care is "yes". As a double check, look at the definition of the nursing diagnosis and see that any symptoms you have are indeed related to a failure of nourishishment of the tissues at the capillary level. As long as your symptoms, goals and interventions all form a nice etiology-cause-treatment relationship to each other that fit with the definition of the diagnosis you will be OK.

Your teaching interventions can be designed to be performed by the care givers (nurses) in the nursing home as well as anyone else taking care of this patient. There is nothing wrong with developing a wound care plan for them. We're talking about continuity of care here. The fact that the patient has no known family is not important (well, it's important, but not for the purpose of what I am discussing, if you get my meaning). Somebody is going to be intimately involved in giving care to this wound and it is likely to be the nurses in the nursing home once she is transferred. As an RN we have a supervisory role as well as a role as a primary care giver. That means that we also have an obligation to put a care plan with nursing interventions and strategies in place for other nurses to follow. Will all nurses follow it? Maybe not, but we have to conclude that they will.

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Specializes in retail NP.

here, i found this for you. hope it helps!

let me understand. . .you are asking for help with organizing and writing goals and nursing interventions for this patient related to the nursing diagnosis of ineffective tissue perfusion, peripheral. is that right?

i am looking at the defining characteristics that you have listed to support this diagnosis (weak pedal pulses, slow healing of stage iv decubitus ulcer on right ischium). the weak pedal pulses definitely fit the definition of this diagnosis ("decrease in oxygen resulting in the failure to nourish the tissues at the capillary level"). however, i disagree with the way you have worded the second item "slow healing" as being a good descriptor. yes, delayed healing is a defining characteristic of this nursing diagnosis, but i think you can be more specific in a description of this particular problem. how long has it taken to heal? also, how has the skin in and around this pressure ulcer changed after 5 years? is there any edema present in the tissues around the ulcer? what about the coloring and description of the wound? is this wound truly due to poor circulation? or is it a problem of the patient not being cooperative with positioning and other interventions since she is severely demented. the reason i'm bringing this up is because your nursing interventions must directly relate back and treat these symptoms, so it is important that you choose and write your symptoms so that you are going to have something to compare and contrast with any advancement that is made in potential wound healing.

some suggestions for goals related to this diagnosis are:

  • maintain, or increase, cognitive status, skin temperature, skin color urinary output.
  • decrease peripheral edema.
  • maintain or increase skin temperature, skin sensation, elasticity, hydration, skin intactness.
  • decrease or improvement in skin flaking, skin scaling, erythema, and/or blanching.
  • maintain or increase capillary refill fingers/toes, skin color, skin integrity, skin temperature of extremities, femoral pulse rate, pedal pulse rate, blood pressure.
  • decrease or improvement in localized pain, peripheral edema and/or necrosis of tissue.

some goals related to the actual wound revolve around the extent of regeneration of cells and tissues:

  • expect to see the appearance of scar formation.
  • decrease or improvement in (purulent, serous, sanguineous, serosanguineous) drainage, skin erythema, surrounding skin bruising, periwound edema, skin temperature elevation, foul wound odor, wound inflammation, macerated skin, necrosis, sloughing, tunneling, undermining, and/or sinus tract formation

these are all taken from nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson, and meridean maas, specifically from listings under the following outcome headings: circulation status, tissue integrity: skin & mucous membranes, tissue perfusion: peripheral, wound healing: primary intention and secondary intention. you will need to write the appropriate language for your care plan for any of the above you might decide to use as goals or outcomes. i listed them primarily to give you some ideas of where you can go with goals, and subsequently, interventions with this particular diagnosis.

nursing interventions can take four forms:

  1. evaluation of the patient condition along a continuum
  2. the performance of actual hands-on nursing care
  3. education of the patient or caregivers
  4. management of the care on behalf of the patient

if one of your goals is to get some healing going in this wound, then your nursing interventions must be directed toward that goal. while the patient may not be able to understand and comply with a teaching plan, her primary caregivers should be able to. so, don't be scared off a teaching plan just because the patient is confused. diabetic and colostomy teaching nurses do this all the time. they give instructions on the care of wounds and colostomies to the people who are going to be primarily responsible for carrying out the care. this is how specialized dressing changes or customized plans get put together and put into action. so, don't be discouraged from developing a plan of wound care thinking that it is going to fall on deaf ears. assuming that this patient is going back, to let's say a snf, any wound care plan can be communicated to the nurses of the snf upon her discharge. this falls within the care management function of the rn.

so, after all that, what i am saying is that you are on the right tract with your nursing diagnosis. here are some resources you might find helpful:

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php

http://www.nursing.uiowa.edu/sites/chronicwound/ - chronic wound healing. a tutorial that includes definitions, descriptions of wounds, assessment, debridement, cleansing, maintaining a moist environment, supporting the wound surfaces and nutrition. has photographs to help show and explain concepts. by professor rita frantz at the university of iowa college of nursing.

http://www.worldwidewounds.com/ - world wide wounds. an online resource for dressing materials and practical wound management information. has links at the bottom of the opening page to acute wounds, dressings and bandages, maggot therapy, miscellaneous, veterinary, diabetic feet, infected wounds, leg ulcers and pressure ulcers.

http://www.thinairproductions.ca/tcoywpreview.htm - "taking care of your wound" video

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Can't you use somewhere in your plan re: ulcer interventions re: nutrition (important for healing), and implementing a q2 hr turning schedule? Just a few thoughts.

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