Care Plan - PAD, Ineffective Tissue Perfusion?

Esme12, ASN, BSN, RN · Nov 14, 2013

That is the problem with using abbreviations that aren't "official" it cause errors and confusion.

nurseprnRN, BSN, RN · Nov 14, 2013

Lab values indicate mildly anemic
Pt warm extremities, cap refill less 3 sec
BLE pulses barely able to palpate, doppler used for auscultation at each site
patient ad lib with 1 person assist but in actuality was fully independent
pt report 0 pain
no plans to discharge until INR reached 2.0-2.5, currently at 1.05 4 days post-op
meds include: heparin IV 1100 units/hr, warfarin 7.25mg, amlodipine 10mg, clopidogrel 75mg
Here is what I have but it doesn't fee right.
Ineffective tissue perfusion r/t obstructed blood flow in peripheral arteries aeb pulses that are not palpable in lower extremities, patient history of intermittent claudication, decreased sensation perception in patients feet.
Anyone have any advice? If this dx works I'm not sure were to go for my outcomes and interventions.

There is no such nursing diagnosis as "Ineffective tissue perfusion." I know you might be misled by something similar in a textbook or "handbook," but your only authoritative source for nursing diagnosis (and your faculty should know this) is the NANDA-I 2012-2014, $29 at Amazon c free two-day delivery or $25 for your Kindle. (We'll get to the rest shortly: Here, a digression...)

As my friend Esme points out, you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. This is not entirely your fault; many, many faculty have a weak grasp on how to explain this better, as evidenced by the huge numbers of nursing students who come here with the same confusion.

You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan handbooks use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Now, returning to your nursing diagnosis.

There is, on page 240, "Ineffective peripheral tissue perfusion," so let's look at what it says.

You said: "Ineffective tissue perfusion r/t obstructed blood flow in peripheral arteries aeb pulses that are not palpable in lower extremities, patient history of intermittent claudication, decreased sensation perception in patients feet."

Diagnosis: Ineffective peripheral tissue perfusion

Definition: Decrease in blood circulation to the periphery that may compromise health.

Defining characteristics: Absent pulses, altered motor function, altered skin characteristics (color, elasticity, hair, moisture, nails, sensation, temperature), ankle – brachial index less than 0.90, blood pressure changes in extremities, capillary refill time greater than 3 seconds, claudication, color does not return to leg on lowering it, delayed peripheral wound healing, diminished pulses, edema, extremity pain, femoral bruit, shorter total distance is achieved in 6 minute walk test, shorter pain-free distances achieved in 6 minute walk test, paresthesia, skin color pale on elevation.

Related factors: Deficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility), deficient knowledge of disease process (e.g., diabetes, hyperlipidemia), diabetes mellitus, hypertension, sedentary lifestyle, smoking.

Okay, now, let's break this down.

We've already discovered that "ineffective tissue perfusion" is not an approved nursing diagnosis. However, "ineffective peripheral tissue perfusion" is.

"Related to" means "caused by." Looking at the list of related factors above, you have a number of choices, but none of them are "obstructed blood flow in peripheral arteries." Which of the approved related factors apply to your patient? It appears that diabetes mellitus and hypertension are both mentioned.

"AEB" means, "These are the things that I observed or identified in the chart that supports my assessment of decreased or ineffective peripheral tissue perfusion." To make this nursing diagnosis, you must identify at least one of the defining characteristics given in the NANDA-I list. You have identified diminished pulses, claudication, and paresthesia; I would be willing to bet that if you looked at that list of defining characteristics, you will find a number of others present in your patient.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on page 475, you will find "tissue perfusion, peripheral, ineffective." This is followed by the lay definition of what circulation status is, major interventions for arterial insufficiency and venous insufficiency, and a long list of suggested and optional interventions from which to choose. It is important to realize that you can just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon.

It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

nik2017, ASN, CNA · Feb 29, 2016

You should teach an online class for POC and nursing Dx. I learned from reading this article than I did in 3 weeks of what was suppose to be learning how to do a POC. Thank you Thank you Thank You!!!

Valcorie34, BSN, MSN, RN · Mar 5, 2016

It sounds like you are missing some key pieces for this diagnosis. Ineffective PERIPHERAL tissue perfusion can reflect perfusion going to the site (feet) or from the site. It can be venous or atrial. If this is what you found on a head to toe assessment, then did you do a focused assessment on the lower extremities? Look at capillary refill on the toes It is at less than 3 seconds or greater? Are the legs swollen, look for edema with this dx. Describe it 0, +1, +3. is it on feet, or up to knees. IS the skin warm or cool to the touch? If the skin in cool to the touch according to the NANDA defining characteristics then it may be venous. if it is pink and way it may be arterial. These scenarios both have suggested interventions listed.

Here is an example from a recent clinical I completed...

Heart has irregular rate and rhythm. Extra heart sounds auscultated at tricuspid, pulmonary and aortic areas.

Radial pulse L +2, R +3. brachial pulse L+2, R+3. No visible edema in upper extremities. Capillary refill in RUE 3, LUE 2. Distended neck veins.

Popliteal Pulse L =0, R +1, Posterior Tibial pulse L =0, R +1. Pedal Pulse L =0, R+1. LLE no pulses able to be palpitated, floor nurse confirmed. Lack of palpable pulse due to +4 edema 7 cm above knee. Leg was warm, pink, and capillary refill of 5 seconds. RLE capillary refill of 2 seconds. Left leg elevated while in bed. Compression ace wrap applied to BLE. No change to capillary refill in 1 hour.

Right leg edema +2, left leg +4 extends 7cm above knee.

I used a dx of deceased cardiac output, and a dx of inadequate peripheral tissue perfusion. ( there were other defining characteristics in assessment)

I don't know if it helps, but its All I could think of. Just try reading the defining characteristics in your NANDA book and assessing further.