help on tissue perfusion

[cardschicarn]

Ok so I need some help on my nursing diagnosis of ineffective tissue perfusion. How do I determine if it is arterial or venous in nature? This directs my interventions.

The reason I am doing my diagnosis of ineffective tissue perfusion is because the client has edema, cyanosis, and swelling in the ankles.

I can't look at the clients chart or go and speak with the client anymore so that is out of the question.

I am leaning to it being arterial because the client has peripheral vascular disease (will narrow or obstruct the vessels), diabetes, and peripheral neuropathy.

What do you think? Need more info?

Thanks

[Daytonite, BSN, RN]

the nursing diagnosis ineffective peripheral tissue perfusion is defined as decrease in blood circulation to the periphery that may compromise health. this diagnosis was added in 2008. your 3 symptoms (edema, cyanosis, and swelling in the ankles) are evidence (defining characteristics) of this diagnosis (problem). it does not distinguish between arterial or venous disease process. the related factors for this diagnoses are:

• 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
  
• hypertension
  
• sedentary lifestyle
  
• smoking
  
• (page 141, nanda international nursing diagnoses: definitions and classifications 2009-2011)
  

what medical disease underlies this nursing problem? the difference between arterial and venous disease is in the presenting symptoms. you need to look up and read about the medical disease that is going on so you order the correct interventions for your patient's symptoms.