interventions for infectious tissue perfusion...

[skygirl]

Can someone help me with interventions for this nursing diagnosis - "disturbed sensory perception related to infectious tissue perfusion As evidenced by necrotic right toe." My teacher wants me to use that dx and find two interventions for it but Im not seeing it in my nursing diagnosis handbook. Thanks!

[Hotdharma2011]

when I'm deciding on interventions, I like to first figure out what my goal is, and the goal is usually the opposite of the diagnosis. with that said, if my patient had impaired tissue perfusion, I would want to increase tissue perfusion. ways to do that, or interventions as we call them would be like....keep affected limb elevated, above heart to increase blood flow; ensure compliance with meds to decrease infection, and thus increase perfusion, and you always want to have some type of 'monitoring' as an intervention so, you could 'monitor perfusion by checking cap-refill and pedal pulse, every 2 hours, and also I'm assuming the patient has DM so you could 'monitor blood glucose'.....or something like that. I hope that helps! good luck!

[criticalHP, MSN, RN]

when I'm deciding on interventions, I like to first figure out what my goal is, and the goal is usually the opposite of the diagnosis. with that said, if my patient had impaired tissue perfusion, I would want to increase tissue perfusion. ways to do that, or interventions as we call them would be like....keep affected limb elevated, above heart to increase blood flow; ensure compliance with meds to decrease infection, and thus increase perfusion, and you always want to have some type of 'monitoring' as an intervention so, you could 'monitor perfusion by checking cap-refill and pedal pulse, every 2 hours, and also I'm assuming the patient has DM so you could 'monitor blood glucose'.....or something like that. I hope that helps! good luck!

I agree with you in that interventions should reflect the end goal in mind, which is usually the opposite of the dx. But some of your interventions to improve perfusion need to be modified to better achieve the goal. Legs should not be elevated but in a dependent position. Blood flow is not improved with elevation above the heart-it is hindered becuase it takes more blood pressure to overcome the gravity force from elevation. Blood pressure needs to be adequate-and sometines permissive hypertension is desired to achieve adequate perfusion. Necrosis r/t to diminished blood flow secondary to an infectious process: this is sepsis related, so look at your sepsis interventions for assistance and tailor the interventions that meet the 'perfusion' goal. For instance the administration of blood thinners (enoxaparin/lovenox, heparin) and therapeutic monitoring thereof. antibiotic administration, as the OP suggested-although this will not directly improve perfusion. ABX's are given to interupt the sepsis progression, but if sepsis is severe and pt is shocky microvascular emboli have already developed (you will see anuria, shock, mental status change, multiple organ failure)

Other intervetions: Rooke boots (warm fuzzy boots used for pts with peripheral vascualr disease and occlusions) are a great way to keep uinder perfused legs and feet warm. Other interventions: check neurovascular status (sensory, motion, and circulation)-use a dopplar ultrasound always as you can not rely on palpation in pts with restricted blood flow.

Hope this helps--good luck.