![]() ![]() Additionally, it may facilitate surgical intervention in ligate bleeders. By continuously monitoring the patient’s drainage output, the nurse can detect early signs of a blood coagulation defect. Additional fluid replacement may be required if blood loss continues. Evaluate the patient’s drainage device and dressings, then determine the features of his/her drainage. These are markers of the patient’s circulatory state and impairments in his/her tissue perfusion. Assess the strength and quality of his/her peripheral pulses. Impaired Perfusion Nursing Interventions Rationale Examine the vital signs of the patient. Nursing Diagnosis: Impaired Perfusion related to decreased blood flow in the arteries or veins secondary to amputation, as evidenced by hematoma, tissue edema, and hypovolemia. ![]() ![]() Impaired Perfusion Nursing Diagnosis Impaired Perfusion Nursing Care Plan 1 Obtain a full medical history to rule out any comorbidities that may contribute to impaired perfusion.Ensure that the patient receives adequate rest in the semi-fowler position.Apply direct pressure to treat minor bleeding.Examine possible contributing variables to the temporary impairment of arterial blood flow.Advise the patient to follow a low-fat, low-sodium diet.Administer IV lines before thrombolytic therapy.Monitor for any indications or symptoms of bleeding.Avoid prolonged dependent positions by constantly changing positions or wriggling fingers and toes Nursing Considerations for Patients with Impaired Perfusion.Avoid restrictive or tight stockings and garters.Wear light clothing such as cotton and wool socks.Vena cava filter Prevention of Impaired Perfusion.This may include the use of thrombolytics. By addressing the low cardiac workload, the patient can minimize the risk of impaired perfusion. For instance, impaired brain perfusion might be caused by hypovolemia, bleeding in the brain, or poor cardiac output. Impaired perfusion can be caused by a variety of different factors/conditions. Atherosclerosis (hardening of the arteries) is more likely by chemical damage to the blood vessels. There is a higher risk of pulmonary embolism (causing venous stasis). Prevention of prolonged immobilization.This is performed to determine if a blockage is serious enough to affect blood flow. Additionally, it gives specific information about the blood circulation in the brain. It also provides detailed information on the distribution of blood or blood flow to the brain. CT perfusion imaging identifies areas of the brain that are inadequately perfused with blood. In an emergency situation, palpitation of pulses close to the heart (e.g., carotid, distal to the location) is utilized to assess the presence of a pulse. Patients with limb trauma may experience impaired distal perfusion due to swelling and reduced blood circulation. To measure capillary refill in trauma and post-surgical patients, observe the time it takes for blood flow and color in tissue to return after pinching a finger or toe for around 5 seconds. Thrombus formation, poor cardiac output, edema, and hypovolemia are all markers of decreased perfusion experienced by trauma patients. Mechanical prosthetic valve Diagnosis of Impaired Perfusion.Family history of coronary artery disease or CAD.Risk lifestyle – may include alcohol abuse, drug abuse, sedentary lifestyle, and/or obesity. ![]() This causes the arteries and blood vessels to harden due to plaque formation. PAD is a cardiovascular disorder that causes blood vessels and arteries to become obstructed. If there is an abnormally high glucose level in the bloodstream, blood vessels may become injured or weakened.
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