Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Maintain skin integrity.
Demonstrate behaviors or techniques to prevent skin breakdown.
Nursing Care Plan Intervention with Rationale
1. Inspect skin, noting skeletal prominences, presence of edema, and areas of altered circulation and pigmentation.
Rationale: Skin is at risk because of impaired peripheral circulation, obesity or emaciation, edema, physical immobility, and alterations in nutritional status.
2. Provide gentle massage around reddened or blanched areas.
Rationale: Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of compromised area may cause tissue injury.
3. Encourage frequent position changes in bed and chair. Assist with active or passive range of motion (ROM) exercises.
Rationale: Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow.
4. Provide frequent skin care; minimize contact with moisture or excretions.
Rationale: Excessive dryness or moisture damages skin and hastens breakdown.
5. Check fit of shoes or slippers and change as needed.
Rationale: Dependent edema may cause shoes to fit poorly, thereby increasing risk of pressure and skin breakdown on feet.
6. Avoid intramuscular route for medication administration.
Rationale: Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown and development of infection.
7. Provide alternating pressure or egg-crate mattress and sheepskin elbow and heel protectors.
Rationale: Reduces pressure to skin and may improve circulation.
Other possible Nursing Diagnosis for Heart Failure: