Nursing diagnosis: risk for ineffective peripheral tissue Perfusion
Risk factors may include
Reduced arterial or venous blood flow; tissue edema, hematoma formation
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Maintain adequate tissue perfusion as evidenced by palpable peripheral pulses; warm, dry skin; and timely wound healing.
Nursing intervention with rationale:
1. Monitor vital signs. Palpate peripheral pulses, noting strength and equality.
Rationale: General indicators of circulatory status and adequacy of perfusion.
2. Perform periodic neurovascular assessments—sensation, movement, pulse, skin color, and temperature.
Rationale: Amputation wound healing is a concern because most are performed for compromised circulation; for example, with peripheral vascular disease (PVD) or damaged soft tissue resulting from trauma. Postoperative tissue edema, hematoma formation, or restrictive dressings may impair circulation to residual limb, resulting in tissue necrosis.
3. Note type of dressing used—soft, soft with pressure wrap, semirigid, or rigid.
Rationale: Postoperative dressing varies, each with its advantages and disadvantages. For example, a soft dressing does not control edema. Adding a pressure wrap distributes pressure, but requires measures to avoid possible limb strangulation. Semirigid dressings (e.g., plaster splint, Unna bandage) or rigid dressings allow for decreased edema and immediate postoperative prosthesis with early ambulation, but limit access to the wound, and possible excessive pressure may lead to compromised healing.
4. Inspect dressings and drainage device, noting amount and characteristics of drainage.
Rationale: Continued blood loss may indicate need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder.
5. Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician immediately.
Rationale: Direct pressure to bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled.
6. Investigate reports of persistent or unusual pain in operative site.
Rationale: Hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain.
7. Evaluate nonoperated lower limb for inflammation and positive Homans’ sign.
Rationale: Increased incidence of thrombus formation in clients with preexisting peripheral vascular disease or diabetic changes.
8. Encourage and assist with early ambulation.
Rationale: Enhances circulation and helps prevent stasis and associated complications. Promotes sense of general well-being.
9. Administer intravenous (IV) fluids and blood products as indicated.
Rationale: Maintains circulating volume to maximize tissue perfusion.
10. Apply antiembolic or sequential compression hose to nonoperated leg, as appropriate.
Rationale: Enhances venous return, reducing venous pooling and risk of thrombophlebitis.