Nursing diagnosis: risk for ineffective tissue Perfusion
Risk factors may include
Reduction or interruption of blood flow—pelvic congestion, postoperative tissue inflammation, venous stasis
Intraoperative trauma or pressure on pelvic or calf vessels—lithotomy position during vaginal hysterectomy
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: (Specify)
Demonstrate adequate perfusion, as evidenced by stable vital signs, palpable pulses, good capillary refill, usual mentation, and individually adequate urinary output.
Be free of edema and signs of thrombus formation.
Nursing intervention with rationale:
1. Monitor vital signs, palpate peripheral pulses and note capillary refill, assess urinary output and characteristics, and evaluate changes in mentation.
Rationale: Indicators of adequacy of systemic perfusion, fluid or blood needs, and developing complications.
2. Inspect dressings and perineal pads, noting color, amount, and odor of drainage. Weigh pads and compare with dry weight if client is bleeding heavily.
Rationale: Proximity of large blood vessels to operative site and/or potential for alteration of clotting mechanism (e.g., cancer) increases risk of postoperative hemorrhage.
3. Turn client and encourage frequent coughing and deep-breathing exercises.
Rationale: Prevents stasis of secretions and respiratory complications.
4. Assist with and/or encourage use of incentive spirometer.
Rationale: Promotes lung expansion and minimizes atelectasis.
5. Avoid high Fowler’s position and pressure under the knees or crossing of legs.
Rationale: Creates vascular stasis by increasing pelvic congestion and pooling of blood in the extremities, potentiating risk of thrombus formation.
6. Assist with and instruct in foot and leg exercises and ambulate as soon as able.
Rationale: Movement enhances circulation and prevents stasis complications.
7. Note erythema, swelling of extremity, or reports of sudden chest pain with dyspnea.
Rationale: May be indicative of development of thrombophlebitis and pulmonary embolus.
8. Apply sequential compression devices (SCDs): antiembolism stockings or pneumatic compression stocking and boots.
Rationale: Aids in venous return; reduces stasis and risk of thrombosis.
9. Administer intravenous (IV) fluids and blood products, as indicated.
Rationale: Replacement of blood losses maintains circulating volume and tissue perfusion.