Which characteristics of the pedal pulses would the nurse assess for a client with a fractured hip?

Ineffective tissue perfusion describes the lack of oxygenated blood flow to areas of the body. Proper perfusion is detrimental to the function of organs and body systems as organs and tissues that are not perfusing will die.  

Understanding the causes of inadequate perfusion, assessment, monitoring, and interventions is imperative for nurses. Ineffective tissue perfusion can be a life-threatening emergency requiring critical thinking and strict monitoring. While some cases of ineffective perfusion are sudden and traumatic (heart attack, gunshot wound), nurses have the opportunity to instruct patients with chronic diseases and modifiable risk factors on how to improve circulation.

Causes of Ineffective Tissue Perfusion (Related to)

• Hypervolemia & hypovolemia (excess fluid & dehydration/blood loss) 
• Low hemoglobin 
• Insufficient blood flow 
• Hypoventilation

Signs and Symptoms (As evidenced by)

Cardiopulmonary 

Subjective: (patient reports) 

• Chest Pain
• Dyspnea 
• Sense of impending doom 

Objective: (nurse assesses) 

• Arrhythmias
• Capillary refill >3 seconds 
• Altered respiratory rate 
• Use of accessory muscles to breathe 
• Abnormal arterial blood gases

Gastrointestinal 

Subjective: (patient reports) 

Objective: (nurse assesses) 

Renal

• High or low blood pressure
• Decreased urine output 
• Elevated BUN/creatinine

Cerebral

• Altered mental status 
• Restlessness 
• Changes in speech 
• Difficulty swallowing 
• Motor weakness
• Changes in pupillary reaction

Peripheral

Subjective: (patient reports) 

• Altered skin sensations 
• Claudication 

Objective: (nurse assesses) 

• Weak or absent peripheral pulses
• Cool skin temperature
• Thickened nails
• Skin discoloration; pallor when legs are raised and rubor when dependent
• Loss of hair to legs
• Edema
• Delayed wound healing

Expected Outcomes

• Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema 
• Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, and no complaints of shortness of breath
• Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion 
• Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time

General Nursing Assessment for Ineffective Tissue Perfusion

1. Take a complete health history. 
Assess for acute and chronic conditions that affect perfusion: history of blood clots, myocardial infarction, congestive heart failure, diabetes, vascular diseases, organ failure. Consider that certain conditions can affect the perfusion of multiple body systems.

2. Be aware of signs of infection. 
If not quickly identified and treated, sepsis can cause poor perfusion and organ failure evidenced by decreased urine output, abrupt mental status change, and mottled skin.

3. Review lab work and test results. 
Arterial blood gases, complete blood counts, electrolytes, and CT scans or ultrasounds should be reviewed for signs of new or worsening perfusion issues. This information can also be referred to for comparison.

Nursing Assessment for Ineffective Cardiopulmonary Perfusion

1. Assess for sudden changes.
Note the presence of sudden chest pain, diaphoresis, respiratory distress, and hemoptysis which could signal a pulmonary embolus. 

2. Assess vital signs and EKG.
Closely monitor blood pressure, heart rate, respirations, and changes in cardiac rhythms. Use this data to compare to baseline information to identify changes in condition. 

3. Monitor hemoglobin levels.
Hemoglobin is a red blood cell component that carries oxygen through the body. If hemoglobin is decreased, less oxygen will be perfused through the body and tissues. 

4. Assess capillary refill.
Capillary refill assesses circulation and peripheral perfusion. If capillary refill time is sluggish, the client may be hypovolemic and lack blood volume to support the circulatory system with adequate oxygenation.

Nursing Interventions for Ineffective Cardiopulmonary Perfusion

1. Administer medications to improve blood flow.
Vasodilators open blood vessels to improve blood flow such as nitroglycerin for chest pain, or hydralazine for high blood pressure. 

2. Provide oxygen as required.
To support oxygenation and perfusion oxygen may be needed to ensure gas exchange. 

3. Surgical Intervention.
Conditions that impede blood flow such as blockages may require coronary angioplasty or bypass surgeries. The nurse is vital in educating the patient and family on procedures and monitoring for complications post-op. 

4. Teach signs of a heart attack.
Symptoms of a heart attack are different for men and women. Men may have direct chest pain while women usually have indirect symptoms such as nausea and jaw, back, or arm pain.

Nursing Assessment for Ineffective Gastrointestinal Perfusion

1. Assess bowel sounds.
Inadequate blood flow can slow peristalsis and digestion of the intestines. Bowel sounds are likely to be hypoactive or absent.  

2. Take note of the location of abdominal pain and characteristics.
Sudden abdominal pain can signal the rupture of an aortic aneurysm. Other conditions such as gallstones, pancreatitis, appendicitis, and bowel obstructions cause severe pain in differing abdominal quadrants. 

3. Monitor changes in stool.
Constipation can result from delayed digestion. Blood in the stool can signal ischemic colitis which results from reduced blood flow to the large intestine. Bright blood or black stools can signal a GI bleed.

Nursing Interventions for Ineffective Gastrointestinal Perfusion

1. Control nausea and vomiting.
Patients who are vomiting may become dehydrated. Administer antiemetics to control vomiting and replace lost fluid and electrolytes through IV fluids and supplements.  

2. Encourage small, easily digested meals.
As patients recover from bowel surgeries or other illnesses, start with liquid or bland diets so as not to overwhelm the gastric system. 

3. Insert NG tube as needed.
Patients who require bowel rest or decompression may require a nasogastric tube. Monitor gastric output for progressing bowel function.

Nursing Assessment for Ineffective Renal Perfusion

1. Evaluate urine output amount and characteristics.
Kidneys that are not perfusing adequately will not produce urine. Monitor for urine output less than 30 ml/hour or very dark, concentrated urine. 

2. Review BUN and creatinine ratio.
Kidney markers such as BUN and creatinine measure waste products that are filtered out by the kidneys. These values will increase if the kidneys are not functioning and filtering correctly. A high BUN to creatinine ratio signals poor blood flow to the kidneys. 

3. Observe for edema.
Kidneys that are not filtering waste products and fluid through urine will result in retention observed as edema and swollen extremities.

Nursing Interventions for Ineffective Renal Perfusion

1. Measure intake and output.
Document accurate intake (oral, IV) against output (urine, emesis) to monitor for fluid imbalance. 

2. Weigh daily.
Weight monitoring can detect worsening fluid retention caused by poorly functioning kidneys. 

3. Teach patients about diet recommendations.
Fluid and salt may be restricted as this can further exacerbate fluid retention. Patients may need to decrease animal protein intake as this can further damage kidneys.

Nursing Assessment for Ineffective Cerebral Perfusion

1. Assess LOC and mentation.
Poor perfusion to the brain may result in confusion, speech changes, poor motor control, vision loss, changes in sensation, and loss of consciousness. 

2. Assess for signs of a stroke.
If blood flow to the brain is impeded by a blood clot or slowed by bleeding, the patient may experience facial drooping, slurred speech, and muscle weakness.  

3. Review medications for interactions.
Medications such as narcotics, sedatives, or overdoses of antiseizure drugs or antihypertensives may mask symptoms or symptoms may improve once the medication is discontinued.

Nursing Interventions for Ineffective Cerebral Perfusion

1. Perform frequent neurological exams.
Neurological exams will be ordered at specified intervals to assess for progression or worsening of mentation. Those suffering a stroke will be assessed using the NIH stroke scale. 

2. Elevate HOB.
If a patient has intracranial pressure (ICP) the HOB should be elevated to 30 degrees and their neck kept in a neutral position to promote circulation and lower pressure. 

3. Administer medications as required.
Sedation may be required to limit movement. Osmotic diuretics will help lower ICP. Corticosteroids can help with inflammation and edema. Thrombolytics will break up a clot impeding blood flow.

Nursing Assessment for Ineffective Peripheral Perfusion

1. Provide a thorough skin assessment.
Take note of edema, wounds or ulcerations, skin color, temperature, hair loss, and thickened nails. 

2. Assess peripheral pulses.
Monitor for absent or weak pulses which indicate poor perfusion. 

3. Assess for pain and numbness.
Patients with conditions such as diabetes, PAD or PVD may lack circulation to extremities. They may experience pain or dulled sensations from poor blood flow.

Nursing Interventions for Ineffective Peripheral Perfusion

1. Use a doppler if needed to assess blood flow.
If peripheral pulses are difficult to palpate, a doppler can assist in locating a pulse. 

2. Apply anti-embolism stockings.
Patients with edema or poor circulation to the lower legs may require compression stockings to increase circulation. 

3. Discourage sitting for long periods or crossing ankles.
This impedes blood flow and venous return. 

4. Encourage lifestyle behaviors to improve blood flow.
Quitting smoking, diet control to manage diabetes, and proper exercise are necessary to control chronic diseases. 

5. Prevent exposure to cold.
Raynaud’s disease results in poor blood flow to smaller arteries, usually the fingers in response to cold or stress. Teach patients to stay inside in cold weather, and use gloves or mittens.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
2. Haskell, R. (2020, March 5). Increased Intracranial Pressure (ICP): What Nurses Need to Know. NursingCenter. https://www.nursingcenter.com/ncblog/march-2020/increased-intracranial-pressure
3. Ischemic colitis. (2020, November 10). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/ischemic-colitis/symptoms-causes/syc-20374001
4. Merx, M. W., & Weber, C. (2007). Sepsis and the Heart. Circulation, 116(7), 793-802. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.106.678359
5. Nutrition and Early Kidney Disease (Stages 1–4). (2020). National Kidney Foundation. https://www.kidney.org/atoz/content/nutrikidfail_stage1-4
6. Understanding Your Lab Values. (2017). National Kidney Foundation. https://www.kidney.org/atoz/content/understanding-your-lab-values