Ineffective Tissue Perfusion

Nursing Diagnosis

 Ineffective Tissue Perfusion

Related to: 

 Excessive blood loss

Possibly evidenced by: 

ADVERTISEMENTS

 Loss of blood
 FHR pattern
 Altered BP compared to baseline
 Altered PR Severe abdominal pain and rigidity
 Pallor
 Changes in LOC
 Decrease urine output
 Edema
 Delay in wound healing
 Positive Homan’s sign
 Skin temperature changes

Desired outcome: 

Nursing Interventions Rationale

Assess patient’s vital signs, O2 saturation, and For baseline data.

skin color.

Monitor for restlessness, anxiety, hunger and These conditions may indicate
changes in LOC decreased cerebral perfusion

Monitor accurately I&O To obtain data about renal

perfusion and function and the
extent of blood loss.
Monitor FHT continuously To provide information regarding
fetal distress and/or worsening
of condition

Assess uterine irritability, abdominal pain and To determine the severity of the
rigidity. placental abruptio and bleeding

Assess skin color, temperature, moisture, turgor, To determine peripheral tissue

capillary refill perfusion like hypervolemia.

Elevate extremity above the level of the heart Helps promote circulation.

Teach patient not to apply uterine pressure Uterine pressure can cause
pooling of venous blood in lower
extremities

Instruct patient and/or SO to report immediately To immediately provide

signs and symptoms of thrombosis: (1) pain in leg, additional interventions
groin (2) unilateral leg swelling (3) pale skin