NCP for Ineffective Tissue Perfusion related to Heart Failure

Nursing Diagnosis for Heart Failure : Ineffective Tissue Perfusion related to decrease in cardiac output, tissue hypoxemia, acidosis and possible thrombus or embolism.

Decreased oxygen delivery, the failure to feed the tissue at the capillary level.

Defining characteristics:

Renal :
  • Changes in blood pressure beyond the limits of the parameters.
  • Hematuria.
  • Oliguria / anuria.
  • Elevation / decrease in BUN / creatinine ratio.
Gastrointestinal :
  • Intestinal hypoactive or absent.
  • Nausea.
  • Abdominal distention.
  • Abdominal pain or does not feel soft (tenderness).
Peripheral :
  • Edema.
  • Positive Homan's sign.
  • Changes in skin characteristics (hair, nails, water / moisture).
  • The pulse is weak or non-existent.
  • Discoloration of the skin.
  • Changes in skin temperature.
  • Changes in sensation.
  • Bluish.
  • Changes in blood pressure in the extremities.
  • Bruit.
  • Too late to recover.
  • Reduced arterial pulsation.
  • Pale skin color in elevation, the color does not return to the decrease in the foot.

  • Abnormalities talk.
  • Limb weakness or paralysis.
  • Changes in mental status.
  • Changes in the motor response.
  • Changes in pupil reaction.
  • Difficulty in swallowing.
  • Changes in habits.
Cardiopulmonary :
  • Changes in the frequency of respiration beyond the limits of the parameters.
  • The use of additional respiratory muscles.
  • Turn over three second capillary (capillary refill).
  • Abnormal arterial blood gases.
  • The feeling of "impending Doom" (Fate threatened).
  • Bronchospasm.
  • Dyspnea.
  • Arrhythmias.
  • Nose redness.
  • Chest retraction.
  • Chest pain.

Related Factors :
  • Hypovolemia.
  • Hypervolaemia.
  • Arterial flow was interrupted.
  • Exchange problems.
  • Venous flow is cut off.
  • Hypoventilation.
  • Mechanical reduction in venous or arterial blood flow.
  • Damage to transport oxygen through the alveolar and capillary membranes.
  • Not comparable between ventilation with blood flow.
  • Poisoning enzyme.
  • Changes in affinity / binding O2 with Hb.
  • The decline in Hb concentration in the blood.

  • Circulation status.
  • Tissue Perfusion: cerebral.
a. Demonstrating circulation status, which is characterized by:
  • Systole and diastole the pressure within the expected range.
  • No orthostatic hypertension.
  • No signs of increased intracranial pressure (no more than 15 mm Hg).
b. Demonstrating cognitive ability, which is characterized by:
  • Communicate clearly and in accordance with ability.
  • Shows attention, concentration and orientation.
  • Process the information.
  • Making the correct decision.
c. Showed intact cranial sensorimotor functions: level of consciousness improved, there is no involuntary movements.


Peripheral Sensation Management.
  • Monitor the presence of certain areas only sensitive to heat / cold / sharp / blunt.
  • Monitor the presence of paresthesia.
  • Instruct family to observe the skin, if there are lesions or lacerations.
  • Use gloves for protection.
  • Limit movement of the head, neck and back.
  • Monitor the ability of defecation.
  • Collaboration of analgesic.
  • Monitor the presence of thrombophlebitis.
  • Discuss about the causes of changes in sensation.

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