D.0009
Perfusi Perifer Tidak Efektif
Kategori : Fisiologis
Subkategori :
Sirkulasi
Definisi
Penurunan sirkulasi darah pada level kapiler yang dapat mengganggu metabolisme tubuh.
Penyebab
1. Hiperglikemia
2. Penurunan konsentrasi hemoglobin
3. Peningkatan tekanan darah
4. Kekurangan volume cairan
5. Penurunan aliran arteri dan/atau vena
6. Kurang terpapar informasi tentang faktor
pemberat (mis, merokok, gaya hidup monoton, trauma, obesitas, asupan garam,
imobilitas)
7. Kurang terpapar informasi tentang proses
penyakit (mis. Diabetes melitus, hiperlipidemia)
8. Kurang aktivitas fisik
Gejala dan Tanda Mayor
Subjektif
(tidak tersedia)
Objektif
1. Pengisian kapiler >3 detik
2. Nadi perifer menurun atau tidak teraba
3. Akral teraba dingin
4. Warna kulit pucat
5. Turgor kulit menurun
Gejala dan Tanda Minor
Subjektif
1. Parastesia
2 Nyeri ekstremitas (klaudikasi intermiten)
Objektif
1. Edema
2. Penyembuhan luka lambat
3. Indeks ankle-brachial <0,90
4. Bruit femoral
Kondisi Klinis Terkait
1 Tromboflebitis
2 Diabetes melitus
3. Anemia
4. Gagal jantung kongestif
5. Kelainan jantung kongenital
6. Trombosis arteri
7. Varises
8. Trombosis vena dalam
9. Sindrom kompartemen
Referensi
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Bortolotto, (2006). Ineffective Peripheral
Tissue Perfusion: Clinical Validation in Patients With Hypertensive
Cardiomiopathy International Journal of Nursing Terminologies and
Classifications, 17(2), 97-108.
Carpernito-Moyet, L. J. (2013). Nursing
Diagnosis Application to Clinical Practice. 13" Ed. Philadelphia
Lippincott Williams & Wilkins.
Doenges, M. E., Moorhouse, M. F, & Murr, A.
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Client Care. 4 Ed. Philadelphia: F A Davis Company
Gengo de Silva, R. C, Monteiro da Cruz, D. L,
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& Consolim-Colombo, F. M. (2006). Ineffective peripheral tissue perfusion
Clinical validation in patients with hypertensive cardiomiopathy. International
Journal Of Nursing Terminologies And Classifications The Official Journal Of
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Hardman, T. H., & Kamitsuru, S (2014)
Nursing Diagnosis Definitions andClassification 2015 2017 10" Ed Oxford
Wiley Blackwell.
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Sridaromont, K. L. & Maramba, P. J.(2012) Cox's Clinical Applications of
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