The nurse assesses the client and establishes a preoperative nursing diagnosis of Potential for altered peripheral tissue perfusion

Question

Which does the nurse include in client teaching to prevent decreased perfusion to the client's extremities while the client is on bed rest? 1. Avoid fluids by mouth until all nausea passes.
2. Flex and rotate ankles every hour while awake.
3. Rest quietly to allow opioid analgesics to work.
4. Keep environmental distractions to a minimum.

Answer 1

2
2. The nurse instructs the client to perform ankle flexion and rotation to promote venous return from the extremities (to prevent thromboembolic complications) and arterial perfusion to provide oxygen for the tissues while the client is not ambulating. The skeletal muscle activity involved with the ankle exercises causes the regional tissue to consume more oxygen. This lowers the oxygen tension in the venous blood returning to the heart and stimulates chemoreceptors to increase the heart rate and provide more oxygenated blood to the tissue.
1. This is a reasonable nursing intervention for a client with nausea and vomiting be-cause continual stimulation of the gut from oral fluids can perpetuate nausea and vo-miting; the nurse instructs the client to take nothing by mouth until the gastrointes-tinal discomfort passes. This does not address the client's problem about tissue per-fusion and, if the client needs fluid, increases the risk of impaired tissue perfusion.
3. This is a reasonable nursing intervention for a client with pain; however, pain con-trol needs to be closely monitored to prevent hypotension because, with a risk of im-paired tissue perfusion, the client can be less likely to tolerate transient hypotension from opioids.
4. If the client is having difficulty with relaxation, reducing distractions can be a neg-ative or positive influence depending on the client's perception. Nonetheless, this is unrelated to altered tissue perfusion.