A client diagnosed with heart failure has ineffective tissue perfusion related to decreased cardiac output. Which of the following nursing actions will monitor and improve tissue perfusion in this patient?

Explanation

• Spacing out activities rather than clustering avoids fatigue and an increased myocardial demand. This intervention promotes activity tolerance

• Active range of motion helps decrease venous pooling and promotes tissue perfusion

• Cool, pale skin is indicative of decreased peripheral tissue perfusion. By assessing the skin color and temperature, prompt interventions can  be made to promote adequate tissue perfusion

• Monitor the client's response to activities. Dyspnea, tachycardia, angina, diaphoresis, dysrhythmias, and hypotension are all indicative that the activity requires a greater myocardial demand than the heart is able to meet, and should be adjusted. This promotes activity tolerance

• A warm environment promotes vasodilation, which decreases preload and promotes tissue perfusion

• There is no need for bed rest

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