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?

Encourage active range of motion.
Monitor client''s response to activities.
Note color and temperature of the skin.
Provide a warm environment.
Space nursing activities.

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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