Final answer:
To evaluate and prevent complications related to ineffective tissue perfusion due to immobility, a nurse should assess capillary refill and encourage early ambulation post-surgery.
Step-by-step explanation:
In the context of assessing and preventing ineffective peripheral tissue perfusion related to immobility during and after surgery, the most appropriate evaluation and preventive measures are:
b. Evaluate by assessing capillary refill; prevent by restricting movement.
Assessing capillary refill time (CRT) is a valuable clinical measure to evaluate peripheral tissue perfusion. It involves pressing on a patient's nail bed or fingertip and observing the time it takes for the color to return after pressure release. Prolonged capillary refill time may indicate inadequate peripheral blood flow.
Preventing complications related to inadequate peripheral tissue perfusion involves encouraging appropriate movement and avoiding prolonged immobility. Restricting movement can further compromise tissue perfusion. Early ambulation, repositioning, leg exercises, and active range-of-motion exercises can help improve circulation and prevent complications associated with immobility, such as venous stasis or thrombosis.
Monitoring other vital signs like blood pressure, heart rate, and oxygen saturation is essential for overall assessment, but assessing capillary refill provides a more direct evaluation of peripheral tissue perfusion. The nurse's interventions primarily focus on promoting mobility rather than restricting it to prevent complications related to ineffective peripheral tissue perfusion.