Ineffective cerebral tissue perfusion
May be related to:
Interruption of blood flow
occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema
Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted
In ischemic stroke, significant hypoperfusionoccur because of vascular occlusion. (Smeltzer et. al. 
. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1896)
Cues Objectives Nursing Interventions RationaleObjective Cues
Altered LOC; memory loss
Changes in motor or sensoryresponses; restlessness
Sensory, language, intellectual, andemotional deficits
Changes in vital signs
Within 8 hours of providing nursinginterventions, the client will:
Demonstrate stable vital signs andabsence of signs of increased ICP.
Display no further deterioration orrecurrence of deficits.
Within 3 days of providing nursinginterventions, the patient will:
Maintain usual or improved LOC,cognition, and motor and sensoryfunction.
Determine factors related to individual situation, cause for coma, decreasedcerebral perfusion, and potential for ICP.Monitor and document neurological status frequently and compare withbaseline. (Refer to CP: Craniocerebral Trauma
Acute Rehabilitative Phase,ND: ineffective cerebral tissue Perfusion for complete neurologicalevaluation.Monitor vital signs noting:Hypertension or hypotension; compare blood pressure (BP) readings in botharmsHeart rate and rhythm; auscultate for murmursRespirations, noting patterns and rhythm
periods of apnea afterhyperventilation, Cheyne-Stokes respirationEvaluate pupils, noting size, shape, equality, and light reactivity.Document changes in vision, such as reports of blurred vision and alterations invisual field or depth perception.Influences choice of interventions. Deterioration in neurological signs andsymptoms or failure to improve after initial insult may reflect decreasedintracranial adaptive capacity, which requires that client be admitted to criticalcare area for monitoring of ICP and for specific therapies geared tomaintaining ICP within a specified range. If the stroke is evolving, client candeteriorate quickly and require repeated assessment and progressive treatment.
If the stroke is “completed,” the neurological defi
cit is nonprogressive, andtreatment is geared toward rehabilitation and preventing recurrence.Assesses trends in LOC and potential for increased ICP and is useful indetermining location, extent, and progression or resolution of CNS damage.May also reveal TIA, which may resolve with no further symptoms or mayprecede thrombotic CVA.Fluctuations in pressure may occur because of cerebral pressure or injury invasomotor area of the brain. Hypertension or hypotension may have been aprecipitating factor. Hypotension may follow stroke because of circulatorycollapse.Changes in rate, especially bradycardia, can occur because of the brain damage.Dysrhythmias and murmurs may reflect cardiac disease, which may haveprecipitated CVA, for example, stroke after MI or from valve dysfunction.Irregularities can suggest location of cerebral insult or increased ICP and needfor further intervention, including possible respiratory support. (Refer to CP:Craniocerebral Trauma
Acute Rehabilitative Phase, ND: risk for ineffectiveBreathing Pattern.)Pupil reactions are regulated by the oculomotor (III) cranial nerve and are usefulin determining whether the brainstem is intact. Pupil size and equality isdetermined by balance between parasympathetic and sympathetic enervation.Response to light reflects combined function of the optic (II) and oculomotor(III) cranial nerves.Specific visual alterations reflect area of brain involved, indicate safetyconcerns, and influence choice of interventions.