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Ineffective Cerebral Tissue Perfusion

Ineffective Cerebral Tissue Perfusion

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Published by Hanya Bint Potawan

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Published by: Hanya Bint Potawan on Nov 22, 2012
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11/14/2013

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Nursing Diagnosis:
 Ineffective cerebral tissue perfusion
May be related to:
 Interruption of blood flow
 — 
occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema
Cause Analysis:
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. [2010]
. 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
Short-term Objective
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.
Long-term Objective
Within 3 days of providing nursinginterventions, the patient will:
 
Maintain usual or improved LOC,cognition, and motor and sensoryfunction.
Independent
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.
 
 
Assess higher functions, including speech, if client is alert. (Refer to ND:impaired verbal [and/or written] Communication.)Position with head slightly elevated and in neutral position.Maintain bedrest, provide quiet environment, and restrict visitors or activities, asindicated. Provide rest periods between care activities, limiting duration of procedures.Prevent straining at stool or holding breath.Assess for nuchal rigidity, twitching, increased restlessness, irritability, andonset of seizure activity.
Collaborative
Administer supplemental oxygen, as indicated.Administer medications, as indicated, for exampleIntravenous thrombolytics, such as tissue plasminogen activator (tPA),alteplase (Activase), and recombinant prourokinase (Prourokinase)Anticoagulants, such as warfarin sodium (Coumadin); lowmolecular- weightheparin, for example, enoxaparin (Lovenox) and dalteparin (Fragmin); anddirect thrombin inhibitor, such as ximelagatran (Exanta)Antiplatelet agents, such as aspirin (ASA), aspirin with extended-releasedipyridamole (Aggrenox), ticlopidine (Ticlid), and clopidogrel (Plavix)AntihypertensivesPeripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine(Pavabid), and isoxsuprine (Vasodilan)Changes in cognition and speech content are an indicator of location and degreeof cerebral involvement and may indicate increased ICP.Reduces arterial pressure by promoting venous drainage and may improvecerebral circulation and perfusion.Continual stimulation can increase ICP. Absolute rest and quiet may be neededto prevent recurrence of bleeding, in the case of hemorrhagic stroke.
Valsalva’s maneuver increases ICP and potentiates risk of 
bleeding.Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizuresmay reflect increased ICP or reflect location and severity of cerebral injury,requiring further evaluation and intervention.Reduces hypoxemia.As the only proven therapy for early acute ischemic stroke, tPA is useful inminimizing the size of the infarcted area by opening blocked vessels that areoccluded with clot. Treatment must be started within 3 hours of initialsymptoms to improve outcomes. Note: These agents are contraindicated inseveral instances
 — 
intracranial hemorrhage as diagnosed by CT scan, recentintracranial surgery, serious head trauma, and uncontrolled hypertension.May be used to improve cerebral blood flow and prevent further clotting whenembolus or thrombosis is the problem.Antiplatelet agents are used following an ischemic stroke or TIA.Preexisting or chronic hypertension requires cautious treatment becauseaggressive management increases the risk of extension of tissue damageduring an evolving stroke. Transient hypertension often occurs during acutestroke and usually resolves without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.These agents are being researched as a means to protect the brain by interruptingthe destructive cascade of biochemical events
 — 
influx of calcium into cells,

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