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 hypoperfusion occur because of vascular occlusion. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1896) Cues Objective Cues  Altered LOC; memory loss  Changes in motor or sensory responses; restlessness  Sensory, language, intellectual, and emotional deficits  Changes in vital signs Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: • Demonstrate stable vital signs and absence of signs of increased ICP. • Display no further deterioration or recurrence of deficits. Long-term Objective Within 3 days of providing nursing interventions, the patient will: • Maintain usual or improved LOC, cognition, and motor and sensory function. Monitor and document neurological status frequently and compare with baseline. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: ineffective cerebral tissue Perfusion for complete neurological evaluation. Monitor vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Hypotension may follow stroke because of circulatory collapse. Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA, for example, stroke after MI or from valve dysfunction. Irregularities can suggest location of cerebral insult or increased ICP and need for further intervention, including possible respiratory support. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: risk for ineffective Breathing Pattern.) Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality is determined 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 safety concerns, and influence choice of interventions. Independent Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP. Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence. Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. May also reveal TIA, which may resolve with no further symptoms or may precede thrombotic CVA. Nursing Interventions Rationale

Heart rate and rhythm; auscultate for murmurs

Respirations, noting patterns and rhythm—periods of apnea after hyperventilation, Cheyne-Stokes respiration

Evaluate pupils, noting size, shape, equality, and light reactivity.

Document changes in vision, such as reports of blurred vision and alterations in visual field or depth perception.

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.

Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion. Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.

Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.

Valsalva’s maneuver increases ICP and potentiates risk of bleeding. Prevent straining at stool or holding breath. Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further evaluation and intervention.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity. Collaborative Administer supplemental oxygen, as indicated. Administer medications, as indicated, for example Intravenous thrombolytics, such as tissue plasminogen activator (tPA), alteplase (Activase), and recombinant prourokinase (Prourokinase)

Reduces hypoxemia.

As the only proven therapy for early acute ischemic stroke, tPA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with clot. Treatment must be started within 3 hours of initial symptoms to improve outcomes. Note: These agents are contraindicated in several instances—intracranial hemorrhage as diagnosed by CT scan, recent intracranial surgery, serious head trauma, and uncontrolled hypertension. May be used to improve cerebral blood flow and prevent further clotting when embolus or thrombosis is the problem.

Anticoagulants, such as warfarin sodium (Coumadin); lowmolecular- weight heparin, for example, enoxaparin (Lovenox) and dalteparin (Fragmin); and direct thrombin inhibitor, such as ximelagatran (Exanta) Antiplatelet agents, such as aspirin (ASA), aspirin with extended-release dipyridamole (Aggrenox), ticlopidine (Ticlid), and clopidogrel (Plavix)

Antiplatelet agents are used following an ischemic stroke or TIA.

Antihypertensives

Preexisting or chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage during an evolving stroke. Transient hypertension often occurs during acute stroke and usually resolves without therapeutic intervention. Used to improve collateral circulation or decrease vasospasm.

Peripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine (Pavabid), and isoxsuprine (Vasodilan) These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events—influx of calcium into cells,

Neuroprotective agents, such as calcium channel blockers, excitatory amino acid inhibitors, and gangliosides

release of excitatory neurotransmitters, buildup of lactic acid—to limit ischemic injury. May be used to control seizures and for sedative action. Note: Phenobarbital enhances action of antiepileptics.

Phenytoin (Dilantin) and Phenobarbital. May be necessary to resolve hemorrhagic situation and reduce neurological symptoms and risk of recurrent stroke. Prepare for surgery, as appropriate—carotid endarterectomy, microvascular bypass, and cerebral angioplasty. Monitor laboratory studies as indicated, such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level. References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p242-244 Provides information about effectiveness and therapeutic level of anticoagulants when used.

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