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 Objectives Nursing Interventions Rationale
Objective Cues Short-term Objective
 Altered LOC; memory loss Within 8 hours of providing nursing Independent
 Changes in motor or sensory interventions, the client will:
responses; restlessness • Demonstrate stable vital signs and
 Sensory, language, intellectual, and Determine factors related to individual situation, cause for coma, decreased Influences choice of interventions. Deterioration in neurological signs and
absence of signs of increased ICP. cerebral perfusion, and potential for ICP. symptoms or failure to improve after initial insult may reflect decreased
emotional deficits • Display no further deterioration or
 Changes in vital signs intracranial adaptive capacity, which requires that client be admitted to critical
recurrence of deficits. 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
Long-term Objective deteriorate quickly and require repeated assessment and progressive treatment.
If the stroke is “completed,” the neurological deficit is nonprogressive, and
Within 3 days of providing nursing treatment is geared toward rehabilitation and preventing recurrence.
interventions, the patient will:
• Maintain usual or improved LOC,
cognition, and motor and sensory Assesses trends in LOC and potential for increased ICP and is useful in
Monitor and document neurological status frequently and compare with determining location, extent, and progression or resolution of CNS damage.
function. baseline. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, May also reveal TIA, which may resolve with no further symptoms or may
ND: ineffective cerebral tissue Perfusion for complete neurological precede thrombotic CVA.
evaluation.

Monitor vital signs noting:

Fluctuations in pressure may occur because of cerebral pressure or injury in

Hypertension or hypotension; compare blood pressure (BP) readings in both vasomotor area of the brain. Hypertension or hypotension may have been a
arms precipitating factor. Hypotension may follow stroke because of circulatory
collapse.

Changes in rate, especially bradycardia, can occur because of the brain damage.
Heart rate and rhythm; auscultate for murmurs 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:
Respirations, noting patterns and rhythm—periods of apnea after Craniocerebral Trauma—Acute Rehabilitative Phase, ND: risk for ineffective
hyperventilation, Cheyne-Stokes respiration 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
Evaluate pupils, noting size, shape, equality, and light reactivity. 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.
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.
Maintain bedrest, provide quiet environment, and restrict visitors or activities, as
indicated. 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, 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)
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)
Antihypertensives
Peripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine
(Pavabid), and isoxsuprine (Vasodilan)
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.
Valsalva’s maneuver increases ICP and potentiates risk of bleeding.
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.
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.
Antiplatelet agents are used following an ischemic stroke or TIA.
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.
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
Phenytoin (Dilantin) and Phenobarbital.
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
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.
May be necessary to resolve hemorrhagic situation and reduce neurological
symptoms and risk of recurrent stroke.
Provides information about effectiveness and therapeutic level of anticoagulants
when used.