Cues and Clues

Objective:
1 Quadriplegia
2 Altered
consciousness
3 Slurring of speech
4 Weakness
of
shoulders
when
tested for Cranial
Nerve 11
5 Slight restlessness
6 O2 Saturation 94%
7 Vital Signs:
Blood Pressure
130/80 mmHg
Respiratory Rate
12 RPM

Nursing
Diagnosis
Altered
cerebral
tissue
perfusion due
to pontine
hemorrhage
secondary to
hypertension

Nursing Care Plan for INEFFECTIVE CEREBRAL TISSUE PERFUSION

Goals and
Analysis
Interventions
Objectives
Blood is a connective Goal:
1 Monitor and
1
tissue composed of a effective
document
liquid extracellular matrix cerebral tissue
neurological status
called blood plasma that perfusion
frequently
dissolves and suspends
various cells and cell Within 7 hours
2 Monitor vital signs
2
fragments.
Blood of rendering
frequently, especially
transports oxygen from the therapeutic
heart rate, presence of
lungs and nutrients from nursing care, the
murmurs, pupils, and
the gastrointestinal tract. patient will:
respirations
The oxygen and nutrients have
subsequently diffuse from
3 Position client with
improvement
the
blood
into
the
head slightly elevated 3
in terms of
interstitial fluid and then
and in neutral
movement
into the body cells. Carbon have increased
position
dioxide and other wastes
O2 saturation
move in the reverse blood pressure
direction, from body cells
4 Instruct to prevent
of at least
to interstitial fluid to
straining at stool or
4
120/80
blood.
Blood
then
holding of breath.
have improved
transports the wastes to
cerebral tissue
various organsthe lungs,
perfusion
kidneys, and skinfor
5 Maintain bedrest,
elimination form the body.
provide quiet
5
Circulating blood helps
environment and
maintain homeostasis of
restrict visitors and
all
body fluids.
In
activities.
addition, blood osmotic
pressure influences the
6 Raise the beds
6
water content of cells,
siderails, and offer to
mainly
through
provide assistance
interactions of dissolved
when moving and/or
ions
and
proteins.
ambulating
However, a condition such
as renal failure causes
7 Provide interventions 7
alterations
in
tissue
that help with
perfusion,
particularly
relaxation, such as
reduction in arterial blood
guided imagery
flow that leads to deprived

Rationale

Evaluation

Determines current
need and enables
immediate response
when required
These are good
indicators of brain
function;
Irregularities signal
further
damage/problems.
Reduces arterial
pressure by
promoting venous
drainage and may
improve circulation

Goals were met,

therefore
nursing care
should be
continued.

Valsalva maneuver
increases intracranial
pressure and

increases risk for

further bleeding.
Prevents increase in
ICP and helps prevent
recurrence of stroke.
Provides safety to the
client

May help prevent

increases in ICP and
promote relaxation,
which prevents stress

After 7 hours of
rendering
therapeutic
nursing care, the
patient :
have
improvement
in terms of
movement
have increased
O2 saturation
blood pressure
of at least
120/80
had improved
cerebral tissue
perfusion

nutrition and oxygenation

at the cellular level.
Decreased tissue perfusion
can be transient with few
or minimal consequences
to the health of the patient.
If the decreased perfusion
is acute and protracted, it
can
have
devastating
effects on the patient.
Diminished cerebral tissue
perfusion may result in
further brain damage or
death if not responded to
immediately.

Encourage DBCE
and reposition
frequently.

Administer
supplemental oxygen
as needed

10 Administer
medications as
needed

11 Have an accurate
intake-output count
and monitor
laboratory studies,
especially PTT and
aPTT

Promotes
oxygenation and
prevents
complications
associated with
decreased brain tissue
perfusion
9 Promotes
oxygenation and
healing of the
cerebral tissue
10 Medications may be
needed together with
other interventions to
promote faster
healing and prevent
complications
11 Provides information
about the
effectiveness of the
drugs used to treat
the condition