NCP: Ineffective Cerebral Tissue Perfusion, Cerebro-vascular Accident (CVA)

Cerebro-vascular Accident (CVA)

Need
ACTIVITY-EXERCISE PATTERN

Nursing Diagnosis
Ineffective cerebral tissue perfusion related to cerebral bleeding secondary to CVA bleed (120cc)

Rationale:
- Cerebrovascular disease refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm, hypertension or other bleeding disorders.
Source:
Doenges, Marilynn, RN, et al. Nursing Care Plans 6th ed. F. A. Davis Company, Philadelphia, PA, USA. 2002

Objective of Care
Within my 8 hours span of care my patient will be able to have effective cerebral tissue perfusion as evidenced by:

a. improved level of consciousness;
b. stable vital signs.

Nursing Interventions
1. Assess vital signs. Get baseline parameters
® This help deterioration of the patients condition. It gives the opportunity to track changes.
2. Assess oxygenation.
® Oxygenation affects cerebral functioning.
3. Monitor neurological status frequently and compare with baseline.
4. Assess drainage of post operative site.
® Congestion can aggravate increase pressure.
® Assesses trends in the level of consciousness and potential for increased ICP.
5. Evaluate papillary reaction.
® Pupil reactions are regulated by the oculomotor cranial nerve and are useful in determining whether the brainstem is intact.
6. Assess skin color and temperature.
® Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
7.Position head slightly elevated and in neutral position.
® Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
8. Provide quite, restful environment.
® Continual stimulation can increase ICP. Prevent rebleeding in the case of hemorrhage.
9. Provide passive ROM.
® Promotes collateral circulation.
10. Administer supplemental oxygen.
® Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/ edema formation.
11. Administer medications as indicated.
® Provides pharmacological for the condition.

Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed. F.A. Davis Company, Philadelphia, PA, USA