NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow


NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

Ineffective Cerebral Tissue Perfusion related to interruption of blood flow: occlusive disease, hemorrhage, cerebral vascular spasm, cerebral edema.

Expected outcomes are:
  • Maintained and increased the level of consciousness, cognition and function of sensory / motor.
  • Reveals stabilization of vital signs and no increase in intracranial pressure.
  • The role of the patient reveals no deterioration / recurrence.

Nursing Intervention:

Independent
  • Determine the factors related to individual situations / causes of coma / decreased cerebral perfusion and a potential increase in intracranial pressure.
  • Monitor and record neurological status on a regular basis.
  • Monitor vital signs.
  • Pupil evaluation (size, shape similarity and reaction to light).
  • Help to change the view, misalnay blurred vision, visual field changes / perceptual field of view.
  • Increasing auxiliary functions, including speech if the patient has impaired function.
  • And gradual elevation of the head in neutral position.
  • Maintain bed rest, provide a quiet environment, set visits as indicated.
  • Provide supplemental oxygen as indicated.
  • Give medications as indicated.

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