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.
