Nursing Care Plans - Ineffective Cerebral Tissue Perfusion

Nursing Care Plan for INEFFECTIVE CEREBRAL TISSUE PERFUSION

Nursing    Analysis  Diagnosis  Diagnosis Objective: 'ltered &rain tumors occur   1. Known case of cerebral  because of proliferation proliferation or   prechiasmatic  prechiasmatic tissue growth growth of abnormal abnormal cells meningioma  perfusion very very rapi rapidl dly y in area areass 2. With edema of the related to centra centrall nervo nervous us syste system m orbital area (eningioma )*+,-. )*+,-. hese hese cells cells will will 3. Has history of of the continue to evolve  blood pressure pressure  prechiasmatic  prechiasmatic compressing healthy brain elavation up to region tissue tissue around around it causing causing 130/0 neurological neurological disturbances. disturbances. !. Has episodes of he client is a nown case restlessness  prechiasmatic  prechiasmatic Subjective: meningioma. ". #ight sided rechiasmatic area of the hemiparesis  brain is the groove on the $. #ight sided upper per surfac rfacee of the hemiplegia sphen sphenoid oid bone bone runnin running g %. &lurring of vision transvers transversely ely between between the opti opticc cana canals ls boun bounde ded d anteriorly by the sphe spheno noid idal al limb limbus us and and  posteriorly by the tuberculum sellae. t forms in relationship to the optic chiasm chiasm.. ptic ptic chiasm chiasm is where where optic optic nerve nerve fibers fibers  pass through to the brain. ' growin growing g tumor tumor in the  prechiasmatic  prechiasmatic region can cause compression on the optic optic chiasm chiasm which which then lead leadss to the the pati patien ent4 t4ss manifest manifestatio ation n of blurring blurring of vision vision changes changes in the visual visual acuity acuity and visua visuall fields. fields. t also compresses compresses Cues and Clues

 

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Goals and  Objectives 5oal6 effective cerebral tissue  perfusion Within % hours of rendering therapeutic nursing care the  patient will6 will6 have improvement in terms of movement have improvement in terms of sensory  perception have decrease or  sustain no further edema maintain a normal blood  pressure have no episode of restlessness displays no signs of increased * have improved cerebral tissue  perfusion

Interventions 1

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(onitor an and document neurological status fre7uently

(oni (onito torr vita vitall sign signss noting6 Hypertension or hypotension heart rate pupillary reaction and respirations osi ositi tion on clie client nt with with head slightly elevated and in neutral  position

Rationale 1

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Evaluation

'sse 'ssess sses es tre trend ndss in 8* andpotential for  increased * and isuseful in determining locatione9tent locatione9tent and  progression or resolution of *+, damage.

5oals were met therefore nursing care should be continued.

'fter % hours of rendering therapeutic nursing care the  patient 6 rre rregu gula lari riti ties es in in thes thesee had improvement are indications of in terms of  problems/complicati  problems/complicatio o movement ns of the brain had functions improvement in terms of sensory  perception #edu #educe cess art arter eria iall sustained no  pressure by further edema  promoting venous maintained a drainage and may normal blood improve cerebral  pressure circulation and had no episode  perfusion. of restlessness displayed no :alsal lsalva va mane maneuv uver er signs of increases intracranial increased *  pressure had improved cerebral tissue  perfusion *ont *ontin inua uall sti stimu mula lati tion on can increase *. 'bsolute rest and •

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nst nstru ruct ct to prev preven entt straining at stool or holding of breath.

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(ain (ainta tain in bed bedre rest st  provide 7uiet 7uiet environment and restrict visitors or activities. rovide rest periods between

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Gr o wi n g hemiplegia. t umor s al so caus es an i n cr e as ei nI CP s i n c ethe cranium and the vertebral canal along with the relatively inelastic dura form a rigid container. 'n increase in any of its contents;brain blood or  *,<;will tend to increase the *. ' rise in the * will then furtther   contribute to the e9isting right sided hemi=paresis hemi=plegia and orbital edema with other   neurologic manifestations such as headache the cushing4s triad vomiting and respiratory symptoms.

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#aise the bed4s siderails and offer to  provide assistance when moving and/or ambulating

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rovides safety to the client

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,tress can further increase *  promoting rela9ation can prevent icrease *

rovide intructions of  rela9ation techni7ues such as meditating > listening to music

?ncourage @&? and reposition fre7uently

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'd minister supplemental o9ygen as needed

10 'dminister medications as needed

11 Have an accurate intae=output count and monitor laboratory studies.

romotes o9ygenation and  prevents complications associated with decreased brain tissue  perfusion A romotes o9ygenation

10 (edications may be needed as adBunct interventions to facilitate lowering of intracranial pressure 11 rovides information about the effectiveness of the drugs used to treat the condition