Nursing Care Plans - Ineffective Cerebral Tissue Perfusion

Cues and Clues
Objective:
1. Known case of
prechiasmatic
meningioma
2. With edema of the
orbital area
3. Has history of
blood pressure
elavation up to
130/80
4. Has episodes of
restlessness
Subjective:
5. Right sided
hemiparesis
6. Right sided
hemiplegia
7. Blurring of vision
Nursing Care Plan for INEFFECTIVE CEREBRAL TISSUE PERFUSION

Nursing
Goals and
Analysis
Interventions
Diagnosis
Objectives
Altered
Brain
tumors
occur Goal:
1 Monitor and
1
cerebral
because of proliferation or effective
document
tissue
growth of abnormal cells cerebral tissue
neurological status
perfusion
very rapidly in areas perfusion
frequently
related to
central nervous system
Meningioma (CNS). These cells will Within 7 hours
of the
continue
to
evolve, of rendering
prechiasmatic compressing healthy brain therapeutic
region
tissue around it, causing nursing care, the
neurological disturbances. patient will:
The client is a known case have
2 Monitor vital signs
prechiasmatic
noting: Hypertension
improvement
2
meningioma.
or hypotension, heart
in terms of
Prechiasmatic area of the
rate, pupillary
movement
brain is the groove on the have
reaction and
upper surface of the
respirations
improvement
sphenoid bone running
in terms of
transversely between the
3 Position client with
sensory
optic canals bounded
head slightly elevated
perception
anteriorly
by
the have decrease or
and in neutral
3
sphenoidal limbus and
position
sustain no
posteriorly
by
the
further edema
tuberculum sellae. It forms
maintain a
in relationship to the optic
normal blood
chiasm. Optic chiasm is
pressure
where optic nerve fibers
4 Instruct to prevent
have
no
episode
pass through to the brain.
straining at stool or
of restlessness
A growing tumor in the
holding of breath.
prechiasmatic region can displays no
4
signs of
cause compression on the
increased ICP 5 Maintain bedrest,
optic chiasm which then
leads to the patients have improved
provide quiet
cerebral tissue
manifestation of blurring
environment, and
perfusion
of vision, changes in the
restrict visitors or
5
visual acuity and visual
activities. Provide
fields. It also compresses
rest periods between
the left hemisphere which
care activities,
then leads to right sided
limiting duration of
hemiparesis
and
procedures
Rationale
Evaluation
Assesses trends in
LOC andpotential for
increased ICP and
isuseful in
determining
location,extent, and
progression
or resolution of CNS
damage.
Goals were met,

therefore
nursing care
should be
continued.
Irregularities in these
are indications of
problems/complicatio
ns of the brain
functions
Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
circulation and
perfusion.
Valsalva maneuver
increases intracranial
pressure
Continual stimulation
can increase ICP.
Absolute rest and
quiet may be needed
After 7 hours of
rendering
therapeutic
nursing care, the
patient :
had
improvement
in terms of
movement
had
improvement
in terms of
sensory
perception
sustained no
further edema
maintained a
normal blood
pressure
had no episode
of restlessness
displayed no
signs of
increased ICP
had improved
cerebral tissue
perfusion
hemiplegia.
Growing
tumors also causes an
increase in ICP since the
cranium and the vertebral
canal, along with the
relatively inelastic dura,
form a rigid container. An
increase in any of its
contentsbrain, blood, or
CSFwill tend to increase
the ICP. A rise in the ICP
will
then
furtther
contribute to the existing
right sided hemi-paresis,
hemi-plegia and orbital
edema
with
other
neurologic manifestations
such as headache, the
cushings triad, vomiting,
and respiratory symptoms.
Raise the beds

siderails, and offer to
provide assistance
when moving and/or
ambulating
Provides safety to the

client
Stress can further

increase ICP,
promoting relaxation
can prevent icrease
ICP
Promotes
oxygenation and
prevents
complications
associated with
decreased brain tissue
perfusion
Promotes
oxygenation
Provide intructions of
relaxation techniques
such as meditating &
listening to music
Encourage DBE and
reposition frequently
Administer
supplemental oxygen
as needed
10 Administer
medications as
needed
11 Have an accurate
intake-output count
and monitor
laboratory studies.
10 Medications may be
needed as adjunct
interventions to
facilitate lowering of
intracranial pressure
11 Provides information
about the
effectiveness of the
drugs used to treat
the condition

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What is the client's diagnosis?

What are the goals of care?

Cues and Clues

Nursing Care Plan for INEFFECTIVE CEREBRAL TISSUE PERFUSION

Goals were met,

Raise the beds

Provides safety to the

Stress can further

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