00201 Ineffective Cerebral Tissue Perfusion Risk

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: 00201
Nanda label: ineffective cerebral tissue perfusion risk
Diagnostic focus: tissue perfusion
Approved 2008 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of ineffective cerebral tissue perfusion is defined as: susceptible to decreased cerebral tissue circulation, which can compromise health.

Risk factors

  • Inappropriate use of substances

Risk population

  • People with recent background of myocardial infarction

Associated problems

  • Abnormal partial serum thromboplastin time
  • Abnormal serum protrombin time
  • Acinetic left ventricular wall segment
  • Arterial dissection
  • Atherosclerosis
  • Atrial fibrillation
  • Atrial Mixoma
  • Blood coagulation disorders
  • Cerebral lesions
  • Brain tumor
  • Carotid stenosis
  • Cerebral aneurysm
  • Dilated cardiomyopathy
  • Disseminated intravascular coagulopathy
  • Embolism
  • Hypercholesterolemia
  • Hypertension
  • Infectious endocarditis
  • Mechanical valvular prostheses
  • Mitral stenosis
  • Pharmacological preparations
  • Sinus node syndrome
  • Therapeutic regime

Suggestions of use

  • The presence of ineffective cerebral tissue perfusion is a medical disease or diagnosis. The results and interventions would correspond to medical or surgical treatments. The role of the nursing professional is to monitor and detect changes in the patient’s condition.
  • Therefore, nursing care must be directed to the use of collaboration problems (for example, possible complication of recent myocardial infarction: ineffective cerebral tissue perfusion).

Suggested alternative diagnostics

  • cardiac spending, decrease in

NOC Results

Note : The following result is used to evaluate the real presence of ineffective cerebral tissue perfusion:

  • Tissue perfusion: cerebral: adequate blood flow in brain vascularization to maintain brain function

Note : The following results are related to the risk factors of the ineffective cerebral tissue perfusion risk label:

  • Blood coagulation: point to which blood is coagula within a normal time period
  • Knowledge: hypertension management: degree of understanding expression about high blood pressure, its treatment and the prevention of its complications
  • Effectiveness of cardiac pumping: sufficiency of the blood volume expelled by the left ventricle to maintain the systemic perfusion pressure
  • Circulatory status: Unidirectional blood flow and without obstruction, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Neurological status: Central and peripheral nervous system capacity to receive, process and respond to internal and external stimuli
  • Severity of physical injury: severity of injuries caused by accidents and trauma

Evaluation objectives and criteria

  • Demonstrates circulatory state, which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised): Systolic and diastolic blood pressure
  • Demonstrates cerebral tissue perfusion, which is manifested by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or without deviation from the normal range):
    • Intracranial pressure
    • Systolic and diastolic blood pressure
  • Demonstrates cerebral tissue perfusion, which is manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Agitation
    • Carotid breath
    • Deterioration of neurological reflexes
    • Vomiting
  • Other examples

    The patient will be able to:

    • Have intact central and peripheral nervous systems
    • Demonstrate intact cranial sensoriomotor functions
    • Demonstrate a normal level of consciousness
    • Show an intact autonomous functioning
    • Present equal and reactive pupils
    • Do not present convulsive activity
    • Do not experience headaches

    NIC Interventions

    • Nursing interventions focus on evaluating and preventing ineffective cerebral tissue perfusion.
    • Cerebral edema management: limitation of brain lesions secondary to brain tissue edema
    • Intracranial pressure monitoring (PIC): Measurement and interpretation of patient data to regulate intracranial pressure
    • Neurological monitoring: Patient data collection and analysis to prevent or minimize possible neurological complications

    Nursing Activities

    Note : Nursing activities will vary depending on the risk factors present. Here only some examples are included.

    Valuations

    • Monitor the following:
      • Vital signs: temperature, ta, pulse and breaths
      • P02, PC02 leukocyte count, pH and bicarbonate levels
      • PAC02, SA02 and hemoglobin levels to determine the contribution of oxygen to the tissues
      • Size, shape, symmetry and reactivity of the pupils
      • diploopia, nystagmus, blurred vision and visual acuity
      • Cepaleas
      • Level of consciousness and orientation
      • Memory, mood and affection
      • Cardiac spending
      • Corneal reflexes, tusigen and nauseous
      • Muscle tone, movements, march and self -perception
    • (NIC) Intracranial pressure monitoring (PIC):
      • Monitor the patient’s intracranial pressure, as well as the neurological response to care and environmental stimuli
      • Monitor the brain perfusion pressure
      • Monitor the presence of fluid infection or exit from the insertion site

    Collaboration activities

    • Keep the hemodynamic parameters (for example, systemic blood pressure) within the prescribed range
    • Manage medications to expand intravascular volume, according to prescription
    • Inducing hypertension to maintain cerebral perfusion pressure, according to prescription
    • Administer osmotic and ASA diuretics, according to prescription
    • Raise the head of the bed from 0 to 45 degrees, depending on the condition of the patient and the medical orders

    Others

    • Reduce as much as possible environmental stimuli
    • (NIC) Intracranial pressure monitoring (PIC):
      • Keep the monitoring system sterilized
      • Space nursing care to reduce as much as possible the elevation of pic