Ineffective Tissue Perfusion : cerebral - Stroke Nanda NIC NOC

Ineffective tissue perfusion: cerebral: a decrease in oxygen supply as a result of the failure to supply network (NANDA)

Related Factors:

• Damage to transport oxygen through the alveolar and or capillary membrane .
• Exchange problem.
• Decrease vein or artery blood flow.

Characteristics:

• Changes in speech
• Changes in pupil reaction
• Extremity weakness or paralysis
• Impaired mental status 
• Difficulty swallowing
• Changes in motor response
• Changes in behavior

NOC:

• Tissue Perfusion: Peripheral: the range in which the flow of blood through the small blood vessels of the extremities and maintaining tissue function.

• Neurology Status: range where the central and peripheral nervous systems receive, process and respond to internal and external stimuli.

• Circulation Status: range where blood flow is blocked, one-way and at the appropriate pressure through large blood vessels of the systemic circulation and pulmuner.

• Cognitive Ability: the ability to perform complex mental processes.


Evaluation Criteria:

• Demonstrate the status of the circulation is characterized by:

• Systolic and diastolic blood pressure in the range expected.
• No orthostatic hypotension.
• No major vascular bruit.
• No signs PTIK (not more than 15 mm Hg).

• Demonstrate the cognitive kemempuan characterized by:

• Communicate clearly and in accordance with ability.
• Shows attention, concentration and orientation.
• Process information.
• Make a decision right circuitry.

• Demonstrate hatched cranial sensory function is intact

• The level of consciousness improved.
• No involuntary movements.

NIC:

• Management Peripheral Sensation

• Monitor the numbness and tingling.
• Monitor fluid status including intake and output.
• Monitor speech function.
• Expect temperatures in the normal range.
• GCS monitor regularly.
• Note the change in vision.

• Intra-cranial Pressure Monitor (ICT)

• Monitor ICT clients and neurology, compared to a normal state.
• Monitor cerebral perfusion pressure.
• Position the head a bit high and the anatomical position.
• Maintain bed rest circumstances.
• Monitor vital signs.
• Collaboration of oxygen, anticoagulation medication, antifibrolitik drugs, antihypertensives, peripheral vasodilatation, stool softeners as indicated.