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.
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