NURSING DIAGNOSIS: Altered cerebral tissue perfusion
related to decreased cerebral blood flow associated with:
cerebral hemorrhage resulting from the underlying disease process or loss of integrity of the ligated vessels;
compression of cerebral vessels (occurs mainly as a result of cerebral edema or accumulation of blood in cerebral tissue);
spasm of the cerebral vessels resulting from trauma to and stretching of the vessels during surgery;
hypotension (can occur as a result of factors such as hypovolemia and peripheral pooling of blood).
The client will maintain adequate cerebral tissue perfusion as evidenced by:
absence of dizziness, visual disturbances, and speech impairments
usual or improved mental status
usual or improved sensory and motor function.
Nursing Actions and
Assess for and report signs and symptoms of decreased cerebral tissue perfusion:
visual disturbances (e.g. blurred or dimmed vision, diplopia, change in visual field)
irritability and restlessness
decreased level of consciousness
paresthesias, weakness, paralysis.
to maintain adequate cerebral tissue perfusion:
perform actions to prevent and treat increased intracranial pressure (see Postoperative Diagnosis 3, actions B and C in the IICP complication)
if client is hypotensive, perform actions
to improve cerebral blood flow
(e.g. administer prescribed sympathomimetic agents, maintain intravenous fluid therapy as ordered)
administer calcium-channel blockers (e.g. nimodipine) if ordered
to reduce cerebral vasospasm
the calcium that is released by the injured neural cells can cause vasospasm
prepare client for surgical intervention (e.g. evacuation of hematoma, ligation of bleeding vessels) if planned.
Consult physician if signs and symptoms of decreased cerebral tissue perfusion persist or worsen.