NURSING DIAGNOSIS: Altered cerebral tissue perfusion

related to:
  1. partial or complete occlusion of the carotid artery by atherosclerotic plaque and/or a thrombus;
  2. a cerebral embolus associated with dislodgment of atherosclerotic plaque or a thrombus from the carotid artery.
Desired Outcome
The client will maintain adequate cerebral tissue perfusion as evidenced by:
  1. mentally alert and oriented
  2. absence of dizziness, visual disturbances, and speech impairments
  3. normal motor and sensory function.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of carotid artery occlusion and/or cerebral embolization (e.g. agitation, lethargy, confusion, dizziness, diplopia, ipsilateral blindness, homonymous hemianopsia, slurred speech, expressive aphasia, paresthesias, hemiparesis, hemiplegia).
  2. Implement measures to maintain adequate cerebral tissue perfusion:
    1. administer anticoagulants (e.g. heparin, warfarin) or antiplatelet agents (e.g. low-dose aspirin, clopidogrel, ticlopidine) if ordered to prevent new or extended thrombus formation and further occlusion of the carotid artery (these medications might be discontinued before surgery to reduce the risk of intraoperative and postoperative hemorrhage)
    2. caution client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed) in order to prevent dislodgment of existing thrombi
    3. perform actions to prevent hypertension in order to reduce the risk of cerebral embolism:
      1. implement measures to reduce stress (e.g. explain procedures, maintain calm environment)
      2. administer antihypertensives as ordered (these medications are sometimes discontinued before surgery to reduce the risk of a critical drop in B/P during and immediately following surgery).
  3. If signs and symptoms of altered cerebral tissue perfusion occur:
    1. maintain client on bed rest with head of bed flat unless contraindicated
    2. administer anticoagulants (e.g. continuous intravenous heparin, warfarin) if ordered
    3. provide emotional support to client and significant others; be aware that the development of signs and symptoms usually necessitates postponement or cancellation of planned surgery.