Altered Mental Status (AMS): Nursing Diagnoses & Care Plans

Ineffective Cerebral Tissue Perfusion

Ineffective cerebral tissue perfusion associated with altered mental status can be caused by decreased cerebral blood flow due to underlying conditions such as metabolic conditions (e.g. hypoglycemia or hypoxia), low levels of acetylcholine synthesis, and substrate deficiency for neural function.

Nursing Diagnosis: Ineffective Tissue Perfusion

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Related to:

• Decrease cerebral blood flow
• Metabolic conditions
• Primary intracranial disease
• A systemic disease affecting the central nervous system (CNS)
• Exogenous toxins
• Drug withdrawal

As evidenced by:

• Decreased Glasgow coma scale (GCS)
• Decreased level of consciousness (LOC)
• Diminished reflexes
• Alterations in pulse rate
• Alterations in blood pressure
• Increased intracranial pressure
• Decrease cerebral perfusion pressure
• Behavioral changes

Expected outcomes:

• Patient will be able to demonstrate effective tissue perfusion as evidenced by the GCS and LOC within normal limits
• Patient will not experience worsening in AMS such as coma or require intubation

Assessment:

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1. Assess vital signs and underlying cause.Persistent fluctuations in vital signs may trigger cerebral hypoperfusion and inadequate blood supply in the brain. The nurse can monitor the vital signs and assess for an underlying cause through a thorough physical examination and history assessment.

2. Assess neurological status.A detailed neurological and cognitive assessment including the Glasgow coma scale (GCS) and level of consciousness (LOC) is done to determine whether there is a nervous system problem. Neurological checks should be performed frequently and routinely to quickly recognize changes.

3. Review medications and use of intoxicants.Assess the client’s medication regimen for overdoses of narcotics or improper use of antihypertensives. Assess for alcohol or illegal substance use affecting AMS.

Interventions:

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1. Determine the appropriate level of care.Collaborate with the interdisciplinary team to determine the appropriate level of care. Patients with AMS related to cerebral perfusion likely require monitoring in the neuro-ICU by specially trained nurses.

2. Administer fluids and electrolytes as prescribed.Fluid resuscitation aims to improve cerebral tissue perfusion and hemodynamics. To compensate for losses and keep circulation and cellular function intact, provide fluids and electrolytes as needed.

3. Prepare the client for surgical procedure as indicated.The client may be a candidate for a surgical procedure such as carotid endarterectomy or evacuation of cerebral hematoma or lesion. The nurse must prepare for a possible surgical procedure to improve tissue perfusion in the brain.

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