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Basic Concepts of Nursing Care for Stroke

Monday, February 10, 2014

Assessment is an early stage and the foundation of the nursing process to identify client problems, in order to give direction to nursing actions. Assessment phase consists of three activities, namely data collection, data classification and formulation of nursing diagnoses. (Lismidar, 1990)

Data Collection

Data collection is to collect information about the health status of the client's overall physical, psychological, social, cultural, spiritual, cognitive, developmental level, economic status, ability to function and lifestyle clients. (Marilynn E. Doenges et al, 1998)

1) The identity of the client
Includes name, age (mostly occurs in old age), sex, education, address, occupation, religion, ethnicity, number of registers, medical diagnosis.

2) The main complaint
Typically, it is found next to the body limb weakness, speech slurred speech, and can not communicate. (Yusuf Misbach, 1999)

3) History of present illness
Hemorrhagic stroke often take place very suddenly, when the client is doing the activity. Usually occurs headache, nausea, vomiting and even seizures to unconsciousness, paralysis of half the body in addition to symptoms or other disorders of brain function. (Siti Rochani, 2000)

4) Past medical history
A history of hypertension, diabetes mellitus, heart disease, anemia, history of head trauma, a long oral contraceptives, use of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)

5) Family medical history
There is usually a family history of suffering from hypertension or diabetes mellitus. (Hendro Susilo, 2000)

6) Psychosocial history
Stroke is a disease that is very expensive. The fee for the examination, treatment and care of the family finances so may confound these cost factors can affect the stability of the emotions and thoughts of clients and families.



Functional Health Patterns

1) Health Perception Health Management Pattern
Usually there is a history of smoking, use of alcohol, use of oral contraceptives.

2) Nutritional Metabolic Pattern
Complaints difficulty swallowing, loss of appetite, nausea and vomiting in the acute phase.

3) Elimination Pattern
It usually occurs on the pattern of urinary incontinence and constipation defecation usually occurs due to decreased intestinal peristalsis.


4) Activity Exercise Pattern
The existence of the difficulty of the move as weakness, sensory loss or paralise / hemiplegi, easily tired.

5) Sleep Rest Pattern
Usually the client has difficulty to break because of a muscle spasm / muscle pain.

6) Cognitive-Perceptual Pattern
The change of relationship and role as the client has difficulty communicating due to impaired speech.

7) Self-Perception-Self-Concept Pattern
Clients feel helpless, hopeless, irritable, uncooperative.

8) Role-Relationship Pattern
At the client's pattern of sensory impaired vision / blurring sight, touch / touch declined in the face and limb pain. In the pattern of cognitive and memory decline usually thought processes.

9) Sexuality-Reproductive
Usually there is a decrease in sexual desire as a result of a stroke several treatments, such as anti-seizure drugs, anti-hypertensive, histamine antagonists.

10) Coping-Stress Tolerance Pattern
Clients usually find it difficult to solve the problem due to impaired thought processes and communication difficulties.

11) Value-Belief Pattern
Clients rarely do worship because of unstable behavior, weakness / paralysis on one side of the body.




Physical Examination

1) The general state
  • Awareness: generally experience loss of consciousness.
  • Speaking voice: sometimes susceptible to interference that is difficult to understand, sometimes can not speak.
  • Vital signs: increased blood pressure, pulse rate varies.
2) Examination of integument
  • Skin: if the client is deprived of oxygen, the skin will appear pale and if so dehydrated skin turgor right ugly. In addition it should also be assessed signs of pressure sores, especially in areas that stand out as the CVA client should Bleeding 2-3 weeks of bed rest.
  • Nails: need to see the presence of finger clubbing, cyanosis.
  • Hair: generally no abnormalities.
3) Examination of the head and neck
  • Head: shape normocephalic.
  • Advance: generally not symmetrical ie oblique to one side.
  • Neck: neck stiffness rare (Satyanegara, 1998)
4) Examination of the chest
  • In respiratory sometimes obtained breath sounds audible Ronchi, wheezing breath sounds or additional, irregular breathing due to decreased cough reflex and swallowing.
5) Examination of the abdomen
  • Obtained as a result of a decrease in intestinal peristalsis long bed rest, and sometimes there is bloating.
6) Examination of inguinal, genetalia, anus
  • Sometimes there incontinensia or urine retention.
7) Examination of the extremities
  • Often obtained paralysis on one side of the body.
8) The neurological
  • Examination of cranial nerves: cranial nerve disorder Generally there VII and XII central.
  • Motor examination: Almost always happens paralysis / weakness on one side of the body.
  • Sensory testing: May occur hemi-hipestesi.
  • Examination of reflexes: In the acute phase of physiological reflexes that paralyzed side will disappear. After a few days the physiological reflex reappears preceded by pathological reflexes. (Jusuf Misbach, 1999)

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