STROKE REPORT INTRODUCTION

A. DEFINITION Stroke or cerebrovascular injury is the loss of brain function caused by the cessation of blood supply to part of the brain is often the culmination of cerebrovascular disease for several years . ( Suzanne C. Smeltzer , 2002 in expression - blogspot 2008) .

A stroke is a sudden loss of brain function caused by the interruption of blood supply to part of the brain ( Brunner & Suddart : 2002) .

According to ( Marilyn E , Doenges : 2000 ) stroke / cerebrovascular disease showed some abnormalities of brain functional and structural ba caused by the pathological state of the cerebral blood vessels or vascular system of the whole brain . Tampered circulatory disorders ( GPDO ) , or known as CVA ( Cerebral Vaskuar Accident ) is a neurodegenerative disorder caused by an interruption of blood flow in the brain can occur suddenly ( within seconds ) or rapidly ( within hours ) with symptoms or signs corresponding to the disturbed area . ( Harsono , 1996) . Stroke is a clinical manifestation of disturbance of cerebral function , both local and overall ( global ) , which takes place quickly , lasting more than 24 hours , or ends with death , without finding the cause other than vascular disorders . B. Etiology The 1 . Thrombosis ( clot fluid causes in the blood vessels of the include: brain ) .

Is the most frequent cause of stroke in the encounter that is 40 % of all stroke cases that have been proven by pathologic experts . Usually closely related to local damage blood vessel 2 . Cerebral walls embolism ( a due blood clot to or other atherosclerosis material ) .

Most cerebral emboli originating from the heart so that flowess a problem faced is actually a manifestation of heart disease .

3 . Ischemia (decrease blood flow to an area of the brain ) . ( Suzanne C. Smeltzer , 2002 ) .

Risk 1

factors .

in

stroke

: hypertension

2 . Cardiovascular disease : the coronary artery , congestive heart failure , atrial fibrillation , congestive 3 4 5 6 . . Increased Diabetes hematocrit mellitus ( ( . . the risk with of cerebral heart high disease ) cholesterol obesity infarction atherogenesis ) )

associated

accelerated

7 . Kontrasepasi oral ( especially with accompanying hypertension , merkok , and high estrogen 8 . Drug levels abuse ( cocaine ) )

9 . Consumption of alcohol ( Suzanne C. Smeltzer , 2002, p 2131 ) . C. SIGNS and SYMPTOMS According Pujianto (2008 ) , a stroke can cause a variety of neurologic deficits , depending on the location of the lesion ( where the blood vessels are clogged ) , size of the area perfusinya inadequate , and the amount of collateral blood flow ( secondary or accessory ) . Signs and symptoms appear in patients with stroke include:

1 . Loss of motor : hemipelgi ( paralisys on a side ) due to lesions in the brain opposite the session , hemiparesis , or weakness of one side of the body

2 . loss of communication : dysarthria ( difficulty speaking ) , dysphasia or aphasia ( loss of speech or speech deektif ) , apraxia ( inability to perform previously learned actions ) . 3 . Disorder per se psi : visual perception dysfunction , impaired visual-spatial relationships , sensory 4 5 . Cognitive . impairment Bladder loss and psychological dysfunction effects . . .

Association of stroke recovery in New South Wales performed with an acronym to make people know when they are in danger of a stroke , or have experienced it without realizing that DANGER ( Henderson , 2002:10 )

1 . Dizziness or unsteadiness ( dizziness or feeling remains in the hands or on the hands and or 2 . A change in mental eyes abilities ( a change in mental abilities ) )

3 . Numbness , weakness , or paralisys in the face , arm or leg on one side of the body (

numbness, weakness , or paralysis of the face, or leg on one side of the body ) 4 . Garbled speech or inability to speak ( speech garbled , or distorted his words , or the inability to speak )

5 . Pproblem eye ( eye problems ) bleak vision that suddenly occur in one eye or double vision .

6 . Report to your doctor immediately ( report to your doctor immediately ) because these symptoms recovered rapidly and perhaps there will be no second warning .

D. Investigations 1 . Radiological Investigations

There are two types of imaging examination techniques ( imaging ) to evaluate cases of stroke or cerebral vascular disease ( disease cerebrovasculer / CVD ) is computed tomographi ( CT scan ) and magnetic resonance imaging ( MRI ) .

CT scan imaging detector known as the most easy , fast and relatively inexpensive for the case of stroke . But in some cases , a CT scan is less sensitive compared to MRI , for example in the case of hyperacute stroke .

To meperkuat diagnosis is usually performed CT scan or MRI . Both of these checks could also help determine the cause of stroke , whether perdarhan , or brain tumors . sometimes performed angiography is the determination of the composition of the blood vessels 2 a. or lymph . creatinine through kapilaroskopi Laboratory fluproskopi .

Investigations phosphokinase

This examination to mengetaui kidney function , also showed massive muscle damage . Examination of these enzymes to determine the levels found in skeletal muscle . Creatinine is a product of muscle breakdown . Creatinine is secreted by the kidneys through filtration and b . GDS secretion ( when kpombinasi blood sugar . )

Examination showed blood sugar when glucose levels in the blood . The state of hyperglycemia or hypoglycemia can lead to the existence of a wider exacerbations . Normal values c ppada stroke patients . > 200 mg / dl .

cholesterol

Cholesterol is a complex compound produced by the body for various functions . Cholesterol from food will increase blood cholesterol . The higher the cholesterol the higher

the likelihood of cholesterol accumulate in the blood vessels . Excess cholesterol will react vessels Daran another substance that settles on the arteries , causing narrowing of the arteries , known as atherosclerosis . The normal value of 150-270 mg / dl depending on age appropriate d . HMT ( hematocrit . )

Hematocrit is the volume of red blood cells in 100 ml . pda cases of stroke is usually an increase in hematocrit . Hematocrit examination done to determine the concentration of red blood cells ( erythrocytes ) in the blood . The smaller the hematocrit increased oxygen content is taken . Value of 40-54 % in men and in women 38-47 % . 3 . Neurological Investigations

a. Glasgow Coma Scale ( GCS ) to determine the level of consciousness of the patient . b c d e f . Pupillary . . . . response The Blood Respiratory The to pulse pressure rate temperature mengetaui rate is is is whether usually usually usually usually there is dilation . . . . .

decreases increased decreased increased

E. Pathophysiology Stroke non hemoraghi divided into thrombotic strokes and embolic stroke . At thrombotic stroke , occlusion due to a blockage of the lumen of blood vessels of the brain due to a growing thrombus Plama increasingly thickened , so that blood flow is not smooth . This decreased blood flow causes ischemia which continues into infarction . Within 72 hours the area will experience edema and necrosis over time will . The most common location of the stroke trobosis is branching large carotid and vertebral artery associated with basilar artery . Trombosik stroke onset is usually slow .

While embolic stroke occurs due to emboli released in other parts of the body up to the carotid artery , emboli are trapped in the blood vessels of the brain that are smaller and usually in areas branching lumen is narrowed carotid arteries in the middle or the Middle Carotid Artery ( MCA ) . With the obstruction by emboli will also cause ischemia ( Pujianto , 2008) Ischemic effects vary with the degree of blood flow length of offending , where a reduction in the blood flow can cause moderate functional impairment only temporary and not permanent damage as occurs in severe ischemia . Effects can cause ischemic lesions in nerve motor

function consisting of lesions in frontal ( temporal and frontal ) , lesions in the internal capsule , and cortical pyramidal lesions on the set of coordination and lesions in the brain stem ( Harsono , 2003:87 ) .

Lesions can occur in the temporal lobe and the frontal lobe . Temporal lobe lesions that attack can cause receptive dysphasia , whereas frontal lobe lesions that attack can cause expressive dysphasia ( Price, 1995:966 ) . In patients who experience stroke symptoms can be decreased so that the coordination of talk that can cause damage to the verbal communication of nursing issues .

Lesions may occur in the internal capsule which can then attack the face , the vagus nerve , and the nerve glosofaring , skeletal muscle and tongue and both upper and lower extremities ( Price, 1995:966 ) . Lesions that invade the vagus nerve glosofaring and can cause difficulty swallowing and can result in damage to the nursing problems swallowing . Of these problems can cause nutritional problems less risk than the body needs .

Lesions in the internal capsule will also affect the function of the extremities , so that stroke survivors can experience symptoms of paralysis contralateral (price , 1995:966 ) that causes damage to physical mobility nursing problems . While that attack the brain stem lesions may disrupt the nervous system that regulates breathing , which can cause problems nursing ineffective breathing pattern .

Thrombus and embolus carried sampaiotak and cause blockage of cerebral arteries will increase intracranial pressure . Increased intracranial pressure can cause narrowing of the artery walls emphasis sehinggan cerebral O2 supply will decrease and can cause problems nursing perfusin ineffective cerebral tissue . Because of shortage of O2 earlier , the brain will tell menyebabklan accumulation of lactic acid , so people who experience a stroke will experience metabolic acidosis and loss of consciousness ( coma ) (price : 1995:966 )

G. ASSESSMENT FOCUS 1 . Identity / Biographical Data Client

Name , TTL , last education , blood type , religion , marital status , address , phone , sex , the closest person to be contacted , the relationship with the elderly , address and sex of the 2 person . / family Family is . History

a) Spouse : life / death , health , age , occupation , address , death , cause of death ,

meningggal

year

b ) Children : life / death , the name , address , year of death , cause of death .

Employment

History

Current employment status , previous employment , income sources and adequacy to the needs , work address , work from home distance , means of transportation . 4 . Environmental History

Type residence / home , number of rooms , number of levels , the number of people who tingggal home / dipanti , degree of privacy , nearest neighbor , address / phone , home conditions 5 . History . Recreation

Hobby / interest , membership organization , vacation trips , activities of anti dip . 6 . Sources / Supporting Sisitem used

The doctor / nurse / midwife / physiotherapy , etc. . Hospitals , clinics , other health services , distance from home / nursing , home health services / homes , food delivered piping , 7 Religion 8 . , nurses . bed rest , worship Current daily by the Ritual habits , beliefs health , ritual family . habits meal .

status

Health status for 1 year and 5 years ago , the main health complaints ( PQRST ) , knowledge / understanding and management of health problems , the degree of overall functions relative to health issues and medical diagnostics .

Reason a

entered )

homes

: Drugs

The name and dose of medication , time and manner of use , physician members , the date and b issue ) prescriptions for immunization drugs . status

Latest date immunization against tetanus , diphtheria , PPD , influenza , etc. . c ) Allergies , food ( , note the agents substances ) ) and , the specific reaction factors ) .

Drugs d e

contact

environmental

Illness Nutrition

24 hour diet , history of improvement and weight loss , problems of nutrition , habits .

Health

Status

of

the

Past

Childhood diseases , penyaki serious or chronic , trauma , hospitalization ( reason , date , place , duration , physician , nurse ) , operation ( type , date , place , reason , clinicians , outcome 10 , treatment . ) , System obstetric history .

Overview

Assess whether there is any sign of any of the following symptoms : a) General Situation

Fatigue , changes in BB last year , changes in appetite , fever , night sweats , kesulian sleep , frequent colds and infections , self-assessment of all health status , ability to perform ADLs , level b of consciousness ( qualitative ) , quantitative ) , TTV

Integument

Lesions / sores , pruritus , pigmentation changes , texture changes , changes in nevi , often bruising , changes signs , changes in nails , corns on the toes and kallus , patterns and lesion healing c bruises , ) elasticity / turgor .

Hemopoetik

Bleeding / bruising abnormal , swollen lymph nodes , anemia , history of blood transfusion . d ) Head

Headache, trauma in the past , dizziness , itchy scalp , lesions / sores . e ) Eye

Vision changes , use of glasses / contact lenses , pain , excessive tears , pruritus , swelling around the eyes , floater , diplopia , blurred , photophobia , skomata , history of infection , the date f of the final inspection , the ) impact on the appearance of ADL .

Ear

Hearing changes , discharge , tinnitus , vertigo , hearing sensitivity , denture equipment , history of infection , date of the final examination , ear care habits , the impact on the appearance g) the of nose ADL and . sinuses

Rhinorrhea , discharge , epistaxis , obstruction , snoring , sinus pain , post nasal drip , allergies h , history ) of infections The , self-assessment mouth on the olfactory ability .

and

throat

Sore throat , lesions / ulcers , hoarseness , voice changes , difficulty swallowing , bleeding gums , caries , prosthetic devices , history of infection , the date of the final inspection , the pattern of brushing your teeth , flossing patterns , problems and the habit of cleaning dentures .

Neck

Stiffness , pain / tenderness , lumps / masses , limitation of movement , enlargement of the thyroid j ) gland . Breast

Lump / mass , pain / tenderness , swelling , discharge from the nipple , breast examination pattern k , the end ) date of mammography .

Respiratory

Cough , sesaknafas , hemoptysis , sputum , wheezing , asthma / allergies , respiratory frequency l , auscultation , ) palpation , percussion , wheezing .

Cardiovascular

Pain / chest discomfort , palpitations , shortness of breath , dipsnea on activities , dipsnea noktural paroksimal , orthopnea , murmurs , edema , varicose veins , leg crippled , paresthesias , leg discoloration .

Gastrointestinal

Dysphagia , can not digest , heartburn , liver enlargement , nausea / vomiting , hematemesis , appetite change , food intolerance , ulcers , pain , jaundice , lumps / masses , changes in bowel habit , diarrhea , constipation , melena , hemorrhoids , bleeding rectum , defecation pattern n ) usually . urinal

Dysuria , frequency , dripping , doubt, encouragement , hematuria , polyuria , oliguria , nocturia o , inkontenensia ) , pain during Male urination , stones , infection .

Reproductive

Genitor

Lesions , discharge , testicular pain , testicular mass , testicular mass , prostate problems , venereal disease , change in sexual desire , impotence , problems of social activity . p ) Women's Reproductive Genitor

Lesions , discharge , dyspareunia , bleeding after intercourse , pelvic pain , cystocele / rectocele / prolapse , venereal disease , infection , problems of sexual activity , menstrual history , ( menarche , date of last menstrual period ) , the date and results of last pap smear . q ) Musculoskeletal

Joint pain , stiffness , joint swelling , deformity , spasm , cramps , muscle weakness , gait problems , back pain , prosthesis , exercise habit patterns , impact on ADL performance . r ) System CNS

Headache , seizures , syncope / drop attacks , paralysis , paresis , coordination problems , tic / tremor s / spasm , ) paresthesia , head injury , memory problems .

Endocrine

System

Heat or cold intolerance , goiter , skin pigmentation / texture , hair changes , polyphagia , polydipsia t Vulnerability u Decreased v Increased ) and ) often ) taste System olfactory salty of affected by , polyuria Immune the disease , . System immunization .

System and

Tasting hot smell system

Psychosocial

Anxiety, depression , insomnia , crying , nervousness , fear , problems in making decisions , difficulty concentrating , feelings of general statement about the decision / frustrating usual coping mechanisms , stress at this time , the issue of death and loss , the impact of ADL performance .

H. Nursing Diagnosis 1 . Changes in cerebral tissue perfusion berhubungan.dengan interruption of blood flow : occlusive disease , hemorrhage , cerebral vascular spasm , cerebral edema . Definition : a state in which an individual experiencing or at risk of experiencing a decline in nutrition and respiration at the cellular level due to a decrease in capillary blood supply . Defining characteristics ( Doenges , ME : 2000 )

Major : changes in the level of consciousness , loss of memory , changes in response to motor / sensory , emotional , sensory deficits , language , intellectual and emotional 2 . Damage to physical mobility related to neuromuscular involvement , weakness , paresthesias , flaccid / hypotonic paralysis , spastic paralysis .

Definition : a state where an individual experiencing or at risk of limitation of physical movement Defining Major Minor : : characteristics decreased restriction ability of but ( to Carppenito move not , L.J limited , : range to immobile 2000 of )

purposefully imposed

motion .

movement

reluctant

move

3 . Damage verbal communication associated with damage to the cerebral circulation , neuromuscular , loss of tone / control muscle fascia / oral

Definition : a state in which an individual experiences / can experience a reduced ability or inability to speak but can understand other people . ( Carpeniti , LJ , 2000 ) Defining damage articulation , disatria , inability to speak , mention characteristics the words .

4 . Sensory perception changes associated with changes in sensory perception , neurological trauma .

Definition : objec where individuals or groups experiencing or at risk of experiencing a change Defining 5 . Self-care deficit related to neuromuscular Disorientation Changes in of time patterns Concentration of , place behavior / , in the number , pattern or interpretation stimulius coming .

characteristics person response decreases hallucinations damage

I. FOCUS OF INTERVENTION 1 . Changes in cerebral tissue perfusion berhubungan.dengan interruption of blood flow : occlusive Objectives intervention 1 2 3 4 ) Location ) of ) Monitor neurological ) the client rather ditn status every few hours ( measuring GCS ) there improvement level disease , hemorrhage and are of no cognitive of , cerebral expected signs function of , vascular spasm , cerebral edema : ICP sensory improved

outcomes increased motor ,

consciousness

Measure head somewhat drug upright

TTV elevated delivery

Collaboration

2 . Damage to physical mobility related to neuromuscular involvement , weakness , paresthesias , flaccid / hypotonic paralysis , spastic paralysis .

Objectives -

and Maintaining Maintaining the

expected optimal integrity

outcomes patient of the

: positioning skin

intervention 1 2 3 ) ) Change Train ) the the active client's and position passive of range right of the oblique motion in left the bertahapp extremities area

Observation

affected

3 . Damage verbal communication associated with damage to the cerebral circulation , neuromuscular Objectives Clients Clients can are identify able an to , loss of and understanding express a of desire tone / control muscle fascia / oral

expected the problems appropriate of level

outcomes communication of desire

intervention 1 2 3 4 ) ) ) Use ) Pinta open-ended the Assess patients questions family the to with to degree follow answers stay " in of simple yes touch " / dysfunction commands " no "

Encourage

with

clients

4 . Sensory perception changes associated with changes in sensory perception , neurological trauma Objectives Clients Increased intervention 1 2 3 ) ) ) Evaluation Assess Give the the of awareness stimulation visual of of disturbance sensations touch can maintain and the level expected of , consciousness outcomes and function . : persptual behavior

ability

demonstrated

5 . Self-care deficit related to neuromuscular damage , decrease in strength , muscle coordination Objectives Clients Can can demonstrate and techniques to expected meet in the the needs of ability outcomes self-care level

perform

self-care

activities

intervention 1 2 ) ) Assess Provide the assistance level to of clients katergantungan as needed

Beikan

positive

feedback

for

every

business

REFERENCES

Long C , Barbara , Medical Surgical Nursing , Volume 2 , London , Foundation for Nursing Education Alumni Association Padjadjaran , 1996.

Tuti Pahria , et al , Nursing Care in Patients with disturbances Persyarafan System , Jakarta , EGC , 1993.

Health Manpower Education Center Department of Health , Nursing Clients Impaired Innervation System , Jakarta , Ministry of Health , 1996 .

C. Smeltzer Suzanne , Brunner & Suddarth , Textbook of Medical Surgical Nursing , Jakarta , EGC , 2002.

Marilynn E , Doengoes , 2000 , Nursing care plan , Issue 3 , Jakarta , EGC , 2000 .

Harsono , Textbook : Clinical Neurology , Yogyakarta , Gadjah Mada University Press , 1996.