Nursing Care Plan Stroke

Assessment

1. Primary Assessment
   • Airway.
     The existence of a blockage / obstruction of the airway by a buildup of secretions from a cough reflex weakness.
   
   
   • Breathing.
     Weakness swallowing / cough / protect the airway, the emergence of difficult breathing and / or irregular, the breath sounds heard Ronchi / aspirations.
   
   
   • Circulation.
     Blood pressure may be normal or increased, hypotension occurred in an advanced stage, tachycardia, normal heart sounds at this early stage, dysrhythmias, skin and mucous membranes pale, cold, cyanosis in advanced stages.
   
   
2. Secondary Assessment
   • Activity and rest.
     Subjective Data :
     • difficulties in activities; weakness, loss of sensation or paralysis.
     • Easy fatigue, difficulty resting (pain or muscle spasms).
     Objective Data :
     • change the level of consciousness.
     • Changes of muscle tone (flaksid or spastic), paraliysis (hemiplegia), general weakness.
     • Disturbance of vision.
     
     
   • Circulation
     Subjective Data :
     • History of heart disease (heart valve disease, dysrhythmias, heart failure, bacterial endocarditis), polycythemia.
     Objective Data :
     • Hypertension arterial
     • Dysrhythmias, ECG changes
     • Absent: possibilities vary
     • Pulse carotid, femoral and iliac artery or abdominal aorta.
     
     
   • The integrity of the ego
     Subjective Data :
     • Feelings of helplessness, loss of hope.
     Objective Data :
     • unstable emotions and anger is not appropriate, kesediahan, joy.
     • Difficulty of expression itself.
     
     
   • Elimination
     Subjective Data :
     • incontinence, anuria
     • abdominal distension (very full bladder), the absence of bowel sounds (ileus paralitik)
     
     
   • Eating / drinking
     Subjective Data :
     • appetite loss.
     • Nausea / vomitus indicates PTIK.
     • Loss of sensation of the tongue, cheek, throat, dysphagia.
     • History of DM, fat in the blood increase.
     Objective Data :
     • Problems in chewing (decreased reflexes palate and pharynx)
     • Obesity (risk factor).
     
     

Nursing Diagnosis

1. Changes in tissue perfusion cerebral blood flow dissolution bd: occlusive disease, bleeding, cerebral vascular spasm, cerebral edema.


2. Damage to physical mobility bd neuromuscular involvement, weakness, paraesthesia, flaksid / hypotonic paralysis, paralysis spastis. Damage perceptual / cognitive.

Intervention

Nursing Diagnosis 1. :
Changes in tissue perfusion cerebral blood flow dissolution bd: occlusive disease, bleeding, cerebral vascular spasm, cerebral edema.
Results Criteria:
* Preserved and rising levels of consciousness, cognition and function of sensory / motor.
* Reveal stabilization of vital signs and no PTIK.
* The role of patients did not reveal any deterioration / relapse.
Intervention:
Independent
* Determine the factors associated with the factor of individual situations / causes of coma / decrease in cerebral perfusion and the potential PTIK.
* Monitor and record the status of regular neurologist.
* Monitor vital signs.
* Evaluation of pupils (size and shape common reaction to light).
* Help to change the view, misalnay blurred vision, visual field changes / perceptual field of vision.
* Help improve the functions, including speaking, if the patient's impaired function.
* Head dielevasikan land softly on the neutral position.
* Keep tirah lying, provide a quiet environment, set up visits according to indications.
* Provide supplemental oxygen according to indications.
* Give medications as indicated:
o Antifibrolitik, eg aminocaproic acid (amicar).
o Antihypertensives.
o peripheral vasodilator, eg cyclandelate, isoxsuprine.
o mannitol.

Nursing Diagnosis 2. :
Ineffective airway clearance bd damage cough, inability to handle mucus.
Results Criteria:
* The patient showed airway kepatenan.
* Symmetrical chest expansion.
* The sound of breathing clean when auscultation.
* There is no sign of respiratory distress.
* GDA and vital signs within normal limits.
Intervention:
* Review and monitor breathing, coughing and secretion reflexes.
* Position the body and head to avoid airway obstruction and provide optimal secretion expenses.
* Sucking secretion.
* Auscultation chest to listen to the sound of the airway every 4 hours.
* Provide appropriate oxygenation advice.
* Monitor Hb as BGA and indications.