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Nursing assessment in stroke patients

Nursing assessment in stroke patients

 

Stroke or cerebrovascular injury is a 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, p 2131)

 

 

Nursing assessment in stroke patients
1. Activity and rest
Subjective Data:
- Difficulties in the move; weakness, loss of sensation or paralysis.
- Tiredness, trouble breaks (pain or muscle spasms)
Objective data:
- Changes in the level of consciousness
- Changes in muscle tone (flaccid or spastic), paraliysis (hemiplegia), general weakness.
- Impaired vision
2. Circulation
Subjective Data:
- History of heart disease (heart valve disease, dysrhythmias, heart failure, bacterial endocarditis), polycythemia.
Objective data:
- Arterial Hypertension
- Dysrhythmias, ECG changes
- Pulsation: the possibility of varying
- Pulse carotid, femoral and iliac artery or abdominal aorta
3. Ego integrity
Subjective Data:
- Feelings of helplessness, despair
Objective data:
- Emotions are unstable and improper angry, sadness, joy
- Difficulties to express themselves
4. Elimination
Subjective Data:
- Incontinence, anuria
- Abdominal distension (bladder is very full), the absence of bowel sounds (paralytic ileus)

5. Eating / drinking
Subjective Data:
- Appetite lost
- Nausea / vomiting indicates PTIK
- Loss of sensation of the tongue, cheeks, throat, dysphagia
- History of DM, Increased fat in the blood
Objective data:
- Problems in chewing (decreased reflexes palate and pharynx)
- Obesity (risk factors)
6. Sensory neural
Subjective Data:
- Dizziness / syncope (prior CVA / TIA while over)
- Headache: the intra-cerebral hemorrhage or sub arachnoid hemorrhage.
- Weakness, tingling / numbness, affected side looks like a lame / off
- Vision is reduced
- Touch: loss of sensors on the collateral in the extremities and the face ipsilateral (same side)
- Impaired sense of taste and smell
Objective data:
- Mental status; coma stage is usually marked bleeding, behavioral disturbances (such as: letergi, apathy, attack) and impaired cognitive function
- Extremity: weakness / paraliysis (contralateral to all types of stroke, uneven hand grip, reduced deep tendon reflexes (contralateral)
- Face: paralysis / parese (ipsilateral)
- Aphasia (damage to or loss of the function of language, expressive possibility / difficulty saying the word, receptive / difficulty saying the word comprehensive, global / combination of both.
- Loss of the ability to know or see, auditory, tactile stimuli
- Apraxia: lose the ability to use motor
- Reaction and pupil size: not dilated and did not react on the lateral side
7. Pain / comfort
Subjective Data:
- Headache varying intensity
Objective data:
- Unstable behavior, anxiety, muscle tension / facial
8. Respiration
Subjective Data:
- Smokers (risk factors)
Signs:
- Weakness swallow / cough / protect the airway
- The emergence of difficult breathing and / or irregular
- Voice breath sounds ronchi / aspiration
9.Keamanan
Objective data:
- Mottrik / sensory: problems with vision
- Changes in the perception of the body, difficulty seeing objects, missing kewasadaan to the sick body
- Not being able to recognize objects, colors, words, and faces never recognized
- Disturbance respond to heat, cold and / disturbances in body temperature regulation
- Disturbance in deciding, little attention to security, reduced self-awareness
10. Social interactions
Objective data:
- Problem speech, inability to communicate
11. Teaching / learning
Subjective Data:
- A family history of hypertension, stroke
- The use of oral contraceptives

12. Consideration home plan
- Determine the medication regimen / therapy treatment
- Assistance to transportation, shopping, meal preparation, personal care and domestic work
(DoengesE, Marilynn, 2000 case 292)

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