Hemorrhagic Stroke - 2 Nursing Diagnosis and Interventions

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Hemorrhagic Stroke - 2 Nursing Diagnosis and Interventions

Nursing Care Plan for Hemorrhagic Stroke

Stroke is a neurological disease that is common and must be dealt with quickly and appropriately. Stroke is a brain dysfunction arising due to sudden occurrence of circulatory disorders of the brain and can happen to anyone and at anytime.

Stroke is the most common disease-causing defects such as limb paralysis, impaired speech, memory and thought processes forms other disability as a result of brain dysfunction.

Around the world, the incidence of stroke average of about 180 per 100,000 per year (0.2%) with a prevalence rate of 500-600 per 100,000 (0.5%).

In fact, many patients who came to the hospital in a state of decreased consciousness (coma). Such circumstances require special handling and care are: general, special, rehabilitation and discharge planning clients.

Knowing the circumstances mentioned above, the role of the nurse in collaboration with other health care team is needed both acute period, or thereafter. That can be implemented include overall health care, ranging promotive, preventive, curative to rehabilitation.


Hemorrhagic Stroke

Definition

Acute neurological dysfunction caused aleh as circulatory disorders of the brain, where it suddenly (several seconds) or quickly (a few hours) symptoms and signs corresponding to the focal area of disturbed tampered. (Djunaedi W, 1992).

According to Hudak and Gallo in the critical care book launch hemorrhagic CVA sudden onset and lasts 24 hours as a result of cerebrovascular desease.



Nursing Diagnosis for Hemorrhagic Stroke

1. Risk for Ineffective airway clearance related to the decline cough reflex.

Goal: not an interruption in airway clearance

Outcomes:
regular respiration, no stridor, Ronchi, whezing, RR: 16-20 x / min, no cough reflex.

Interventions:

1. Observe the speed, depth and breath sounds.
R /: respiratory rate indicates the body's attempt to meet the needs of O2.

2. Perform suction with extra caution when audible stridor.
R /: decreased cough reflex, causing bottlenecks spending secretions.

3. Maintain a half-sitting position, not pressed to one side.
R /: Ventilation easier when the position of the head in a neutral position, causing the emphasis to one point increase in ICT.

4. Perform chest physiotherapy.
R /: claping and vibrating cilia stimulates bronchial secretions to issue

5. Explain to the family about the change position every 2 hours.


2. Imbalanced Nutrition Less Than Body Requirements related to muscle weakness swallow.

Goal: Nutritional needs of clients are met.

Outcomes: either turgor, the intake can be entered in accordance
needs, there is the ability to swallow, the sonde is removed, increased weight 1kg.

Intervention:
1. Observations texture, skin turgor.
R /: to know the client's nutritional status.

2. Perform oral hygiene.
R /: oral hygiene stimulate appetite.

3. Observation intake out put.
R /: to know the client's nutritional balance.

4. Observation position and the success of the sonde
R / menghundari risk for infection / irritation

5. Collaboration:
- Provision of diet / sonde on schedule
R / help meet the nutritional needs of the client because the client swallow reflex decrease.

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