Self-care deficit related to Stroke

Nursing Care Plan for Stroke : Self-care deficit


Definition of Stroke

Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly (within seconds) or raised quickly (within hours) with symptoms and signs corresponding to the focal area disturbed.

Cerebrovascular accident (CVA) also called Stroke is a condition in which the occurrence of neurological deficits caused by decreased blood flow to certain areas of the brain tissue.
Neurological deficits caused by ischemia caused necrotising cells in brain tissue in various areas of the brain.

In the U.S., stroke is the third leading cause of death after heart disease and cancer. This disease can be prevented or minimized by efforts: blood pressure under control, increase awareness of the necessary diet and avoid smoking.


Etiology of Stroke

The occurrence of stroke is caused by the presence of thrombi and emboli that cause the narrowing or occlusion of one of the perfect blood vessels that supply blood to the brain, also if there is bleeding (hemorrhagic). Stroke due to pressure on the walls of blood vessels and arteries spasm, rarely encountered.

1. Thrombosis:

Is the formation of blood clots in blood vessels that can lead to narrowing of the lumen of a blood vessel blockage even happen. Thrombosis is a major cause of cerebral infarction. Two-thirds of strokes are caused by thrombosis due to hypertension and diabetes mellitus both of which can lead to atherosclerosis.

Another factor that can be at risk of thrombosis is an oral contraceptive, coagulation disorders, polycithemia, arteritis, chronic hypoxia, and dehydration. Thrombosis occurs as a result of the formation of atheroma thus narrowing the lumen of blood vessels. Thrombus causing hypoperfusion, infarction and ischemia.

At first occurred paresis (decrease / reduction in force and limb movement), aphasia (language function disorder), paralysis, impaired consciousness, visual disturbances.

2. Embolism:

Blockage / cerebral artery occlusion by an embolus, which resulted in necrosis and edema in the area supplied by the blood vessel blockage.

Embolism is the second leading cause of stroke. Generally derived from the inner lining of the heart (endothelial) where plaque is formed which is then separated and flowed in the blood circulation. If embolism is walking / running on the smaller blood vessels then place it will clog embolism or vascular branching.
Embolism associated with disease / heart problems, namely atrial fibrillation, cardiac infarction, infective endocarditis, rheumatic heart disease, and atrial septal defect. Another cause is not often that air embolism, fat embolism due to fracture femor, amniotic fluid after delivery, and the presence of a tumor.

The attack is sudden. The patient is fully conscious, although patients also feel headache. Prognosis depends location of the blood vessel blockage.

3. Intracerebral hemorrhage:

Bleeding in the brain caused by the rupture of a blood vessel. Intracerebral hemorrhage is usually caused by the presence of hypertension. Another cause is a brain tumor, trauma, thrombolytic treatment, and aneurysm rupture.
Hypertension and atherosclerosis cause degenerative change in the artery walls, causing rupture and hemorrhage. Blood mass will suppress brain tissue. This pressure causes the brain tissue of urgency and decreased blood flow to the brain due to ischemia and infarction.

The area that is often experienced intracerebral hemorrhage putamen and the internal capsule (50%), thalamus, brain hemisper, and pons. Clients will experience a severe headache, nausea and vomiting, loss of ability to walk, dysphagia, eye movement disorders. Bleeding in the post is very dangerous because it is part of the basic life functions. Pons can lead to bleeding in hemiplegia, coma, hyperthermia, and subsequently died.

The prognosis is very bad intracerebral hemorrhage: 70% of patients died due to intracerebral hemorrhage.

4. Subarachnoid hemorrhage:

Caused by the aneurysm, vascular abnormalities, trauma, and hypertension. Aneurysms often occur in patients with atherosclerosis, trauma, hypertension, or vascular abnormalities that are usually congenital bleeding can also be caused by anticoagulant treatment, treatment trhrombolitik, and symphatomimetic.

Bleeding that occurs suppress arachnoid space and cause headache, dizziness, loss of consciousness, nausea, vomiting, fever, pain in the neck and back, paralysis, coma, and later died.


Prevention of Stroke

Primary prevention is to avoid the risk of public health education. Maintain body weight and cholesterol within normal limits, and avoid smoking or using oral contraceptives. Treatment / control diabetes, hypertension and heart disease.

Provide information to clients in connection with the illness with strokes. If already had a stroke, in this situation the goal is to prevent the occurrence of complications with respect to stroke and myocardial wider in the future. In the event of immobility will increase the risk of injury in connection with paralysis and aspiration of the airway. Further Prevention is monitoring the risk factors that can be identified.


Nursing Diagnosis for Stroke : Self-care deficit related to decrease in strength and endurance.

Goal:

Patients can help themselves according to their needs, and be able to express their needs.

Intervention:

1. Assess the capability and level of deficiency to perform day-to-day needs.
2. Maintain support, with a strong attitude.
3. Give positive feedback for any thing done or success.
4. Avoid doing something for patients to do their own patients, but provide assistance as needed

Rational:

1. Assist in anticipating / planning meeting individual needs.
2. Patients will require empathy, care giver to know that will help patients consistently.
3. Increase feelings of self meaning.
4. The patient may be very frightened and very dependent.

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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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Nursing Interventions for Impaired Physical Mobility related to Stroke

Nursing Diagnosis and Interventions for Impaired Physical Mobility

In general, vascular disorders of the brain or stroke is a disorder of cerebral circulation. Is a focal neurologic disorder that can occur secondary to a pathological process in the cerebral blood vessels, such as thrombosis, embolus, rupture the vessel wall or vascular disease basis, such as atherosclerosis, arteritis, trauma, aneurysm and developmental abnormalities.

Stroke can also be interpreted as a functional disorder of the brain that are:

• and focal or global
• acute
• last between 24 hours or more
• caused disturbances of brain blood flow
• not caused by tumor / infection

Classification based on pathology:

1. Hemorrhage stroke: a stroke that occurs because blood vessels in the brain ruptures causing ischemic and hypoxia in the downstream. Causes of hemorrhage stroke include: hypertension, aneurysm rupture, arterivenosa malformations,

2. Non-hemorrhage stroke: stroke caused by embolus and thrombus.


Nursing Diagnosis for Stroke: Impaired Physical Mobility related to neuromuscular weakness, the inability of cognitive perception

Evidenced by:

Inability to move, on the physical environment: weakness, coordination, limited range of motion, decreased muscle strength.

The patient goals / evaluation criteria;

• No contractures, foot drop.
• There is an increasing function of the ability of feeling, or compensation of the body
• Appears behavioral skills / engineering activities
• The maintenance of skin integrity

Nursing Interventions: Impaired Physical Mobility - Nursing Care Plan for Stroke

Independent

• Change position every two hours (prone, supine, oblique)
• Start training active / passive range of motion in all extremities
• Support your limb in a functional position, use a foot board at the time during the period of paralysis. Keep head in neutral.
• Evaluate the use of assistive devices regulatory position
• Help improve sitting balance
• Help manipulated to influence the skin color of edema or normalize circulation
  
  

Collaborative

• Consul assigned to physiotherapy
• Assist in electrical stimulation gave the
• Use a special bed as indicated

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