Nursing Care Plan Stroke

Friday, January 15, 2010

Assessment
1. Primary Assessment
o Airway.
The existence of a blockage / obstruction of the airway by a
buildup of secretions from a cough reflex weakness.
o

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
o 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.
o

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).
o

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.

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