Nursing

Diagnosis for
Stroke Patients

Overview
Overview
Background

WHO 2007: 15 million /year. 5 million die, 5

million in disability state
Indonesia 2007: 500 000. 125 000 die & the
others disability
2

Lanjutan pendahuluan
Lanjutan pendahuluan

AANN: time is a brain

AHA & NSA: perawatan harus dilakukan 3 - 6 jam
pertama terkena serangan untuk mendapatkan hasil
yang baik saat pasien pulang.
Fase akut antara 1-3 hari perawatan memerlukan
pengawasan yang berkelanjutan terhadap semua
sistem tubuh.
3

Lanjutan pendahuluan
Lanjutan pendahuluan

Pasien stroke berisiko terhadap komplikasi

sehingga penangan harus cepat untuk mencegah
komplikasi yang lebih parah dan kematian.
Hasil pengkajian yang baik menentukan
pembuatan diagnosa yang tepat, begitu seterusnya
terhadap perencanaan, implementasi dan evaluasi
keperawatan.

Pengkajian
wawancara

Pemeriksaan fisik

Data subjektif

observasi

Data objektif
Pengelompokan
data

Nursing
diagnosis

 Carpenito, 1997 menyatakan diagnosa keperawatan

adalah suatu pernyataan yang menguraikan respon
manusia (keadaan kesehatan atau pola interaksi yang
berkesinambungan antara aktual dan potensial) dari
individu atau kelompok di mana perawat dapat secara
legal mengidentifikasi dan melakukan intervensi untuk
memelihara kesehatan.

Diagnosa keperawatan

 Bervariasi
Tergantung luas kerusakan dan kondisi pasien

Diagnosa keperawatan
stroke

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Absent cough
Adventitious breath sounds
Changes RR
Changes in respiratory rhythm
Cyanosis
Difficulty vocalizing
Diminished breath sounds
Dyspnea
Excessive sputum
Ineffective cough
Orthopnea
Reslestness
Wide-eyed

Ineffective airway
Clearance

 At risk for a decrease in cerebral tissue circulation that

may compromise health
Risk factor: carotid stenosis, aortic atherosclerosis,
cerebral aneurysm, hypertension, hypercholesterolemia,
thrombolytic therapy

Risk for ineffective

cerebral tissue perfusion

 Decreased, delayed, or absent ability to receive, process,

transmit and/or use a system symbols
Cannot speak
Difficulty expressing thoughts
Difficulty forming sentences
Difficulty forming words
Difficulty comprehending usual communication pattern
Speaks with difficulty

Impaired verbal
communication

Decreased reaction time

Difficulty turning
Limited range of motion
Slowed movement

Impaired physical
mobility

 Impairment in sensory and motor response, mental

representation, and spatial attention of the body, and the
corresponding environment, characterized by inattention
to one side and overattention to the opposite side

Unilateral neglect

 Abnormal functioning of the swallowing mechanism

associated with deficits in oral, pharyngeal or esophageal
structure or function
Dysphagia affects between one - third and one - half of
all stroke patients

Impaired swalloing

 Dysfunction in urine elimination

Incontinence
Urinary incontinence is common after a stroke, reported to
affect 32 79% of patients.
Bowel function is often affected by a stroke; up to 60% of
those in rehabilitation wards experience constipation.
Faecal incontinence is often related to functional
disability, and more than 30% of stroke patients are
incontinent of faeces at 7 10 days, 11% at three months
and later.

Impaired urinary
elimination

 Caregiver role strain

Distress spiritual

Psychososial problems