- The general state
Awareness: Generally, decreased consciousness
The voice spoke: Some disorders are difficult to understand, sometimes can not talk
Vital signs: increased blood pressure, pulse rate varied.
- Examination of Integument
Skin: If the client is less oxygen skin will look pale. If less fluid, it's ugly skin turgor. In addition, it should also be assessed signs of pressure sores, especially on areas that stand out as the client CVA Bleeding should bed rest 2-3 weeks
Nails: Need to see a finger clubbing, cyanosis
Hair: Generally no abnormalities
- Examination of the head and neck
Head: Shape normocephalic
Advance: Generally not symmetrical is lopsided to one side
Neck: Stiff neck rare (Satyanegara, 1998)
- Examination of the chest
In breathing audible breath sounds sometimes obtained ronchi, wheezing breath sounds or additional, irregular breathing due to decreased cough reflex and swallowing.
- Examination of the abdomen
Obtained decrease intestinal peristalsis caused by bed rest periods, and sometimes there are bloated.
- Examination of inguinal, genital, anal
Sometimes there incontinensia or urinary retention.
- Examination of the extremities
Often obtained paralysis on one side of the body.
- Examination of neurology
- Cranial Nerve
Generally there is interference with cranial nerve VII and XII central.
Almost always happens paralysis / weakness on one side of the body.
Hemihypesthesia can occur.
In the acute phase of physiological reflexes are paralyzed side will disappear. After several days of physiological reflexes will reappear didahuli with pathological reflexes.
- Cranial Nerve
Investigations of Stroke
- Radiological Examination
- CT scan: hyperdense focal obtained, sometimes get in the ventricles, or spread to the brain surface. (Linardi Widjaja, 1993)
- Magnetic resonance imaging (MRI) to show the area that experienced hemorrhagic. (Marilynn E. Doenges, 2000)
- Cerebral angiography: to find the source of bleeding such as aneurysms or vascular malformations. (Satyanegara, 1998)
- X-ray of the thorax: to show the state of the heart, whether there is an enlargement of the left ventricle, which is one sign of chronic hypertension in patients with stroke. (Jusuf Misbach, 1999)
- Laboratory Tests
- Lumbar puncture: a red liquor inspection is usually found in massive bleeding, minor bleeding while liquor is usually normal color (xanthochromia) during the first days. (Satyanegara, 1998)
- Routine blood tests
- Chemical examination of blood: in acute stroke hyperglycemia may occur. Blood sugar can reach 250 mg in the serum and then gradually fell back. (Jusuf Misbach, 1999)
- Complete blood count: fatherly look for abnormalities in the blood itself. (Linardi Widjaja, 1993)