Physical Examination and Investigations of Stroke

Physical Examination of Stroke

1. 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.


2. 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


3. Examination of the head and neck
   Head: Shape normocephalic
   Advance: Generally not symmetrical is lopsided to one side
   Neck: Stiff neck rare (Satyanegara, 1998)


4. 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.


5. Examination of the abdomen
   Obtained decrease intestinal peristalsis caused by bed rest periods, and sometimes there are bloated.


6. Examination of inguinal, genital, anal
   Sometimes there incontinensia or urinary retention.


7. Examination of the extremities
   Often obtained paralysis on one side of the body.


8. Examination of neurology
   • Cranial Nerve
     Generally there is interference with cranial nerve VII and XII central.
   • Motor
     Almost always happens paralysis / weakness on one side of the body.
   • Sensory
     Hemihypesthesia can occur.
   • Reflex
     In the acute phase of physiological reflexes are paralyzed side will disappear. After several days of physiological reflexes will reappear didahuli with pathological reflexes.

Investigations of Stroke

1. 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)
   
   
2. 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)

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Basic Concept of Nursing Care Plan for Stroke

Assessment is an early stage and the foundation of the nursing process to identify client problems, in order to give direction to nursing actions. Assessment phase consists of three activities: data collection, data classification and formulation of nursing diagnoses. (Lismidar, 1990)

Data Collection

Data collection is to collect information about the overall health status of the client's physical, psychological, social, cultural, spiritual, cognitive, developmental level, economic status, ability to function and lifestyle of patients. (Marilynn E. Doenges et al, 1998)

a) The identity of the client
Includes name, age (most often in old age), sex, education, address, occupation, religion, ethnicity, date and time of hospital admission, registration number, medical diagnosis.
b) The main complaint
Limb weakness typically found next to the body, speech pelo, and can not communicate. (Jusuf Misbach, 1999)
c) History of present illness
Hemorrhagic stroke often take place very suddenly, when the client is doing the activity. Usually occurs headache, nausea, vomiting and even seizures to unconsciousness, paralysis symptoms besides half body or other brain dysfunction. (Siti Rochani, 2000)
d) History of previous illness
A history of hypertension, diabetes mellitus, heart disease, anemia, history of head trauma, a long oral contraceptives, use of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)
e) A family history of disease
There is usually a family history of hypertension or diabetes mellitus. (Hendro Susilo, 2000)
f) Psychosocial History
Stroke is a disease that is very expensive. The cost for testing, treatment and care of the family finances that can disrupt these cost factors can affect the stability of the emotions and thoughts of clients and families.


The Patterns of Health Functions

1) Pattern perception of healthy living and governance
There is usually a history of smoking, alcohol use, use of oral contraceptives.
2) The pattern of nutrition and metabolism
Complaints difficulty swallowing, loss of appetite, nausea and vomiting in the acute phase.
3) The pattern of elimination
It usually occurs in the urinary incontinence and bowel habit constipation usually occurs due to decreased intestinal peristalsis.
4) The pattern of activity and exercise
There is the difficulty of the move as weakness, sensory loss or paralise / hemiplegia, tiredness.
5) The pattern of sleep and rest
Usually clients are having difficulties to rest because of muscle spasms / muscle pain.
6) The pattern of relationships and roles
A change in the relationship and role as client has difficulty communicating due to impaired speech.
7) The pattern of perception and self-concept
Clients feel helpless, hopeless, irritable, uncooperative.
8) The pattern of sensory and cognitive
At the client's pattern of sensory impaired vision / blurring sight, touch / touch down on the face and extremity pain. On the pattern of cognitive decline typically memory and thought processes.
9) Patterns of sexual reproduction
It usually occurs due to decreased sexual desire of some of the treatment of stroke, such as anti-seizure drugs, anti-hypertensive, histamine antagonists.
10) The pattern of response to stress
Clients often find it difficult to solve due to the disruption of thinking and difficulty communicating.
11) The pattern of values ​​and beliefs
Clients rarely practicing because of unstable behavior, weakness / paralysis on one side of the body.

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Impaired Verbal Communication related to Stroke

Nursing Diagnosis for Stroke : Impaired Verbal Communication

A stroke is a medical emergency that occurs when the blood flow to the brain is interrupted. This typically occurs when a blood clot blocks the flow of blood, thereby preventing the brain from getting the oxygen that it needs. Without oxygen, the brain cannot function properly and could be permanently damaged.

Stroke are the third leading cause of death in the United States. Even if you don't die, strokes are one of the causes of brain damage.

Stroke may cause language and speech problems, abnormally slow and cautious behavior, problems judging distances, impaired judgment and behavior, short-term memory loss and other memory problems, balance problems, and more. Therefore, it is extremely important that everyone know about the symptoms of strokes. If caught early, brain damage treatment can take place and the stroke victim can live an ordinary life.

There are many different symptoms that a person may suddenly experience if he or she is having a stroke. Every person may experience slightly different symptoms, but what makes stroke signs stand out is that the symptoms occur suddenly and are easily spotted by others. If you notice a sudden onset of any of the following, be sure to seek emergency treatment as soon as possible:

Numbness or weakness, especially on one side of the body

• Slurring of speech
• Disorientation or confusion
• Loss of balance or trouble walking
• Severe headache

The Risk Factors

1. Age
Human aging is the biological process that is unavoidable but controllable. Starting at age 40, the cells in our body begin this process causing the deterioration of some functions of our body. Most people of this age group already have some form of cholesterol building up in their arteries and high blood pressure resulting in an increased risk of stroke.

2. Heredity
People with a family history of stroke have a greater chance of stroke than those do not have such a family history.

3. Race
Because of frequent high blood pressure in African Americans, they have a significantly higher risk of stroke than their Caucasian counterparts.

4. High blood pressure
High blood pressure causes hardening and thinning of arterial walls and makes our heart work harder to pump blood throughout our body resulting in heart diseases as well as increasing the risk of stroke.

5. Excessive alcohol consumption
Drinking one cup of wine for women and 2 cups of wine for men might help to increase the circulation of blood as well as providing more oxygen for cells. However, excessive drinking not only damages the normal function of liver but also raises high blood pressure, increasing the risk of stroke.

6. Diabetes
Diabetes with unhealthy diet causes high levels of glucose in the bloodstream. Diabetics have a greater risk of stroke, because high levels of glucose damage the arterial wall as well as clotting the arteries and blood vessels.

7. Gender
Males have a 20% greater risk of stroke than females.

8. Smoking
Smokers may be exposed to toxic cadmium, causing high blood pressure and heart diseases as well as contributing to a higher risk of stroke.

Nursing Diagnosis for Stroke: Impaired Verbal Communication related to damage to the cerebral circulation neuromuscular damage, loss of muscle tone / control muscle fascia / oral weakness / general fatigue.

Expected outcomes are:

• Indicate an understanding of communication problems.
• Creating a communication method which needs to be expressed.
• Using the resources appropriately.

Nursing Interventions for Stroke: Impaired Verbal Communication

1. Assess the functional type as the patient does not seem to understand the words or have difficulty speaking / making sense of their own.
Rational: To help determine the areas and degree of cerebral damage and the difficulty that occurs in several stages of the communication process.

2. Ask the patient to write a name or short sentences.
Rational: Assess the ability to write and correct deficiencies in reading, which is also part of the sensory aphasia and motor aphasia.

3. Provide alternative methods of communication. Ex: write on the board and give visual clues.
Rational: Provides communication of needs based on the state / the underlying deficit.

4. Anticipate and meet the needs of patients.
Rational: Beneficial reduce frustration.

5. Collaboration on a speech therapist.
Rational: Serves to identify needs therapy.

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Impaired Physical Mobility - Ineffective Cerebral Tissue Perfusion related to CVA / Stroke

Nursing Diagnosis and Nursing Interventions for CVA / Stroke

1. Nursing Diagnosis: Impaired Physical Mobility related to the function of neurological damage.

Nursing Interventions:

• Assess the functional capabilities and severity of abnormalities.
• Maintain body alignment (using a board bed, air mattress or a standard board as indicated.
• Turn and change position every 2 hours.
• Elevate the extremity pain with pillows.
• Perform range of motion exercises for all active or passive limb every 2 hours to 4 hours.
• Encourage hands, fingers and leg exercises.
• Give the patient as indicated ancillary equipment.
• Encourage the patient to perform activities of daily needs.
• Start to order a progressive ambulation aids to sit in a balanced position from the procedures to move from bed to a chair to reach equilibrium.
• Consult with the physician and the treatment (Tucker, 1998).

2. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow, occlusive disorders, hemorrhage, cerebral vasospasm, cerebral edema.

Nursing Interventions:

• Monitor or record the neurological status as often as possible and compare it to standard or normal state.
• Monitor vital signs.
• Record the data changes such as the blindness of vision, or visual field disturbances in perception.
• Assess the higher functions, such as speech function.
• Put your head slightly elevated position and the anatomical position (neutral).
• Maintain a state of bed rest, creating a peaceful environment, limit the activities of visitors or patients as indicated.
• Help prevent the occurrence of straining during defecation and breathing force (continuous cough).
• Collaboration in pembarian oxygen and drugs as indicated (Doenges, 2000).

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