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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