Nursing In stroke patients

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Nursing In stroke patients

Nursing In stroke patients


Definition

In general, brain blood vessel disorders or stroke is the interruption of cerebral circulation. It is a focal neurologic disorder that can arise secondary to a pathological process in cerebral blood vessels, such as thrombosis, embolus, vessel wall rupture or basic vascular disease, such as atherosclerosis, arteritis, trauma, aneurysms and abnormalities of development.

Stroke can also be interpreted as a functional disorder of the brain that are:

and focal or global
acute
lasts between 24 hours or more
brain caused by interruption of blood flow
not caused by tumor / infection



Classification

Strokes can be classified according to the etiology or basic course of the disease. In accordance with the course of the disease, a stroke can be divided into three types, namely:

Cursory ischemic attack / TIA (Trans Ischemic Attack) local neurological disorders that occur for a few minutes to several hours. The symptoms will disappear spontaneously and completely in less than 24 hours.
Progressive / inevolution (stroke developing) a stroke that occurred is still growing which looks increasingly severe neurological disorders and worse. The process can run 24 hours or several days.
Stroke complete / completed: maximal neurological disorders since the initial attack with little improvement. Stroke where neurologisnya deficit at the onset of more severe, can then improve / settled.


Classification based on pathology:

Haemorrhagic stroke
Strokes that occur because the blood vessels in the brain ruptures causing iskhemik and hypoxia in the downstream. Hemorrhage causes of stroke include: hypertension, rupture of aneurysms, arterial malformations venosa. Usually it happens while doing the activity or when it is active, but can also occur at rest. Awareness of patients generally declined.

Non-haemorrhagic stroke
Can be either ischemia or cerebral embolism and thrombosis, usually occurs when after a long rest, get up from bed or in the morning. There were no bleeding but there is cause hypoxia ischemia and subsequent edema may occur secondary. Awareness umummnya good.



Etiology

Some of the following circumstances can cause a stroke include:

Cerebral Thrombosis
Thrombosis occurs in the blood vessel occlusion causing ischemia of the brain tissue causing edema and congestion Dapa in sekitarnya.Thrombosis usually occurs in older people who are sleeping or waking. This can occur because of decreased sympathetic activity and decrease in blood pressure which can cause ischemia serebral.Tanda and neurological symptoms are often worse at 48 hours after thrombosis.

Some of the following circumstances can cause thrombosis of the brain:
Atherosclerosis
Atherosclerosis is the hardening of blood vessels and reduced flexibility or elasticity of blood vessel walls. The clinical manifestations of atherosclerosis manifold. Damage can occur through the following mechanisms:
Lumen of narrowed arteries and result in reduced blood flow.
Sudden occlusion of blood vessels due to thrombosis.
This place is the formation of thrombus, then let go of pieces of thrombus (embolus)
Artery walls become weak and occurred aneurysm then torn and bleeding.
Hypercoagulasi on polysitemia
Blood grew thicker, increasing viscosity / hematocrit increase cerebral blood flow may slow down.
Arteritis (inflammation of the arteries)

Embolism
Cerebral embolism is a blockage of blood vessels of the brain by a blood clot, fat and air. In general embolism originating from thrombus in the heart of the matter and cerebral arteries clog the system. These emboli is rapid and symptoms arise less than 10-30 seconds. Some circumstances may cause embolism following:
Heart valves damaged by rheumatic Heart Desease. (RHD)
Myocardial infarction
Fibrillation. The situation led to various forms of arrhythmia ventricular emptying so that small blood clots form and at times completely emptied by removing the embolus-small embolus.
And non-bacterial endocarditis by bacteria, causing the formation of clots in the endocardium.

Haemorrhagic
Intracranial or intracerebral hemorrhage, including bleeding in the subarachnoid space or into the brain tissue itself. Bleeding can occur because of atherosclerosis and hypertension. Due to rupture of cerebral blood vessels causes blood leakage into the parenchyma of the brain that can lead to stress, displacement and separation of adjacent brain tissue, so the brain will swell, depressed brain tissue, resulting in cerebral infarction, edema, and possible brain herniation.

The cause of brain hemorrhage the most common:
Berry aneurysm, usually congenital defect.
Fusiformis aneurysm of atherosclerosis.
Aneurysms myocotik of necrosis and vasculitis septis embolism.
Arteriovenous malformations, there was a linkage relationship of the arteries, so that the arterial blood directly into a vein.
Ruptured cerebral arterioles, which causes hypertension due to thickening and degeneration of blood vessels.

General Hypoksia
Severe Hypertension
Cardiac Pulmonary Arrest
Cardiac output falls due to arrhythmia

Local hypoxia
Cerebral artery spasm, which is accompanied by subarachnoid hemorrhage.
Brain artery vasoconstriction accompanied migraine headaches.



Signs and Symptoms

Stroke causes nuurologik deficit, depending on the location of the lesion (where the blocked blood vessel), size of the area perfusinya inadequate and the amount of collateral blood flow. Stroke will leave residual symptoms because the brain functions will not improve completely.

Paralysis on one side of the body (hemiparese or hemiplegia)
Paralyzed on one side of the face "Bell's Palsy"
Weak or tight muscle tone
Decreased or loss of taste
Visual field disturbance "Homonimus Hemianopsia"
Language disorders (Disatria: difficulty in forming words; afhasia or disfasia: talk defeksif / loss of speech)
Impaired perception
Impaired mental status



Pathophysiology

Thrombosis (trombo disease - Occlusive) is the most frequent cause of stroke. Cerebral arteriosclerosis and cerebral circulation slowdown is the main cause of cerebral thrombosis, which is a common cause of stroke. Signs of cerebral thrombosis varies. Headaches are uncommon awitan. Some patients experience dizziness, seizures and cognitive changes or some other common awitan. In general, cerebral thrombosis did not occur suddenly, and temporary loss of speech, hemiplegia or paresthesias in a half body paralysis may precede awitan heavily on a few hours or days.

Thrombosis occurs usually something to do with local damage due to blood vessel walls atrosklerosis. The process of atherosclerosis characterized by fatty plaque in the lining of the artery intima. Part artery intima sereberi become thin and stringy, whereas the cells - muscle cells disappear. Lamina internal elastika torn and frayed, so that the vessel lumen partially filled by the sclerotic material. Plaque tends to form on the branches or place - a place that curve. Thrombi were also associated with a place - such a special place. Vessels - blood vessels that have a risk in an increasingly rare sequence is as follows: internal carotid artery, vertebral basilaris the top and bottom. The loss of the intima will make the exposed connective tissue. Platelets stick to exposed surfaces so that the surface of blood vessel walls become rough. Platelets will melepasakan enzyme, adenosine diphosphate initiated coagulation mechanism. Fibrinotrombosit Stoppers can be separated and form emboli, or can remain in place and eventually it will clog the artery completely.

Embolism: embolism sereberi including a second sequence of the various major cause of stroke. Patients with embolism usually younger than patients with thrombosis. Most emboli sereberi derived from a thrombus in the heart, so that the problem faced is actually a manifestation of heart disease. Although less common, the embolus may also be derived from plaque ateromatosa karotikus sinus or internal carotid artery. Each part of the brain can undergo embolism, but the embolus embolus usually will clog parts - a narrow part .. place the most frequently attacked sereberi artery embolus sereberi is the media, especially the top.

Cerebral hemorrhage: cerebral hemorrhage, including the third highest among all major causes GPDO cases (Brain Blood Vessel Disorder) and is the tenth of all cases of this disease. Intracranial bleeding is usually caused by cerebral artery rupture. Extravasation of blood occurs in the brain and / or subarachnoid, so the network that lies nearby will be shifted and depressed. Blood is very irritating to the brain tissue, resulting in vasospasm on around the bleeding artery. These spasms can spread throughout the brain and the circle hemisper wilisi. Blood clot that initially resemble soft red jelly will eventually dissolve and shrink. In light of histological brain located in the vicinity of the clot can be swollen and have necrosis. Because the action of the enzyme - the enzyme will occur melting process, thus forming a cavity. After several months of all necrotic tissue will be replaced by the astrocyte and capillary - forming fabric of new capillaries around the cavity earlier. Finally, the cavity filled by fibers - fibers that have astroglia proliferation. Subarachnoid hemorrhage is often associated with rupture of an aneurysm. Most aneurysms of the circle wilisi. Hypertension or bleeding disorders facilitate the possibility of rupture. Often there is more than one aneurysm.

Nursing in patients with stroke


Assessment

Changes in level of consciousness or responivitas as evidenced by the movement, refused to change its position and response to stimulation, oriented to time, place and person
Presence or absence of voluntary or involuntary limb movements, muscle tone, posture, and position of the head.
Flaksiditas stiffness or neck.
Opening eyes, comparative pupil size and pupillary reaction to light and ocular position.
The color of the face and extremities, skin temperature and humidity.
The quality and frequency of pulse, respiration, arterial blood gases as indicated, body temperature and arterial pressure.
The ability to speak
The volume of fluid drunk, and expelled urine volume per 24 hours.
History of hypertension, smoking, food habits and age.


From the general assessment of the above can be described as follows:

Primary Assessment
Airway
The blockage / obstruction of the airway by the buildup of secretions due to weakness of cough reflex.
Breathing
The weakness of swallowing / cough / protect the airway, breathing difficult emergence and / or irregular breath sounds audible ronchi / aspiration.
Circulation
TD can be normal or increased, hypotension occurred in stages, tachycardia, normal heart sounds at an early stage, dysrhythmias, skin and mucous membranes pale, cold, cyanosis at later stages.

Secondary Assessment
Activity and rest
Subjective Data:
difficulties in activities; weakness, loss of sensation or paralysis.
Fatigue, difficulty resting (pain or muscle spasms).
Objective data:
Changes in level of consciousness.
Changes in muscle tone (flaksid or spastic), paraliysis (hemiplegia), general weakness.
Impaired vision.

Circulation
Subjective Data:
History of heart disease (heart valve disease, dysrhythmias, heart failure, bacterial endocarditis), polycythemia.
Objective data:
Arterial Hypertension
Dysrhythmias, ECG changes
Pulsation: the possibility of varying
Carotid pulse, femoral and iliac artery or abdominal aorta.

Ego integrity
Subjective Data:
Feelings of helplessness, loss of hope.
Objective data:
Emotions are volatile and angry that was not right, kesediahan, joy.
Difficulty in self expression.

Elimination
Subjective Data:
Incontinence, anuria
Abdominal distension (very full bladder), absence of bowel sounds (paralytic ileus)

Eating / drinking
Subjective Data:
Loss of appetite.
Nausea / vomitus indicates PTIK.
Loss of sensation of the tongue, cheek, throat, dysphagia.
History of diabetes, increase fat in the blood.
Objective data:
Problems in chewing (decreased reflexes palate and pharynx)
Obesity (risk factor).

Sensory Neural
Subjective Data:
Dizziness / syncope (prior CVA / temporary during TIA).
Headache: the intra-cerebral hemorrhage or sub-arachnoid haemorrhage.
Weakness, tingling / numbness, affected side looks like paralyzed or dead.
Sight reduced.
Touches: loss of sensors on the side of the collateral in the extremities and the face ipsilateral (same side).
Impaired sense of taste and smell.
Objective data:
Mental status: coma usually marks the stage of hemorrhage, behavioral disorders (such as: letergi, apathetic, attack) and impaired cognitive function.
Extremity: weakness / paraliysis (contralateral) in all types of strokes, unbalanced hand, decreased deep tendon reflexes (contralateral).
Faces: paralysis / parese (ipsilateral).
Aphasia (damage or loss of function of language), expressive possibility / difficulty saying the word, receptive / difficulty saying the word comprehensive, global / combination of both.
Losing the ability to know or see, auditory, tactile stimuli.
Apraksia: lose the ability to use the motor.
Reaction and pupil size: not dilated and not reacting the same on the ipsi lateral.

Pain / comfort
Subjective Data:
A headache that varies in intensity.
Objective data:
Unstable behavior, restlessness, muscle tension / facial.

Respiration
Subjective Data:
Smokers (risk factor).

Security
Objective data:
Motor / sensory: problems with vision.
Changes in the perception of the body, trouble seeing objects, missing kewasadaan against the body of the sick.
Not able to recognize objects, colors, words, and faces ever recognized.
Disturbance responds to heat, and cold / body temperature regulation disorders.
Interference in the decision, a little attention to security, reduced self-awareness.

Social Interaction
Objective data:
Problem talk, the inability to communicate.
(E Doenges, Marilynn, 2000).



Nursing diagnoses that may arise

Damage to physical mobility bd decreased muscle strength, control
Ineffective tissue perfusion associated with brain hemorrhage, brain edema
Lack of self-care b.d physical weakness
Damage to brain damage b.d verbal communication
Risk of damage to skin integrity bd mechanical factors
The risk of infection decreased b.d primary defense.

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