Plan and Nursing Stroke Haemoragic

Plan and Nursing Stroke Haemoragic

A. Definition

Stroke is generally a neurological deficit that has a sudden attack and lasted 24 hours as a result of disruption of the blood vessels of the brain (Hudak and Gallo, 1997)

Stroke is used to name or hemiparalisis hemiparese syndrome due to vascular lesions, which are regions of the brain suddenly is not receiving blood because the arteries are clogged memperdarahi area, broken or cracked.

B. STROKE HAEMORAGIK

It is part of the classification of stroke, where intra-cerebral hemorrhage and possibly sub-arachnoid hemorrhage caused by rupture of blood vessels of the brain in certain areas. Genesis normally while doing the activity, but can also at rest and patient awareness of general decline.

C. Pathophysiology

D. RISK FACTORS

Hypertension, smoking, heart disease, especially artrial fibrillation, cerebral aneurysm, aterosclerosis, previous stroke or TIA, diabetes, polycythemia, elderly

E. CLINICAL SYMPTOMS

· Sudden headache

· Paraesthesia, paresis, Plegia partial body

· Dysphagia

· Aphasia

· Impaired vision

· Changes in cognitive abilities

F. EXAMINATION SUPPORT

· CT Scan: Haemoragi: sub-dural, sub aracnoid, intra-cerebral. Edema, ischaemia

· EEG: Identify areas of lesions and electric wave

· Angiography: Haemoragi, arterial obstruction, occlusion and rupture

· MRI: infarction, hemorrhage, arterial venous disorders

· Lumbar Punksi: In Sub-Arachnoid haemorrhage and intra-cerebral cerebro spinal fluid

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G. MANAGEMENT

1. Acute Phase:

· Maintain vital functions: airway, breathing, oxygenation and circulation

· Reperfusion with trombolityk or vasodilation: Nimotop

· Prevention ICT improvement

• Reduce cerebral edema with diuretics

2. Post acute phase

· Prevention spatik paralysis with antispasmodik

· Fisiotherapi Program

· Handling psychosocial problems

H. ASSESSMENT OF NURSING HOME

· Monitor vital signs

· Monitor level of consciousness

· Assessing the function of elimination

· Assessing the involuntary movements

· Assessing the ability of ADLs

· Assessing the ability of muscle movement

I. NURSING DIAGNOSIS THAT MAY ARISE

· Pain b.d. head cerebral vascular disorders: cerebral hemorrhage

· Perfuisi Impaired cerebral edema, brain tissue bd

· Self care deficit b.d partial paralysis

· Impaired physical mobility bd physical weakness / motor

· Constipation b.d. sensorimotor disorder

· Worried b.d. lack of knowledge about the disease and its treatment

· Risk of disruption of skin integrity bd a long bed rest

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