Nursing Care Plan for Stroke : Self-care deficit
Definition of Stroke
Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly (within seconds) or raised quickly (within hours) with symptoms and signs corresponding to the focal area disturbed.
Cerebrovascular accident (CVA) also called Stroke is a condition in which the occurrence of neurological deficits caused by decreased blood flow to certain areas of the brain tissue.
Neurological deficits caused by ischemia caused necrotising cells in brain tissue in various areas of the brain.
In the U.S., stroke is the third leading cause of death after heart disease and cancer. This disease can be prevented or minimized by efforts: blood pressure under control, increase awareness of the necessary diet and avoid smoking.
Etiology of Stroke
The occurrence of stroke is caused by the presence of thrombi and emboli that cause the narrowing or occlusion of one of the perfect blood vessels that supply blood to the brain, also if there is bleeding (hemorrhagic). Stroke due to pressure on the walls of blood vessels and arteries spasm, rarely encountered.
1. Thrombosis:
Is the formation of blood clots in blood vessels that can lead to narrowing of the lumen of a blood vessel blockage even happen. Thrombosis is a major cause of cerebral infarction. Two-thirds of strokes are caused by thrombosis due to hypertension and diabetes mellitus both of which can lead to atherosclerosis.
Another factor that can be at risk of thrombosis is an oral contraceptive, coagulation disorders, polycithemia, arteritis, chronic hypoxia, and dehydration. Thrombosis occurs as a result of the formation of atheroma thus narrowing the lumen of blood vessels. Thrombus causing hypoperfusion, infarction and ischemia.
At first occurred paresis (decrease / reduction in force and limb movement), aphasia (language function disorder), paralysis, impaired consciousness, visual disturbances.
2. Embolism:
Blockage / cerebral artery occlusion by an embolus, which resulted in necrosis and edema in the area supplied by the blood vessel blockage.
Embolism is the second leading cause of stroke. Generally derived from the inner lining of the heart (endothelial) where plaque is formed which is then separated and flowed in the blood circulation. If embolism is walking / running on the smaller blood vessels then place it will clog embolism or vascular branching.
Embolism associated with disease / heart problems, namely atrial fibrillation, cardiac infarction, infective endocarditis, rheumatic heart disease, and atrial septal defect. Another cause is not often that air embolism, fat embolism due to fracture femor, amniotic fluid after delivery, and the presence of a tumor.
The attack is sudden. The patient is fully conscious, although patients also feel headache. Prognosis depends location of the blood vessel blockage.
3. Intracerebral hemorrhage:
Bleeding in the brain caused by the rupture of a blood vessel. Intracerebral hemorrhage is usually caused by the presence of hypertension. Another cause is a brain tumor, trauma, thrombolytic treatment, and aneurysm rupture.
Hypertension and atherosclerosis cause degenerative change in the artery walls, causing rupture and hemorrhage. Blood mass will suppress brain tissue. This pressure causes the brain tissue of urgency and decreased blood flow to the brain due to ischemia and infarction.
The area that is often experienced intracerebral hemorrhage putamen and the internal capsule (50%), thalamus, brain hemisper, and pons. Clients will experience a severe headache, nausea and vomiting, loss of ability to walk, dysphagia, eye movement disorders. Bleeding in the post is very dangerous because it is part of the basic life functions. Pons can lead to bleeding in hemiplegia, coma, hyperthermia, and subsequently died.
The prognosis is very bad intracerebral hemorrhage: 70% of patients died due to intracerebral hemorrhage.
4. Subarachnoid hemorrhage:
Caused by the aneurysm, vascular abnormalities, trauma, and hypertension. Aneurysms often occur in patients with atherosclerosis, trauma, hypertension, or vascular abnormalities that are usually congenital bleeding can also be caused by anticoagulant treatment, treatment trhrombolitik, and symphatomimetic.
Bleeding that occurs suppress arachnoid space and cause headache, dizziness, loss of consciousness, nausea, vomiting, fever, pain in the neck and back, paralysis, coma, and later died.
Prevention of Stroke
Primary prevention is to avoid the risk of public health education. Maintain body weight and cholesterol within normal limits, and avoid smoking or using oral contraceptives. Treatment / control diabetes, hypertension and heart disease.
Provide information to clients in connection with the illness with strokes. If already had a stroke, in this situation the goal is to prevent the occurrence of complications with respect to stroke and myocardial wider in the future. In the event of immobility will increase the risk of injury in connection with paralysis and aspiration of the airway. Further Prevention is monitoring the risk factors that can be identified.
Nursing Diagnosis for Stroke : Self-care deficit related to decrease in strength and endurance.
Goal:
Patients can help themselves according to their needs, and be able to express their needs.
Intervention:
- Assess the capability and level of deficiency to perform day-to-day needs.
- Maintain support, with a strong attitude.
- Give positive feedback for any thing done or success.
- Avoid doing something for patients to do their own patients, but provide assistance as needed
Rational:
- Assist in anticipating / planning meeting individual needs.
- Patients will require empathy, care giver to know that will help patients consistently.
- Increase feelings of self meaning.
- The patient may be very frightened and very dependent.
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