Stroke or cerebrovascular accident (CVA) or brain attack, is when poor blood flow to the brain results in cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic due to bleeding.
Symptoms of Stroke
Nursing Diagnosis and Nursing Intervention for Stroke
Symptoms of Stroke
- Sudden numbness or weakness of the face, arm or leg (especially on one side of the body)
- Sudden confusion, trouble speaking or understanding speech
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause
Nursing Diagnosis and Nursing Intervention for Stroke
- Ineffective cerebral tissue perfusion related to brain hemorrhage, edema
Goal :
Adequate tissue perfusion with indicators: Adequate tissue perfusion is based on peripheral pulse pressure, skin warmth, adequate urine output.
Plan of action :- Monitor neurologic status
R /: Knowing the tendency of the level of awareness and potential increase in intra-cranial pressure and know the location. Area and progress damage the central nervous system. - Monitor respiratory status
R: / Respiratory irregularity can give the location of the damage / increase in intra-cranial pressure. - Monitor heart sound
R /: Bradycardia may occur as a result of brain damage. - Place the head with a slightly elevated position and in a neutral position
R /: Lowering arterial pressure to improve drainage and improve circulation - Manage medications
R /: Prevention / treatment reduction intra-cranial pressure. - Give Oxygen as indicated
R /: Reducing hypoxia.
- Monitor neurologic status
- Impaired physical mobility related to decreased muscle strength
Outcome :- The joints are not stiff
- There was no muscle atrophy
Plan of action :- Exercise therapy
Joint mobility- Explain to the patient and the patient's family, the purpose of joint movement exercises.
- Monitor the location and discomfort during exercise
- Use a loose-fitting clothing
- Assess the ability of patients to the movements
- Encourage active ROM
- Teach ROM active / passive on the patient and patient's family.
- Change the position of the patient every 2 hours.
- Assess progress / advancement training.
- Self Care Assistance
- Monitor the independence of patients
- Assist the patient in terms of self-care: eating, bathing, toileting.
- Teach family in the fulfillment of self-care patients.
Physical disability and psychological patient, can reduce the daily personal care and can be fulfilled with the help of personal hygiene for patients can be maintained.