NEUROLOGY SYSTEM

STROKE NON HEMORAGIC A. DEFINITION Stroke or cerebrovascular disease refers to any sudden nurologic disorder that occurs due to restriction or cessation of blood flo through the arteries su!!ly the brain. The ter" stroke is usually used s!ecifically to describe cerebral infarction. The ter" is still old and still co""only used is cerebrovascular accident #$rice% &''() Stroke or cerebrovascular in*ury #+,A) is a loss of brain function caused by the cessation of blood su!!ly to the brain. That is usually caused by thro"bosis% e"bolis"% ische"ia% and he"orrhage #s"elt-er% &''&). Stroke is neurological disease that is co""on and should be treated a!!ro!riately. Stroke is a brain dysfunction that arises due to sudden occurrence of circulatory disorder of the brain that can ha!!en to anyone #.utta/in% &''0).

1. $AT2O$23SIO4O53 +erebral infarction is the reduction of blood su!!ly to a !articular area in the brain. The e6tent of infarction de!ends on factors such as the location of blood vessels and an inade/uate a"ount of collateral circulation to the area su!!lied by the blocked artery. The blood su!!ly to the brain can be changed #the slo er or faster) on local disturbances #thro"bosis% e"bolis"% he"orrhage% and vascular se!as"e) or because of co""on disorders #hy!o6ia due to lung and heart disorders). Atherosclerosis is often an i"!ortant factor for the brain% thro"bus "ay ru!ture of the blood vessel all and carried as e"boli in the blood strea". Thro"bus result7 8) Ische"ic brain tissue su!!lied by blood vessels relevant% &) ede"a and congestion in the surrounding area. Areas of ede"a is caused greater dysfunction than the infarct area it self. Ede"a can be reduced in a fe hours or so"eti"es after a fe days. 9ith reduced ede"a% clients began to sho i"!rove"ent. 1ecause thro"bosis is usually not fatal% if not bleeding "asiv. Occlusion of the "iddle cerebral artery by an e"bolus% causing ede"a and

necrosis follo ed by thro"bosis. If there se!sis infectius ill e6!and the blood vessel all% there ill be an abces or ence!halitis% if the rest of the infection are the blood vessels that clogged causing aneurys" dilation of blood vessels. This leads to cerebral he"orrhage% or ru!ture if the aneurys" ru!tures. 1leeding in the brain caused by the ru!ture of blood vessels arteriosklerotik and hy!ertension. Intra-cerebral he"orrhage ill lead to a very broad co"!arison of overall "ortality cerebrovascular vascular disease% because e6tensive bleeding occurred during the destruction of the brain% increased intracranial !ressure and "ay cause "ore severe brain herniation or cerebral valks by forag"en "agnu". Death "ay be caused by co"!ression of the brain ste"% he"isfer of brain% and secondary brain ste" he"orrhage or bleeding into the brain ste" e6tension. $er"eation of blood into the ventricles of the brain occurs in a third of cases of brain hae"orrhage in caudate nucleus% and !ons kala"us. If the cerebral circulation is blocked% can develo!"ent of cerebral hy!o6ia. +hanges in cerebral ano6ia due to long-ter" reversible :-("enit. Ano6ia irreversible changes hen "ore than 8' "inutes. Ano6ia can often occur due to a variety of disorders% one cardiac arrest. 1esides brain of !arenki" da"age% due to the relatively "ore bleeding volu"e ill lead to increased intracranial !ressure and cerebral !erfusion !ressure resulted in the disru!tion of drainage and brain.

+. +4ASSIFI+ATION Stroke can be classified according to etiology or basic of the disease. In the course of the disease% a stroke can be divided into three ty!es% such as 7 8. Transient Ische"ic Attack #TIA) TIA is an acute focal neurologic deficit caused by cerebral ische"ia cursory and ithout residual disa!!eared again /uickly ithin no "ore than &: hours &. Ische"ic ;eversible Neurogical Deficit #;ind) ;IND is an acute focal neurologic deficit caused by cerebral ische"ia lasting "ore than &: hours <. Stroke in Evolution #!rogessing stroke)

Stroke in evolution is an acute focal neurologic deficit due to circulatori disorder of the brain takes !laces !rogressively and reached a "a6i"u" ithin a fe hours until a fe days. :. Stroke In ;esolution Stroke in resolution is an acute focal neurologic deficit due to circulatory disorder of the brain that sho ed i"!rove"ent and reached a "a6i"u" ithin a fe hours until a fe days. =. +o"!leted Stroke #cerebral infarction) +o"!leted stroke is an acute focal neurological deficit due to occlusion or circulatory disorders of the brain /uickly beco"es stable ithout orsening again.

+lassification "odifications .arshall 7 2ae"orrhagic stroke a stroke that occurs because the blood vessels in the brain ru!tures causing ische"ic and hy!o6ic do nstrea". The cause of hae"orrhage stroke include7 hy!ertension% ru!ture of aneurys"s% arteriovenous "alfor"ations venosa. >sually it ha!!ens hen doing activities or hile active% but can also occur at rest. A areness !atients generally declined. Non-hae"orrhagic stroke hen after a long rest% slee! or aking u! in the "orning. No bleeding% but the cause hy!o6ia ische"ia and subse/uent ede"a "ay occur secondary. +onsciousness better. is usually can be either ische"ia or cerebral e"bolis" and thro"bosis% usually occurs

D. ETIO4O53

Thro"bosis #blood clots in the blood vessels of the brain) +erebral atherosclerosis and the slo do n is the "ain cause of cerebral

circulation% cerebral thro"bosis is a co""on cause of stroke. +erebral e"bolis" #blood clot or other "aterial brought to the brain fro" other !arts of the body). $athological abnor"alities in the left ventricel% such as endocarditis% infections% rheu"atic heart disease and "yocardial infarction and !ul"onary infections are the !laces of origin e"bolis". E"bolus usually clog the "iddle cerebral artery or branches da"aging cerebral circulation. Ische"ia #decreased blood flo to an area of the brain). +erebral ische"ia

#insufficiency of blood su!!ly to the brain) is "ainly due to constriction of athero"a in the arteries that su!!ly blood to the brain. +erebral he"orarahage #ru!ture of cerebral blood vessels ith brain tissue or

bleeding into the s!ace around the brain). 2e"orrahage can occur outside dura"eter #e6tradural he"orrahage and e!idural)% under dura"eter #subdural hae"orrahage)% the roo" is subarachnoid #subarachnoid he"orrhage) or the substance of the the brain # intacerebral he"orrahage) #s"elt-er% &''&) ithin

E. SI5N AND S3.$TO.S Strokes cause a variety of neurologic deficit% sy"!to"s arise fro" s!ecific brain regions fail due to disru!tion of blood flo to the area% de!ending on the location of the lesion # here the blood vessels are blocked)% the si-e of the area that !erfusinya not ade/uate% and the a"ount of collateral blood flo #secondary or accessory ). Sy"!to"s include7 Generally occurs suddenly, there s !a n n the head "arasthes a, !ares s, "le# a !art o$ the %ay. Stroke is a disease of the "otor neurons and resulting in loss of voluntary control of the "otor "ove"ent. In the early stages of stroke% the clinical !icture is usually !aralysis a!!eared and disa!!eared or decreased dee! tendon refle6es. &ys!ha# a% loss of co""unication other brain functions in stroke is influenced by language and co""unication. Stroke is the "ost co""on cause of a!hasia. 4anguage

and co""unication dysfunction can be "anifested by the follo ing? dysarthria #difficulty s!eaking)% dys!hasia or a!hasia #s!eech i"!air"ent due to brain disorders)% a!ra6ia #inability to !erfor" !reviously learned actions). & sorders o$ !erce!t on, is the inability to inter!ret sensations. Stroke can cause visual !erce!tual dysfunction% i"!aired visual-s!atial relationshi!s% and sensory loss. ,isual !erce!tual dysfunction due to disru!tion of the !ri"ary sensory !ath ays bet een the eyes and the visual corte6. I"!aired visual-s!atial relationshi!s #getting the relationshi! of t o or "ore ob*ects in a s!atial area) is often seen in !atients left he"i!legia. $atients "ay not be able to ear clothes ith ithout assistance because

of the inability to "atch the outfit to the body.>ntuk hel! !atients% caregivers can take ste!s to set the environ"ent and get rid of furniture because !atients ith !roble"s of !erce!tion easily distracted. It "ay be "ore severe% and auditory Chan#es n co#n t 'e and !sycholo# cal e$$ects, if the da"age occurs in the frontal lobe% learning ca!acity% "e"ory and intellectual functioning of higher cortical "ight be corru!ted. This dysfunction can be de"onstrated in a field li"ited attention% difficulty in understanding% forgetfulness and lack of "otivation that led to the !atient@s face frustrating !roble"s in their rehabilitation !rogra". Other !sychological !roble"s are also co""on and is "anifested by e"otional lability% hostility% frustration% resent"ent and lack of coo!eration. (ladder &ys$unct on, after stroke !atients "ay e6!erience te"!orary urinary incontinence due to confusion% inability to co""unicate needs% and inability to use the urinal due to da"age "otor and !ostural control. So"eti"es after a stroke atonik bladder% the sensation of da"age in res!onse to bladder filling. So"eti"es the e6ternal urinary s!hincter control is lost or reduced. During this !eriod the catheteri-ation inter"inten ith sterile techni/ue. 9hen the tendon refle6es increased "uscle tone back% increased bladder tone and s!asticity of the bladder can occur. Neurolo# c &e$ c t Stro)e Cl n cal Man $estat ons are as *ollo%s+
Numbe Neurological deficit Manifestation

ould be useful and give a gentle re"inder of

here

the ob*ect is !laced. Sensory loss due to stroke can be either a light touch or da"age ith loss !ro!riose!si #the ability to sense the !osition and ell as the difficulties in inter!reting visual sti"uli% tactile "ove"ent of the body) as

Visual field deficit a)Homonimus Hemlanopsia b) Loss of peripheral vision c) Diplopia

a) Did not realize a person or object, ignoring one side of the bod , difficult judging distance b) difficult seeing at night, una!are of the object or object boundar " c) Double Vision

"otor deficit a) he"i!aresis b) 2e"i!legia c) Ata6ia d) Disatria e) Dys!hagia

a) !ea#ness of face, arm, and leg on the same side" b) $aral sis of the face, arm, and leg on the same side" c) %al#ing unstead , unable to unif the foot" d) Difficult in forming !ords e) Difficult in s!allo!ing"

. /

Sensory deficits7 $arastesia verbal deficits a) Fascia e6!ressive b) Fascia rece!tive c) global a!hasia

pins and needles a) Not being able to spell a !ord that can be understood b) Not able to understand the spo#en !ord, unable to spea# but no sense c) & combination of receptive and e'pressive aphasia

cognitive deficits

Loss of short-and long-term memor , decreased field of attention, inabilit to concentrate, and changes in valuation"

E"otional deficit

Loss of self-control, emotional labilit , depression, !ithdra!al, fear, resentment, and feelings of isolation"

NURSING CARE
&" Case

Tn. A received in a hos!ital e"ergency Soeto"o on && October &'8&. Tn.A co"!lained could not "ove his ar"s and legs to the right since yesterday felt "uscles of the ar" and the right leg is hen get u! in bed. Tn. A eak and canBt function it suddenly%

nu"bness% di--iness% nausea. +lient has a history of hy!ertension since 8 years ago% s"oked a !ack a day% and occasionally drink alcohol% Tn. A also has a history of high cholesterol. +urrently% Tn. A as "oved to roo" &'= by a nurse. Obtained results of vital sign Te"!erature7 <(.= degrees celsius% hearth rate of 00 ti"es !er "inute% blood !ressure 80'C88' ""2g% res!iration &: ti"es !er "inute% neurological status7 consciousness co"!os "entis% 5+S7 .6 E: ,=% he has good co""unication to the nurse.
(" Nurs n# Assess2ent

5eneral Data Infor"ation 8. $ersonal Data Na"e Se6 Age 7 7 7 .r. A .ale == years old

Dob

E"!loyee

&. +hief +o"!laint +an not "ove his right ar"s and right legs. <. $ast 2ealth 2istory Tn. A has a history of hy!ertension since & years ago% a history of high cholesterol and unhealthy lifestyle. :. Fa"ily 2istory 2is father also suffered fro" hy!ertension and had died of heart disease and his "other had died si6 "onths ago due to co"!lications fro" cancer illness. =. Allergies The !atient does not have a history of drugs% ani"als% foods or any other allergies. (. +urrent .eds $atient do not get any treat"ent at this ti"e. E. AD4BS at ho"e a. 2ygiene 7 he canBt doing !ersonal hygiene inde!endently b. 1ladder and bo el eli"ination 7 2e has !roble"s urinaring and bo el "ove"ents% he canBt "ove to the toilet by hi" self. c. Diet habits 7 2e has dietary of salt. d. 2ealth $ractice 7 no s!orts activities conducted client% only so"eti"es on Sunday. 0. 4ife style habits !atient have the habit of s"oking a !ack a day% and occasionally drinking alcohol. $hysic E6a"ination 8. ,ital sign 7 1lood !ressure $ulse ;es!iration Saturation Te"!erature &. 2eightC9eight7 2eight 7 9eight 7 <. .usculusceletal 7 7 7 7 7 8(= centi"eter == kilogra"s 80'C88' ""2g 00 b!" &: b!" F' G <(%=o +

2e eight is average for the nor"al eight

"uscle strength Ar" and right leg is re"oved falling do n. eak% the client disable to "ove his right ar" and leg% can be & & = =

ith a sustained% but if the backings off the ar" and feet has

)" Analys s o$ &ata

No. Sub*ective data

Data Focus

$roble" Ineffective cerebral tissue !erfusion

Etiology Ische"ic cerebrovascular

!atient said7 headache and sto"ach feels /ueasy Ob*ective data

*" TD7 80'C88' ""2g +" +T scan7 it a!!ears the ische"ic

cerebral corte6
," S!O&7 F'G

&.

Sub*ective data $atient said 7

*" +an not "ove his ar" and feet to the

I"!aired "obility hen get u! in

!hysical !aresis !aralysis

or

right since yesterday bed

+" Feel the "uscles of his ar" and leg

right are Ob*ective data

eak and disable to "ove%

feel nu"bness
*" !atient see"s

eak

+" !atientBs "obili-ation only can be done

on the bed <. .uscle strength & & <. = = Deficit self care 7 9eakness

Sub*ective data

!atient said that could not do on their o n bathing and

self-care because of Ob*ective data

eak ar" and leg toileting

AD47 bathing and toileting assisted by a nurse C fa"ily &3 Nurs n# Care "lan 8. I"!aired cerebral tissue !erfusion related intracranial he"orrhage% ische"ia #e"bolis" or thro"bosis) NO+ Tissue !erfusion 7 cerabral% neorological status% blood coagulation% "edication res!on +o""on e6!ected outco"e 7 After being given a &:-hours of nursing care for the !atient is e6!ected to sho !erfusion. a. $atient "aintains o!ti"al cerebral tissue !erfusion b. As evidenced by 5+S score greater than 8< c. Absence of ne neurological deficits and stable blood !ressure NI+ a. +erebral !erfusion !ro"otion b. Neurological "onitoring c. .edication ad"inistration Ongoing assess"ent a. Assess neurological status #serially) using National Institutes of 2ealth Stroke Scale #NI2SS) or 5lasgo +o"a Scale ;ationales 7 This inforation is used to deter"ine the effects of stroke and identify life- threatening co"!lications such as increased intracranial !rressure #I+$). The NI2SS is a standardi-ed asses"ent of consciousness% vision% sensory and "otor res!onses% s!eech and language function. b. Assess !ast history of cardiac dysrhyth"ias% hy!ertension% s"oking ;ationales 7 +ardiac orku! is arranted if stroke is e"bolic% atrial fibrilation is a "a*or cause of e"bolic stroke. 2y!ertension see"s to be related to he"orrhagic stroke. Atherosclerosis and transient isce"ic attacks are assocciated ith thro"botic stroke. signs of increasing the effectiveness of the cerebral tissue

c. .onitor vital sign as needed ;ationales 7 Fre/uent assess"ent of blood !ressure #1$) is essential. A nor"otensive state is desired to !ro"ote effective cerebral !erfusion !ressure. d. .onitor fluid intake and urine out!ut ;ationales 7 A decrease in urine out!ut "ay indicate decreased renal !erfusion and an associated decrease in cerebral !erfusion. Thera!eutic intervension a. Ad"inister the follo ing "edications7 8) Thro"bolytics ;ationales 7 Thro"bolytics are given to dissolve clots in cerebral vessels. &) Anticoagulants and anti!latelet drug ;ationales 7 Anticoagulants and anti!latelet drug are given to reduce clot for"ation and !revent e6tension of e6isting clots. <) Antihy!ertensives ;ationales 7 Antihy!ertensives are give to control severe hy!ertension and "aintain cerebral !erfusion :) Os"otik diuretics ;ationales 7 Os"otik diuretics are given to decrease I+$ by reducing cerebral ede"a. b. ;aise head of bed no higher than <' degrees ;ationales 7 +urrent evidence suggests that elevating the head of bed reduces I+$ by increasing cerebral venous outflo . c. Hee! the !atientBs head and neck in neutral !osition ;ationales 7 This !osition !ro"otes venous drainage fro" the brain and decrease I+$. d. Avoid unnecessarycare activities ;ationales 7 Fre/uent sti"ulation of the !atient can serve as a no6ious sti"ulus and increases brain activity and I+$. &. I"!aired !hysical "obility related to !aresis or !aralysis

NO+ .obility +o""on e6!ected outco"e 7 after being given a &:-hour nursing care for !atients ho!efully can be e6!ected to gradually !erfor" range of "otion e6ercises and alking inde!endently. a. $atient enable to "ove the !araly-e e6tre"ity and "aintain the ability of the nor"al e6tre"ity. b. $atient de"onstrates use of ada!tive techni/ues that !ro"ote a"bulation and transferring c. $atient is free of co"!lications of i""obility% as evidenced by intact skin% absence of thro"bo!hlebitis% nor"al bo el !attern% and clear breath sounds NI+ .obility "anage"ent a. Assess degree of eakness in both u!!er and lo e e6tre"ities ;ationales 7 There "ay be differing degress of involve"ent on the affected side. b. Assess ability to !erfor" range of "otion #;O.) to all *oints ;ationales 7 This asses"ent !rovides data on the e6tent of any !hysical !roble"s. The data ill guide thera!y to !ro"ote "obility. Testing by a !hysical thera!ist "ay be needed. c. Observe for activities or situations that increase or decrease "uscle tone ;ationales 7 Initially "uscles de"onstrate hy!orefle6ia% hich later !rogresses to hy!errefle6ia. Activities that cause s!astic res!onse can be !ost!oned until later in recovery. d. .onitor skin integrity for areas of blanching or redness ;ationales 7 I"!aired "obility increases the risk for skin breakdo n. e. If the !atient is not in severe "usculosceletal disorder% !re!are for 6-ray e6a"ination ;ationales 7 The 6-ray fil" ill confir" correct !lace"ent of bone% indicate the !resence of rib fractures and other abnor"alities like defor"ity and etc. <. Self care deficit 7 bathing and toileting related to eakness or tiredness NO+

Self-care 7 bathing% Self-care 7 toileting +o""on e6!ected outco"e 7 after being given a &:-hour nursing care is e6!ected to !atients AD4s needs such as toileting can be ade/uately "et. a. $atient safely !erfor"s #to "a6i"u" ability) self-care activities b. $atient identifies resources that are useful in o!ti"i-ing oneBs autono"y and inde!endence NI+ Self-+are Assistance Ongoing assess"ent a. .onitor res!iratory rate and rhyth"%breath sounds% and ability to handle secretionsAsses the !atientBs ability to !erfor" activities of daily living #AD4s) effectively and safely on a daly basis using an a!!!ro!riate assess"ent tool% such as the Functional Inde!endence .easures #FI.). ;ationales 7 The !atient "ay only re/uire assistance ith so"e selfcare "easures. A variety of tools are available% de!ending on the clinical setting. Such tools !rovide ob*ective data for baselines. For e6a"!le% the FI. "easures 80 selfcare ites related to eating% bathing% roo"ing% dressing toileting% bladder adn bo el "ange"ent% transfer% a"bulation% and stair cli"bing. b. Asses the !atientBs need for assistive decices. Assess the need for ho"e health care after discharge. ;ationales 7 assistive devices increase inde!endence in !eror"ance of AD4s. Shortened hos!ital stays have resulted in !atients being "ore dibilitated on discharge and therfore re/uiring"ore devices. c. Identify !reference for food% !ersonal care ite"s and other things. ;ationales 7 the !atient is "ore likely to !artici!ate in self-care that su!!orts his or her indvidual and !ersonal !references. d. If indicated% assess for ga refle6 or need for s allo ing evaluatio by s!eech thera!ist befor initial oral feeding. ;ationales 7 absence of gag refle6 or inability to che or s allo assistance at ho"e. Occu!ational thera!ists have access to a ide range of self-hel!

!ro!erly "ay lead to choking or as!iration. Thera!iutic intervention a. $lace !atient in o!ti"al !osition for feeding% !referably sitting u! in a chair? su!!ort ar"s% elbo s% and rists% as needed ;ationales 7 !ro!er !ositioning can "ake the task easier hile also and reducing risk for as!iration. b. Ensure that consistency of diet is a!!ro!riate for the !atientBs ability to che s allo % as assessed by the s!eech thera!ist. ;ationales 7 thickened se"isolid foods like !uddding anf hot cereal are "ost easily s allo ed and less likely to be as!irated c. +onsider a!!ro!riate setting for feeding here the !atient has su!!ortive assistance yet is not e"barrassed. ;ationales 7 E"barrass"ent or fear of s!illing food on self "ay hinder the !atientBs atte"!ts to feed self. d. $rovide fre/uent encourage"ent and assistance ith dressing as needed ;ationales 7 Assistance can reduce energy e6!enditure and rustration. 2o ever% care needs to be taken so the care !rovider does not rush through tasks% negating the !atientBs atte"!ts. e. $lan daily activities so the !atient is rested before activity ;ationales 7 A !lan that balances !eriods of activity ithout undue fatigue and frustration. f. $lace the !atient in heelchair or statinoary chair ;ationales 7 Dressing can be fatiguing. A chair that !rovides "ore su!!ort for the body than sitting on the side of the bed conserves energy hen dressing. g. .aintain !rivacy during bathing as a!!ro!riate ;ationales 7 the need fro !rivacy is funda"ental for "ost !atients h. Instruct the !atient to select bath ti"e hen he or she is rested and unhurried ;ationales 7 hurrying "ay result in accidents% and the energy re/uierd for these activities "ay be substantial. i. Encourage the !atient to bahe self as "uch as he or she is ca!able of. Assist co"!letion of bath% brushing teeth% shaving% and so on% only as needed. ;ationales 7 hos!ital orkers and fa"ily caregivers are oftern in a ith ith !eriods of rest can hel! the !atient co"!lete the desired activity

hurry and do "ore for !atients tha needed% thereby *. Evaluate slo ing the !atientBs efforts at regaining inde!endence. or docu"ent !revious and urrent !atterns for toileting? institute a ill

toileting schedule that factors these habits into the !rogra". ;ationales 7 The effectiveness of the bo el or bladder !rogra" !atient are res!ected k. Assist the !atient in re"oving or re!lacing necessary clothing ;ationales 7 +lothing that is difficult to get into and out of "ay co"!ro"ise a !atientBs ability to be continent. l. Assists ith bed "obility by doing the follo ing7 8) Allo the !atient to ork at o n rate of s!eed &) Encourge the !atient to use the stronger side #if a!!ro!riate) as "uch as !ossible. ;ationales 7 1ed "obility !revents disabling conractures% !ressure ulcers% and "uscle akness fro" disuse. .any factors hen develo!ing or "ay influence a !atientBs ability to "ove freely% and each of these factors "ust be conseiderd taching a !atien a ne syste" for selfcare. be enhanced if the natural and !ersonal !atterns of the

ENGLISH IN NURSING
NEUROLOGY SYSTEM

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