NEUROLOGY SYSTEM

STROKE NON HEMORAGIC 1. Definition Stroke or cerebrovascular disease refers to any sudden neurologic disorder that occurs due to restriction or cessation of blood flow through the arteries supply the brain. The term stroke is usually used specifically to describe cerebral infarction. The term is still old and still commonly used cerebrovascular accident (Price !""#$ Stroke or %&' (cerebrovascular in(ury$ is a loss of brain function caused by the cessation of blood supply to the brain. That is usually caused by thrombosis embolism ischemia and hemorrhage (smelt)er !"1"$. Stroke is neurological disease that is common and should be treated appropriately. Stroke is a brain dysfunction that arises due to sudden occurrence of circulatory disorder of the brain that can happen to anyone (*utta+in !"",$.

!. P'T-.P-/S0.1.2/ The reduction of blood supply to a particular area in the brain as a cerebral infraction. The e3tent of infarction depends on factors such as the location of blood vessels and an inade+uate amount of collateral circulation to the area supplied by the blocked artery. The blood supply to the brain can be changed (the slower or faster$ on local disturbances (thrombosis embolism hemorrhage and vascular sepasme$ or because of common disorders (hypo3ia due to lung and heart disorders$. 'therosclerosis is often an important factor for the brain thrombus may rupture of the blood vessel wall and carried as emboli in the blood stream. Thrombus result4 1$ 0schemic brain tissue supplied by blood vessels

Foot note Atherosclerosis : a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol. Edema : Abnormal fluids accumulation in the intercellular tissue spaces.

relevant !$ edema and congestion in the surrounding area. 'reas of edema is caused greater dysfunction than the infarct area it self. 5dema can be reduced in a few hours or sometimes after a few days. 6ith reduced edema clients began to show improvement. 7ecause thrombosis is usually not fatal if not bleeding massively. .cclusion of the middle cerebral artery by an embolus causing edema and necrosis followed by thrombosis. 0f there sepsis infectius will e3pand the blood vessel wall there will be an abces or encephalitis if the rest of the infection are the blood vessels that clogged causing aneurysm dilation of blood vessels. This leads to cerebral hemorrhage or rupture if the aneurysm ruptures. 7leeding in the brain caused by the rupture of blood vessels arteriosklerotik and hypertension. 0ntra-cerebral hemorrhage will lead to a very broad comparison of overall mortality cerebrovascular vascular disease because e3tensive bleeding occurred during the destruction of the brain increased intracranial pressure and may cause more severe brain herniation or cerebral valks by foragmen magnum. Death may be caused by compression of the brain stem hemisfer of brain and secondary brain stem hemorrhage or bleeding into the brain stem e3tension. Permeation of blood into the ventricles of the brain occurs in a third of cases of brain haemorrhage in caudate nucleus and pons calamus. 0f the cerebral circulation is blocked can development of cerebral hypo3ia. %hanges in cerebral ano3ia due to long-term reversible 8-# minutes. 'no3ia irreversible changes when more than 1" minutes. 'no3ia can often occur due to a variety of disorders one cardiac arrest. 7esides brain of parenkim damage due to the relatively more bleeding volume will lead to increased intracranial pressure and cerebral perfusion pressure resulted in the disruption of drainage and brain.

9. %lassification

Stroke can be classified according to etiology or basic of the disease. 0n the course of the disease a stroke can be divided into three types such as 4 1. Transient 0schemic 'ttack (T0'$ T0' is an acute focal neurologic deficit caused by cerebral ischemia cursory and without residual disappeared again +uickly within no more than !8 hours
Foot note: Edema : Abnormal fluids accumulation in the intercellular tissue spaces. Necrosis : a condition of death of tissues Sepsis infection: contamination of the bacteria that causes the infection

!. 0schemic :eversible ;eurogical Deficit (:ind$ :0;D is an acute focal neurologic deficit caused by cerebral ischemia lasting more than !8 hours 9. Stroke in 5volution (progessing stroke$ Stroke in evolution is an acute focal neurologic deficit due to circulatori disorder of the brain takes places progressively and reached a ma3imum within a few hours until a few days. 8. Stroke 0n :esolution Stroke in resolution is an acute focal neurologic deficit due to circulatory disorder of the brain that showed improvement and reached a ma3imum within a few hours until a few days. <. %ompleted Stroke (cerebral infarction$ %ompleted stroke is an acute focal neurological deficit due to occlusion or circulatory disorders of the brain +uickly becomes stable without worsening again.

7ig classification of stroke 4 -aemorrhagic stroke a stroke that occurs because the blood vessels in the brain ruptures causing ischemic and hypo3ic downstream. The cause of haemorrhage stroke include4 hypertension rupture of aneurysms arteriovenous malformations

venosa. =sually it happens when doing activities or while active but can also occur at rest. 'wareness patients generally declined. - ;on-haemorrhagic stroke can be either ischemia or cerebral embolism and thrombosis usually occurs when after a long rest sleep or waking up in the morning. ;ot have any bleeding but the cause hypo3ia ischemia and subse+uent edema may occur secondary. %onsciousness is undercontrol. 8. 5tiology Thrombosis (blood clots in the blood vessels of the brain$ %erebral atherosclerosis and the slow down of blood circulation is the main cause of cerebral circulation cerebral thrombosis is a common cause of stroke. %erebral embolism (blood clot or other material brought to the brain from other parts of the body$. Pathological abnormalities in the left ventricel such as endocarditis infections rheumatic heart disease and myocardial infarction and pulmonary infections are the places of origin embolism. 5mbolus usually clog the middle cerebral artery or branches damaging cerebral circulation. 0schemia (decreased blood flow to an area of the brain$. %erebral ischemia (insufficiency of blood supply to the brain$ is mainly due to constriction of atheroma in the arteries that supply blood to the brain. %erebral hemorarahage (rupture of cerebral blood vessels with brain tissue or bleeding into the space around the brain$. -emorrahage can occur outside durameter (e3tradural hemorrahage and epidural$ under durameter (subdural haemorrahage$ the room is subarachnoid (subarachnoid hemorrhage$ or within the substance of the the brain ( intacerebral hemorrahage$ (smelt)er !""!$

<. Sign and symptoms

Strokes cause a variety of neurologic deficit symptoms arise from specific brain regions fail due to disruption of blood flow to the area depending on the location of the lesion (where the blood vessels are blocked$ the si)e of the area that perfusinya not ade+uate and the amount of collateral blood flow (secondary or accessory$. Symptoms include4 2enerally occurs suddenly there is pain in the head Parasthesia paresis Plegia part of the way. Stroke is a disease of the motor neurons and resulting in loss of voluntary control of the motor movement. 0n the early stages of stroke the clinical picture is usually paralysis appeared and disappeared or decreased deep tendon refle3es.
-

Dysphagia loss of communication other brain functions in stroke is influenced by language and communication. Stroke is the most common cause of aphasia. 1anguage and communication dysfunction can be manifested by the following> dysarthria (difficulty speaking$ dysphasia or aphasia (speech impairment due to brain disorders$ apra3ia (inability to perform previously learned actions$.

Disorders of perception is the inability to interpret sensations. Stroke can cause visual perceptual dysfunction impaired visual-spatial relationships and sensory loss. &isual perceptual dysfunction due to disruption of the primary sensory pathways between the eyes and the visual corte3. 0mpaired visual-spatial relationships (getting the relationship of two or more ob(ects in a spatial area$ is often seen in patients with left hemiplegia. Patients may not be able to wear clothes without assistance because of the inability to match the outfit to the body.=ntuk help patients caregivers can take steps to set the environment and get rid of furniture because patients with problems of perception easily distracted. 0t would be useful and give a gentle reminder of where the ob(ect is placed. Sensory loss due to stroke can be either a light touch or damage may be more severe with loss propriosepsi (the ability to sense the position and movement of the

body$ as well as the difficulties in interpreting visual stimuli tactile and auditory %hanges in cognitive and psychological effects if the damage occurs in the frontal lobe learning capacity memory and intellectual functioning of higher cortical might be corrupted. This dysfunction can be demonstrated in a field limited attention difficulty in understanding forgetfulness and lack of motivation that led to the patient?s face frustrating problems in their rehabilitation program. .ther psychological problems are also common and is manifested by emotional lability hostility frustration resentment and lack of cooperation. 7ladder Dysfunction after stroke patients may e3perience temporary urinary incontinence due to confusion inability to communicate needs and inability to use the urinal due to damage motor and postural control. Sometimes after a stroke atonik bladder the sensation of damage in response to bladder filling. Sometimes the e3ternal urinary sphincter control is lost or reduced. During this period the catheteri)ation interminten with sterile techni+ue. 6hen the tendon refle3es increased muscle tone back increased bladder tone and spasticity of the bladder can occur. ;eurologic Deficit Stroke %linical *anifestations are as @ollows4
;umber

;eurological deficit &isual field deficit a$-omonimus -emlanopsia b$ 1oss of peripheral vision c$ Diplopia

*anifestation a$ Did not reali)e a person or ob(ect ignoring one side of the body difficulty (udging distance b$ difficulty seeing at night unaware of the ob(ect or ob(ect boundary. c$ Double &ision

motor deficit a$ hemiparesis b$ -emiplegia

a$ weakness of face arm and leg on the same side. b$ Paralysis of the face arm and leg on

the same side.

c$ 'ta3ia d$ Disatria e$ Dysphagia

c$ 6alking unsteady unable to unify the foot. d$ Difficulty in forming words e$ Difficulty in swallowing.

3 4

Sensory deficits4 Parastesia verbal deficits a$ @ascia e3pressive b$ @ascia receptive c$ global aphasia

pins and needles

a$ ;ot being able to spell a word that can be understood b$ ;ot able to understand the spoken word unable to speak but no sense c$ ' combination of receptive and e3pressive aphasia

cognitive deficits

1oss of short-and long-term memory decreased field of attention inability to concentrate and changes in valuation.

5motional deficit

1oss of self-control emotional lability depression withdrawal fear resentment and feelings of isolation.

NURSING CARE
A. Case

Tn. A received in a hospital emergency Soetomo on !! .ctober !"1!. Tn.A complained could not move his arms and legs to the right since yesterday when get up in bed. Tn. A has felt muscles of the arm and the right leg is weak and canBt function it suddenly numbness di))iness nausea. %lient has a history of hypertension since 1 year ago smoked a pack a day and occasionally drink alcohol Tn. A also has a history of high cholesterol. %urrently now Tn. A was moved to room !"< by a nurse. .btained results of vital sign Temperature4 9#.< degrees celsius hearth rate of ,, times per minute blood pressure 1,"C11" mm-g respiration !8 times per minute neurological status4 consciousness compos mentis 2%S4 *3 58 &< he has good communication to the nurse.
B. Nursing Assess en!

2eneral Data 0nformation 1. Personal Data ;ame Se3 'ge Dob 4 4 4 4 *r. A *ale << years old 5mployee

!. %hief %omplaint %an not move his right arms and right legs. 9. Past -ealth -istory Tn. A has a history of hypertension since ! years ago a history of high cholesterol and unhealthy lifestyle. 8. @amily -istory -is father also suffered from hypertension and had died of heart disease and his mother had died si3 months ago due to complications from cancer illness.

<. 'llergies The patient does not have a history of drugs animals foods or any other allergies. #. %urrent *eds Patient do not get any treatment at this time. E. 'D1BS at home a. -ygiene 4 he canBt doing personal hygiene independently b. 7ladder and bowel elimination 4 -e has problems urinaring and bowel movements he canBt move to the toilet by him self. c. Diet habits 4 -e has dietary of salt. d. -ealth Practice 4 no sports activities conducted client only sometimes on Sunday. ,. 1ife style habits patient have the habit of smoking a pack a day and occasionally drinking alcohol. Physic 53amination 1. &ital sign 4 7lood pressure Pulse :espiration Saturation 4 4 4 4 1,"C11" mm-g ,, bpm !8 bpm F" G

Temperature !. -eightC6eight4 -eight 4 6eight 4 9. *usculusceletal muscle strength

4 1#< centimeter << kilograms

9# <o %

-e weight is average for the normal weight

'rm and right leg is weak the client disable to move his right arm and leg ! < ! < can be removed with a sustained but if the backings off the arm and feet has falling down. ! H the score for having contraction but cannot moves. < H the score for independently mobili)ation
C. Ana"#sis $% &a!a

;o.

Data @ocus Sub(ective data headache and stomach feels +ueasy .b(ective data
1. TD4 1,"C11" mm-g 2. %T scan4 it appears the

Problem 0neffective cerebral tissue perfusion

5tiology 0schemic cerebrovascular

ischemic cerebral corte3

3. Sp.!4 F"G

!.

Sub(ective data

0mpaired

paresis paralysis

or

1. %an not move his arm and feet physical

to the right since yesterday mobility when get up in bed

2. @eel the muscles of his arm

and leg right are weak and

disable numbness .b(ective data

to

move

feel

1. patient seems weak 2. patientBs mobili)ation only can

be done on the bed 9. *uscle strength ! ! 9. < < Deficit self care 4 6eakness

Sub(ective data

could not do on their own self- bathing and care because of weak arm and leg toileting .b(ective data 'D14 bathing and toileting assisted by a nurse C family &' Nursing Care ("an 1. 0mpaired cerebral tissue perfusion related intracranial hemorrhage ischemia (embolism or thrombosis$ ;.% Tissue perfusion 4 cerabral neorological status blood coagulation medication respon %ommon e3pected outcome 4 'fter being given a !8-hours of nursing care for the patient is e3pected to show signs of increasing the effectiveness of the cerebral tissue perfusion. a. Patient maintains optimal cerebral tissue perfusion b. 's evidenced by 2%S score greater than 19 c. 'bsence of new neurological deficits and stable blood pressure ;0% a. %erebral perfusion promotion b. ;eurological monitoring c. *edication administration .ngoing assessment

a. 'ssess neurological status (serially$ using ;ational 0nstitutes of -ealth Stroke Scale (;0-SS$ or 2lasgow %oma Scale :ationales 4 This inforation is used to determine the effects of stroke and identify life- threatening complications such as increased intracranial prressure (0%P$. The ;0-SS is a standardi)ed assesment of consciousness vision sensory and motor responses speech and language function. b. 'ssess past history of cardiac dysrhythmias hypertension smoking :ationales 4 %ardiac workup is warranted if stroke is embolic atrial fibrilation is a ma(or cause of embolic stroke. -ypertension seems to be related to hemorrhagic stroke. 'therosclerosis and transient iscemic attacks are assocciated with thrombotic stroke. c. *onitor vital sign as needed :ationales 4 @re+uent assessment of blood pressure (7P$ is essential. ' normotensive state is desired to promote effective cerebral perfusion pressure. d. *onitor fluid intake and urine output :ationales 4 ' decrease in urine output may indicate decreased renal perfusion and an associated decrease in cerebral perfusion. Therapeutic intervension a. 'dminister the following medications4 1$ Thrombolytics :ationales 4 Thrombolytics are given to dissolve clots in cerebral vessels. !$ 'nticoagulants and antiplatelet drug :ationales 4 'nticoagulants and antiplatelet drug are given to reduce clot formation and prevent e3tension of e3isting clots. 9$ 'ntihypertensives :ationales 4 'ntihypertensives are give to control severe hypertension and maintain cerebral perfusion 8$ .smotik diuretics

:ationales

4 .smotik diuretics are given to decrease 0%P by

reducing cerebral edema. b. :aise head of bed no higher than 9" degrees :ationales 4 %urrent evidence suggests that elevating the head of bed reduces 0%P by increasing cerebral venous outflow. c. Ieep the patientBs head and neck in neutral position :ationales 4 This position promotes venous drainage from the brain and decrease 0%P. d. 'void unnecessarycare activities :ationales 4 @re+uent stimulation of the patient can serve as a no3ious stimulus and increases brain activity and 0%P. !. 0mpaired physical mobility related to paresis or paralysis ;.% *obility %ommon e3pected outcome 4 after being given a !8-hour nursing care for patients hopefully can be e3pected to gradually perform range of motion e3ercises and walking independently. a. Patient enable to move the paraly)e e3tremity and maintain the ability of the normal e3tremity. b. Patient demonstrates use of adaptive techni+ues that promote ambulation and transferring c. Patient is free of complications of immobility as evidenced by intact skin absence of thrombophlebitis normal bowel pattern and clear breath sounds ;0% *obility management a. 'ssess degree of weakness in both upper and lowe e3tremities :ationales 4 There may be differing degress of involvement on the affected side. b. 'ssess ability to perform range of motion (:.*$ to all (oints

:ationales 4 This assesment provides data on the e3tent of any physical problems. The data will guide therapy to promote mobility. Testing by a physical therapist may be needed. c. .bserve for activities or situations that increase or decrease muscle tone :ationales 4 0nitially muscles demonstrate hyporefle3ia which later progresses to hyperrefle3ia. 'ctivities that cause spastic response can be postponed until later in recovery. d. *onitor skin integrity for areas of blanching or redness :ationales 4 0mpaired mobility increases the risk for skin breakdown. e. 0f the patient is not in severe musculosceletal disorder prepare for 3ray e3amination :ationales 4 The 3-ray film will confirm correct placement of bone indicate the presence of rib fractures and other abnormalities like deformity and etc. 9. Self care deficit 4 bathing and toileting related to weakness or tiredness ;.% Self-care 4 bathing Self-care 4 toileting %ommon e3pected outcome 4 after being given a !8-hour nursing care is e3pected to patients 'D1s needs such as toileting can be ade+uately met. a. Patient safely performs (to ma3imum ability$ self-care activities b. Patient identifies resources that are useful in optimi)ing oneBs autonomy and independence ;0% Self-%are 'ssistance .ngoing assessment a. *onitor respiratory rate and rhythm breath sounds and ability to handle secretions'sses the patientBs ability to perform activities of daily living ('D1s$ effectively and safely on a daly basis using an

apppropriate assessment tool such as the @unctional 0ndependence *easures (@0*$. :ationales 4 The patient may only re+uire assistance with some self-care measures. ' variety of tools are available depending on the clinical setting. Such tools provide ob(ective data for baselines. @or e3ample the @0* measures 1, self-care ites related to eating bathing rooming dressing toileting bladder adn bowel mangement transfer ambulation and stair climbing. b. 'sses the patientBs need for assistive decices. 'ssess the need for home health care after discharge. :ationales 4 assistive devices increase independence in perormance of 'D1s. Shortened hospital stays have resulted in patients being more dibilitated on discharge and therfore re+uiringmore assistance at home. .ccupational therapists have access to a wide range of self-help devices. c. 0dentify preference for food personal care items and other things. :ationales 4 the patient is more likely to participate in self-care that supports his or her indvidual and personal preferences. d. 0f indicated assess for ga refle3 or need for swallowing evaluatio by speech therapist befor initial oral feeding. :ationales 4 absence of gag refle3 or inability to chew or swallow properly may lead to choking or aspiration. Therapiutic intervention a. Place patient in comfort position for eating preferably sitting up in a chair> support arms elbows and wrists as needed :ationales 4 proper positioning can make the task easier while also reducing risk for aspiration. b. 5nsure that consistency of diet is appropriate for the patientBs ability to chew and swallow as assessed by the speech therapist. :ationales 4 thickened semisolid foods like puddding anf hot cereal

are most easily swallowed and less likely to be aspirated c. %onsider appropriate setting for feeding where the patient has supportive assistance yet is not embarrassed. :ationales 4 5mbarrassment or fear of spilling food on self may hinder the patientBs attempts to feed self. d. Provide fre+uent encouragement and assistance with dressing as needed :ationales 4 'ssistance can reduce energy e3penditure and rustration. -owever care needs to be taken so the care provider does not rush through tasks negating the patientBs attempts. e. Plan daily activities so the patient is rested before activity :ationales 4 ' plan that balances periods of activity with periods of rest can help the patient complete the desired activity without undue fatigue and frustration. f. Place the patient in wheelchair or statinoary chair :ationales 4 Dressing can be fatiguing. ' chair that provides more support for the body than sitting on the side of the bed conserves energy when dressing. g. *aintain privacy during bathing as appropriate :ationales 4 the need fro privacy is fundamental for most patients h. 0nstruct the patient to select bath time when he or she is rested and unhurried :ationales 4 hurrying may result in accidents and the energy re+uierd for these activities may be substantial. i. 5ncourage the patient to bahe self as much as he or she is capable of. 'ssist with completion of bath brushing teeth shaving and so on only as needed. :ationales 4 hospital workers and family caregivers are oftern in a hurry and do more for patients tha needed thereby slowing the patientBs efforts at regaining independence.

(. 5valuate

or document previous and urrent patterns for toileting>

institute a toileting schedule that factors these habits into the program. :ationales 4 The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected k. 'ssist the patient in removing or replacing necessary clothing :ationales 4 %lothing that is difficult to get into and out of may compromise a patientBs ability to be continent. l. 'ssists with bed mobility by doing the following4 1$ 'llow the patient to work at own rate of speed !$ 5ncourge the patient to use the stronger side (if appropriate$ as much as possible. :ationales 4 7ed mobility prevents disabling conractures pressure ulcers and muscle wakness from disuse. *any factors may influence a patientBs ability to move freely and each of these factors must be conseiderd when developing or taching a patien a new system for selfcare.

ENGLISH IN NURSING
NEUROLOGY SYSTEM

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(ROGRAM STU&I ILMU KE(ERA+ATAN ,AKULTAS KE(ERA+ATAN UNI-ERSITAS AIRLANGGA SURA)AYA

2.12