STROKE

(Cerebrovascular Accident)

Nursing
Care
Management
Dr Juliana Christina, S.Kep.Ners, MNg, PhD
 OUTLINE
 Definition, classification, risk factors
Statistics & epidemiology
Causes & Pathophysiology
 Clinical manifestations & Complications
Preventions
Assessment & Diagnostic Findings
Medical & Surgical Management
Nursing Management (Assessment, Diagnosis, Care
planning and goals, Interventions & Evaluation
Discharge and Home care guidelines
What is STROKE?
A neurological disorder characterized
by blockage of blood vessels. Clots
form in the brain and interrupt blood
flow, clogging arteries and causing
blood vessels to break, leading to
bleeding.
Rupture of the arteries leading to the
brain during stroke results in the
sudden death of brain cells owing to a
lack of oxygen.
Stroke can also lead to depression and
dementia
 CAUSES
 Large artery thrombosis. Large artery thromboses are
caused by atherosclerotic plaques in the large blood vessels
of the brain.
 Small penetrating artery thrombosis. Small penetrating
artery thrombosis affects one or more vessels and is the
most common type of ischemic stroke.
 Cardiogenic emboli. Cardiogenic emboli are associated
with cardiac dysrhythmias, usually atrial fibrillation.
Pathophysiology
 Classification
Ischemic stroke. Haemorrhagic stroke.
This is the loss of Haemorrhagic strokes
function in the brain as a are caused by bleeding
result of a disrupted into the brain tissue, the
blood supply. ventricles, or the
subarachnoid space.
 Risk Factors
Non- modifiable : Modifiable:
 Advanced Age (>55  Hypertension
years) Atrial Fibrillation
Gender (Male) Hyperlipidaemia
Race (African American) Obesity
 Smoking
Diabetes
 Statistics & epidemiology

The second leading cause of Di Indonesia stroke merupakan

death and a major contributor penyebab kematian terbanyak
to disability worldwide. ketiga dengan angka kematian
sebanyak 138.268 jiwa atau
The prevalence of stroke is 9,7% dari total kematian
highest in developing
countries, with ischemic stroke
being the most common type.
It affects roughly 13.7 million
people and kills around 5.5
million annually
 Prevention
•(C) Cek kesehatan secara
berkala,
•(E) Enyahkan asap rokok,
•(R) Rajin beraktivitas fisik,
•(D) Diet sehat dengan kalori
seimbang,
•(I) Istirahat cukup dan
•(K) Kelola stress;
 Clinical manifestations
Haemorrhagic: Non- Haemorrhagic:
Perubahan tingkat kesadaran Perubahan tingkat kesadaran
(coma) Mual muntah
Sakit kepala mual muntah
Reflek lemah
Mengigil/ berkeringat
Peningkatan ICP fasia (Gangguan komunikasi)
Afasia Difasia (Gangguan
memahami kata)
Hipertensi
Kesemutan
Distress pernafasan
Nyeri kepala
Kejang sampai tidak sadar
 Complications

•Tissue ischemia
If cerebral blood flow is inadequate, the amount of oxygen
supplied to the brain is decreased, and tissue ischemia will
result.
•Cardiac dysrhythmias
The heart compensates for the decreased cerebral blood flow,
and with too much pumping, dysrhythmias may occur.
 Assessment and Diagnostic Findings
Lumbar puncture
PET scan
Pressure is usually normal and CSF is clear in
Demonstrates structural
cerebral thrombosis, embolism, and TIA.
Pressure elevation and grossly bloody fluid abnormalities, oedema,
suggest subarachnoid and intracerebral hematomas, ischemia,
. and
haemorrhage. CSF total protein level may be infarctions.
elevated in cases of thrombosis because of
inflammatory process. LP should be performed
if septic embolism from bacterial endocarditis
is suspected.

MRI Cerebral angiography CT- SCAN

Shows areas of Helps determine specific cause . Provides data on cerebral
infarction, of stroke, e.g., haemorrhage or metabolism and blood
haemorrhage, and obstructed artery, pinpoints site flow changes.
areas of ischemia. of occlusion or rupture.
 Assessment and Diagnostic Findings
Transcranial Doppler ultrasonography EEG
Identifies problems based
Evaluates the velocity of blood flow
on reduced electrical
through major intracranial vessels;
activity in specific areas
identifies Aortic Valve disease, e.g.,
of infarction; and. can
problems with carotid system (blood
differentiate seizure activ
flow/presence of atherosclerotic
ity from CVA damage.
plaques)

SKULL-X RAY
May show a shift of pineal gland to the opposite side from an
expanding mass; calcifications of the internal carotid may be visible
in cerebral thrombosis; partial calcification of walls of
an aneurysm may be noted in subarachnoid haemorrhage.
 Assessment and Diagnostic Findings

ECG and echocardiography

To rule out cardiac origin as source of embolus (20% of
strokes are the result of blood or vegetative emboli
associated with valvular disease, dysrhythmias, or .

endocarditis).

Laboratory studies to rule out systemic causes

CBC, platelet and clotting studies,
erythrocyte sedimentation rate (ESR),
chemistries (glucose, sodium).
 Medical Management
 Recombinant tissue plasminogen activator:
Prescribed unless contraindicated, and there
should be monitoring for bleeding.
 Increased ICP Management: Osmotic diuretics,
maintenance of PaCO2 at 30-35 mmHg, and
positioning to avoid hypoxia through elevation of
the head of the bed.
 Endotracheal Tube: Intubation to establish patent
airway if necessary.
 Hemodynamic monitoring: To avoid an increase in
blood pressure.
 Neurologic assessment: to determine if the stroke
is evolving and if other acute complications are
developing
Ventriculoperitoneal Shunt
 Surgical Management

Carotid endarterectomy: Hemicraniectomy:

The removal of atherosclerotic To remove flap of the
plaque or thrombus from the skull and open the dura
carotid artery to prevent stroke in May be performed to
patients with occlusive disease of decrease ICP
the extra cranial cerebral arteries.
Nursing Management : Assessment
Acute Phase: Post- Acute Phase:
• Perubahan tingkat kesadaran • Mental status (Ingatan, orientasi dan
• Adanya pergerakan voluntary or Bahasa)
involuntary movements of extremities. •Sensation and perception (usually the
• Kaku leher patient has decreased awareness of
pain and temperature).
• Respon membuka mata, ukuran pupil,
dan reaksi pupil terhadap cahaya •Motor control (pergerakan ekstremitas
• Warna kulit wajah dan ekstremitas; atas dan bawah, kemapuan menelan,
suhu tubuh dan kelembapan kulit status nutrisi dan cairan, Inetgritas kulit,
funngsi emliminasi urine dan fecal
• Kemampuan berbicara
• Kemampuan melakukan akitifitas
• Tanda pendarahan sehari-hari (ADLs)
• Tekanan darah
Nursing Management :Assessment
• Keluhan utama
• Riwayat penyakit sekarang: Kronologis? Gejala?
Faktor pencetus
• Riwayat penyakit dahulu: Hipertensi, jantung,
diabetes, kontrasepsi?
•Riwayat kesehatan keluarga: Penyakit genetic
• Riwayat Psikososial- spiritual: emosi, cemas, gelisah
 Physical Assessment (Neuro)
Wajah Nervus V (Trigeminus) Ketika diusap kornea mata dengan
kapas halus, pasien akan menutup
kelopak mata
Nervus VII (facialis) Alis mata simetris, dapat
mengangkat alis, mengerutkan
dahi, kesulitan mengunyah, wajah
tidak simetris
Nervus II (optikus): Luas pandang baik 90°, visus 6/6
Mata Nervus III (okulomotorius) Diameter pupil 2mm/2mm, pupil
isokor dan anisokor, palpebral dan
reflek kedip dapat dinilai jika
pasien bisa membuka mata
Nervus IV (troklearis): Pasien dapat mengikuti arah
tangan perawat ke atas dan bawah
Nervus VI (abdusen) Pasien dapat mengikuti arah
tangan perawat ke kiri dan kanan
Visual Disturbances
Assessment Physical Assessment (Neuro)
Hidung Nervus I (olfaktorius) Dapat mengidentifikasi
penciumanK ketajaman
penciuman antara kiri dan kanan
berbeda
Nervus VIII Dapat melakukan keseimbangan
(vetibulokoklearis): gerakan tangan
Mulut dan Nervus VII (facialis) Bibir simetris atau asimetris ,
Gigi dapat mengidentifikasi rasa
Nervus IX (glossofaringeus) Pergerakan ovula tidak simetris,
bibir tidak simetris
Assessment Physical Assessment (Neuro)
Mulut dan Gigi Nervus XII (hipoglosus) Dapat menjulurkan lidah dan
menggerakkan ke kiri dan kanan,
artikulasi bicara kurang jelas
Telinga Nervus VIII Respon pendengaran lemah
(vestibulokoklearis)
Leher Nervus X (vagus): Gangguan menelan (stroke
haemoragik). Pemeriksaan kaku
kuduk (+) dan bludzensky 1 (+)
Assessment Physical Assessment (Neuro)
Ekstremitas Nervus XI (aksesorius) Tidak dapat melawan tahanan
Atas pada bahu (stroke non hemoragik)
Reflek Bicep Negative/ no response
Ektremitas Reflek bluedzensky 1 Positive
Bawah
Reflek babinsky Positive
Opposite Side Affected
Nursing Process: Assessment
LOC SaO2
Restlessness Paresthesias
Dizziness Weakness
Vision Changes Paralysis
Pupils Seizures
Vital Signs Respiratory Status
Pain Swallowing
Nursing Diagnosis: Cerebrovascular
Disorder
Ineffective Cerebral Tissue Incontinence
Perfusion
Self-Care Deficit
Ineffective Airway Clearance
Impaired Verbal
Risk for Injury Communication
Impaired Physical Mobility Disturbed Thought Processes
Imbalanced Nutrition Deficit Knowledge
Disturbed Sensory perception
Risk for Impaired Skin integrity
 NURSING INTERVENTIONS
Risk for Ineffective Cerebral Tissue
Perfusion
Monitor Neurological Status (LOC), pupillary reactions
Monitor Vital Signs and ICP
Monitor fluid intake & output
Monitor Coagulation Studies
Monitor Medication Effects (diuretic)
Position: semi fowler to relieve pressure
Report Changes
Ineffective Airway Clearance
Monitor Lung Sounds, Cough, Respirations
Monitor Oxygen supply
Position to Maintain Open Airway
Encourage to Cough and Deep Breathe
Suctioning
 Risk for Injury

Monitor Neuro Status and

Report Changes
Administer Anticonvulsant
as Ordered
Implement Seizure
Precautions
Offer Toileting on Schedule
Impaired Physical Mobility
Gangguan mobilitas fisik berhubungan dengan
gangguan neuromuskular

Refer to Physiotherapy
Start an active rehabilitation program when
consciousness returns
Perform ROM Exercises
Encourage to Mobilize short and frequent (sitting, standing &
walking)
Turning q2 Hours
 Imbalanced Nutrition
Defisit nutrisi berhubungan dengan ketidakmampuan menelan
makanan

Keep NPO Until Swallowing Evaluated

Consider Tube Feeding if Necessary
Implement Aspiration Precautions :
•Avoid thin liquid/use thickening agents
•Upright position during and after eating
and drinking (45 min)
• Cut food into small pieces/ modify
consistency
 Disturbed Sensory Perception
Gangguan persepsi sensori berhubungan dengan
ketidakmampuan menghidu dan melihat
Assess & Monitor for Sensory Deficits
Teach Patient to Scan Environment
Approach patient with a decreased field of vision on the side where visual perception
is intact; place all visual stimuli on this side.
Teach patient to turn and look in the direction of the defective visual field to
compensate for the loss; make eye contact with patient, and draw attention to
affected side.
Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
Remind patient with hemianopia of the other side of the body; place extremities so
that patient can see them.
Risk for Impaired Skin Integrity
Monitor Skin for Breakdown (bonny areas)
Keep skin clean and dry, gently massage
Maintain adequate nutrition
Keep Perineal Area Clean and Dry
Use Barrier Cream PRN
Turn Patient q2 Hours
Use Lift Sheet to Reposition
Consider Pressure-Reducing Mattress
 Incontinence/Elimination
Monitor for Incontinence
Determine Usual Elimination Patterns
Provide Assistance with Toileting Schedule/offer bedpan
/urinal
Respond Quickly to Requests for Help
Provide high fiber diet and adequate fluid intake (unless
contraindicated)
Perform intermittent sterile catheterization during the
period of loss of sphincter control.
 Self Care Deficit
Encourage /Assist with personal hygiene (Oral hygiene)
Help patient to set realistic goals; add a new task daily.
As a first step, encourage patient to carry out all self-care activities on the
unaffected side.
Make sure patient does not neglect affected side; provide assistive devices
as indicated.
Improve morale by making sure patient is fully dressed during ambulatory
activities.
Assist with dressing activities
Provide emotional support and encouragement to prevent fatigue and
discouragement.
Impaired Verbal Communication
Assess Verbal Ability
Consult Speech Pathologist
Answer Call Light in Person
Listen Patiently
Provide Communication Aids
Keep Communication Appropriate

on’t Assume Patient Does Not

Understand
Picture Board
Disturbed Thought Processes
Monitor Changes in Thought Processes
Place Calendars, Clocks in Environment
Reduce Stressors
Maintain Patient’s Usual Routines
Communicate Slowly and Clearly
Involve Family
 Deficient Knowledge
Explain What Happened to Patient
Explain Tests and Procedures
Orient Patient and Family to Setting
Provide Instruction for Care at Home
Evaluate Need for Home Nursing
 Evaluation
Improved mobility. Achieved a form of
Absence of shoulder communication.
pain. Maintained skin
Self-care achieved. integrity.
Relief of sensory and Continence of bowel
perceptual deprivation. and bladder.
Prevention of aspiration. Improved thought
processes.
Discharge and Home Care
Guidelines
Consult an occupational therapist
Physical therapy
Antidepressant therapy
Support Groups
Asses caregivers