Askep Stroke

NURSING CARE REPORTON NON HAEMORAGIC STROKE

By :M. Luthfianoor R.

010028

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGEINTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

ACADEMIC YEAR 2011/2012

1. AssesmentA. Identity

Identity of the ClientName : Mr. JAge : 59 yearsGender : MaleMarital Status : MarriedAddress : Antasan Raden RT. 20 A No. 15 GOccupation : (not reviewed) Religion : IslamTribe / Nation : Banjarese / IndonesianMRS Date : 10 – 07 – 2011Review Date : 12 – 07 – 2011Medical Diagnosis : Non-Hemoragic StrokeRMK Number : 148676

Identity of Person in ChargeName : Mr. SAge : 32 yearsGender : MaleAddress : Antasan Raden RT. 20 A No. 15 GOccupation : Private EmployeeRelationship with the Client : Son of the Client

B. History of DiseaseMain ComplaintThe weakness of left part of the body (stroke)(other data are not reviewed)

History of Present DiseaseThe weakness of right part of the body since morning of July 10th followed by vomiting, headache, the swollen of feet and hands since the third stroke, hypertension, lip oblique to the left.(other data are not reviewed)

History of Previous DiseaseClient stated that he had the same disease for three times.

History of Family’s DiseaseAlmost all client’s family members had been hospitalized but with different disease.(other data are not reviewed)

C. Physical ExaminationGeneral ConditionClient is in full consciousness, the client looks weak but he still able to do activities by himself.Eye : The client able to open his eyes spontaneously, but there is a little

disturbance in his vision.Verbal : The client able to speak, difficult to understand.Motoric : The client has difficulty in moving his extremity.

Vital SignsBlood Pressure: 160/90 mmHgPulse : 96x/minuteRespiration : 22x / minuteTemperature : 36,7° C(Anthropometric data are not reviewed)

SkinGenerally, condition of Client’s skin is normal, client’s temperature is 36,7° C, the colour of Client’s skin looks normal

Head and NeckThe structure of Client’s head looks normal, there is no lesion or abnormality in Client’s head, the distribution of client’s hair looks rare and white (gray hair). Client’s neck is clean, there is no lesion or abnormality on client’s neck.

Eyes and VisionClient’s eyes looks symmetric, there is no dirt, no lesion, client’s cornea is clear, sclera is white, client doesn’t use any visual aids.

Nose and SmellingClient’s nose looks normal and there is no inflammation, there is no secretion or liquids coming out of his nose, client’s olfactory function are good.

Ear and HearingThe structure of client’s ears are symmetric, there is no inflammation/bleeding. Client’s hearing function is well, client responses if he is called, client’s ear looks clean, there is no dirt or liquids coming out from client’s ear, no hearing aids that is used by the client.

Mouth and DentalGeneral condition of mouth and dental is clean, client’s mouth is oblique to the left, mucosal lip colour is brown and looks dry, client’s tongue is clean and there is no lesion

or bleeding. There is no difficulty in swallowing food but client has a little difficulty in chewing. Client doesn’t use false teeth.

Chest, Heart, and LungsThe shape of client’s chest is symmetric; breathing frequency is 24 x / minute. CRT back more than 2 seconds.(other data are not reviewed)

AbdomenThe condition of Client’s abdomen is clean and there is no lesion on client’s abdomen.(other data are not reviewed)

GenitalClient is male, he is 59 years old, and client has been married.(Other data are not reviewed)

Upper Extremities and Lower ExtremitiesStructure of client’s upper extremities is symmetric, infuse is attached on upper right extremities, oedema in lower extremities.(other data are not reviewed)

D. Physical, Biological, Psychological, and Spiritual Needs1) Activity and Resting

At home : Client only does activities in room and taking a nap 1-2 hours every day, and at night 6-7 hours every day.

At hospital : Client takes a nap 1 hour/day, at night around 5-6 hours/day. There is no disturbance in sleeping.

2) Personal HygieneAt home : Client usually taking a shower twice a day, brushing his teeth once a

day, and washing his hair if its dirty.At hospital : Client is just being wiped by his family.

3) NutritionAt home : Client’s eating pattern is 3 times a day with main food like rice plus

varied side dishes.At hospital : Client eats three times a day, but only half of the portion.

4) EliminationAt home : Urination pattern 1-4 times a day, elimination once a day, usually in

the morning.At hospital : Urinating 1-3 times a day, the colour is yellow, and elimination once

a day.

5) Psychological : The thing that the Client’s family think is about Client’s condition and disease. The family also hopes that the Client will recover and can do activities normally to all his body parts after getting treatment and medication from hospital

6) Social : The relationship of family and other people when they’re at home is good and when at hospital client is visited by his family and neighbours.

7) Spiritual : Client’s religion is Islam. Religious activity thate is performed before the sickness is five times prayer, at hospital the client still doing the prayer.

8) Sexuality : Client is a male, has been married and has children.

E. Data FocusA. Subjective Data

- Client’s family said that the client’s head is dizzy.

- Client’s family said that the headache appears when the Client does activities.

- Client’s family said that the pain scale is 2, bearable pain.

- Client’s family said that the pain comes suddenly

- Client’s family said that the Client can’t do any activity.

- Client’s family said that the Client’s family got a fever.

- Client’s family said that the Client feels the pain in the neck.

B. Objective Data1. Inspection

- Client looks weak

- Activity scale is 4 (fully dependent)

- Muscle scale 3333 4444 3333 4444

- Temperature : 36,7° C

- Client looks nervous

2. Percussion

3. Palpation- Pulse : 96x/minute

- Respiration: 22x/minut

- Skin turgor back in ± 2 seconds

4. Auscultation- Blood Pressure: 160/90 mmHg

- Heart’s Sound: single S1S2

C. InvestigationLaboratory Result

Examination Result Reference UnitSGOT 19 L up to 37 L up to 20 u/dl

Bilirubin T 0,9 Up to 1,1 u/dlBilirubin D 0,7 Up to 0,25 Mg/dl

Indirect Bilirubin 6,2SGPT 46 Up to 37 u/dl

Kidney Physiology TestCreatinine 4,84 1,1 – 0,6Urid Acid 12 3,4 – 7,6

Blood FatCholesterol 288 Up to 200 Mg/dl

Triglycerides 199 60 - 150 Mg/dl

D. Pharmacological Therapy- Inj. Rantin 2 x 1 amp

- Inj. Lapibol 1 x 1 amp

- Blood pres 1 x ½ tab

- Platogrip 1 x 1

- Neurochol 1 x 1 tab

- Cholestat 30 mg

- Pre infus lasix ½ amp

- Infus lasix 1 x ½ amp

- IVVD Rl 20 drops/minute

F. Data Analysis

No Data Problems Cause1 SD:

- Client’s family said that the client’s head is dizzy.

- Client’s family said that the headache appears when the Client does activities.

- Client’s family said that the pain scale is 2, bearable pain.

- The pain comes suddenly- Client’s family sait that the Client

can’t do any activity.- Client’s family said that the Client’s

family got a fever.- Client’s family said that the Client

feels the pain in the neck.

OD:P : the pain comes when the Client

does activitiesQ : the pain is like given heavy loadsR : the pain is on the neckS : the pain scale is 2 (can be beared)T : the pain comes suddenly

Client looks weakBP: 160/90 mmHgClient looks nervous

Pain Increase in celebral vascular

2 SD:- Client’s family stated that the Client

doesn’t want to eat.OD:- Client looks weak

Nutrition is less than what the body needs

Not able to swallow the food

3 SD:- Client’s family stated that the Client

is difficult to do activitiesOD:- Client looks weak- Activity scale shows that the Client

needs help in doing activities- Scale 3333 4444

3333 4444

Damage of physical mobility

Decreased muscle strength

G. Intervention

No Nursing Diagnoses Purpose intervention Rational1 Headache r.t increase in cerebral vascular

indicated with:- Client’s family said that the Client is

dizzy.- Client’s family said that the pain comes

when the Client does activity.- Client’s family said that the pain scale is

3 (bearable pain)- Client’s family said that the headache

feels like given a heavy loads- The pain comes suddenly.

Headache can be reduced in 3 days of treatment with expected result:- Client’s family doesn’t

complaint that the Client doesn’t feel dizzy, pain scale is 0, there is no pain in the head.

1. Examination of pain characteristics.

2. TTV observation3. Maintaining bed rest4. Collaboration with

medicine

1. Knowing the pain quality.

2. Knowing Client’s general condition.

3. Reducing the pain

2 Nutrition less than body needs r.t incapable in absorbing indicated with:- Client’s family said that the Client can

not eat.- Client looks weak

Nutrition less that body needs can be resolved in 3 days treatment with expected result:- Client can eat- Client does not look weak

1. Feeding the patient via oral.

2. Examination of nutrition status

3. Collaboration in giving medicine

1. Fulfilling Client’s nutrition needs

2. Knowing the cause of the lack of input.

3. Adjusting Client’s condition

3 The damage of physical mobility r.t decreased muscle strength indicated by:- Client’s family said that the Client is

difficult to do activities.- Client looks weak- Activity scale is 3- Scale 3333 4444

3333 4444

The damage of physical mobility can be resolved i 3 days treatment with expected result:- Client can do activities- Client does not look weak- Activity scale 0- Muscle scale 5555 5555

5555 5555

1. Examine the limitation of activity and muscle strength.

2. Change the position of the Client periodically.

3. Give help in Client’s activity.

1. Knowing client’s condition.

2. Preventing skin damage.

3. Helping client’s activity.

H. Implementation

No Day / Date Time Dx Implementation Evaluation Action1 Monday

11 – 07 – 2011 14.30

17.00

20.00

I

1. Examine the characteristics of pain

2. Observe TTV

3. Giving Antrain Injection4. Giving captopril oral medicine

P = the pain comes when doing activitiesQ= the pain is like given heavy loadsR= the pain is on neckS = the pain scale is 3T= the pain comes suddenly

TD = 160/90 mmHg R =25x / minute

N = 84 x/minute T = 36° C

Client looks weak when the injection is givenClient is given oral medicine

Monday11 – 07 – 2011

15.00

15.30II

1. Examine Client’s nutrition status

2. Giving food

Client said that he has been not eating for 2 days

Client only spend a quarter of given portionMonday11 – 07 – 2011

14.00

16.00

18.00

20.00

III

1. Examine client’s limitation

2. Change Client’s position



Client’s family said that Client has difficulties in dong his activities, Client can only lie down and sit.

Client’s anxiety is lessen

Client’s anxiety is lessen

Client’s anxiety is lessenTuesday12 – 07 – 2011

8.00

11.00

I 1. Examine the characteristics of pain

2. Giving food


Client only spend a quarter of given portion

12.00 3. Observe TTV TD = 150/100 mmHg R =24x / minute

N = 90 x/minute T = 36,5° CTuesday12 – 07 – 2011

08.30

11.00II


2. Giving food

Client is willing to eat, but just a little.

Client spends a half of given portionTuesday12 – 07 – 2011

09.00

10.0012.0014.00

III

1. Examine Client’s activity limitations

2. Change Client’s position3. Change Client’s position4. Change Client’s position

Client’s family said that the Client always try to walk and do activities by himself.

Wednesday13 – 07 – 2011

14.00

15.00

17.00

15.30

I

1. Examine the characteristics of pain

2. Giving food

3. Observe TTV

4. Giving Albumin


Client only eat half of given portion


N = 86 x/minute T = 36° C

Client looks calmWednesday13 – 07 – 2011

14.30II


2. Giving oral medicine: Captopril

Client is willing to eat

Helping to decrease Client’s blood pressureWednesday13 – 07 – 2011

14.3016.00

III 1. Examine Client’s activity limitations

Client’s family said that the Client always try to act independently

2. Change Client’s positionClient’s anxiety seems reduced

Thursday14 – 07 – 2011

14.00

15.0015.00

I

1. Examine pain characteristics

2. Giving food3. Giving oral medicine: Captopril

P = the pain comes when doing activitiesQ= the pain is like given heavy loadsR= the pain is on neckS = the pain scale is 2T= the pain comes suddenlyClient eats full portionHelping to decrease Client’s blood pressure

Thursday14 – 07 – 2011

14.00

17.00 II

1. Examine Client’s nutrition

2. Observe TTV

Client eats calmly


N = 80 x/minute T = 36° CThursday14 – 07 – 2011

14.00

18.00III

1. Examine Client’s activity limitations


Client’s family said that the Client always try to act independently

Client’s anxiety seems reduced

Friday15 – 07 – 2011

11.0011.0012.00 I

1. Giving food2. Giving oral medicine: Captopril3. Observe TTV

Client eats calmlyHelping to decrease Client’s blood pressureTD = 130/90 mmHg R =

24x / minuteN = 80 x/minute T = 36° C

Friday15 – 07 – 2011

08.00II

Examine Client’s nutrition status Client eats calmly

Friday15 – 07 – 2011

08.00III

Examine client’s activity limitations Client’s family said that the client can do his activities by himself and the Client can not wait to go home.

I. Evaluation

No Day / Date Time Dx Implementation1 Monday

11 – 07 – 2011 21.00 1 S : Client’s family said that the Client still experiencing headache

O: Pain CharacteristicP = the pain comes when doing activitiesQ = the pain is like given heavy loadsR = the pain is on neckS = the pain scale is 3T = the pain comes suddenly

TTVTD= 160/90 mmHg R = 25x / minuteN = 84 x/minute T = 36° C

A: headache problem has not resolvedP : continued the intervention

2 2 S: Client’s family said that the Client does not want to eatO: Client looks weakA : nutrition problems has not resolvedP: continued the intervention

3 3 S : Client’s family said that the Client is difficult to do activitiesO: activity scale is 3A: Physical mobility damage has not resolvedP : continued the intervention

4 Tuesday12 – 07 – 2011

1 S : Client’s family said that the headache is lessenO: Client looks anxious

Client’s pain characteristicP = the pain comes when doing activitiesQ = the pain is like given heavy loadsR = the pain is on neckS = the pain scale is 3

T = the pain comes suddenly

TTVTD = 150/100 mmHg R = 24x / minuteN = 90 x/minute T = 36,5° C

A: A part of headache problem is resolvedP : continued the intervention

5 2 S : Client’s family said that the Client has feverO: Client looks weakA: Nutrition problem has not resolvedP : continued the intervention

6 3 S : Client’s family said that the Client is difficult to do activitiesO: activity scale is 3A: Physical mobility damage has not resolvedP : continued the intervention

7 Wednesday13 – 07 – 2011

1 S : Client’s family said that the headache is like the day beforeO: Client looks anxious

Client’s pain characteristicP = the pain comes when doing activitiesQ = the pain is like given heavy loadsR = the pain is on neckS = the pain scale is 3T = the pain comes suddenly

TTVTD = 150/100 mmHg R = 32x / minuteN = 86 x/minute T = 36° C


8 2 S : Client’s family said that the Client can not eatO: Client looks weakA: Nutrition problem has not resolvedP : continued the intervention

9 3 S : Client’s family said that the Client is trying to be independentO: activity scale is 3A: A part of Physical mobility damage is resolvedP : continued the intervention

10 Thursday14 – 07 – 2011

1 S : Client’s family said that the headache is lessenO: Client looks calm



11 2 S : Client’s family said that the Client eats calmlyO: Client looks weakA: A part of nutrition problem is resolvedP : continued the intervention

12 3 S : Client’s family said that the Client can do activitiesO: activity scale is 2A: A part of Physical mobility damage is resolvedP : continued the intervention

13 Friday15 – 07 – 2011

1 S : Client’s family said that the headache is starting to goneO: Client looks calm


TTVTD = 130/90 mmHg R = 24x / minute

N = 80 x/minute T = 36° CA: Headache problem is resolvedP : Intervention is stopped, patient go home

14 2 S : Client’s family said that the Client can eatO: client looks healthyA: Nutrition problem is resolvedP : intervention is stopped, patient go home

15 3 S : Client’s family said that the Client is already independent, but still weakO: activity scale is 2A: A part of Physical mobility damage is resolvedP : intervention is stopped, patient go home

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