Nursing Assessment for Hemorrhagic Stroke

According to the WHO. (2007) Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly with signs and symptoms according to the focal area of the brain is disrupted.

Stroke is a disorder of brain function that occurs anatomy suddenly and quickly, due to disturbance of brain haemorrhage. Stroke or Cerebral vascular Accident (CVA) is a loss of brain function caused by the cessation of blood supply to part of the brain (Brunner and Suddarth, 2008).


Assessment

1. Primary Assessment

Airway
The blockage / obstruction of the airway by a buildup of secretions due to the weakness of the cough reflex.
Breathing
Weakness swallow / cough / protect the airway, breathing hard onset and / or irregular, audible breath sounds Ronchi / aspiration.
Circulation
Blood pressure may be normal or increased, hypotension occurs at an advanced stage, tachycardia, abnormal heart sounds at an early stage, dysrhythmias, skin and mucous membranes pale, cold, cyanosis at an advanced stage.

2. Secondary Assessment

1. Activity and rest
Subjective Data:

• difficulties in the move; weakness, loss of sensation or paralysis.
• tiredness, trouble breaks (pain or muscle spasms).

Objective data:

• Changes in the level of consciousness.
• Changes in muscle tone (flaccid or spastic), paraliysis (hemiplegia), general weakness.
• visual impairment.

2. Circulation
Subjective data:

• A history of heart disease (heart valve disease, dysrhythmias, heart failure, bacterial endocarditis), polycythemia.

Objective data:

• Arterial hypertension.
• Dysrhythmia, ECG changes.
• Pulsation: varied possibilities.
• Pulse carotid, femoral and iliac artery or abdominal aorta.

3. Ego integrity
Subjective data:

• feeling helpless, hopeless.

Objective data:

• emotional instability and anger that are not appropriate, sadness, joy.
• difficulty of self expression.

4. Elimination
Subjective data:

• incontinence, anuria.
• abdominal distention (very full bladder), absence of bowel sounds (paralytic ileus).

5. Eating / drinking
Subjective data:

• loss of appetite.
• nausea / vomiting indicate the presence of increased intracranial pressure.
• loss of sensation of the tongue, cheeks, throat, dysphagia.
• History of diabetes, Increased fat in the blood.

Objective data:

• problems in chewing (declining reflexes palate and pharynx).
• obesity (risk factors).

6. Neuro-sensory
Subjective data:

• dizziness / syncope (prior CVD / temporary for TIA).
• headache: the intra-cerebral hemorrhage or subarachnoid hemorrhage.
• weakness, tingling / numbness, affected side looks like a lame / death
• reduced visibility.
• touch: loss of sensors on the collateral of the extremities and the face of the ipsilateral (same side).
• sense of taste and smell disorders.

Objective data:

• mental status; coma usually mark the bleeding stage, behavioral disturbances (such as lethargy, apathy, attack) and impaired cognitive function.
• extremity: weakness / paraliysis (contralateral to all types of strokes, do not draw the hand grip, reduced tendon reflexes in (contralateral).
• facial paralysis / parese (ipsilateral).
• aphasia (damage or loss of function of language, expressive possibilities / difficulty saying words, receptive / trouble saying the word comprehensive, global / combination of both.
• lose the ability to know or see, auditory, tactile stimuli.
• apraxia: lose the ability to use the motor.
• reaction and pupil size: unequal dilatation and not react on the ipsilateral side.

7. Pain / comfort
Subjective data:

• headache that vary in intensity.

Objective data:

• unstable behavior, anxiety, muscle tension / facial.