Askep Stroke

Askep Pasien dengan Stroke

2 Pembagian Utama Stroke :
1. Ischemic (85%), : vascular occlusion & significant hypoperfusion,
2. hemorrhagic (15%), adanya extravasation of blood into the brain (American Heart

Association, 2000).



Penyebab Stroke
•Ischemic strokes karena :
    1. large artery thrombosis (20%),
    2. small penetrating artery thrombosis (25%),
    3. cardiogenic embolic stroke 20%),
    4. cryptogenic (30%) and
    5. other (5%)

•Stroke perdarahan karena :
    1. Intracerebral hemorrhage
    2. Subarachnoid hemorrhage
    3. Cerebral aneurysm
    4. Arteriovenous malformation

Stroke Infark

Patofisiologi Stroke infark
•Turunnya aliran darah otak <25 mL/100 g/min -> pernafasan anaerob -> mitokondria

menghasilkan asam laktat --> perubahan pH, penurunan ATP --> gangguan pertukaran ion membran -->

penurunan fungsi sel.

•--> peningkatan permeabilitas membran terhadap kalsium --> kalsium masuk ke dalam sel &

pembentukan glutamat --> menyebabkan kerusakan cell membrane, diproduksi lebih banyak calcium
dan glutamate, vasoconstriction, and the terciptanya radikal bebas. -> perluasan area 

infark
•Daerah awal infark tersebut disebut dengan penumbra
•Calsium canel blocker dapat menghambat influks Ca ke dalam sel.


Manifestasi Klinik Stroke Iskemik :

Tanda dan Gejala
-Rasa tebal atau kelemahan pada wajah, tangan, kaki, khususnya satu sisi
-Kebingungan atau perubahan status mental
-Gangguan bicara atau memahami pembicaraan
-Gangguan Pengelihatan
-Kesulitan berjalan, kepeningan, atau kehilangan koordinasi keseimbangan
-Sakit kepala tiba-tiba
-Gangguan lapang pandang


Gangguan Pengelihatan perifer
Manifestasi :
- Sulit melihat pada malam hari
- Tidak menyadari obyek atau tepi obyek
Tindakan :
-Letakkan obyek pada pusat lapang pandang klien
-Dukung pasien dengan penggunaan tongkat atau obyek lain untuk mengidentifikasinya dalam lapang pandang perifer mereka.
- Kemampuan mengemudi perlu dievaluasi

Diplopia
Manifestasi : pandangan double

Tindakan :

- Jelaskan kepada pasien lokasi obyek saat meletakkannya dekat pasien
- Letakkan dengan konsisten alat-alat perawatan pada tempat yang sama.



Motor Deficits
Hemiparesis
•Manifestasinya : Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere)
Tindakan :
•Letakkan obyek dalam jangkauan pasien pada sisi yang
Instruksikan untuk melatih kekuatan pada sisi yang sehat.

Waspada : pada masa akut --> dapat terjadi infark kembali

Hemiplegia :
•Paralysis of the face, arm, and leg on the same side (due to a lesion in the oppositehemisphere)
Tindakan :
•range-of-motion exercises to the affected side.
•immobilization as needed to the affected side.
•Maintain body alignment in functional position.
•Exercise unaffected limb(angota badan)  to increase mobility, strength, and use.

Ataxia
•Staggering(kejutan) , unsteady(goyah) gait
•Unable to keep feet together; needs a broad base to stand
Tindakan :
•Support patient during the initial ambulation phase.
•Provide supportive device for ambulation (walker, cane).
•Instruct the patient not to walk without assistance or supportive device.

Gejala Lain
•Ataxia
•Dysarthria
•Dysphagia
•Paresthesia
•Verbal Deficits
•Coqnitive Deficits
•Emotional Deficits

•Kehilangan respon motorik
•Gangguan persepsi
•Gangguan sensorik
•Gangguan coqnitive & Efek Psichologic

Pencegahan
•Screening faktor risiko
•Nonmodifiable risk factors : umur, gender, race.
•Modifiable risk factor : hipertensi, atrial fibrillasi, hiperlipidemia, obesitas, merokok,diabetes.

Pengkajian pada fase akut
• Change in the level of consciousness or responsiveness as evidenced by movement, resistance to changes of position, and response to stimulation; orientation to time, place,and person
• Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body posture; and position of the head
• Stiffness or flaccidity of the neck
• Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
• Color of the face and extremities; temperature and moisture of the skin
• Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure
• Ability to speak
• Volume of fluids ingested or administered; volume of urine excreted each 24 hours
• Presence of bleeding
• Maintenance of blood pressure within the desired parameters


Setelah fase akut
•assesses mental status (memory,attention span, perception, orientation, affect, speech/language),
•sensation/perception (usually the patient has decreased awarenessof pain and temperature),
•motor control (upper and lowerextremity movement), swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladderfunction.
•Pengkajian selanjutnya fokus pada : any impairment of function in the patient’s daily activities

Diagnosa Keperawatan
• Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
• Acute pain (painful shoulder) related to hemiplegia and disuse
• Self-care de.cits (hygiene, toileting, grooming, and feeding) related to stroke sequelae
• Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
• Impaired swallowing
• Incontinence related to .accid bladder, detrusor instability, confusion, or dif.culty in communicating
• Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
• Impaired verbal communication related to brain damage
• Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased mobility
• Interrupted family processes related to catastrophic illness and caregiving burdens
• Sexual dysfunction related to neurologic de.cits or fear of failure

Potensial Komplikasi
• Decreased cerebral blood .ow due to increased ICP
• Inadequate oxygen delivery to the brain
• Pneumonia

IMPROVING MOBILITY AND PREVENTING
JOINT DEFORMITIES

•the strong flexor muscles exert control over the extensors. --> The arm tends to adduct (adductor muscles are stronger than abductors) and to rotate internally.
•The elbow and the wrist tend to flex, the affected leg tends to rotate externally at the hip joint and flex at the knee, and the foot at the ankle joint supinates and tends toward plantar flexion.
•Lakukan tindakan untuk mengurangi tekanan, bantu mempertahankan good body alignment,
•Karena flexor muscles lebih kuat dari extensor muscles, a posterior splint applied at night to the affected extremity --> prevent flexion and maintain correct positioning during sleep.

Preventing Shoulder Adduction
•a pillow is placed in the axilla when there is limited external rotation; this keeps the arm away from the chest.
•A pillow is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than the more proximal joints.
•the elbow is positoned higher than the shoulder and the wrist higher than the elbow. This helps to prevent edema and the resultant joint fibrosis that will limit range of motion if the patient regains control of the arm


Positioning the Hand and Fingers

•The fingers are positioned --> barely flexed.
•The hand --> slight supination (palm faces upward), --> functional position.
•If the upper extremity is flaccid, a volar resting splint can be used to support the wrist and hand in a functional position.
•If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. a dor-sal wrist splint is useful in allowing the palm to be free of pressure.
•Every effort is made to prevent hand edema.

Changing Positions
•should be changed every 2 hours.
•A pillow is placed between the legs before the patient is turned.
•To promote venous return and prevent edema, the upper thigh should not be acutely flexed.
•The amount of time spent on the affected side should be limited if sensation is impaired.
•If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh.     This helps to promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures.

•The prone position also helps to drain bronchial secretions and prevents contractural deformities of the shoulders and knees.


Establishing an Exercise Program

•The affected extremities are exercised passively and put through a full range of motion four or five times a day
•Guna latihan :
    - meningkatkan mobilitas
    - mencegah kontraktur
    - meningkatkan sirkulasi
    - mendapatkan kembali kontrol motorik
    - mencegah venostasis dan trombosis

•Pada awalnya ekstremitas flasid --> lebih sering dilakukan mobilitas
•Hati-hati tanda emboli atau kelebihan kerja jantung saat aktifitas meliputi : shortness of breath, chest pain, cyanosis,and increasing pulse rate with exercise.

Preparing for Ambulation
•Segera mulai saat pasien sadar“ pada stroke bleeding tidak bisa dilakukan sampai perdarahan hilang”
•mencapai duduk seimbang --> kursi roda --> mencapai berdiri seimbang --> latihan jalan.
•Waktu ambulasi sebaiknya pendek namun sering

PREVENTING SHOULDER PAIN
•70% pasien mengalami
•3 masalah terjadi : painful shoulder, subluxation of the shoulder, and shoulder–hand syndrome.
•A flaccid shoulder joint may be overstretched by the use of excessive force in turning the patient or from overstrenuous arm and shoulder movement.
•To prevent shoulder pain,  never lift the patient by the flaccid shoulder or pull on the affected arm or shoulder. If the arm is paralyzed, subluxation (incomplete dislocation) at the shoulder can occur from overstretching the joint capsule and musculature by the force of gravity when the patient sits or stands in the early stages after a stroke.

ENHANCING SELF-CARE
•The first step on the unaffected side. Such activities as combing the hair, brushing the teeth, shaving with an electric razor, bathing,and eating can be carried out with one hand and are suitable for self-care.
•The nurse must be sure that the patient does not neglect the affected side.

Managing sensory-perceptual difficulties
•Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock,calendar, and television) should be placed on this side.
•The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss.
•The nurse should make eye contact with the patient and draw his or her attention to the affected side by encouraging the patient to move the head.
•The nurse may also want to stand at a position that encourages the patient to move or turn to visualize who is in the room.
•Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision.
•The patient with homonymous hemianopsia (loss of half of the visual fiield) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. The patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to constantly remind the patient of the other side of the body

Intervensi lain :
•Menolong Memenuhi Nutrisi
•Mencapai Kontrol Bladder / BowelMencapai Kontrol Bladder / Bowel
•Memperbaiki proses berpikir asien
•Mendukung komunikasi
•Mempertahankan integritas kulit
•Memperbaiki koping keluarga


•Menolong koping pasien menghadapi disfungsi seksual
•Mendukung asuhan berbasis komunitas dan rumah
•Kelanjutan Asuhan

Stroke Perdarahan
•Karena adanya perdarahan dalam jaringan otak, subarachnoid, ventrikel.
•80% terjadi karena hipertensi yang tidak terkontrol

Patofisiologi
•Metabolisme otak terganggu akibat terekspose darah, peningkatan tekanan intrakranial, iskemia sekunder, dan vaso spasme.

Manifestasi klinik
•Mirip dengan stroke iskemik
•Pada waktu sadar --> biasanya sakit kepala berat
•Tanda lain yang sering pada intraserebral hemoragik : muntah, perubahan kesadaran tiba-tiba, kejang focal,
•Coma

Komplikasi
•Rebleeding
•Cerebral vasospasm
•Acute hydrosephalus
•seizures

Pengkajian Keperawatan
Meliputi :
-Reaksi pupil yang lambat
-Disfungsi motorik / sensorik
-Defisit saraf kranial
-Gangguan bicara, pandangan
-Sakit kepala, kaku kuduk
-Perubahan tingkat kesadaran, ngantuk, kesulitan bicara

Diagnosa Keperawatan
•Ketidakefektifan perfusi serebral berhubungan dengan perdarahan atau vasospasm
•Gangguan persepsi sensori
•Kecemasan

Masalah Kolaboratif
Potensial Komplikasi :
•Vasospasm
•Kejang
•Hidrosephalus
•Reebleeding
•Hiponatremia

Intervensi optimalisasi Perfusi Jaringan Serebral
•Monitor ketat fungsi saraf : tekanan darah, pulse, tingkat kesadaran, reaksi pupil, fungsi motorik.
•Status Respirasi Juga diperhatikan

Aneurysm Precaution
•Sediakan lingkungan nonstimulasi
•Bedrest,  dalam ruang yang tenang, batasi pengunjung.
•Tempat tidur dinaikkan 15-30 derajad
•Aktivitas mendadak yang menyebabkan kenaikan tekanan darah dihindari.
•Pasien dipakaikan elastic complression untuk mencegah DVT
•Dilakukan personal care : makan dan mandi cegah stimulus yang mengerahkan tenaga lebih.

Mengurangi kecemasan dan gangguan sensori
•Stimulasi sensori yang minimun
•Pada pasien yang sadar, jelaskan pembatasan-pembatasan yang dilakukan
•Orientasikan realitas
•Buat pasien tetap diberi informasi yang tetap.
•Beri jaminan yang tepat.

Memonitor dan Memenej Komplikasi
•Waspada tanda vasospasme : sakit kepala yang meningkat, penurunan tingkat kesadaran (bingung, disorientasi, letargi) adanyaafasia, paralisis.
•Bila kejang : pertahankan jaln nafas, cegah injuri, beri segera obat antikejang
•Pasien dengan hidrosefalus : monitor tanda gangguan kesadaran : mengantuk, perubahan perilaku,ataix gait.
•Waspada tanda rebleeding : sakit kepala hebat, mual, muntah, penurunan tingkat kesadaran, defisit neurologis lainnya.
•Waspada tanda hiponatremia ( serum sodium < 135 mEq / L)

Terimakasih.
Sumber :
Smeltzer , Suzanne C. et all.2006. Brunner & Suddart, Medical – Surgical Nuring.11`ed.Walter Kluwer, Lippincott, Williams & Wilkins.