EKSPLORATION ROLE AND FUNCTION CHANGING OF FAMILY

WITH POST-STROKE PATIENT IN MANADO CITY

PROPOSAL

ANDREAS KUTIKA
14061006

NURSING SCIENCE STUDY PROGRAM

NURSING FACULTY
UNIVERSITY CATHOLIC OF DE LA SALLE MANADO
2018
 CHAPTER I

1.1 BACKGROUND OF THE STUDY

Nowadays, stroke befits a grievous threat in health world field and in earnest concern to
resolve it. World Federation of Neurology (2017) has declared it too, through their conference
collaborated with World Stroke Organization which has promoted a slogan and topic “Stroke is a
brain attack!” Prevent it and threat it”. Stroke diseases impact in physic as paralysis and cause
patient unable to do the activity before and decrease social communication and role.
(Owlexa,2015). Stroke also impact in the economic side from 2014 to 2018, more than one-fifth
of national finance health insurance. The government which has release Healthy Indonesia Card
to cover eight types of catastrophic disease, one of them is a stroke (Kompas, in pressreader,2018).
From that information above we coincide that stroke is really serious disease and threat for the
world at this time.

The incidence of stroke is very high in the world at this time. Each two seconds somebody in
the world predict will have stroke disease and approximately 1 in 8 death incidents worldwide
reasoned by stroke (Stroke Association,2017). World Health Organization (2017) has update 10
diseases caused of death globally and Ischemic Heart disease and stroke are the first diseases have
killed over 15 million after the last 15 years and make them as a world’s biggest killers. Especially
for stroke has consumed 6,2 Million in 2015 (Pietrangelo et al,2017). According to Junaidi (in
Rohmatul Laily,2016) In America has estimated around 500.000 new patients of stroke and
150.000 patients died cause of stroke. Those data make us sure that stroke is rampant the world at
this time.

Stroke in Asia has a high number than others continents. More than 60 % population in the
world and have a higher mortality of stroke. The lowest rates are observed in Japan
(43.4/1,000,000 person-years and Singapore (47.9/100,000 person-years), followed by
Bangladesh, Papua New Guinea, and Bhutan. The highest rates are observed in Mongolia
(222.6/100,000 person-years) and Indonesia (193.3/100,000 person-years), followed by Myanmar
and North Korea. WHO (2010) explained too, that countries in South East Asia region have 4,4
billion people have a stroke. And the country which befits the most number of incidents is
Indonesia (Wayunah and Saefulloh,2016). Therefore, the countries in Asia need to improve in
terms of handling stroke.
 Indonesia as a developing country has made noncommunicable disease as they concern
especially stroke, which becomes one the biggest killer of death in Indonesia. Riskesdas (2013)
has published that the prevalence of stroke in Indonesia based on a diagnosis of health workforce
is 7 per mi and 12,1 per mi is diagnosed as a symptom. The area with the highest prevalence of
stroke in Indonesia is North Sulawesi (10,8%). Then followed by Yogyakarta (10,3%), after that
Bangka Belitung and DKI Jakarta have 9,7 percent. Those cases are the reflection of health
minister department in Indonesia.

The highest incidence of stroke is located in the province of North Sulawesi. In the province
of North Sulawesi, the prevalence of stroke was found to be 10.8 / 1000 inhabitants (per mile). In
2013, has found the data in Irina F Neuro BLU RSUP Prof. Dr. R. D. Kandou Manado, there
were recorded 69 patients with stroke. With Hemorrhagic stroke are 16 people and Ischemic
stroke (Non-Hemorrhagic) are 53 people (Patient Registration Book Irina F Neuro BLU RSUP
Prof. Dr. R. D. Kandou Manado, 2013 in Heidy Patricia, 2015). An increase in the incidence of
stroke survivors in the Minahasa tribe, which is the majority population in North Sulawesi
Province, are estimated to be associated with an increased incidence of stroke risk factors. Stroke
risk factors are diabetes mellitus, mental health disorders, smoking, obesity, and hypertension.
Hypertension is a common problem in stroke patients and persists after a stroke attack.
Therefore, based on the results of the research in RSUP Prof. Dr. R. D. Kandou Manado shows
there are 60-80% stroke patients who are handled are Minahasa tribe.

Minahasa tribe is famous for their habit and tradition, which is one of any caused stroke
incidence in North Sulawesi province. Add more to unhealthy eating patterns that Canada's
citizen fond to eat fat meat like a rat and dog meat, this statement has published by Government
Hospital Prof. Dr. R.D. Kandow (etcadm,2018). Consume more fat meat and high cholesterol
food with low or none fiber are made in productive ages or young generation. That make stroke
at this time can strike not only to old ages but for the young age too who shall not control their
lifestyle. Beside on eating pattern of lifestyle, according to Dourman (2013, in Purwaningtiyas,
2014), he said that if someone rare to doing exercise or sport, less of sleep cause work or
anything are caused many cases for productivity patient with stroke. Than Bhat, et.al research
(2008) in Purwaningtiyas (2014) said smoking is one of the risk factors for stroke. Those pieces
of evidence proof bad lifestyle and wrong eating patterns are caused the stroke.
 Because of stroke disease, the government actually have done several program and
intervention. The health department of Indonesia are attempting especially in North Sulawesi has
prioritized education and socialization about noncommunicable disease including stroke
(Issetiabudi,2016). Rehabilitation according to WHO standard, stroke patient will get motoric
therapy, speech impaired, cognitive function etc. Own goal for rehabilitation is to reach patient
independence then the patient could interact with social and adapt mentally. And the last goal is
they can do their daily activity without a help (Widyo,2014). For reaching that goal, stroke
patient needs full support from his caregiver or family

Family or caregiver have significant role and function in patient's rehabilitation. According
to Friedman (2010) in Ratnasari (2014) family own the health care function, where family
maintains member’s health in order to take high productivity. It cannot be denied, family as a
caregiver who has to treat the patient will feel the negative impact physically, emotionally,
financially until in the family function (Paul, 2005 in Tofat 2015). Negative conditions are felt
by the family as the caregiver is called caregiver burden and this also implies a change in family
function.

Associated with families who care for patients at home, there have been several studies that
examine on these subject. As Ratnasari's (2014) study illustrates how families make health
decisions in families with recurrent strokes, which ultimately leads to the patient’s treatment and
care. Furthermore, other qualitative research that examines the caregiver experience in caring for
post-stroke patients at home in the work area of Benda Baru Health Center South Tangerang
City. From this study shows that caregiver who serves the patient is a partner of the patient. By
revealing that there are positive experiences such as the proximity of patients with family and to
the creator. At the same time, negative impacts such as emotional change and behavior in which
caregivers feel sad and changes in the family (Julianti,2013). From those studies before
indicating clearly the change in family function who take care stroke patients.

Based on the problems in the background above, it is necessary to do research on the

changing role and function of the family with post-stroke patients. Moreover, another reason for
this study is because of the high incidence of stroke that has implications for paralysis if not
handled seriously. Secondly, the impact that from the stroke such as paralysis, impaired vision
and hard to speak will not only be felt from the patient side, but the burden will be felt by the
people closest to the patient. Furthermore, there is no research specifically with this variable in
the area of researchers. Through this research is expected to see the real role and function
changes in the family.

1.2 Objective
To explore role and function changing of the family as a caregiver of the post-stroke patient.

1.3 Research Question

How does the role and function of the family with post-stroke patient change?

1.4 Chapter Resume

Chapter one is the introductory chapter that consist of four-part such as background that tells
about the reason for making this research, also tell about the specific data from international,
national and local. The research goal is the main goal in making this research, research question
and chapter summary is the brief summary of every chapter.

Chapter two is the literature review, in this chapter researcher discussing theory regarding
the title of research. This chapter also discusses the research variables such as dependent and
independent variables, those variables are the stroke, role and function changing of family and
also related research and application of nursing theory.

Chapter three is the framework in this chapter researcher will be explaining about the
framework that discusses in chapter two framework in this chapter based on Marilyn Friedman
Family Theory. In this chapter will be explained regarding the relationship between the variables
to the nursing theory.

Chapter four is research method. This chapter elucidates the design of this research is
qualitative study and using the in-depth interview to collect the data. This chapter also elucidates
regarding the location and time of research, amount of population, the sample for research, what
instrument involve in this research, how the data collected, how to analyze the data after
collection and also elucidate about research ethics.
 CHAPTER II

2.1 Stroke
Stroke is also known as Cerebrovascular Accident (CVA) or brain attack. The blood supply is
interrupted for a particular part of the brain, and causes brain cells to die, this result makes patient
losing brain function in the affected area (DiGiulio,2014). According to Junaidi (2011), stroke is
a brain functional disruption or disease like nerve paralysis cause blood flow to brain has
hampered. On simply, acute stroke defined as brain disease effect of blood supply cessation to
brain cause blockage also called ischemic stroke or bleeding also called hemorrhagic stroke. Stroke
is defined as a deficit (disorder) function of the nervous system that occurs suddenly and caused
by blood circulation disorders of the brain. Stroke occurs due to disruption of blood vessels in the
brain. Disturbance of the brain circulation can clogging blood vessels of the brain or rupture of
blood vessels in the brain. The brain that should get the supply of oxygen and nutrients to be
disturbed. Lack of oxygen supply to the brain will lead to the death of nerve cells (neurons).
Impaired brain function will lead to symptoms of stroke (Pinzom & Asanti, 2010).

Stroke has classified into several kinds, and it determine by the manifest of stroke. First, TLA
(transient ischemic attack) is a mild stroke cause ischemic manifest just in a second. Then RIND
(Reversible Ischemic Neurologic Deficit) is a stroke (mild) such as a nerve disorder by ischemic
that can heal till perfect in 1x24 hours. After that Non Hemorhagica Stroke (Stroke without
bleeding) is an ischemic infarction stroke, which occurs due to lack of blood flow or is blocked in
some areas of the brain. Patient awareness is usually normal. While as Hemorrhagica stroke (stroke
with bleeding) is a bleeding stroke that is experienced by the tearing of the blood vessel wall in
the brain. Patient awareness is usually decreased (Irianto,2014)

The etiology of Stroke cause because a blockage of arterial blood flow (ischemic stroke) is like
a formation of blood clots or also because of rupture or leaking in the blood vessels (hemorrhagic
stroke) which is the cause in general. Blood clots originated from an unstable plaque or an embolus
retained in the blood vessels. While bleeding occurs from trauma or spontaneously, as in
hypertensive disease. When the blood does not reach the brain tissue then ischemia occurs. it also
affects the lack of oxygen and glucose in the brain. Without nutrients in the long time’s period the
brain cells can die, so the infarct happens in one area. A permanent deficit is caused by infarct. So
patients with a history of hypertension, diabetes mellitus, high cholesterol, obesity, atrial
fibrillation, smoking and the use of oral contrareption. Translucent Ischemic Attack can also be
experienced by interference with blood flow to a specific area of the brain temporarily and
symptoms can last between several minutes and 24 hours (DiGiulio,2014).

Signs and symptoms of stroke are varies and depending on the affected part. On the body can
feel tingling, then numb, or feels like burning or exposed to chili. Then body that weakens until
the paralysis is proper only partly of the body, whether on the left or right only. Mouth and tongue
are oblique if it wants to straighten. stroke sufferers experience disruption when swallowing and
often choking when drinking. Besides that, patients also experience speech disorders, a pelo or
difficult to understand his accentuate. Patient also have disturbance in reading and writing, where
the writing begin looks bad. Patient also hard to walking and must walk slowly. They also unable
to understand others conversation (Irianto,2014). Downgrades in intellectual as become forgetful
and unable to counting again. Those show how hard stroke manifest into patient or sufferer

The incidence of stroke cannot be separated from the risk factors that are classified into two
that can and cannot be controlled. Starting from uncontrollable risk factors such as age (risk of
stroke increases after 55 years and over). In addition, sex, lineage, race or ethnicity (African
American race according to AHA is more at risk than Caucasian race), diabetes, arterosclerosis
and heart disease. Furthermore, several factors that can be controlled include obesity, lack of
physical activity and exercise, smoking, consuming alcohol and drugs, high blood pressure
(hypertension), dangerous blood cholesterol level, and sleep apnea (snoring with breathing stops
for 10 seconds) (SUIRAOKA,2012)

The pathophysiology of a stroke cannot be separated from the part and function of the brain.
The brain is in dire need of oxygen because, in the event of anoxia such as events in stroke, the
brain can experience metabolic changes, cell death and permanent damage that occurs within the
range of 3 to 10 minutes (total inactivity). Lack of oxygen levels in a minute can lead to loss of
consciousness, and if in a long time can cause microscopic necrosis of neurons, the necrotic area
is known as infarction (Wijaya et al, 2013). In addition, there is also cerebral infarction that occurs
when the reduced blood supply to certain areas of the brain. The spread of the infarct itself depends
on factors such as the location, the size of the blood vessels and the adequacy of the collateral
circulation of the part to be supplied by the clogged blood vessels (Kirana et al, 2016). Such is
how the incidence of anoxia to cerebral infarction that occurs in the brain.

In addition, according to Satyanegara (2010), local constriction of early artery results in slight
changes in blood flow, then stenosis is severe enough to exceed critical limits leading to the rapid
and drastic reduction of blood. Occlusion of an artery in the brain will lead to the reduction of an
area where normal surrounding brain tissue that still has good bleeding trying to help blood supply
through existing anastomosis pathways. The initial changes that occur in the cortex arising from
the occlusion of blood vessels are like the dark color of venous blood, decreased blood flow
velocity and slightly dilation of the arteries and arterioles. So there will be swelling in this area.
During the process of this event, autoregulation is useless so that blood flow follows inactively
any changes in arterial blood pressure. Therefore it can be concluded, decreased cerebral blood
flow to a certain threshold will trigger a series of disorders of neural function and permanent
destruction occurs on the network

The occurrence of infarct stroke according to Price S (2005) in Bararah T (2013) states that
stroke infarction caused by obstruction or freezing in a larger artery on cerebrum circulation, which
can be caused by the clot (thrombus) formed in the vessels in the brain or in vessels distal organ.
In the distal vascular thrombus, clotting may be released or may be in the heart and then carried
through the arterial system to the brain as an embolus. A blockage in the carotid artery often
undergoes the formation of atherosclerotic plaque in the blood vessels resulting in narrowing. If
the narrowing reaches a critical level, increased turbulence around the blockage will cause a sharp
decrease in the rate of blood flow to the brain resulting in decreased brain perfusion and tissue
necrosis occurring in the brain. So it can be inferred, the result of obstruction or freezing in an
artery can result in disruption of brain perfusion and the occurrence of tissue necrosis in the brain.

Stroke also has several complications if not treated seriously. According to Nugroho et al (2016)
there are various complications usually encountered by stroke patients, such as: decreased cerebral
blood flow, cerebral hypoxia, cerebral embolism, urinary tract infections, aspiration pneumonia,
incontinence, thrombophlebitis, corneal abrasion, contractures, decubitus, encephalitis, congestive
heart failure, district, vasospasm, and hydrocephalus. While the accounts of Henderson L (2002)
in the Goddess R (2011) complications of stroke are: blood clots, pneumonia, joint stiffness,
decubitus, dysrhythmia, respiratory failure, impaired thinking and recall, total partial depression
in arms, depression, difficulty speaking, difficulty in swallowing. All possible complications above
suggest a serious treatment in stroke patients.

The handling of strokes that have been done in America, shows a very significant progress.
Since the previous stroke was the third leading cause of death in America, it has become the fourth.
This is because the handling of stroke as early as possible in the event of an attack done well
(American Heart Association / American Stroke Association, AHA / ASA 2013). According to
the American Heart Association / American Stroke Association, AHA / ASA (2013) says that
stroke treatment should be done as soon as possible. Delivery of medical team from receipt of
stroke patient or even up to depart more than 90 seconds while for the time required until a medical
team arrived at a patient location that is less than 8 minutes. Therefore, early treatment will reduce
the current highest incidence of deaths

The management of pre-hospital itself according to Nuartha (2008) in Wirawan (2013) is

divided into several stages namely. First, for acute stroke patients need to respond to suspected
patients. Then the patient suspected of having a stroke is a family or someone else, immediately
do detection FAST test (facial palsy, weakness of the arm, speech disorder). After that family or
another person who can contact the ambulance at the nearest primary stroke service center or the
nearest hospital, to detect back FAST (facial palsy, arm weakness, speech impairment) as well as
initial management. Initial management is resuscitation and stabilization in which ambulance
officers contact the PSC or the nearest hospital for emergency management and then transport
patients promptly and organize vital signs (Nuartha, 2008 in Wirawan, 2013). The role of the
family or others who find the patient in the hospital.

The other management of stroke according to Brunner and Suddarth (2002) in Ningtiyas I
(2017) is divided into two phases: the acute phase and the rehabilitation phase. The acute phase is
a phase where the condition of stroke patients is still not stable. Generally, in the act of treatment
at the hospital, patients who have a stroke can be treated in the stroke treatment room than in the
usual care unit. Because in the stroke treatment room, stroke-affected patients have better
outcomes than usual care setting (patients with different diseases). Stroke patients themselves can
be more independent, easier in socializing with people around until having a better quality of life
in the end. The acute phase of a stroke usually lasts from 48 hours to 72 hours. Patients who
experience coma at admission have poor prognostic considerations. Conversely, if the patient is
fully aware of the prognosis is very good. The main priority in the acute phase is to keep the airway
and ventilation fixed.

Furthermore, the second phase is the rehabilitation phase. The rehabilitation phase is a process
of recovering stroke patients with achievements to maximize the physical capacity and functional
capability of stroke patients, so they can independently perform daily activities. The subject of the
main target at this stage is the patient's family. This rehabilitation includes improving mobility,
avoiding shoulder pain, avoiding falling patients, achieving self-care, improving the thinking
process, achieving communication, maintaining skin integrity and improving family functions and
no further complications (MoH RI, 2012). In the rehabilitation phase, patients can be hospitalized,
centered on rehabilitation or at home depending on how severe or unsuccessful the stroke is or can
be with a number of factors such as health status, the prognosis of survival, and dependence on
treatment. The process of healing stroke patients with rehabilitation in the long term requires
patience and persistence of stroke and family as a caregiver in doing rehabilitation. Rehabilitation
period often makes us lazy in doing every exercise, call it the range of motion exercises. Therefore,
the role and function of the family as the caregiver is crucial to the achievement of management
in this rehabilitation phase.

2.2. Role and Function of Family

Health development should start from the family. The family is a group of people connected by

marriage, adaptation and birth bonds aimed at creating and maintaining a common culture,

enhancing the physical, mental, and emotional and social development of the individual within it,

judging by regular interactions and characterized by dependence and relationships to achieve

common goals. (Duval, 1972, in Ali, 2010)

Furthermore, adopted from a traditional definition in Burgess & Locke (1953, pp.7-8) says, "A

family is a group of persons united by ties of marriage, blood, or adoption, constituting a single

household, interacting and communicating with each other in their respective social roles of

husband and wife, mother and father, son and daughter, brother and sister; and creating and

maintaining a common culture "(Kaakinen et al,2018)

Everyone has a role in his life. Role theory tells the purpose of the various interactions. Roles can

be defined by behaviors to build a life of value or maintain integrity in difficult circumstances. The

role of helping members to maximize household resources and identify the way each member is

concerned with each other (Yu-Nu, Yea-ing Lotus, Min-Chi, & Pei Shan, 2011 in Sharon et al,

2016). According to H (2013) a role is something normatively expected from a person in a

particular social situation in order to fulfill expectations. The role of the family is the specific

behavior one might expect in a family context. Thus, the role of the family describes a set of

interpersonal behaviors, traits, activities related to the individual in particular positions and

situations. The role of the individual in the family is based on the expectations and behavior

patterns of family, group, and society. A role is a set of interpersonal behaviors, properties, and

activities that relate to individuals in particular positions and units. Each family member has their

own roles (Ali, 2010).

In Health Lex number 23 of 1992 article 5 states, "everyone is obliged to participate in

maintaining and improving the health status of individuals, families and the environment". From

the above article, it is clear that the family is obliged to create and maintain health in an effort to

improve the level of optimal health degree. Where each family member has their own roles.

Starting with father, mother, and child. Fathers as family leaders have a role that is a breadwinner,

educator, protector/guardian, giving feelings of security for all family members and as well as

members of certain community groups. Furthermore, the mother is the one who takes care of the

household, caregiver, the person who educates the children, the patron of the family as well as the

breadwinner of the family as well as the members of the society of a particular social group. And

the last is a child, is a person who acts as a psychosocial performer according to physical, social,
moral and spiritual development. Thus, the role of the family according to the structure of the

family.

A good family is a family that can fulfill every function. Friedman (1998) in Harnilawati

(2013) outlines some functions in general. Starting from the effective function, it is the primary

family function to teach everything to prepare family members to connect with others. the second,

the socialization function, is to develop and train children for social life before leaving home to

connect with others outside the home. Third, the function of reproduction is a function to maintain

the generation and maintain family continuity. the fourth, the economic function, is the family

functioning to meet the economic needs of the family and a place to develop the ability of

individuals to increase income to meet family needs. Furthermore, the function of health

care/maintenance, namely the function to maintain the state of health of family members in order

to still have high productivity.

As for Efendi (1998: 36) in Harnilawati (2013) said there are three basic functions of a

family to members of his family. First is love. Love is to give affection, attention, sense of security,

warmth to family members so as to enable them to grow and develop according to age and needs.

Second is foster care. Foster is toward the needs of nursing and nursing children so that health is

always maintained, so it is expected to make their children healthy both physical, mental, social

and spiritual. And the third is a teaser. Sharpening is to meet the educational needs of children, so

ready to become an adult human self-supporting in preparing for its future.

2.3. Related research

In this related study, researchers used some of the online accesses of the downloaded journals and

other websites used to fulfill the contents of this section. Researchers use websites such as google-

scholar to get journal references related to the keywords used: qualitative, stroke, family roles and
functions, stroke data in North Sulawesi, stroke handling, and stroke risk factors. The researcher

got the reference of 5 related journals based on the problem/title of research both from Indonesia

and from North Sulawesi itself with the titles as follows.

Description of Family in Deciding Health Action in Families with Recurrent Stroke in Puskesmas

Ciputat Timur Working Area,Caregiver Experience in Taking Care of Post Stroke Patient at Home

in the Work New Area of Puskesmas Community in South Tangerang City, Relationship of Family

Support with Post-Stroke Elderly Life Quality in Working Area of Gajahan Surakarta Community

Health Center, Family Experience in Caring for Post-Stroke Family Members in Territory

Puskesmas Pekauman Banjarmasin and Family Support Correlation with Self Efficacy on Patients

with Disease Stroke in Room Patient Poli Heritage General Hospital Regions Sultan Syarif

Mohamad Alkadrie City Pontianak

Ratnasari (2014) at Home at The East Ciputat Puskesmas Working Area. The purpose of

this study was to find out how families in deciding health measures on family members with

recurrent stroke. With qualitative research method with descriptive phenomenology approach and

data retrieval research done by in-depth interview. Participants were selected by purposive

sampling technique. Participants in this study were family members who served in making

decisions, especially those related to health problems in the family. Data were analyzed by virgin

analysis steps in qualitative research including data reduction, data display, content analysis, and

conclusions. The results of this study obtained the decision of the family in deciding health

measures include the following themes, the factors that influence decision-making, decision-

making process, the family in deciding the financing of treatment, the family in deciding the use

of health services, the psychological impact on decision-making delegates, ways to prevent

recurrent strokes, and non-compliance.

 Julianti (2013) at Home in Working Area of Puskesmas Benda Baru Kota Tangerang

Selatan. The objective of the study was to determine the caregiver experience in treating post-

stroke patients at home and how caregivers interpreted the experience. The method used is

qualitative research with descriptive phenomenology approach, for data retrieval conducted by in-

depth interview. Informants were selected by purposive sampling technique. Informants in this

study is a caregiver who is in charge of treating post-stroke patients at home. Data were analyzed

using Burns & Grove technique. The results showed that caregiver caring for post-stroke patients

at home was mostly done by a couple of patients. Home-caregiver care includes daily assistance,

activity training, spiritual fulfillment, medication management, and help in socializing with the

environment. In doing home care, the caregiver experiences some positive positive things such as

the proximity of the patient to the family, the caregiver can get closer to the creator as well as

negative experiences such as the presence of emotional and behavioral changes in the patient that

makes the caregiver feel sad and the family in the family. Such treatment experience changes the

caregiver in the form of psychological, physical, social, and spiritual changes in the family

caregiver and affects the caregiver's ability to care for the patient.

Reni Octaviani (2017) in the Working Area of Puskesmas Gajahan Surakarta. The purpose

of this study to determine the relationship of family support to the quality of life of post-stroke

elderly in the working area of Puskesmas Gajahan Surakarta. The research design is descriptive

correlative with cross-sectional approach. The sample was 46 respondents using purposive

sampling technique. The data collection tools used are family support interview guides and post-

stroke quality of life. Data processing using Rank Spearman. The results showed that 54.3% of

respondents received good family support. Respondents who have a high quality of life and
respondents who have a low quality of life are comparable (50%). There is a relationship of family

support to the quality of life of elderly post-stroke with p-value 0.000.

Fetriyah et al (2016) in the working area of the Pekauman Pusuman Banjarmasin. The

objective of the study was to explore in depth the experience of families in caring for post-stroke

family members in Pekakesmas Banjarmasin working area. Method for this research used

qualitative’s design research with phenomenology approach, the informant was chosen by

purposive sampling consist of 6 main informant that is family of main caregiver, and 6 informant

triangulation that is the member of the post-stroke family. Data collection using in-depth interview

techniques with interview guidelines. Data analysis using Milles and Huberman model. The results

of the study were the whole family experienced a change of role in the family, post-stroke impact

on economic, physical aspects such as fatigue and weight changes, psychological form of stress

and irritability, interruption of interaction with local people, no impact on the spiritual family.

Most families are able to provide post-stroke care well. Most families do not find it difficult to

care for family members after a stroke.

Arsyta et al (2016) in the Outpatient Room of Poly Saraf Sultan Syarif Mohamad Alkadrie

General Hospital of Pontianak City. This study aims to determine the relationship of family support

with self-efficacy in patients with stroke in Outpatient Poly Saraf Sultan Syarif Mohamad Alkadrie

General Hospital of Pontianak city. This research method using quantitative research type with an

analytic observational design with cross-sectional approach. The total population of 70 people and

the number of samples as many as 41 stroke patients in Outpatient Room Poly Saraf Sultan Syarif

Mohamad Alkadrie General Hospital Pontianak City who underwent outpatient in space poly

nerve. The sample selection was chosen by nonprobability sampling. The instrument of this

research is a questionnaire. The statistical analysis used to test the hypothesis is the Spearman test.
The result of the research is respondents with good family support as many as 21 people with the

percentage of 51.2% and good self-efficacy as many as 23 people with a percentage of 56.1%.

Spearman statistical test results obtained significant value p = 0.000 (p <0.05)

Tabel 2.3 Penelitian Terkait

Design/
The benefits and
Method/ Population / sampling
No Writer Place Year Goal Result / or limitations of
Statistic / sample
the research
Test

1 Erythrina Home in 2017 To determine the Qualitative Families who had The results showed that This research is
Julianti Working caregiver members with post- caregiver caring for the first
research
Area of experience in stroke patients with post-stroke patients at experience of
with
Puskesmas treating post- primary informants home was mostly done researchers, so
Benda stroke patients at descriptive amounted to seven post- by a couple of patients researchers still
Baru Kota home and how stroke patients and face a lot of
phenomenol
Tangerang caregivers caregivers from each limitation to listen
ogy
Selatan interpreted the family would be made and pay attention
experience. approach, informants and to all the disclosed
sampling technique with informant.
for data
purposive sampling.
retrieval

conducted

by in-depth

interview
2 Nining Home at 2014 The purpose of With Participants were The results of this study The study focuses
Ratnasari The East this study was to selected by purposive obtained the decision of on the decision of
qualitative
Ciputat find out how sampling technique. the family in deciding the family in
research
Puskesmas families in Participants in this study health measures include choosing health
Working deciding health method with were family members the following themes, services, so that
Area measures on who served in making the factors that influence other matters
descriptive
family members decisions, especially decision-making,etc. relating to
phenomenol
with recurrent those related to health decisions in
stroke ogy problems in the family . patient medication
Sample of this research compliance,
approach
are three primary exercise, stress
and data
participants and support management,
retrieval participants in this stopping the use
research is officer of of roko have not
research
Puskesmas. been explored
done by in-
more deeply
depth

interview
3 Reni The 2017 To determine the The The sample was 46 The results showed that Researchers found
Octaviani Working relationship of research respondents using limitations in this
54.3% of respondents
Area of family support to design is purposive sampling study among the
received good family
Puskesmas the quality of life descriptive technique. The data respondents used
Gajahan of post-stroke correlative collection tools used are support. Respondents in this study are
Surakarta elderly in the with cross- family support elderly. In elderly
who have a high quality
working area of sectional interview guides and often found the
of life and respondents
Puskesmas approach post-stroke quality of existence of
Gajahan life. Data processing who have a low quality dementia
Surakarta using Rank Spearman
of life are comparable
and the statistical
(50%). There is a
analysis used to test the
hypothesis is the relationship of family
Spearman test
support to the quality of

life of elderly post-

stroke with p-value

0.000.

4. Fetriyah In the 2016 To explore in Qualitative’ The informant was The results of the study Research or
et al working depth the s design chosen by purposive were the whole family journal does not
area of the experience of research sampling consist of 6 experienced a change of include the
Pekauman families in with main informant that is role in the family, etc. limitations of the
Pusuman caring for post- phenomenol family of main study
stroke family caregiver, and 6
 Banjarmas members in ogy informant triangulation
in Pekakesmas approach that is the member of the
Banjarmasin post-stroke family
working area.

5 Arsyta et The 2016 To determine the Quantitative The total population of The result of the Research or
al Outpatient relationship of research 70 people and the research is respondents journal does not
Room of family support type with an number of samples as with good family include the
Poly Saraf with self- analytic many as 41 stroke support as many as 21 limitations of the
Sultan efficacy in observation patients in Outpatient people with the study
Syarif patients with al design Room Poly Saraf Sultan percentage of 51.2%
Mohamad stroke in with cross- Syarif Mohamad and good self-efficacy
Alkadrie Outpatient Poly sectional Alkadrie General as many as 23 people
General Saraf Sultan approach Hospital Pontianak City with a percentage of
Hospital of Syarif Mohamad who underwent 56.1%. Spearman
Pontianak Alkadrie outpatient in space poly statistical test results
City General Hospital nerve. The sample obtained significant
of Pontianak city selection was chosen by value p = 0.000 (p
nonprobability <0.05)
sampling
2.4 Nursing Theory
Review of family members/
Family Assessment:
individual:
Identity data, sociocultural,
Environment, structure,
Mental Identification, physical
function, emotional and sosial

Identify family and

individual issues (Nursing

Diagnosis)

Nursing Plan

Arrangement of goals, identify sources, define alternatives,

choose interventions and choose priorities.

Intervention

Implementation of the briefing plan

Resources

Nursing Evaluation
 A family nursing process according to Yura and Walsh (1978) in Friedman (1998) is the

core and essence of nursing. This process is central to all nursing actions, applicable under any

circumstances, within a specific framework of reference, concept, theory or philosophy. The

family nursing process will tend to be different to who the target treatment is. Differences depend

on the family's conceptualization of the nurse in practice. Not only see an individual in the family

(traditional) but see the family as a unit or system.

The family nursing process starts from the assessment. The assessments should think

interactions (Wright and Leashey, 1984 in Friedman, 1998). This is where the role of a nurse who

must understand the concept of the family. So the nurse can conceptualize the problem.The process

of nursing assessment is colored by the continuous collection of information on the meaning

attached to the temporary information in the collection. Where the collected data is analyzed and

classified so that the collection becomes systematic. Data collection is a key requirement for

identifying issues. However, even if the assessment is the first step, the data is kept in the collection

as long as the service is provided, which would indicate the dynamic, interactive and flexible

nature of this process.

The collection of data on the family is derived from various sources such as interviews

with clients in relation to past events, and present and objective findings, written or oral

information from referrals, various family-handling agencies and members of the health team

others. An important aspect to keep in mind is to build trust relationships. When we create a

relationship of trust where there is mutual respect, communication goes hand in hand with the
review process and the orientation stage of working with a family. So, these beliefs and

relationships form the place and foundation for effective family care.

After the assessment, it is time to identify family problems and this stage is called within

the scope of the nursing practice as a family nursing diagnosis. Family diagnoses are an extension

of nursing diagnoses to the family system and are the result of an assessment of care. Family

nursing diagnoses include the actual and potential health problems which, due to education and

experience, the nurses are able and allowed to handle it (Gordon, 1978 and 1982). The diagnoses

are used as "a basis for projection of results, planning interventions, and evaluating the results

achieved.

Planning is done after the appointment of a diagnosis of the problem to be addressed after

being viewed in terms of priority. Planning involves the formulation of client-oriented goals.

Together set these goals on possible sources, illustrate alternative approaches for meeting

purposes, select specific nursing orders, mobilize resources (including mobilizing self-care

capabilities), and operations planning (prioritize and write how planning is done gradually ). The

nursing care plan acts as an action plan.

Once at the planning stage, go into the intervention stage. The intervention phase begins

with the completion of the treatment plan. Implementation can be done by many people; clients

(individuals or families), nurses, and other members of the healthcare team, extended family, and

others in the family social network.

The last one is the evaluation phase. Evaluation is based on how effectively the

interventions are made by family, nurses, and others. Effectiveness is determined by looking at the
responses and family outcomes (how the family responds), not the interventions being

implemented. Again, evaluation is a joint effort between nurses and families.

 CONCEPTUAL FRAMEWORK

In this chapter will be described the conceptual framework of the Friedman Nursing Theory of

family nursing.

3.1 Concept Framework

The conceptual framework used in this study is the Friedman concept framework. In

Friedman's theory described the family nursing process, which consists of family assessment,

individual assessment, problem identification, intervention planning, implementation, and family

nursing evaluation (Andarmoyo, 2012). Researchers will focus on family-related studies in this

study, so researchers can explore changes in the role and function of the family as a result of stroke.

From that, the basic guidelines to create a framework of this research concept using Friedman's

theory.
 Review of family members/
Family Assessment:
individual:
Identity data, sociocultural,
Environment, structure,
Mental Identification, physical
function, emotional and sosial

Role and Function Change of

Family

Nursing Plan

Arrangement of goals, identify sources, define alternatives,

choose interventions and choose priorities.

Intervention

Implementation of the briefing plan

Resources

Nursing Evaluation
 CHAPTER IV

RESEARCH METHODS

This chapter discusses the research design used, the time and location of the study, the population

and the sample used, as well as the research instrument used and the research process to be used,

along with the research ethics and data analysis in the following study

4.1 Research Design

This research uses qualitative descriptive research with phenemology approach. Qualitative

research method is a research method where researchers collect and analyze data in the form of

words and deeds of human actions without trying to quantify the data that has been obtained

(Afrizal, 2015). This study aims to describe or explain any important events that occur (Nursalam,

2008). In conducting interviews the researcher should be able to defend himself on how the

interviews are conducted, pay attention and also to understand each reaction of the respondents,

also pay attention to and understand each reaction of the respondents, and pay attention to the

respondent's proper feedback, and pay attention to the respondent's appropriate feedback ensuring

good communication during the interview (Yati, 2014).

4.2 Research Sites

Research carried out in Cardiac Vaskular Brain Centre (CVBC) Center Dr Prof. Dr R.D Kandou

Manado

4.3 Research Time

This research begins with the preparation of proposals on February-May 2018

4.4 Population
In a qualitative study, the population is also defined as a generalization region consisting of objects

/ subjects that have certain qualities and characteristics that have been determined by a researcher
to be studied so that can be drawn conclusions that exist (Sugiyono, 2014). The population in this

study is the patient's family with stroke who regularly control in Cardiac Vaskular Brain Centre

(CVBC) Center Dr Prof. Dr R.D Kandou Manado. According the data we found in Manado post

(2018) that’s showed 326 patient stroke left the hospital alive in 2017 and patient are suggested by

doctor to visit outpatient room especially CVBC in a certain time.

4.5 Sample
The sample is part of the population. This study uses purposive sampling technique, where the

sample selection is based on strong consideration, because the selected sample is based on certain

criteria that match the problem to be studied (Jenita, 2016). The number of samples is the total

sampling with the number of respondents ...

4.6 Research Instruments

In qualitative research, researchers are intsrumen of the research itself that is equipped by several

data collection tools so that research takes a long time (Suyanto, 2011). The researcher is the main

instrument that has been prepared by some guiding questions as a guide in conducting research by

interviewing informant, recording device to record the conversation during interview, and also

accompanied by stationery to record the important result and other documents (Sugiyono, 2014)

Guiding question: ...

4.7 Data Collection

In the process of collecting data, researchers get a permit from the faculty of nursing to conduct a

survey ....

Data collection techniques is the most strategic step in a study, because the purpose of the study

itself is to collect data (Sugiyono, 2014). This research uses in depth interview method, where the
researcher is directly involved with the life of the subjects studied and question and answer done

without using the guideline that was prepared before and done many times (Sujarweni, 2014).

4.8 Data Analysis

The qualitative data analysis is to present important data from the collected, and present the

compiled information, and conclude or interpret the data presented (Miles, 1992 in Afrizal, 2015).

In this study using thematic analysis which is divided from six steps (Braun & Clarke, 2013),

namely: Familiarisasi data

4.9 Research Ethics

The researcher prior to conducting the research must obtain prior approval from the research ethics

is a set of rules and principles of ethics agreed upon collectively concerning the relationship

between the researcher and the research informant and all the things involved in the research

(Siswanto et al, 2014). Principles of ethical principles in research are, among other things, treating

informants in a respectful manner, maintaining the confidentiality of identity and information from

informants, and determining whether the research is conducted openly or secretly, and providing

informed consent to the respondent (Nursalam, 2008).

Some ethical principles