NURSING CARE REPORT ON NON HAEMORAGIC STROKE

By : M. Luthfianoor R.

010028

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM ACADEMIC YEAR 2011/2012

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Assesment A. Identity Identity of the Client Name Age Gender Marital Status Address Occupation Religion Tribe / Nation MRS Date Review Date Medical Diagnosis RMK Number

: : : : : : : : : : : :

Mr. J 59 years Male Married Antasan Raden RT. 20 A No. 15 G (not reviewed) Islam Banjarese / Indonesian 10 07 2011 12 07 2011 Non-Hemoragic Stroke 148676

Identity of Person in Charge Name : Age : Gender : Address : Occupation : Relationship with the Client :

Mr. S 32 years Male Antasan Raden RT. 20 A No. 15 G Private Employee Son of the Client

B. History of Disease Main Complaint The weakness of left part of the body (stroke) (other data are not reviewed) History of Present Disease The 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 Disease Client stated that he had the same disease for three times. History of Familys Disease Almost all clients family members had been hospitalized but with different disease. (other data are not reviewed)

C. Physical Examination General Condition Client 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 Signs Blood Pressure : 160/90 mmHg Pulse : 96x/minute Respiration : 22x / minute Temperature : 36,7 C (Anthropometric data are not reviewed) Skin Generally, condition of Clients skin is normal, clients temperature is 36,7 C, the colour of Clients skin looks normal Head and Neck The structure of Clients head looks normal, there is no lesion or abnormality in Clients head, the distribution of clients hair looks rare and white (gray hair). Clients neck is clean, there is no lesion or abnormality on clients neck. Eyes and Vision Clients eyes looks symmetric, there is no dirt, no lesion, clients cornea is clear, sclera is white, client doesnt use any visual aids. Nose and Smelling Clients nose looks normal and there is no inflammation, there is no secretion or liquids coming out of his nose, clients olfactory function are good. Ear and Hearing The structure of clients ears are symmetric, there is no inflammation/bleeding. Clients hearing function is well, client responses if he is called, clients ear looks clean, there is no dirt or liquids coming out from clients ear, no hearing aids that is used by the client.

Mouth and Dental General condition of mouth and dental is clean, clients mouth is oblique to the left, mucosal lip colour is brown and looks dry, clients 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 doesnt use false teeth. Chest, Heart, and Lungs The shape of clients chest is symmetric; breathing frequency is 24 x / minute. CRT back more than 2 seconds. (other data are not reviewed) Abdomen The condition of Clients abdomen is clean and there is no lesion on clients abdomen. (other data are not reviewed) Genital Client is male, he is 59 years old, and client has been married. (Other data are not reviewed) Upper Extremities and Lower Extremities Structure of clients 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 Needs 1) 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 Hygiene At 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) Nutrition At home

: Clients 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) Elimination At 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 Clients family think is about Clients 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 theyre at home is good and when at hospital client is visited by his family and neighbours. : Clients religion is Islam. Religious activity thate is performed before the sickness is five times prayer, at hospital the client still doing the prayer. : Client is a male, has been married and has children.

7) Spiritual

8) Sexuality

E. Data Focus A. Subjective Data - Clients family said that the clients head is dizzy. - Clients family said that the headache appears when the Client does activities. - Clients family said that the pain scale is 2, bearable pain. - Clients family said that the pain comes suddenly - Clients family said that the Client cant do any activity. - Clients family said that the Clients family got a fever. - Clients family said that the Client feels the pain in the neck. B. Objective Data 1. 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 - Hearts Sound: single S1S2

C. Investigation Laboratory Result Examination SGOT Bilirubin T Bilirubin D Indirect Bilirubin SGPT Kidney Physiology Test Creatinine Urid Acid Blood Fat Cholesterol Triglycerides

Result 19 0,9 0,7 6,2 46 4,84 12

Reference L up to 37 L up to 20 Up to 1,1 Up to 0,25 Up to 37 1,1 0,6 3,4 7,6

Unit u/dl u/dl Mg/dl u/dl

288 199

Up to 200 60 - 150

Mg/dl Mg/dl

D. Pharmacological Therapy - Inj. Rantin 2 x 1 amp - Inj. Lapibol 1 x 1 amp - Blood pres 1 x tab - Platogrip 1x1 - Neurochol 1 x 1 tab - Cholestat 30 mg - Pre infus lasix amp - Infus lasix 1 x amp - IVVD Rl 20 drops/minute

F. Data Analysis No Data 1 SD: - Clients family said that the clients head is dizzy. - Clients family said that the headache appears when the Client does activities. - Clients family said that the pain scale is 2, bearable pain. - The pain comes suddenly - Clients family sait that the Client cant do any activity. - Clients family said that the Clients family got a fever. - Clients family said that the Client feels the pain in the neck. OD: P : the pain comes when the Client does activities Q : the pain is like given heavy loads R : the pain is on the neck S : the pain scale is 2 (can be beared) T : the pain comes suddenly Client looks weak BP: 160/90 mmHg Client looks nervous 2 SD: - Clients family stated that the Client doesnt want to eat. OD: - Client looks weak SD: - Clients family stated that the Client is difficult to do activities OD: - Client looks weak - Activity scale shows that the Client needs help in doing activities - Scale 3333 4444 3333 4444 Nutrition is less than what the body needs Not able to swallow the food Problems Pain Cause Increase in celebral vascular

Damage of physical mobility

Decreased muscle strength

G. Intervention No Nursing Diagnoses 1 Headache r.t increase in cerebral vascular indicated with: - Clients family said that the Client is dizzy. - Clients family said that the pain comes when the Client does activity. - Clients family said that the pain scale is 3 (bearable pain) - Clients family said that the headache feels like given a heavy loads - The pain comes suddenly. 2 Nutrition less than body needs r.t incapable in absorbing indicated with: - Clients family said that the Client can not eat. - Client looks weak 3 The damage of physical mobility r.t decreased muscle strength indicated by: - Clients family said that the Client is difficult to do activities. - Client looks weak - Activity scale is 3 - Scale 3333 4444 3333 4444 Purpose Headache can be reduced in 3 days of treatment with expected result: - Clients family doesnt complaint that the Client doesnt feel dizzy, pain scale is 0, there is no pain in the head. intervention Examination of pain characteristics. TTV observation Maintaining bed rest Collaboration with medicine Rational 1. Knowing the pain quality. 2. Knowing Clients general condition. 3. Reducing the pain

1. 2. 3. 4.

Nutrition less that body needs can be resolved in 3 days treatment with expected result: - Client can eat - Client does not look weak 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. Feeding the patient via oral. 2. Examination of nutrition status 3. Collaboration in giving medicine 1. Examine the limitation of activity and muscle strength. 2. Change the position of the Client periodically. 3. Give help in Clients activity.

1. Fulfilling Clients nutrition needs 2. Knowing the cause of the lack of input. 3. Adjusting Clients condition 1. Knowing clients condition. 2. Preventing skin damage. 3. Helping clients activity.

H. Implementation No 1 Day / Date Monday 11 07 2011 Time 14.30 Dx Implementation 1. Examine the characteristics of pain Evaluation Action the pain comes when doing activities the pain is like given heavy loads the pain is on neck the pain scale is 3 the pain comes suddenly 160/90 mmHg T = 36 C R =

P= Q= R= S= T=

17.00

2. Observe TTV

TD = 25x / minute N = 84 x/minute

20.00

3. Giving Antrain Injection 4. Giving captopril oral medicine 1. Examine Clients nutrition status II 2. Giving food 1. Examine clients limitation 2. Change Clients position 3. Change Clients position 4. Change Clients position 1. Examine the characteristics of pain

Monday 11 07 2011 Monday 11 07 2011

15.00 15.30 14.00

Client looks weak when the injection is given Client is given oral medicine Client said that he has been not eating for 2 days Client only spend a quarter of given portion Clients family said that Client has difficulties in dong his activities, Client can only lie down and sit. Clients anxiety is lessen Clients anxiety is lessen Clients anxiety is lessen P = the pain comes when doing activities Q= the pain is like given heavy loads R = the pain is on neck S = the pain scale is 3 T = the pain comes suddenly Client only spend a quarter of given portion

16.00 18.00 20.00 8.00

III

Tuesday 12 07 2011

11.00

2. Giving food

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3. Observe TTV 1. Examine Clients nutrition status II 2. Giving food 1. Examine Clients activity limitations III 2. 3. 4. 1. Change Clients position Change Clients position Change Clients position Examine the characteristics of pain

Tuesday 12 07 2011 Tuesday 12 07 2011

08.30 11.00 09.00 10.00 12.00 14.00

TD = 150/100 mmHg 24x / minute N = 90 x/minute T = 36,5 C Client is willing to eat, but just a little.

Client spends a half of given portion Clients family said that the Client always try to walk and do activities by himself.

Wednesday 13 07 2011

14.00

P= Q= R= S= T=

the pain comes when doing activities the pain is like given heavy loads the pain is on neck the pain scale is 3 the pain comes suddenly

15.00 17.00

2. Giving food 3. Observe TTV

Client only eat half of given portion TD = 32x / minute N = 86 x/minute Client looks calm Client is willing to eat Helping to decrease Clients blood pressure Clients family said that the Client always try to act independently 150/100 mmHg T = 36 C R =

15.30 Wednesday 13 07 2011 Wednesday 13 07 2011 14.30 II 14.30 16.00

4. Giving Albumin 1. Examine Clients nutrition status 2. Giving oral medicine: Captopril 1. Examine Clients activity limitations

III

Clients anxiety seems reduced Thursday 14 07 2011 14.00 2. Change Clients position 1. Examine pain characteristics P = the pain comes when doing activities Q= the pain is like given heavy loads R = the pain is on neck S = the pain scale is 2 T = the pain comes suddenly Client eats full portion Helping to decrease Clients blood pressure Client eats calmly TD = 150/100 mmHg R = 24x / minute N = 80 x/minute T = 36 C Clients family said that the Client always try to act independently Clients anxiety seems reduced 2. 1. 2. 3. Change Clients position Giving food Giving oral medicine: Captopril Observe TTV Client eats calmly Helping to decrease Clients blood pressure TD = 130/90 mmHg R 24x / minute N = 80 x/minute T = 36 C Client eats calmly

I 15.00 15.00 14.00 17.00 II 2. Giving food 3. Giving oral medicine: Captopril 1. Examine Clients nutrition 2. Observe TTV 1. Examine Clients activity limitations III 18.00 Friday 15 07 2011 11.00 11.00 12.00

Thursday 14 07 2011

Thursday 14 07 2011

14.00

Friday 15 07 2011 Friday 15 07 2011

08.00 08.00

II III

Examine Clients nutrition status Examine clients activity limitations

Clients family said that the client can do his activities by himself and the Client can not wait to go home.

I. Evaluation No 1 Day / Date Monday 11 07 2011 Time 21.00 Dx 1 Implementation S : Clients family said that the Client still experiencing headache O: Pain Characteristic P = the pain comes when doing activities Q = the pain is like given heavy loads R = the pain is on neck S = the pain scale is 3 T = the pain comes suddenly TTV TD = 160/90 mmHg R = 25x / minute N = 84 x/minute T A: headache problem has not resolved P : continued the intervention 2 2

36 C

Tuesday 12 07 2011

S : Clients family said that the Client does not want to eat O: Client looks weak A : nutrition problems has not resolved P : continued the intervention S : Clients family said that the Client is difficult to do activities O: activity scale is 3 A: Physical mobility damage has not resolved P : continued the intervention S : Clients family said that the headache is lessen O: Client looks anxious Clients pain characteristic P = the pain comes when doing activities Q = the pain is like given heavy loads R = the pain is on neck S = the pain scale is 3 T = the pain comes suddenly

Wednesday 13 07 2011

A: P: S: O: A: P: S: O: A: P: S: O:

TTV TD = 150/100 mmHg R = 24x / minute N = 90 x/minute T = 36,5 C A part of headache problem is resolved continued the intervention Clients family said that the Client has fever Client looks weak Nutrition problem has not resolved continued the intervention Clients family said that the Client is difficult to do activities activity scale is 3 Physical mobility damage has not resolved continued the intervention Clients family said that the headache is like the day before Client looks anxious Clients pain characteristic P = the pain comes when doing activities Q = the pain is like given heavy loads R = the pain is on neck S = the pain scale is 3 T = the pain comes suddenly TTV TD = 150/100 mmHg R = 32x / minute N = 86 x/minute T = 36 C A part of headache problem is resolved continued the intervention Clients family said that the Client can not eat Client looks weak Nutrition problem has not resolved continued the intervention Clients family said that the Client is trying to be independent

A: P: S: O: A: P: S:

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Thursday 14 07 2011

O: A: P: S: O:

11

12

13

Friday 15 07 2011

A: P: S: O: A: P: S: O: A: P: S: O:

activity scale is 3 A part of Physical mobility damage is resolved continued the intervention Clients family said that the headache is lessen Client looks calm Clients pain characteristic P = the pain comes when doing activities Q = the pain is like given heavy loads R = the pain is on neck S = the pain scale is 3 T = the pain comes suddenly A part of headache problem is resolved continued the intervention Clients family said that the Client eats calmly Client looks weak A part of nutrition problem is resolved continued the intervention Clients family said that the Client can do activities activity scale is 2 A part of Physical mobility damage is resolved continued the intervention Clients family said that the headache is starting to gone Client looks calm Clients pain characteristic P = the pain comes when doing activities Q = the pain is like given heavy loads R = the pain is on neck S = the pain scale is 2 T = the pain comes suddenly TTV TD = 130/90 mmHg R = 24x / minute N = 80 x/minute T = 36 C

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A: P: S: O: A: P: S: O: A: P:

Headache problem is resolved Intervention is stopped, patient go home Clients family said that the Client can eat client looks healthy Nutrition problem is resolved intervention is stopped, patient go home Clients family said that the Client is already independent, but still weak activity scale is 2 A part of Physical mobility damage is resolved intervention is stopped, patient go home