IV. NURSING PROCESS 4.1 Assessment 1. Nursing History a.

Patient identity Name Gender (male more to risk get CVA than female) Age (old people more to risk get CVA) Race Religion Education Occupation Address

b. History of present illness Chief complain (decrease of aware, speak rero) Present illness history c. Past nursing history History of contagious diseases d. Family health history Hereditary diseases (Hypertension, diabetes mellitus) Allergic history 2. Observation and Physical Examination a. B1 : Breathing (Respiratory system) Complain (SOB/cough/pain, etc) Ineffective airway clereance Ineffective breathing pattern - Rhythm - Breathing - Sound Impaired gas exchange Risk of aspiration

 Risk for suffocation (chocking) b. B2 : Bleeding (Cardiovascular system) Skin (pallor/cyanosis) Temperature (cool) Altered cerebral perfusion c. B3 : Brain (Nerverous system) Increase intracranial pressure Activity intolerance Headache (why, when, where) Vision problem (loss, double, blurred) Eye pain Numbness,paralysing

d. B4 : Bladder (Genitourinaty system) Condition of urine (stream/color/appearance) Urine balance (frekuency output/input) Altered pattern of urinary elimination e. B5 : Bowel(Gastrointestinal system) Body weight, Hb, Albumin Vomite/nausea/anorexsia Frequency of meal Felling of fullness (where) Nutrition less than body requirements Ability to chew,swallow

f. B6 : Bone (Bone-Muscle-Integument) Muscle (weakness,pain,fatique) Impaired physical mobility 3. Phsycososial Assessment Anxiety Ineffective coping,denial

Grieving Hopelessness Noncompliance Spiritual Distress Parental Role conflict

4. Diagnostic Test and Medical Tretment EEG,MRI,CT-Scan Blood Test(creatinine,FBC,TFTs,LFTs,lipid urinary,glucose) 4.2 Dx Nursing( nursing diagnosis ) 1. Problem Etiology : Physical mobility

: A stroke in the cerebellum or the part of the brain that control balanceand coordination,that causes abnormal reflexes of the head and upper body,balance problem.

Sign and Symptom : Difficulty to walking,cant to move or feel on one or both sides of the body (paralysis) 2. Problem Etiology : : Impaired verbal communication neurological impairment Problem with word and word order making difficulties And writing,undestanding of language 3. Problem Etiology : Impaired disgestive system

Sign and symptom : in reading

: Function mechanism swallow corresponding abnormal with dagradation of structur functionof oral,pharingeal or esophageal.dagradation of gag reflex,degradation of strength of muscules disgestive.

Sign and symptom : Difficult to chew food,unable to swallowing,stiff abdomen.

4. Problem Etiology

: Anxiety : Fearness of death feeling of tension, apprehension, nervousness and worried by activation of the automatic nervous system.The situation are predictable and expected emotional responses to heart failure. : Psychological aspec.

Sign and symptom

4.3. Intervention No Nursing Diagnosis Aphasia Goal Statement ( NOC ) 1. The patient can speak batter than before nursing care. The patient can demonstrate communication technique. The patient can speak normally people. Intervention ( NIC ) Give knowledge to patients family about how to know patient need. To teach patient share what patient need pass writing Refered for consult Use hand signal Bell signal Use gesture To comprehend by patient to be reached requirement of base. Determining area damage of cerebal that happened and difficulty of patient in a few or entire/all communications phase. Rationale

2.

Dysphagia resulting nutrition supporting deficit

Demonstrating right eating method for exact individual situation with prevented aspiration. Oral hygine Consult to dietitian for diet plan

Lips stimulation for open and close mouth manually by soft stressing in upper lip or under the chin if needed. Touch inner cheek whit tongue spatel or place ice to recognize tongue weakness. Administer food slowly in the quite

Using gravity to make absorb process become easier and minimalis aspiration risk to happen. Giving sensory stimulation that can build act to absorb and increasing input Increasing

space. Start giving orally half liquid food, soft food for patient can easily swallow like egg or jelly Suggest patients to us strow for drinking Asses adequate alent Suctionequipment Position correctly -sit up right (600900)

endrophine realizing inside of brain and increasing apettite Giving replacement liquid and food if patient cant put anything by mouth.

3.

Physical mobility demage

Keep on optimal position from function that proved by there is not contracture, increasing the strength and function of body which kompesation Demonstrate attitude that giving possibilities to do activities, keep the skin integrity.

Observe functionally early demage frequently. Change the position minimal 2 hours. Start to do active and passive movement for all eksternity when in. Use arms struck when patient in stand position. Evaluate helping stuff using for position order during the paralistics spatic period. Keep legs on netral position with trokanter roll

Identify the weaknes/strengt h of muscle and give information about rehabilitation Minimalize muscle atropy, increase sirculation, helping to prevent kontracture Increase venas blood stream and help to prevent the build of ederma. Help and train back sensory line, increase prosprioseptics and motoric respons. Increase evarage distribution of weight which

decrease pressing to certain skeleton and help to prevent skin demage. Help to fix sensor strength and increase volunteer sensor control. 4. Anxiety Absence of anxiety, do the constructive coping with the disease Absence of anxiety after 12 hour nursing care, Constructive coping after get explanation about her/his condition Knowing his/her feeling identificate causal factor, decrease of anxiety, client can demonstrated the positive problem solving, client can identificate right sources. Advice close people in rehabilitation patient program Collaboration sold the pain control efectivity. Give antransietas aget that recommended like diazepam(Valium), prn and evaluate the effectiveness Bring the simple explanation from the whole caring during the bed pain periode happen. Repeat the explanation in a detail manner after the pain was controlled Stay with pationt The supporter system like nearly people, may help and make strong the self defend mechanism Bad anxiety increase the heart that was weak Patient can control some information only when the worried and too much information increase their fear. Pain Influence the study.

4.4. Evaluation S : Subjective : interview & symptom Impaired disgestive system The patients nutritions can achieve. Phisical mobility The patient can move withouth helped by other people. Impaired verbal communication The patient can communication with other people and the people can understand what patient said. Anxiety The patient have be fresh main better then before and can life like normally people. O : Objective : Laboratory test With CT Scan not found edema,hematoma,ischemia & infarc from patients body.If still there signs disease like above, the patient need theraphy for that. A : Assessment Goal made : stop planning Goal partially made : continue and modify Goal not made : modify New problem : new assessment P : Planning Stop planning : goal made Continue and modify : goal not made New assessment : new problem

V. REFERENCES Cerebrovascular Accident at Dorland's Poket Medical Dictionary Nursalam. 2006. English In NursingMidwifery Science and Technology. Surabaya: School of Nursing, Faculty of Medicine, Airlangga University Carpenito,Lynda Juall. 1998. Nursing Care & Documentation. New York: Lipincott. Moore,Mary Courtney. 2000. Poket Guide Nutrition and Diet Therapy. Jakarta:Hipokrates. . VI. APPENDIXES