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Asuhan Keperawatan Pasien Stroke

Diagnosa Keperawatan yang Mungkin Muncul pada pasien Stroke
  1. Bersihan jalan nafas tidak efektif b.d. penumpukan sputum (karena kelemahan, hilangnya refleks batuk)

  2. Penurunan perfusi serebral b.d. adanya perdarahan, edema atau oklusi pembuluh darah serebral

  3. Gangguan mobilitas fisik b.d. kerusakan neuromuskuler, kelemahan, hemiparese

  4. Gangguan komunikasi verbal b.d. kerusakan neuromuscular, kerusakan sentral bicara

  5. (Risiko) gangguan nutrisi kurang dari kebutuhan b.d. intake nutrisi tidak adekuat


Diagnosa Keperawatan Stroke

Diagnosa Keperawatan 1. :

Tujuan
Pasien mampu mempertahankan jalan nafas yang paten.

Kriteria hasil :
  • Bunyi nafas vesikuler
  • RR normal
  • Tidak ada tanda-tanda sianosis dan pucat
  • Tidak ada sputum

Intervensi
  • Auskultasi bunyi nafas
  • Ukur tanda-tanda vital
  • Berikan posisi semi fowler sesuai dengan kebutuhan (tidak bertentangan dgn masalah keperawatan lain)
  • Lakukan penghisapan lender dan pasang OPA jika kesadaran menurun
  • Bila sudah memungkinkan lakukan fisioterapi dada dan
  • latihan nafas dalam
  • Kolaborasi :
    • Pemberian ogsigen
    • Laboratorium: Analisa gas darah, darah lengkap dll
    • Pemberian obat sesuai kebutuhan.


Diagnosa Keperawatan 2. :

Tujuan
Perfusi serebral membaik

Kriteria hasil :
  • Tingkat kesadaran membaik (GCS meningkat)
  • fungsi kognitif, memori dan motorik membaik
  • TIK normal
  • Tanda-tanda vital stabil
  • Tidak ada tanda perburukan neurologis

Intervensi
  • Pantau adanya tanda-tanda penurunan perfusi serebral :GCS, memori, bahasa respon pupil dll.
  • Observasi tanda-tanda vital (tiap jam sesuai kondisi pasien)
  • Pantau intake-output cairan, balance tiap 24 jam
  • Pertahankan posisi tirah baring pada posisi anatomis atau posisi kepala tempat tidur 15-30 derajat
  • Hindari valsava maneuver seperti batuk, mengejan dsb
  • Pertahankan ligkungan yang nyaman
  • Hindari fleksi leher untuk mengurangi resiko jugular
  • Kolaborasi:
    • Beri ogsigen sesuai indikasi
    • Laboratorium: AGD, gula darah dll
    • Penberian terapi sesuai advis
    • CT scan kepala untuk diagnosa dan monitoring


Diagnosa 3. :

Tujuan
Pasien mendemonstrasikan mobilisasi aktif

Kriteria hasil :
  • tidak ada kontraktur atau foot drop
  • kontraksi otot membaik
  • mobilisasi bertahap

Intervensi
  • Pantau tingkat kemampuan mobilisasi klien
  • Pantau kekuatan otot
  • Rubah posisi tiap 2 jan
  • Pasang trochanter roll pada daerah yang lemah
  • Lakukan ROM pasif atau aktif sesuai kemampuan dan jika TTV stabil
  • Libatkan keluarga dalam memobilisasi klien
  • Kolaborasi :
    • Fisioterapi


Diagnosa 4. :

Tujuan
Komunikasi dapat berjalan dengan baik

Kriteria hasil :
  • Klien dapat mengekspresikan perasaan
  • Memahami maksud dan pembicaraan orang lain
  • Pembicaraan pasien dapat dipahami

Intervensi
  • Evaluasi sifat dan beratnya afasia pasien, jika berat hindari memberi isyarat non verbal
  • Lakukan komunikasi dengan wajar, bahasa jelas, sederhana dan bila perlu diulang
  • dengarkan dengan tekun jika pasien mulai berbicara
  • Berdiri di dalam lapang pandang pasien pada saat bicara
  • Latih otot bicara secara optimal
  • Libatkan keluarga dalam melatih
  • komunikasi verbal pada pasien
  • Kolaborasi dengan ahli terapi wicara.


Diagnosa 5. :

Tujuan
Kebutuhan nutrisi terpenuhi

Kriteria hasil :
  • Tidak ada tanda-tanda malnutrisi
  • Berat badan dalam batas normal
  • Conjungtiva ananemis
  • Tonus otot baik
  • Lab: albumin, Hb, BUN dalam batas normal.

Intervensi
  • Kaji factor penyebab yang mempengaruhi kemampuan menerima makan/minum
  • Hitung kebutuhan nutrisi perhari
  • Observasi tanda-tanda vital
  • Catat intake makanan
  • Timbang berat badan secara berkala
  • Beri latihan menelan
  • Beri makan via NGT
  • Kolaborasi : Pemeriksaan lab(Hb, Albumin, BUN), pemasangan NGT, konsul ahli gizi.
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