NURSING CARE IN PATIENT

WITH POST STROKE

Erfin Firmawati, Ns., MNS

Nursing Care in Patient with
Post Stroke
Prevention of Complications
• Dysphagia
• Pressure Ulcer
• Falls
• Bladder and Bowel problems
• Deep vein Thrombosis (DVT)
• Pain
 Dysphagia (swallowing impairment)
Dysphagia is difficulty in swallowing, vary in severity with
symptoms ranging from mild throat discomfort to disability to
eat
Dysphagia occurs from 48,7% of stroke patient at RSCM.
Nursing diagnosis (NANDA 2015-2017):
 Imbalanced nutrition: less than body requirements r/t
weakness of muscles required for swallowing
 Impaired swallowing
 Nursing intervention for Dysphagia

• Assess the ability of swallow: Use The Gugging

Swallowing Screen
• Oral hygiene, oral feeding, provide lollipop (to
enhance tongue strength); feeding assistance;
posture modification during provide feeding;
collaboration: non oral feeding
• Training patient & family caregiver in feeding
techniques, modify food texture and fluid
The Gugging Swallowing Screen
Michaela Trapl et al. (2007)
 Pressure Ulcer
• Pressure Ulcer is localized injury to the skin and/or
underlying tissue usually over a bony prominence,
as a result of pressure, or pressure in combination
with shear and/or friction (EPUAP & NPUAP, 2009)

 Immobility
Cause of PU on Stroke
 Sensory impairment
Patient

PU on Stroke patient pressure

sores:
26 (22%)(Sackley et al., 2008)
Prevent Pressure Ulcer
 Nursing Care to Prevent PU
Nursing Diagnosis: risk impaired skin integrity
Nursing Intervention:
•Assess skin regularly, risk of PU using Braden Scale
•Clean skin; avoid hot water & irritating cleaning agents.
•Use emollients on dry skin, Do not massage bony
prominences
•Protect skin from moisture-associated damage (e.g.,
urinary and/or fecal incontinence, wound exudates)
•Use lubricants, protective dressings, and proper lifting
techniques during transferring and turning of clients.
•Protect high-risk areas such
•Teach patient & caregivers the prevention protocol.
(EPUAP & NPUAP, 2009)
Staging of Pressure Ulcer
Protocols by Level of Risk
At Risk (15 to 18)
• Frequent turning
• Maximal remobilization
• Protect heels
• Manage moisture, nutrition and friction and shear
• Support surface if bed or chair bound
• If other major risk factors are present (advanced age,
fever, poor dietary intake of protein, hemodynamic
instability) advance to next level of risk
• Teaching & training family caregivers about treatment

Braden (2001)
Moderate Risk (13 to 14)
• Turning Schedule
• Use foam wedges for 30 lateral positioning
• Active/reactive support surface
• Maximal remobilization
• Protect heels
• Manage moisture, nutrition, and friction and
shear
• If other major risk factors are present,
advance to next level of risk
• Teaching & training family caregivers about
treatment

Braden (2001)
 Protocols by Level of Risk
High Risk (10 to 12)
• Increase frequency of
Turning
• Supplement with small
shifts
• Use foam wedges for 30
lateral positioning
• Maximal remobilization
• Protect heels
• Manage moisture,
nutrition, and friction and
shear
Very High Risk (9 or less)
• All of the activities before
PLUS
• Use support surface if
patient has: Intractable
pain OR Severe pain
exacerbated by turning
OR Additional risk factors
Teaching & training family
caregivers about
treatment for high &
very high risk of PU
Braden (2001)
 Evidence Based Nursing related to Mobilization
(Tarihoran (2010)

• Using Quasy experimental study: 33 stroke pt (16 in control

group & 17 in experimental group)
• Provide 300 laterally posititioning, evaluated pressure ulcer
within 3x24 hours
• Giving buffer when laterally posititioning 300. Buffer is
made of non-elastic foam, placed in the sacral region, with
a duration of 1 hour once at side to the area to experience
weakness
• 2 hours in the supine and laterally positition to an area that
is not weak,
• The head in elevation positition on 300to keep the body in
stable position
• Result: statistically significant p 0.0039, OR: 9.6 (control
group almost 10x risk for develop of grade 1 PU)
 Risk of Fall
Stroke patient has a risk of fall

Nursing Diagnosis: Risk of falls

(NANDA 2015-2017)

Nursing intervention:
 Fall risk assessment:
use MORSE FALL SCALE (Morse, 1985)
 Use a bed barrier
Involve family caregiver to do prevention risk
of falls
Morse Fall Scale
Bowel & Bladder Problem
Nursing Diagnosis:
Functional Urinary Incontinence

Nursing Diagnosis:
Constipation r/t immobility
 Nursing intervention:
Functional Urinary Incontinence
 • Kegel Exercise

• Make schedule
to urinate
• Use commode
 Nursing intervention: Constipation
• Assess frequency of bowel elimination
• adequate intake of fluid, and fiber and to help
the patient establish a regular toileting
schedule
• sphincter-strengthening exercises
• instructions on regular toilet habits
• Excercise
• Collaboration: Provide laxatives
 Deep Vein Thrombosis (DVT)
• DVT is the formation of a
blood clot (thrombus)
within a deep vein
predominantly in the legs.
• The risks of DVT after
stroke are increased in
patients with restricted
mobility that it can make
stasis of venous circulation
(Kappelle, 2011).
 Signs & Symptoms of DVT

• Pain
• Swelling
• Redness warmness
• Engorged
superficial veins
 Assess risk of DVT: Authar DVT
risk assessment scale
 Early mobilization
 Compression stockings
 Intermittent pneumatic
compression (IPC)
IPC is an effective method of
reducing the risk of DVT of
patients who are immobile
after stroke (Clots in Legs Or
sTockings after Stroke/CLOTS
Trials Collaboration, 2013)
 Authar DVT risk assessment scale
Component: • Scoring:
• Age
<10 Low risk
• Mobility
11-14 Moderate Risk
• Trauma risk category
• Current high risk disease >15 High Risk
• Body Mass Index (BMI)
• Special risk category
• Surgical intervention Authar, (1998)
 Pain
Stroke patient with hemiplegia complained shoulder
pain
Nursing Diagnosis: Acute Pain
Nursing Intervention:
- Pain assessment
- Sleep position properly
- Massage: slow stroke back massage (SSBM) on
shoulder pain (Atashi et al., 2012)
- Range of Motion
- Avoid pull the weak arm
- Positions and supportive devices to help support a
painful shoulder or arm.
 Activities of Daily Living (ADL)

Mostly stroke patient has ADL problems

Nursing Diagnosis: Self-care deficit (dressing,
toileting, self-feeding, grooming, & bathing)
Nursing Intervention:
• Assess level of independence
• Assist patient to fulfill patients’ ADL
• Help patient to achieve ADL independence
• Involve family caregiver in fulfillment of
patients’ ADL
Thank You