Assessment is an early stage and the foundation of the nursing process to identify client problems, in order to give direction to nursing actions. Assessment phase consists of three activities: data collection, data classification and formulation of nursing diagnoses. (Lismidar, 1990)
Data Collection
Data collection is to collect information about the overall health status of the client's physical, psychological, social, cultural, spiritual, cognitive, developmental level, economic status, ability to function and lifestyle of patients. (Marilynn E. Doenges et al, 1998)
a) The identity of the client
Includes name, age (most often in old age), sex, education, address, occupation, religion, ethnicity, date and time of hospital admission, registration number, medical diagnosis.
b) The main complaint
Limb weakness typically found next to the body, speech pelo, and can not communicate. (Jusuf Misbach, 1999)
c) History of present illness
Hemorrhagic stroke often take place very suddenly, when the client is doing the activity. Usually occurs headache, nausea, vomiting and even seizures to unconsciousness, paralysis symptoms besides half body or other brain dysfunction. (Siti Rochani, 2000)
d) History of previous illness
A history of hypertension, diabetes mellitus, heart disease, anemia, history of head trauma, a long oral contraceptives, use of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)
e) A family history of disease
There is usually a family history of hypertension or diabetes mellitus. (Hendro Susilo, 2000)
f) Psychosocial History
Stroke is a disease that is very expensive. The cost for testing, treatment and care of the family finances that can disrupt these cost factors can affect the stability of the emotions and thoughts of clients and families.
The Patterns of Health Functions
1) Pattern perception of healthy living and governance
There is usually a history of smoking, alcohol use, use of oral contraceptives.
2) The pattern of nutrition and metabolism
Complaints difficulty swallowing, loss of appetite, nausea and vomiting in the acute phase.
3) The pattern of elimination
It usually occurs in the urinary incontinence and bowel habit constipation usually occurs due to decreased intestinal peristalsis.
4) The pattern of activity and exercise
There is the difficulty of the move as weakness, sensory loss or paralise / hemiplegia, tiredness.
5) The pattern of sleep and rest
Usually clients are having difficulties to rest because of muscle spasms / muscle pain.
6) The pattern of relationships and roles
A change in the relationship and role as client has difficulty communicating due to impaired speech.
7) The pattern of perception and self-concept
Clients feel helpless, hopeless, irritable, uncooperative.
8) The pattern of sensory and cognitive
At the client's pattern of sensory impaired vision / blurring sight, touch / touch down on the face and extremity pain. On the pattern of cognitive decline typically memory and thought processes.
9) Patterns of sexual reproduction
It usually occurs due to decreased sexual desire of some of the treatment of stroke, such as anti-seizure drugs, anti-hypertensive, histamine antagonists.
10) The pattern of response to stress
Clients often find it difficult to solve due to the disruption of thinking and difficulty communicating.
11) The pattern of values and beliefs
Clients rarely practicing because of unstable behavior, weakness / paralysis on one side of the body.
Data Collection
Data collection is to collect information about the overall health status of the client's physical, psychological, social, cultural, spiritual, cognitive, developmental level, economic status, ability to function and lifestyle of patients. (Marilynn E. Doenges et al, 1998)
a) The identity of the client
Includes name, age (most often in old age), sex, education, address, occupation, religion, ethnicity, date and time of hospital admission, registration number, medical diagnosis.
b) The main complaint
Limb weakness typically found next to the body, speech pelo, and can not communicate. (Jusuf Misbach, 1999)
c) History of present illness
Hemorrhagic stroke often take place very suddenly, when the client is doing the activity. Usually occurs headache, nausea, vomiting and even seizures to unconsciousness, paralysis symptoms besides half body or other brain dysfunction. (Siti Rochani, 2000)
d) History of previous illness
A history of hypertension, diabetes mellitus, heart disease, anemia, history of head trauma, a long oral contraceptives, use of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)
e) A family history of disease
There is usually a family history of hypertension or diabetes mellitus. (Hendro Susilo, 2000)
f) Psychosocial History
Stroke is a disease that is very expensive. The cost for testing, treatment and care of the family finances that can disrupt these cost factors can affect the stability of the emotions and thoughts of clients and families.
The Patterns of Health Functions
1) Pattern perception of healthy living and governance
There is usually a history of smoking, alcohol use, use of oral contraceptives.
2) The pattern of nutrition and metabolism
Complaints difficulty swallowing, loss of appetite, nausea and vomiting in the acute phase.
3) The pattern of elimination
It usually occurs in the urinary incontinence and bowel habit constipation usually occurs due to decreased intestinal peristalsis.
4) The pattern of activity and exercise
There is the difficulty of the move as weakness, sensory loss or paralise / hemiplegia, tiredness.
5) The pattern of sleep and rest
Usually clients are having difficulties to rest because of muscle spasms / muscle pain.
6) The pattern of relationships and roles
A change in the relationship and role as client has difficulty communicating due to impaired speech.
7) The pattern of perception and self-concept
Clients feel helpless, hopeless, irritable, uncooperative.
8) The pattern of sensory and cognitive
At the client's pattern of sensory impaired vision / blurring sight, touch / touch down on the face and extremity pain. On the pattern of cognitive decline typically memory and thought processes.
9) Patterns of sexual reproduction
It usually occurs due to decreased sexual desire of some of the treatment of stroke, such as anti-seizure drugs, anti-hypertensive, histamine antagonists.
10) The pattern of response to stress
Clients often find it difficult to solve due to the disruption of thinking and difficulty communicating.
11) The pattern of values and beliefs
Clients rarely practicing because of unstable behavior, weakness / paralysis on one side of the body.
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