Assessment is an early on stage too the foundation of the nursing procedure to position customer problems, inward guild to give administration to nursing actions. Assessment stage consists of iii activities: information collection, information classification too formulation of nursing diagnoses. (Lismidar, 1990)Data Collection
Data collection is to collect information close the overall wellness condition of the client's physical, psychological, social, cultural, spiritual, cognitive, developmental level, economical status, might to role too lifestyle of patients. (Marilynn E. Doenges et al, 1998)
a) The identity of the client
Includes name, historic menstruum (most ofttimes inward former age), sex, education, address, occupation, religion, ethnicity, engagement too fourth dimension of infirmary admission, registration number, medical diagnosis.
b) The primary complaint
Limb weakness typically constitute side past times side to the body, speech communication pelo, too tin non communicate. (Jusuf Misbach, 1999)
c) History of introduce illness
Hemorrhagic stroke ofttimes receive got house real suddenly, when the customer is doing the activity. Usually occurs headache, nausea, vomiting too fifty-fifty seizures to unconsciousness, paralysis symptoms too one-half trunk or other encephalon dysfunction. (Siti Rochani, 2000)
d) History of previous illness
A history of hypertension, diabetes mellitus, nub disease, anemia, history of caput trauma, a long oral contraceptives, occupation of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)
e) Influenza A virus subtype H5N1 business solid unit of measurement history of disease
There is commonly a business solid unit of measurement history of hypertension or diabetes mellitus. (Hendro Susilo, 2000)
f) Psychosocial History
Stroke is a illness that is real expensive. The toll for testing, handling too attention of the business solid unit of measurement finances that tin disrupt these toll factors tin impact the stability of the emotions too thoughts of clients too families.
The Patterns of Health Functions
1) Pattern perception of salubrious living too governance
There is commonly a history of smoking, alcohol use, occupation of oral contraceptives.
2) The designing of nutrition too metabolism
Complaints difficulty swallowing, loss of appetite, nausea too vomiting inward the astute phase.
3) The designing of elimination
It commonly occurs inward the urinary incontinence too bowel habit constipation commonly occurs due to decreased intestinal peristalsis.
4) The designing of activity too exercise
There is the difficulty of the displace every bit weakness, sensory loss or paralise / hemiplegia, tiredness.
5) The designing of slumber too rest
Usually clients are having difficulties to balance because of musculus spasms / musculus pain.
6) The designing of relationships too roles
A alter inward the human relationship too role every bit customer has difficulty communicating due to impaired speech.
7) The designing of perception too self-concept
Clients experience helpless, hopeless, irritable, uncooperative.
8) The designing of sensory too cognitive
At the client's designing of sensory impaired vision / blurring sight, touching / touching downwards on the aspect upward too extremity pain. On the designing of cognitive turn down typically retentiveness too idea processes.
9) Patterns of sexual reproduction
It commonly occurs due to decreased sexual wish of around of the handling of stroke, such every bit anti-seizure drugs, anti-hypertensive, histamine antagonists.
10) The designing of reply to stress
Clients ofttimes honor it hard to solve due to the disruption of thinking too difficulty communicating.
11) The designing of values and beliefs
Clients rarely practicing because of unstable behavior, weakness / paralysis on 1 side of the body. Sumber http://nanda-nursinginterventions.blogspot.com/