After taking a history that leads to the client's complaints, a physical examination is very useful to support the data from the history study. Physical examination should be carried out systematically (B1-B6) with a focus on physical examination on B3 (Brain) examinations that are directed and associated with complaints from clients.
B1 (Breathing)
On inspection, the client has cough, increased sputum production, shortness of breath, use of accessory muscles to breathe, and increased respiratory rate. Auscultation of additional breath sounds such as rhonchi in clients with increased production of secretions and decreased coughing ability, which is often found in stroke clients with decreased level of consciousness / coma. In a client with a composmentis level of consciousness, there is no abnormality in the examination of the respiratory inspection. Thoracic palpation revealed right and left tactile premise. Auscultation revealed no additional breath sounds.
B2 (Blood)
Assessment of the cardiovascular system revealed shock (hypovolemic shock) which often occurs in stroke clients. Blood pressure is usually elevated and massive hypertension may occur (blood pressure >200 mmHg).
B3 (Brain)
Stroke causes a variety of neurologic deficits, depending on the location of the lesion (which blood vessel is blocked), the size of the inadequately perfused area, and collateral blood flow (secondary or accessory). Damaged brain lesions do not heal completely. The B3 (Brain) assessment is a focused examination and is more complete than assessments in other systems.
B4 (Bladders)
After stroke, clients may experience temporary urinary incontinence due to confusion, inability to communicate needs, and inability to control bladder due to impaired motor and postural control. Sometimes control of the external urinary sphincter is lost or reduced. During this period, intermittent catheterization with sterile technique is performed. Persistent urinary incontinence indicates extensive neurologic damage.
B5 (Bowel)
There were complaints of difficulty swallowing, decreased appetite, nausea and vomiting in an acute phase. Nausea and vomiting are caused by an increase in stomach acid production, causing nutritional problems. The pattern of defecation is usually constipation due to decreased intestinal peristalsis. The presence of persistent pelvic incontinence indicates extensive neurologic damage.
B6 (Bone)
Stroke is a disease that can result in loss of voluntary control of motor movements. Because the upper motor neurons are crossed, impaired voluntary motor control on one side of the body can indicate damage to the upper motor neuron on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis on one side) due to a lesion on the opposite side of the brain. Hemiparesis, or weakness on one side of the body, is another sign. On the skin, if the client lacks 02 the skin will look pale and if there is a lack of fluid then the skin turgor will be poor. In addition, it is also necessary to study the signs of pressure sores, especially in areas that are prominent because stroke clients have physical mobility problems.
Stroke - Causes, Risk Factors, Symptoms and Problems that Occur After a Stroke
