I was hoping to get some assistance with my care plan.
Patient is a 78YO Hispanic female (no english), had a CVA and now has left flaccid hemiplegia. Alert and conscious now, can feed herself, but otherwise bed-bound, needing complete assistance with bathing, toileting, hygiene. Hasn't had a BM for 3-4 days She also has a foley catheter. Alos has chronic arthritis pain unrelated to this incident.
I have come up with some diagnoses:
Impaired physical mobility r/t neuromuscular impairment secondary to CVA aeb limited ability to perform fine and gross motor skills.
Constipation r/t decreased activity aeb decreased frequency (last BM 11/16).
Chronic Pain r/t actual or potential tissue damage aeb reports of pain (rates pain at 6/10).
Risk for infection: Risk factor: invasive procedure (foley catheter insertion).
Anxiety r/t change in health status aeb vocalization of uncertainty regarding future.
I guess, there should be some kind of self care deficit diagnosis in here too, right? What kind of diagnosis could I put for her chief complaint (CVA)? Also, I wonder if I could throw in an educational diagnosis too?
Would someone be kind enough to help with the above questions? It would be great if someone could help me prioritize these too!!
Oh, yes, I missed the language barrier. The correct diagnosis for that is Impaired Verbal Communication R/T cultural development AEB inability to speak or understand English.
Last edit by Daytonite on Nov 22, '08