Care Plan Diagnoses for CVA patient

  1. 0
    Hello everyone!
    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!!

    Thanks!
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  3. 7 Comments so far...

  4. 1
    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
    donsterRN likes this.
  5. 0
    How about impaired social interaction r/t language barrier.

    Or something along those lines. I am not sure i phrased that right, but you get the idea. She cant communicate with the staff unless they speak Spanish.

    Maybe an impaired communication r/t language barrier???
  6. 0
    You guys are awesome!! Thank you so much! This really helps a lot.
    The only thing I was wondering is if I could stick a deficient knowledge in there... Maybe even a unilateral neglect?
  7. 0
    Quote from Daytonite
    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.
    Where would this diagnosis fit in the priority list?
    I have my diagnoses prioritized as:
    1.Impaired physical mobility
    2.Constipation
    3. toileting self-care deficit
    4. bathing/hygiene self-care deficit
    5. Anxiety r/t change in health status
    6. Unilateral neglect r/t left hemiplegia
    7. Risk for infection
    8. Risk for impaired skin integrity
    9. Deficient knowledge(disease process)

    I know you guys have been more than helpful, maybe you could help me just a little bit more! This is my first ever care plan for a grade. Thanks!!
  8. 0
    1. constipation (physiological need for elimination)
    2. impaired physical mobility (physiological need for movement)
    3. toileting self-care deficit (physiological need for comfort/elimination)
    4. bathing/hygiene self-care deficit (physiological need for comfort)
    5. unilateral neglect r/t left hemiplegia (safety need from physiological threat)
    6. anxiety r/t change in health status (safety need from psychological threat)
    7. deficient knowledge(disease process) (what disease? specify the name of the disease) (safety need for protection)
    8. risk for infection (anticipated physiological need for control of body temperature)
    9. risk for impaired skin integrity (anticipated physiological need for safety)
  9. 0
    Hi Daytonite, I really appreciate all your help! I was thinking about the Impaired verbal communication and where that diagnosis would fit in... What do you think??
    Thanks.
  10. 0
    i need to apologize for accidentally erasing the list of diagnoses i posted before. i didn't realize that when i added the impaired verbal communication i did it as an edit to my other post. i cleared the post, added the diagnosis, and clicked the send button before i had realized what i had done. all the data was lost. i guess you must have saved or copied it though. impaired verbal communication is a safety need on the same level with unilateral neglect, so either one can be sequenced first because they are both pretty much about figuring out the patient's needs.
    1. constipation (physiological need for elimination)
    2. impaired physical mobility (physiological need for movement)
    3. toileting self-care deficit (physiological need for comfort/elimination)
    4. bathing/hygiene self-care deficit (physiological need for comfort)
    5. unilateral neglect r/t left hemiplegia (safety need from physiological threat)
    6. impaired verbal communication (safety need from physiological threat)
    7. anxiety r/t change in health status (safety need from psychological threat)
    8. deficient knowledge(disease process) (what disease? specify the name of the disease) (safety need for protection)
    9. risk for infection (anticipated physiological need for control of body temperature)
    10. risk for impaired skin integrity (anticipated physiological need for safety)


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