I'm hoping someone may be able to help me with a care plan that I am working on. My patient is a 92yo F admitted with new onset weakness with facial droop and shortness of breath. She was diagnosed with an ischemic stroke which progressed into a hemorrhagic stroke by the third day of care. She also had a chest x-ray which showed pneumonia and worsening CHF. She had been NPO due to dysphagia but they had since put her on "comfort care" and were considering transferring to hospice and since this decision had been made it was ordered that if requested she was allowed to eat and drink anything that she wanted. I cared for her over 2 days. On my first day of care she was not able to support herself and was completely dependent on me to move her, sit her up straight, etc. She was lethargic but still able to respond when spoken to. She mostly spoke in single words but had occassional moments where she would even tell me a short stories about herself. She did request oatmeal for breakfast and orange juice and repeatedly asked for water and ice chips through the first day. She was completely dependent on me to feed her and I gave her very small sips of the drinks she wanted by spoon. She denied any pain throughout both days. Vital signs were not being taken due to the decision for her to be on comfort care however I did check her pulse a few times which was 105-120 each time, her respirations were shallow and 28-35/min. She was receiving 2L NC. Her peripheral pulses were very weak and you could hear the fluid in her lungs without even needing a stethoscope. On the second day of care she was even more lethargic and was no longer making any conversation and it usually took a few attempts to get her to respond to questions, sometimes she didn't respond at all. She did request water repeatedly through the day. Her heart rate and respirations were in the same ranges as the previous day and her peripheral pulses were barely palpable.
I've been looking at a few nursing diagnoses but for my case study I need to narrow down to the top three. The ones I'm considering are:
-Ineffective Tissue Perfusion
-Impaired Physical Mobility
-Risk for Aspiration
-Impaired Gas Exchange
-Impaired Cerebral Tissue Perfusion
-Risk for ineffective Airway Clearance
I'd love to hear from anyone who can help me narrow down this list!