I need help with a care plan for a 52year old pt. who has CVA (l. side weakness) with a PMH of ETOH abuse and HTN. He is well oriented with VS- BP 138/78, R 16, T 98.7, Apical 96, P 94. His S1, S2 are normal and incontinent to bladder/bowel. He has difficulty swallowing and hence a decreased appetite. He needs maximum assist with self-care and wheel-chair bound. He has a huge stage III decubitus that is not draining and gets a wet to dry dressing.
His WBC is 10.6, Hg 11.6, Platelets 769, Hct 33.8 with Na 134, Cl 96, BUN 14, K 4.6, CO2 28, Creatinine 0.5, Glucose 95. He is 6'2" and 138lb. and has C. Diff. His meds are esomeprazole, thiamine chloride, metoprolol, lisinopril, heaprin, lorazepam, folic acid, ritalin, lexapro and supplements.
Help, Help - I'm 1st year with no idea how to begin for a care map and plan.