CVA(Basal Ganglion Infarction)

Nursing Students Student Assist

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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.

Specializes in med/surg, telemetry, IV therapy, mgmt.

prioritized by maslow:

  1. alteration in nutrition (nutrition)
  2. impaired skin integrity (nutrition)
  3. impaired physical mobility (mobility)
  4. impaired verbal communication (safety)
  5. anxiety (emotional - safety/security)
  6. grieving (psychosocial - safety/security)
  7. risk for aspiration (anticipatory oxygen need)
  8. risk for infection (anticipatory temperature regulation)
  9. risk for injury: falls (anticipatory safety need)

some of the diagnoses you are using are re-worded in the updated and current nanda language. is this going to be ok with your instructors to use the diagnoses you listed above and not the current ones? the 2007-2008 language is

  1. imbalanced nutrition: [less than, or more than] body requirements
  2. impaired skin integrity
  3. impaired physical mobility
  4. impaired verbal communication
  5. anxiety
  6. grieving
  7. risk for aspiration
  8. risk for infection
  9. risk for falls

Holy cow....you have described the patient I am doing my care plan on almost exactly in this post. I am not reading this until after I do mine so I am not influenced in any way. It is almost as though we had the same patient though, weird.

Why are you giving out information about a patient. That is a breech in there confidentiality. Thats one mistake as a new nurse you made.

Specializes in med/surg, telemetry, IV therapy, mgmt.
Why are you giving out information about a patient. That is a breech in there confidentiality. Thats one mistake as a new nurse you made.

Cool your jets! This was not a breech of confidentiality. No names or places were exchanged. This could have been any of a thousand patients.

Anyway, the original post is 3 years old! You're a little late noticing it.

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