CVA(Basal Ganglion Infarction)

  1. 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.
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  2. 15 Comments

  3. by   oMerMero
    You need to think about what needs to be done with the patient, what he needs help with. Start with thinking about what is abnormal about the patient? You have created a good picture of the patient. I would start by making a list of the abnormals. What ideas have you come up with so far for the care plan? Sometimes developing a care plan for a patient is not as easy as posting it online and letting someone else figure it out. We can help you, but you need to let us know that you have put some thought into it.
  4. by   Nrs_angie
    Well hi there...

    Ive been out of school a while now and ive never done a "care map" but we did do "care plans" alll the time... I got to be GREAT at them... they were even kinda fun after a while... Wow.. I am such a NERD!

    So I am assuming a care map is similar to a care plan...

    so what you need are Nursing Diagnoses first...

    Do you have a list of NANDA approved Nursing Diagnoses?

    If you have a list ... do any of them jump out at you??

    If you have a Nursing Dx book... look up CVA and it will suggest ones that apply to that problem.

    A big one that jumps out at me is IMPAIRED PHYSICAL MOBILITY

    the objective data that relates to this problem is the fact that he is wheelchair bound, has a large stage 3 pressure ulcer due to the immobility, and also needs complete care provided for him.

    Good luck
  5. by   Daytonite
    first of all, if you have read any of the information in the stickys:
    then you know that every care plan follows the steps of the nursing process which are:
    1. assessment (collect data from medical record and by doing a physical assessment of the patient)
    2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    now, you've provided some very good assessment information (step #1). some things you need to do with some of that information is to look up information about cvas, etoh abuse and htn. you want to know what causes them, their pathophysiology, signs and symptoms, complications, how they are diagnosed and treated. pay particular attention to their signs and symptoms. you want to double check to make sure you didn't miss any of them in your patient. if you did then you need to add them to your assessment. also look up the normals for the lab values. a few of this patient's lab values are a bit abnormal and you want to know what the significance of these abnormal values are. there are links to lab references where you can get this information on this thread: http://allnurses.com/forums/f205/med...es-258109.html. you also need to look up each of the medications that this patient is taking to verify that it is being given for the medical diagnoses that you already know about. if you find a medication being given for something you don't know about, then something was missing from the doctor's history and physical. it may or may not be important to know that information. also, with some medications, there may be important nursing implications that you might have to work into your nursing interventions in the care plan.

    all right, having done that, you can now move on the step #2 of the nursing process which is to make a list of your abnormal assessment data. i did this from what you listed in your post.
    • incontinent to bladder/bowel
    • difficulty swallowing
    • decreased appetite
    • left side weakness
    • needs maximum assist with self-care
    • wheel-chair bound
    • huge stage iii decubitus that is not draining and gets a wet to dry dressing
    • wbc is 10.6 (normal is 5 - 10)
    • hg 11.6 (normal male is 14-18)
    • hct 33.8 (normal male is 42-52)
    • platelets 769 (normal is 150-400)
    • na 134 (normal is 136-145)
    • has c. diff
    now, what you have is a list of symptoms (nanda calls them defining characteristics). i call it a shopping list. you need a nursing diagnosis reference of some sort because it's now time to go shopping for nursing diagnoses. you are looking for diagnoses that have some of the same symptoms (defining characteristics) that this patient has on this list. this patient will at the least have diagnoses related to incontinence, mobility, swallowing and skin integrity.

    as for your care map, a care map is just the physical way you are going to present this information. you will find information about care maps and some student examples of them on this sticky thread:
    if you are still having trouble picking a nursing diagnosis or formulating your nursing diagnostic statements, post your questions and i will give you more help.
  6. by   treysdaddy08
    "easy" care plans to write are self-care deficits (: inability to feed/bathe/transfer self r/t L sided weakness secondary to CVA), I would try one of those. Also, 6'2 and 132 lbs, I would wonder if he's not getting the nutrition he needs, that can also be a care plan
  7. by   snursee2b
    Thanks a lot for the guidance. Here is what I've come up with:

    - Impaired swallowing r/t weakness of the swallowing muscles on the left side and diminished swallowing reflex AMB cva with left side weakness, difficulty swallowing liquids, "Mr. F. chokes everytime he eats".
    - Impaired skin integrity r/t immobility and pressure ulcer AMB pressure ulcer 12x16cm, wheel chair bound, inadequate nutrition, bladder/bowel incontinence
    - Impaired physical mobility r/t neuromuscular impairment AMB inability to move purposefully within the environment including bed mobility, transfers, and ambulation, reluctance to attempt movement, prolonged bed rest, depression
    - Alteration in pattern of urinary elimination: Incontinence r/t limited physical mobility AMB pt. wears a diaper, indwelling foley catheter, impaired mobility
    - Impaired verbal communication r/t cerebral impairment AMB weak speech, stuttering, difficulty vocalizing words.

    I have to have a teaching and psychosocial diagnoses and am thinking disturbed body image and the verbal respectively. Also, I know some of his labs are abnormal but, how do I tie those in with the diagnoses I have come up with?

    Your help is greatly appreciated!!
  8. by   snursee2b
    Thanks a lot for the guidance. Here is what I've come up with:

    - Impaired swallowing r/t weakness of the swallowing muscles on the left side and diminished swallowing reflex AMB cva with left side weakness, difficulty swallowing liquids, "Mr. F. chokes everytime he eats".
    - Impaired skin integrity r/t immobility and pressure ulcer AMB pressure ulcer 12x16cm, wheel chair bound, inadequate nutrition, bladder/bowel incontinence
    - Impaired physical mobility r/t neuromuscular impairment AMB inability to move purposefully within the environment including bed mobility, transfers, and ambulation, reluctance to attempt movement, prolonged bed rest, depression
    - Alteration in pattern of urinary elimination: Incontinence r/t limited physical mobility AMB pt. wears a diaper, indwelling foley catheter, impaired mobility
    - Impaired verbal communication r/t cerebral impairment AMB weak speech, stuttering, difficulty vocalizing words.

    I have to have a teaching and psychosocial diagnoses and am thinking disturbed body image and the verbal respectively. Also, I know some of his labs are abnormal but, how do I tie those in with the diagnoses I have come up with?

    Your help is greatly appreciated!!
  9. by   Daytonite
    ok, i see a few problems with your nursing diagnostic statements. let me take them one-by-one. . .
    impaired swallowing r/t weakness of the swallowing muscles on the left side and diminished swallowing reflex amb cva with left side weakness, difficulty swallowing liquids, "mr. f. chokes everytime he eats".
    nursing diagnosis (problem): impaired swallowing
    related factor (etiology): weakness of the swallowing muscles on the left side (this is ok) and diminished swallowing reflex (this one i'm not sure of)
    defining characteristic (symptom/s):
    • cva with left sided weakness - a cva is a medical diagnosis and you shouldn't use this. you can use the left sided weakness. first of all, your nursing interventions are going to be treating the patient's symptoms. how are you going to treat a cva? seriously, where in your nursing textbooks can you find nursing interventions for a "cva"? you will find nursing interventions for the manifestations (left sided weakness, incontinence, visual problems, swallowing problems, anxiety, etc.,) of a cva, but not to treat the impairment of the blood circulation in the brain which is what a cva is. do you see that rationale of this?
    • difficulty swallowing liquids - this is ok
    • "mr. f. chokes everytime he eats" - this is ok
    impaired skin integrity r/t immobility and pressure ulcer amb pressure ulcer 12x16cm, wheel chair bound, inadequate nutrition, bladder/bowel incontinence
    nursing diagnosis (problem): impaired skin integrity
    related factor (etiology):
    your related factor for this diagnosis has to be something that is the direct reason for the cause of the skin breakdown. immobility is too broad. pressure ulcer is another way of stating the problem, or nursing diagnosis. here is the listing of the related factors for this diagnosis (page 199, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international):
    • destruction of skin layers
    • disruption of skin surface
    • invasion of body structures
    defining characteristic (symptom/s):
    • pressure ulcer 12x16cm - good! can you add more descriptors such as color, presence of any drainage and the amount and any odor? was the ulcer staged (i, ii, iii, or iv) by any of the staff nurses? this will indicate how deep and what tissues were involved.
    • wheel chair bound - good. this is physical immobility
    • inadequate nutrition - ok
    • bladder/bowel incontinence - good. this is the skin being in the presence of moisture.
    i would rewrite this as impaired skin integrity r/t destruction of skin layers amb pressure ulcer 12x16cm, wheel chair bound, inadequate nutrition, bladder/bowel incontinence.
    impaired physical mobility r/t neuromuscular impairment amb inability to move purposefully within the environment including bed mobility, transfers, and ambulation, reluctance to attempt movement, prolonged bed rest, depression
    nursing diagnosis (problem): impaired physical mobility
    related factor (etiology): neuromuscular impairment - good!
    defining characteristic (symptom/s):
    • depression - this does not belong here. it belongs in a whole different nursing diagnosis. you were looking for a psychosocial diagnosis. here is your symptom for it.
    alteration in pattern of urinary elimination: incontinence r/t limited physical mobility amb pt. wears a diaper, indwelling foley catheter, impaired mobility
    nursing diagnosis (problem): the 2007-2008 nanda reference has this diagnosis listed as impaired urinary elimination
    related factor (etiology): limited physical mobility
    so, was the patient originally able to get to the bathroom or reach the urinal? that is what i thought immediately. is that right? if so, this is the wrong diagnosis to use and you should be using toileting self-care deficit. why is this patient wearing a diaper if he has a foley catheter? is it because he is incontinent of the bowel? then you definitely need to use toileting self-care deficit. i would also suggest that with a catheter in place he no longer has a urinary elimination problem and you need to instead consider using risk for infection [the infection being a uti] or risk for injury [the injury being the possibility of the patient pulling the catheter out]. otherwise, the related factors for this diagnosis are:
    • anatomical obstruction
    • multiple causality
    • sensory motor impairment (which happens with a cva)
    • urinary tract infection
    defining characteristic (symptom/s): i'm not even addressing this because i think this is a wrong diagnosis to even use.
    impaired verbal communication r/t cerebral impairment amb weak speech, stuttering, difficulty vocalizing words.
    nursing diagnosis (problem): impaired verbal communication
    related factor (etiology): cerebral impairment - ok
    defining characteristic (symptom/s): weak speech, stuttering, difficulty vocalizing words - all ok

    very good!
    with regard to a psychosocial diagnosis, i mentioned above that you had a symptom of depression for one of them. possible nursing diagnoses to use with this and that would be appropriate for a cva patient would be grieving r/t loss of (or change in) health or impaired social interaction r/t limited physical mobility or limited ability to talk. the use of either would depend upon the symptoms the patient is exhibiting that would support the use of them.

    your teaching diagnosis would be the good old knowledge deficit. think about the many adjustments that the patient is going to have to make in regard to accomplishing his adls. taking his medications is going to be more important than ever. this patient will need to undergo a lot of rehabilitation, so there is all kinds of learning and adjustments that he will have to go through over the next year or two. i would go to the medline plus website (http://www.medlineplus.gov/) and use the search box to input the word "stroke" and check out the various links that come up. you should get linked into a lot of information about strokes and aftercare of stroke.

    with regard to your abnormal labs. . .
    • if your patient has c-diff, he no doubt has diarrhea. right? is that why he is diapered? he's probably on an antibiotic (flagyl?) as well. there's a nursing diagnosis you can use for this: diarrhea r/t infectious process (due to c-diff enteritis) amb [the patient's symptoms--the number of loose liquid stools per day]
    • the low hemoglobin (11.6) and hematocrit (33.8) could be due to anemia, cirrhosis, hemorrhage, dietary insufficiencies, or malnutrition. you did mention that this man had an alcohol abuse problem. alcoholics are notorious for having bad nutrition. alcohol trumps food in their daily lives. is there an underlying liver pathology going on? because this would account for some of his hypertension, malnutrition and his low hemoglobin/hematocrit. his elevated platelet count could indicate an iron deficiency anemia. these labs might be due to a nutritional problem. i would also suggest that this might be where your teaching diagnosis could be introduced because low hemoglobin and hematocrits don't happen overnight unless there has been a big loss of blood. when they are tied into a nutritional problem, then teaching the patient how to maintain a better diet is a way to go. i doubt he'll be pursuing his drinking habits anymore if he can't have access to his alcohol, so this might be a good time to start teaching him about a balanced diet with an emphasis on iron rich foods to boost his iron and raise his blood counts.
    • low sodium occurs when a patient has diarrhea or malnutrition problems
    alright. give this another whack.
  10. by   snursee2b
    here are my corrections:
    - impaired swallowing r/t weakness of the swallowing muscles on the left side amb left sided weakness, difficulty swallowing liquids, "mr. f. chokes everytime he eats".
    - impaired skin integrity r/t destruction of skin layers amb

    pressure ulcer - stage iii, 12x16cm, red and yellowish in color, no drainage, wheel chair bound, inadequate nutrition, bladder/bowel incontinence.
    - impaired physical mobility r/t neuromuscular impairment amb reluctance to attempt movement, prolonged bed rest
    - toileting self-care deficit: incontinence r/t impaired transfer ability/mobility status (toileting) amb pt. wears diaper, indwelling foley catheter
    - diarrhea r/t infectious process (c-diff enteritis) amb 3 loose liquid stools per day, low na
    teaching:
    - impaired verbal communication r/t cerebral impairment

    amb weak speech, stuttering, difficulty vocalizing words - knowledge deficit r/t new diagnosis amb not correctly performing the prescribed nutritional behavior
    - alteration in nutrition: less than body requirements r/t dysphagia caused by cva amb weight more than 30% below ideal for height and frame, muscle weakness, 6'2"/138lb, low hg 11.6. low hct 33.8, hx of alcohol abuse, elevated platelet count

    psychosocial



    grieving r/t loss of physical abilities amb depression, medication for depression
  11. by   Daytonite
    impaired swallowing r/t weakness of the swallowing muscles on the left side amb left sided weakness, difficulty swallowing liquids, "mr. f. chokes everytime he eats".
    ok - i would re-write this as impaired swallowing r/t weakness of the swallowing muscles on the left side amb left sided weakness, difficulty swallowing liquids and statement by ____ that "mr. f. chokes every time he eats."
    you need to identify who said "mr. f. chokes every time he eats", otherwise we assume it was the patient and it doesn't sound grammatically like the patient said that unless you change it to "i choke every time i eat."

    your goals and nursing interventions should address the left sided weakness of the mouth, the swallowing difficulties and strategies to prevent choking on food. here is a link to a webpage on this diagnosis: [color=#3366ff]impaired swallowing
    impaired skin integrity r/t destruction of skin layers amb pressure ulcer stage iii, 12x16cm, red and yellowish in color, no drainage, wheel chair bound, inadequate nutrition, bladder/bowel incontinence.
    impaired skin integrity r/t physical pressure over a bony prominence amb stage iii pressure ulcer that measures 12 x 15 cm on the (location) that is red and yellow in color with no drainage.
    • in your nursing goals and interventions you will address the treatment for this ulcer. make sure you include the location of this ulcer in your diagnostic statement. i'm curious as to where it is. i also gave you the wrong information on the related factors for this diagnosis. the related factor has to be what caused the skin breakdown. i'm just guessing that it was because of pressure over a bony prominence. correct that if i am wrong.
    • here is a link that has the information on this diagnosis: [color=#3366ff]impaired skin integrity
    • you will be addressing nursing interventions for the patient being wheelchair bound in the diagnosis for impaired physical immobility; for inadequate nutrition in the diagnosis for imbalanced nutrition: less than body requirements; for incontinence in the toileting self-care deficit.
    impaired physical mobility r/t neuromuscular impairment amb reluctance to attempt movement, prolonged bed rest.
    ok - i would write as impaired physical mobility r/t neuromuscular impairment amb reluctance to attempt movement and prolonged bed rest.
    aim your goals and nursing interventions at helping to get the patient up out of bed and moving. here is a link that has information on this diagnosis: [color=#3366ff]impaired physical mobility
    toileting self-care deficit: incontinence r/t impaired transfer ability mobility status (toileting) amb pt. wears diaper, indwelling foley catheter
    i would write this diagnosis as toileting self-care deficit r/t impaired mobility and inability to independently transfer amb observation that the patient is not able to get to the bathroom without assistance, is not able to tell when he needs to defecate and is incontinent of bowel.
    • wearing diapers isn't fully describing the situation. you need to get the fact that he is incontinent into the symptoms. i don't see where the presence of the foley catheter affects this diagnosis, but that is a decision you need to make. i still see the catheter as being a risk for infection.
    • here is a link to a webpage on this diagnosis: http://www1.us.elsevierhealth.com/me...ex.cfm?plan=43
    diarrhea r/t infectious process (c-diff enteritis) amb 3 loose liquid stools per day, low na
    i would re-write this as diarrhea r/t infectious process due to c-diff enteritis amb three loose liquid stools per day and a low sodium of 134.

    put an "and" between per day and low na just to make the diagnostic statement grammatically correct. here is a weblink for information on the goals and interventions for this diagnosis: diarrhea
    teaching:
    impaired verbal communication r/t cerebral impairment amb weak speech, stuttering, difficulty vocalizing words
    put an "and" between stuttering and difficulty vocalizing to make the statement grammatically correct. address strategies to help the patient with his weak speech, stuttering and difficulty vocalizing in your interventions. make sure they focus on teaching the patient since the focus of this dx is teaching. here is a weblink to a page for information on this diagnosis: [color=#3366ff]impaired verbal communication
    knowledge deficit r/t new diagnosis amb not correctlyperforming the prescribed nutritional behavior
    i would re-word this as knowledge deficit, diet r/t lack of interest due to excessive alcohol intake amb not correctly performing recommended nutritional habits in the past.
    the knowledge deficit has to be specified in the diagnostic title. in this case, the deficit (and the teaching) is going to be about the correct diet he needs to follow, is that correct? thus, knowledge deficit, diet. your nursing intervention is to teach the patient (or caregiver) a proper balanced diet that he needs to follow. you can go on the internet and find resources to get this information. focus on the teaching because your next nursing diagnosis is going to focus on the actual diet the patient is going to be getting.
    alteration in nutrition: less than body requirements r/t dysphagia caused by cva amb weight more than 30% below ideal for height frame, muscle weakness, 6'2"/138lb, low hg 11.6 low hct 33.8, hx of alcohol abuse, elevated platelet count
    i would re-write this to correct the grammar as imbalanced nutrition: less than body requirements r/t dysphagia caused by cva amb body weight more than 30% below ideal for his height of 6'2" and weight of 138 pounds, muscle weakness, low hemoglobin of 11.6 and low hematocrit of 33.8.
      • the history of alcohol abuse cannot be used as a symptom to support this diagnosis, so you have to remove it from the statement. it's more of a historical fact.
      • the elevated platelet count is still a mystery to me and i really don't know where it fits in, but i don't feel that it fits in here without a low iron count to support an iron deficiency anemia
      • your interventions need to specifically address how you are going to get the patient's weight increased (include regular weighing of the patient) and improving his h&h.
      • [color=#3366ff]imbalanced nutrition: less than body requirements
    psychosocial:
    grieving r/t loss of physical abilities amb depression, medication for depression
    i would re-write this as grieving r/t loss of physical abilities amb depression
      • is the medication for depression contributing to the patient's grieving? are you saying that it is a symptom of his grieving. if not, you can't use it as a symptom. if the medication is causing his depression, then you have a side effect of a medication and probably need to use a different nursing diagnosis, but not grieving. keep in mind that everything that follows "amb" is a symptom that supports the nursing diagnosis and is something that you are going to have nursing interventions for.
      • i would strongly recommend that you read some of the information that the medline plus website links you to on stroke rehabilitation to help you with your nursing interventions for this diagnosis.
      • [color=#3366ff]grieving
    i think you are well on your way. make sure your goals and interventions address the patients symptoms or the etiologies (causes) of the problems he has. good luck!
  12. by   Conrad283
    Quote from snursee2b
    here are my corrections:
    - impaired swallowing r/t weakness of the swallowing muscles on the left side amb left sided weakness, difficulty swallowing liquids, "mr. f. chokes everytime he eats".
    i just don't like the "impaired swallowing," i don't think it sounds good imo. i'd rather see, "high risk for aspiration r/t dysphagia e/b ...

    - impaired skin integrity r/t destruction of skin layers amb pressure ulcer - stage iii, 12x16cm, red and yellowish in color, no drainage, wheel chair bound, inadequate nutrition, bladder/bowel incontinence.
    alteration in skin integrity r/t bowel/bladder incontinence e/b presence of pressure ulcer.

    - impaired physical mobility r/t neuromuscular impairment amb reluctance to attempt movement, prolonged bed rest
    not so bad, that could work.

    - toileting self-care deficit: incontinence r/t impaired transfer ability/mobility status (toileting) amb pt. wears diaper, indwelling foley catheter
    i don't think incontinence is a nursing dx. something happens as a result of incontinence, but i don't think you can use it as a nursing dx.

    - diarrhea r/t infectious process (c-diff enteritis) amb 3 loose liquid stools per day, low na
    same as above.

    teaching:
    - impaired verbal communication r/t nuerological impairment amb weak speech, stuttering, difficulty vocalizing words - knowledge deficit r/t new diagnosis amb not correctly performing the prescribed nutritional behavior
    see suggestion in bold

    - alteration in nutrition: less than body requirements r/t dysphagia caused by cva amb weight more than 30% below ideal for height and frame, muscle weakness, 6'2"/138lb, low hg 11.6. low hct 33.8, hx of alcohol abuse, elevated platelet count
    i don't think you have to elaborate as much, but nonetheless, that's a good one.

    psychosocial
    grieving r/t loss of physical abilities amb depression, medication for depression
    do you think it's grieving? or maybe a fear of unknown

    you could also do a psychosocial for change in lifestyle since the patient is wc bound.

    good luck!
  13. by   snursee2b
    Daytonite,

    I have a hard time listing in order of priority. Please help. I need this for Friday! Here is what I have:
    1. Alteration in Nutrition
    2. Risk for Aspiration
    3. Risk for Infection
    4. Impaired Physical Mobility
    5. Impaired Skin Integrity
    6. Risk For Injury: falls
    7. Anxiety
    8. Grieving
    9. Impaired Verbal Communication
  14. by   Daytonite
    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

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