First Care Plan, Help?

DolceVita, ADN, BSN, RN · Mar 13, 2011

I have a case study that I need to write a care plan for, and I'm having trouble choosing 7 nursing problems and prioritising. I feel like we've been thrown in the deep end as we haven't been taught really anything on care plans These are the ones I've come up with and I'd just like to know if I'm on the right track and if theres anything I'm missing. I'd greatly appreciate any input :)
My 7 nursing problems:
impaired verbal communication
impaired swallowing
impaired physical mobility
functional urinary and faecal incontinence related to impaired mobility
self-care deficit
grieving
risk for altered nutrtion, less than body requirements
My top prioritised problem is:
impaired swallowing, as I feel this can both affect the patient's safety (as a risk for aspiration) and nutrition and hydration. Is there a better one?
If you've got this far
The Case Study:
You are a student nurse on Day 6 of your 10 days practicum on a medical ward at a regional hospital. Your client Mr Cruz, aged 62 years is a caretaker at the local caravan park, where he lives alone in an onsite caravan. Mr Cruz is a widower as his wife passed away 2 years ago from breast cancer; he has 3 children who live in Sydney.
Mr Cruz has a past history of hypertension and has been a smoker for 20 years. He has been admitted to the medical ward two days ago with Cerebrovascular Accident (CVA), with occlusion of the middle cerebral artery, ® hemiplegia, ® homonymous hemianopia and partial expressive aphasia. Since admission to the hospital he has had a very poor appetite just tastes the food and pushes it away, he has trouble chewing and swallowing. He also suffers some urinary and faecal incontinence, as he cannot get to the toilet on time due to his impaired mobility. His vital signs at 0600 hrs today are temperature 37.1 degrees Celsius; pulse 72 bpm and regular, respirations 18 per minute and BP150/95 mm Hg.
This morning he is teary and becoming increasingly withdrawn. He requires some assistance with his ADLs, mobilisation and transfers.
You are assigned to care for Mr Cruz on a morning shift and commence plan for discharge in two weeks.

Functional urinary incontinence

Bowel incontinence

Powerlessness

Feeding self care deficit

Bathing self care deficit

Hopelessness

Spiritual distress

risk for situational low self esteem

Disturbed body image

Grieving is excellent but make sure you mean about his change in function as you have no evidence that it would be about his wife.

You'll see that I put in a lot of the touchy-feely ones. f this was my patient I would be extremely concerned about his mood. He was clearly an active man and has just suffered a huge loss of function.

Do you have to rank the ones you choose?

DolceVita, ADN, BSN, RN · Mar 13, 2011

I just answered my own question.

Your first priority with a guy like this is the impaired swallowing. You may wish to make it "risk for aspiration" if it fits.

I see you had the incontinence...sorry.

suzers26 · Mar 15, 2011

I agree with what you have listed. I just wanted to say the first thing that sticks out to me is "occlusion of the middle cerebral artery". This decreases oxygen perfusion and can continue to cause serious problems.

As far as prioritizing, start with the ABCs, then Maslow's hierarchy of needs.

suga_junkie, BSN, RN · Mar 15, 2011

Grieving is excellent but make sure you mean about his change in function as you have no evidence that it would be about his wife.
You'll see that I put in a lot of the touchy-feely ones. f this was my patient I would be extremely concerned about his mood. He was clearly an active man and has just suffered a huge loss of function.
Do you have to rank the ones you choose?

Thanks very much for your ideas. Yep, grieving was definitely in relation to his loss of function, I definitely agree that his mood is concerning. I'm just having trouble choosing between Grieving/Hopelessness/Powerlessness/Ineffective individual coping and probably others too :uhoh3: I don't have to rank them, just outline 7 nursing diagnoses and then choose the top priority and write a care plan on it.

suga_junkie, BSN, RN · Mar 15, 2011

I agree with what you have listed. I just wanted to say the first thing that sticks out to me is "occlusion of the middle cerebral artery". This decreases oxygen perfusion and can continue to cause serious problems.
As far as prioritizing, start with the ABCs, then Maslow's hierarchy of needs.

Ooh yeah I didn't think of that, thanks!

I'm definitely going to modify my top 7 nursing diagnoses. Choosing just 7 is turning out to be quite difficult!