to care plan, follow the steps of the nursing process. . .
step 1 assessment
- assessment consists of:
step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- a health history (review of systems) - admitted with aloc, decreased speech and decreased interaction and a temp of 100.2 (this is common in dementia patients who cannot tell us they are ill) these are signs of illness. probably an infection of some sort.
- performing a physical exam - low grade temp of 95.5- this patient was admitted with aloc, but there is no neuro assessment. because of the patient's heart and atrial fib, the heart should be assessed. no heart or lung sounds were assessed. atrial fibrillation is a rapid, irregular heart rate which can be easily assessed by taking a pulse. ??? it is also the main reason why people have cvas (strokes) that result in one sided paralysis which this patient has. there is a lot of heart related disease going on. is he symptomatic? any sob, cough, edema, skin color changes? speech problems are a safety issue.
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - being non-ambulatory results in a lot of self-care deficits. how does this patient accomplish urination and defecating? are there skin care issues? how does he bathe, brush his teeth and change his clothes? how does he eat? if he has a need, how does he make it known to others?
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - cva, seizure disorder, cad, cabg, htn, arthritis, dementia, atrial fib, this patient also has cad with is a chronic and progressive heart disease. the cabg was done for the cad. his htn is also a complication of the cad. what medications is the patient on for the cad and the htn? his htn seems to be under control. every one of these diseases should be looked up and its pathophysiology and signs and symptoms found. compare them against what you saw in the patient. a good website to do this on is the online merck manual: http://www.merck.com/mrkshared/mmanual/sections.jsp
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - he is on oxygen at 2l/minute. why? did he have a breathing problem? it may be because of his cad--does he get chest pain because of his cad?
- make a list of the abnormal assessment data - this is the data you listed
step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- non ambulatory
- left side paralysis
- temp was 35.3 (95.5)
- responsive, but it took him a few minutes to formulate what he needed to say
- bun 38 (normal is 10-20)
- creatinine 1.24 (normal is 0.6 to 1.2)
- match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -
step #3 planning (write measurable goals/outcomes and nursing interventions)
- decreased cardiac output r/t altered electrical conduction aeb irregular heart rate
- impaired physical mobility r/t neuromuscular impairment secondary to cva aeb left side paralysis
- self-care deficits
- impaired verbal communication r/t decreased circulation to speech center of the brain secondary to dementia and cva aeb difficulty and slowness in expressing thoughts verbally
- risk for deficient fluid volume r/t physical impairment affecting access to fluid intake
- risk for impaired skin integrity r/t physical immobility
ineffective tissue perfusion r/t decreased arterial blood flow (because of past stroke) m/b altered level of consciouness.
ineffective tissue perfusion should not be used unless the cva is new and happening right now.decreased cardic output r/t altered contractility (because he has afib for past 2 yrs) m/b ???? how am i seeing it in him
atrial fibrillation is a problem caused by an error in the electrical conduction, not the contractility of the heart. it is manifested by a rapid, irregular heart rate. read about the signs and symptoms of atrial fibrillation.impaired physical mobility r/t muscular skeletal impairment m/b left side paralysis
the related factor (cause) of the impaired physical mobility is neuromuscular impairment caused by the cva.