My first scenario - Need to come up with a mini-care plan and diagnosis.

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Hello! I am in my second semester, but my first semester of clinicals and my first time working with care plans. I have as homework the following scenario to work with, and a simple form on which to fill out a mini care plan.

"A 76 year old female is admitted to an extended care facility with a history of fractured right hip after a fainting spell 3 months ago. Shed had successful rehabilitation after which she returned to her small apartment where she lived alone. Two weeks ago she was admitted to the hospital for acute CVA. She has a right sided hemiplegia, speech is slurred and she has difficulty swallowing. She is withdrawn; responds slowly to questions but the staff can understand her request. She is dependent for ADL's. Vital signs B/P 133//86, P 82 regularly irregular, R 22, T. 99. You are the nurse assigned to care for her today."

Given that information, I am trying to come up with a diagnosis. For the purposes of this assignment, I'm only supposed to use one diagnosis, and it has to be the priority. I'm stuck between "ineffective Tissue Perfusion" and "impaired physical Mobility" (I put in quotation marks because I think it's weird the way the book has it capitalized).

It's annoying not to have subjective data to work with... anyway. For ineffective Tissue Perfusion, I'm not sure what I would put for a related factor. The Nurse's Pocket Guide I have lists several related factors, none of which I can for sure say apply in this scenario. I'm not sure whether that rules out this as a possible diagnosis, or if the diagnosis is determined only by the defining characteristics. In the defining characteristics, the things from the scenario that seem to apply are: speech abnormalities, paralysis, and difficulty in swallowing.

For impaired physical Mobility, I think the diagnostic statement could be "impaired physical Mobility r/t neuromuscular impairment (right sided hemiplegia), AEB inability to perform gross/fine motor skills on right side". I'm not sure if my related factors and AEB parts are worded correctly though... they're similar to what the Pocket Guide lists, but I modified them a little to fit the situation, and I'm not positive that's correct to do.

The reason I'm stuck is because I would prefer to use ineffective Tissue Perfusion, as it's a circulation problem and therefore takes priority, however, since I don't seem to have enough data to support that, I think I would have to go with the Mobility one, as a safety issue.

Can someone please give me some insight as to whether I'm on the right track, if I'm missing something important, and help me figure out which diagnosis to use? I'm leaning towards Mobility, but since there's the possiblity of a circulation problem (I think), I'm not sure.

Thank you! (Sorry for the length... I wasn't sure how to make it shorter).

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

when you are care planning you are engaged in problem solving, so you need to use the nursing process which is your problem solving tool. follow its steps in sequence. a lot of preliminary work goes into step #1 (assessment) which is the data gathering and the foundation of everything else that will follow:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

    • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - what do you know about cvas (strokes)? what are their signs and symptoms? part of assessment is knowing what the pathophysiology, signs and symptoms and medical treatment is. what signs and symptoms of the cva does she have? look at the other two previous problems she has (the fractured hip and the fainting spell 3 months ago). is the fainting spell possibly related to the cva? what are fainting spells and what might be the cause of them? she also has a pulse that is regularly irregular. hmmm. does that have significance? is it connected to the fainting? how is the previously fractured right hip potentially going to affect her rehabilitation from this stroke since she has been left with right sided hemiplegia?

  • admitted to the hospital for acute cva
  • history of fractured right hip
  • fainting spell 3 months ago

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all problems must have signs and symptoms. here they are. the scenario gave them to you. whatever is abnormal during your physical exam and questioning of the patient is abnormal data that becomes evidence of some problem.

  • pulse is regularly irregular
  • right sided hemiplegia
  • speech is slurred
  • has difficulty swallowing
  • withdrawn
  • responds slowly to questions but the staff can understand her requests
  • dependent for adl's

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - the trick is figuring out what nursing diagnoses the data belong to. that is why you need a nursing diagnosis reference to help you out when you are first learning to diagnose. . .you are being asked to list a priority diagnosis. diagnoses are usually prioritized by maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). ineffective tissue perfusion would be a nice diagnosis to use except for one problem--i don't think you have enough evidence to use it. this patient was admitted to the hospital 2 weeks ago, so her difficulty swallowing, slurred speech and slow response to questions which are a defining characteristics of acute cerebral perfusion problems because of oxygen deprivation began 2 weeks ago. what you are seeing now are the permanent damage she is left with. to use ineffective tissue perfusion for your assignment you need to know the pathophysiology of the cva. was it a blood clot (interruption of blood flow) or a hemorrhage (impaired transport of oxygen)? we don't know and that ios a problem because we can't identify an etiology. i don't like the regularly irregular pulse. that tells me that there is a cardiac arrhythmia. one of the biggest causes of strokes is arrhythmias. cvas are also a cardiovascular event. fainting is also a symptom of anemia. i want to diagnose this lady with

  • decreased cardiac output r/t altered heart rate aeb regularly irregular pulse of 82

but the next problem i see would be

  • impaired swallowing r/t neuromuscular impairment aeb difficulty swallowing

why? because nutrition issues follow oxygen and circulation on maslow hierarchy. swallowing is necessary to eating.

it's annoying not to have subjective data to work with

there was actually a lot of subjective data given. it is a matter of deciding how you want to use and apply it as defining characteristics with nursing diagnoses.

for ineffective tissue perfusion, i'm not sure what i would put for a related factor.

me neither and i mentioned why above. not enough information was given about the type of stroke the patient had.

for impaired physical mobility, i think the diagnostic statement could be "impaired physical mobility r/t neuromuscular impairment (right sided hemiplegia), aeb inability to perform gross/fine motor skills on right side".

it would be
impaired physical mobility r/t neuromuscular impairment and history of recently fractured right hip aeb right sided hemiplegia
. the problem with it is that there are other nursing problems that take priority over this.

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I seem to keep running in circles with this.

Um... I think the fainting spell 3 months ago might have had something to do with the stroke, maybe it was a TIA, since those sometimes occur before a CVA?

I'm still trying to get my mind around the decreased cardiac output diagnosis. It's OK to use that, with just the irregular heart rate as evidence? Wouldn't we have to know how the pulse is irregular, like what kind of rhythm it is? Or would that be part of the interventions, to figure out what rhythm it is, or monitor the rhythm, or something like that?

Also, you mention that there was a lot of subjective data in the scenario. I'm not seeing it... I only see objective data. I guess I'm missing it because I don't see anything said by the patient, except for the fact that the patient must have said something to the staff, since it is known that she responds slowly to questions, but since I don't have any idea what she said, it's not obvious to me what the subjective data could be. The only thing I can think of is that maybe the fact that she lived alone in a small apartment is something she told someone.

I'm stuck! I think I'll try putting together a care plan based on decreased cardiac output, but I need to understand why that diagnosis is OK.

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

i'm sorry, i meant to say "objective" data. however, the scenario gives you a lot of data. whether the data is objective or subjective it is still abnormal data and that is what is needed to supply evidence of problems.

i'm still trying to get my mind around the decreased cardiac output diagnosis. it's ok to use that, with just the irregular heart rate as evidence? wouldn't we have to know how the pulse is irregular, like what kind of rhythm it is?

it is
regularly
irregular. to those of us who have worked in telemetry it means this patient probably has atrial flutter which is very similar to atrial fibrillation, one of the underlying culprits of cvas. regularly irregular is a description of the pulse. it is an assessment. only a doctor can officially diagnose what kind of rhythm it is.

here are webpages about this diagnosis:
decreased cardiac output
and
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=09

i think i'll try putting together a care plan based on decreased cardiac output, but i need to understand why that diagnosis is ok.

read up on cvas. they are a cardiovascular problem often a complication of heart arrhythmias such as atrial fibrillation and atrial flutter which allows blood clots to form in the heart and then be pumped around in the circulatory system where they get trapped in a blood vessel of a brain and the patient ends up having a stroke. it's not much of a far stretch to find they might be having problems with their heart rate. we are not doctors. all we can do is assess and note that something is not normal. the heart is supposed to beat nice and regularly. hers isn't. what i would be thinking. . .did the doctor fix the problem that caused her stroke? maybe it has reared its ugly little head again and i better get on the horn and let somebody know we have a problem here. otherwise, we may have another stroke coming along very shortly.

the only nursing diagnosis we have for irregular pulses is
decreased cardiac output
which covers a multitude of problems in the heart. cardiac output, the physiologic concept, is the amount of blood that the heart pumps out of each ventricle to meet the oxygenation needs of a person's body. if the pump is not working up to par then how can oxygenation be totally adequate? your choice in interventions:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)

  • care/perform/provide/assist (performing actual patient care)

  • teach/educate/instruct/supervise (educating patient or caregiver)

  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

if all you can do is assess the pulse, document your findings, notify the doctor of the current findings and observe for signs and symptoms of hypoxia, then that is a plan. it is not our job to medically diagnose the problem. it is our job to recognize that something is not normal and get the right people notified and involved so the patient gets the help she needs for the problem. that's how we manage it. we are managers of her care. we take our fires as we find them and stamp them out.

your other choice is to go for one of the adls and the scenario is loaded with plenty of those or the depression. pick your poison. you can't nurse someone who will die of their physiologic problems which is why you have to prioritize what you need to do first. on a care plan, i would take care of the pulse situation first, then address the swallowing. next, the mobility. then, i would list the self-care deficits. the depression which is psychosocial would be addressed last. read about cvas. look at the maslow list. remember that this patient had her cva 2 weeks ago. ultimately, you get to make the final decision because this is your assignment. you said you were to come up with the priority diagnosis. my priority diagnosis would be
decreased cardiac output
because of the pulse and i have told you my thinking. your instructor might think it wrong. you know your instructor better than me and had the advantage of attending all her lectures.

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Thanks, I'll go on that. I guess I was just confused because I'm still unfamiliar with how exactly to pick a nursing diagnosis. So you can still use a nursing diagnosis when you have only one of the defining characteristics?

And I'm not really familiar with my professor yet, I've only had one clinical session with her yet, no lectures. I'll just see how it goes.

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

Well, dazzle her that you picked up on something you weren't quite sure of, but you are trying to figure out. In healthcare we don't ignore something because we don't understand it. Tell someone. Yes, you can use a nursing diagnosis even if the patient only has one of the defining characteristics. That is how nursing diagnosis is different from medical diagnosis. Our diagnosing is more flexible. Your instructors may come up with rules that you need more than one defining characteristic, but that is because you are in their world and playing for a grade. In the real world you only need one.

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How do we know that the regularly irregular pulse is abnormal? I read in my med-surg book that irregular heart rhythm is an age-related change caused by increase of size of the left atrium.

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

Did you take anatomy? Check your anatomy book and see what it has to say about the heart and the heartbeat.

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Woohoo! She liked it! Sort of... and I went to an RN who's tutoring in my school's success center and she told me that when I'm given a scenario, and I don't know the client's baseline and stuff, not to assume or go off on tangents in my head about whether the "textbook" might be normal for that person, or under certain circumstances.

I almost got really upset though, when my professor started reading through the scenario in class (it sounded like she was reading it for maybe the 2nd time or so), and she got to the part about the "regularly irregular" rhythm, and she said it sounded like a typo to her, so she was going to consider it a regular heart rate. Fortunately, when I explained that I was interpreting it as an irregular heart rate that was irregular on a regular basis, which I was considering an arrhythmia, which is one of the defining characteristics of Decreased Cardiac Output, she said that was fine.

Boy, I could have fallen over when she said that the regularly irregular heart rate was a typo though... that would've invalidated my entire care plan!

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

I'm glad it all worked out. The bigger picture is that you realize that you must (1) look at your assessment data first and (2) determine what the problem is from the data that you are given. I'm always trying to find ways to explain that concept to students that makes common sense. I don't like to use the doctor analogy because we do use some of the same signs and symptoms and I don't want to confuse people with medical diagnoses. They are not the same as nursing diagnoses. Car mechanics and plumbers follow a similar process, but I don't understand their terminology or what they really do. However, a car mechanic can't get in and solve a car's problem until they look under the hood and do an assessment first. They don't, as a rule, write a formal care plan but the same kind of problem solving logic is going on in their profession as well. After some time and experience you can run this stuff through your brain in an instant. Writing it down takes a whole lot longer.

The next care plans will be a little easier. Carry on, nurse.

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