Quote from gette
hi am new to this site am i am a first year nursing student and i am having difficulty with this scenario.
mr. t.h is 68 years of age and was admitted to a geriatric care facility two days ago and complains of feeling weak, difficulty swallowing and feeding self. he has severe right sided weakness from a stroke (cerebral vascular accident - cva), and cannot mobilize independently. he is disoriented and attempts to get out of bed. he has a reddened area at the sacrum and his right elbow and has had no bowel actions since entering the facility.
can someone please help me with two actual diagnoses and one risk diagnoses and also the nursing care plan and two priority needs. thanks can a get some assist tonite plz
we will help you but we won't give you "two actual diagnosis, one risk diagnosis and also the care plan and two priority needs".
what information can you get from this information as i think this is a book scenario and not an actual patient assessment. if someone is weak are they at risk for injury? if they are confused and weak does that make it worse? how would they be injured? nursing care is like being a detective....you are given clues and you need to use your knowledge and skill to get to the bottom of the mystery to help the patient and ward off any trouble.
if they can't swallow properly what can happen to them as a consequence of not getting enough food or asparating it into their lungs....what risk does that pose to them, nutritionally and infection wise?
if they can't get around or "mobilize independently" what risk does that expose them to....can they wash themselves? dress themselves? do they have a deficit in their daily activities? what effect does the cva have on the affected side? what risk is there to that extremity? know your disease process and pathophysiology.
is his skin at risk from being unable to reposition himself or by injuring himself trying to get around without help.......does this show in his already has a reddened bottom and elbow?
has his lack of proper nutrition affected his bodily functions? or could it be his immobility from the cva that has altered his bowel function.
what do you have so far? you need a care plan book as you will be using it all through school.
first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. there are many threads about this and a great nurse and an contributor daytonite
(rip) is one of the greats. i use her information and advice all the time.
since i sense you are already concerned about this care plan writing business, i would urge you to read about the nursing process. a care plan follows the 5 steps of the nursing process. if you have a care plan book, or you can often find one or two in a library, you want to pay particular attention to the beginning chapter(s) which usually have a discussion about the nursing process. they are often only a few pages long. however, this is important information that pretty much sums up what you are supposed to know and understand at the end of your nursing course. care mapping is nothing more than a different physical format of presenting a care plan. the underlying concept of the nursing process, however, is still very much at the very heart of each and every care map. so, you have got to know what it is and what is involved in every step.
all nurses has two "sticky" threads in two different nursing student forums on care plans where you can also find information. there isn't a lot of information on care maps there, but my experience has been that students who are taught how to care map have a much better understanding of the nursing process and how all the pieces of assessment, outcomes and interventions all fit together. also, there are two links you can access that are attached to the bottom of every one of my posts. they are forms that all members of all nurses are free to download, print and use if you think they will be a help to you as you are learning to assess patients and write care plans.
for help with writing care plans see:
"don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- 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)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met) "
i hope this helps......do you have any questions?