Care Plan - CVA (Basal Ganglion Infarction)

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

[MegNeoNurse]

First you need to choose a nursing Dx. Maybe risk for aspiration? Impaired skin integrity? Self care deficit? Careplans suck, I feel your pain. Do you have a care planning book? Those help SO much. I wouldn't have been able to make it this far without them!

[Daytonite, BSN, RN]

first you need to choose a nursing dx. maybe risk for aspiration? impaired skin integrity? self care deficit? careplans suck, i feel your pain. do you have a care planning book? those help so much. i wouldn't have been able to make it this far without them!

i answered this members questions on the nursing student assistance forum at this thread: https://allnurses.com/forums/nursing-student-assistance-forums/262421-cva-basal-ganglion-infarction.html

first you need to choose a nursing dx.

this is wrong, wrong, wrong! first, you need to sort through the data and make a list of the abnormal items. these are the patient's symptoms. these are the items that become the evidence to support any nursing diagnoses you eventually choose. then, you choose a nursing diagnosis.

(from page 4 of

nursing diagnosis handbook: a guide to planning care

, 7th edition, by betty j. ackley and gail b. ladwig)

"when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.

• highlight or underline the relevant symptoms.
  
  
• make a short list of the symptoms.
  
  
• cluster similar symptoms.
  
  
• analyze/interpret the symptoms.
  
  
• select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.
  
  

the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."

careplans suck

better get used to them because they are a requirement in every hospital inpatient and nursing home resident medical record chart. this is a federal law (title 42). that is why you are being taught how to do them. more than that, they are documentation that you performed the nursing process which is how we problem solve. as an rn this is what you will be expected to know how to do--problem solve in caring for patients. care planning is a skill that places you above lpns and cnas in the nursing world. i wouldn't openly admit in front of them that you think care plans suck because it disrespects you and other rns in their eyes. i take this as a personal insult to my ability as an rn. i don't think care plans suck and i take great pride in my ability in doing them as a part of my professional duty. i had difficulty learning how to do them at first too, but i knuckled down and eventually learned the process. that's part of why i take the time to help you guys understand how to do them.