Care plan...Help!!

[bri2012]

I am stuck on my care plan and really need some assistance. I have a client who is 103 diagnosed with acute but ill defined cerebrovascular disease, HTN, muscular waste and disuse atrophy, and unspecified cerebral artery occlusion. She is in a wheelchair or in her bed, she does not do physical therapy and she weighs about 94 lbs and only eats about 25% of her meals and mostly eats chocolate candy.

Now I have came up with 3 diagnosis of:

Risk for Impaired skin integrity with my cues being poor nutrition intake, Braden skin risk assessment score 15, urgency and sometimes does not make it to bathroom, and being in wheelchair/bed.

The goal that I have came up with is to keep her skin intact for the next week and I need four interventions but I could only come up with 3....monitor skin q2hr. Lotion skin so it wont get dry. and turn her q2hr while she is in bed I need help with a 4th one.

Risk for falls: cues are cannot bear weight on her right leg, falls score of 9, sometimes tries to use bathroom without assistance.

Goal is to keep her free from falls in the next week.

Interventions: Maintain room free of clutter. Put call light within reach so she can ask for assistance. Im having trouble with the other two that I need.

Nutrition Imbalance - less than body requirements: : cues are eats 25% of meals. wt. loss of 5lbs in the last 3 months. and she only eats her chocolate candy. Goal is to consume adequate nutrition

I could only come up with two interventions for this one as well... Encourage proteins and have someone sit with her at meals to encourage her to eat more.

If someone could please help me out I would appreciate it! Thanks!

[DolceVita, ADN, BSN, RN]

In the risk for falls: other interventions you should consider a bed/chair alarm. It is one thing to provide a call light nearby but the patient should be able to demonstrate its use. Also, assess the patient's judgement in using the call light. Toileting regimens are useful for people who get up to use the toilet without calling for assistance. Also, answering the call light promptly is important.

Also determine if the getting up to use the bathroom is new or old behavior. If new assess why. Does she have new urgency/frequency etc? Is she on too many laxatives?

If you have access to Ackley for nursing diagnoses and interventions you might find this a bit easier. If you don't have a care planning book yet use this:

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/index.php

[solneeshka, BSN, RN]

When I read your description of your patient, I'm worried about stroke more than anything! I know you can't put that as a nursing diagnosis, but something like "risk for impaired tissue perfusion" would work. I'm afraid she'll have a brain bleed because of the "acute but ill defined cerebrovascular disease" (?!), and I'm afraid she'll toss a clot because it sounds like she's not really moving. You have some really good diagnoses going, you've done a good job!

[ladyangel341]

I won't do risk NCP's...You should go to NCP that needs immediate care or prioritize your NCP's. Risk is just needed when theres no problem you can think of...but you got lot of problem here in a single disease.. Risk would be a last resort.

Ineffective cerebral tissue perfusion related to interruption of arterial flow

Self-care deficit: bathing/hygiene, dressing/grooming, toileting related to decrease strength/neuromuscular impairment

Impaired physical immobility related to decrease strength and endurance or neuromuscular impairment.

Nutritional Imbalance less than body requirements related to lack of information which I will mention chocolate candy...

Fear of impairment or death related to (I include this because most of the patients experience acute stroke have this but I can't find the R/T with your given data)

Just expand this...I would also suggest reading the all Gordon's functional health patterns and jut down the things that apply to your patient

Hope I helped^^:heartbeat

[DolceVita, ADN, BSN, RN]

Where on earth did you get the idea that "risk for" diagnoses are just needed when you can't think of something else? I would worry about an instructor teaching students that kind of thinking.