Care Plan - Hemorrhagic Stroke

[ChelseaSN]

Hello!

I'm hoping someone may be able to help me with a care plan that I am working on. My patient is a 92yo F admitted with new onset weakness with facial droop and shortness of breath. She was diagnosed with an ischemic stroke which progressed into a hemorrhagic stroke by the third day of care. She also had a chest x-ray which showed pneumonia and worsening CHF. She had been NPO due to dysphagia but they had since put her on "comfort care" and were considering transferring to hospice and since this decision had been made it was ordered that if requested she was allowed to eat and drink anything that she wanted. I cared for her over 2 days. On my first day of care she was not able to support herself and was completely dependent on me to move her, sit her up straight, etc. She was lethargic but still able to respond when spoken to. She mostly spoke in single words but had occassional moments where she would even tell me a short stories about herself. She did request oatmeal for breakfast and orange juice and repeatedly asked for water and ice chips through the first day. She was completely dependent on me to feed her and I gave her very small sips of the drinks she wanted by spoon. She denied any pain throughout both days. Vital signs were not being taken due to the decision for her to be on comfort care however I did check her pulse a few times which was 105-120 each time, her respirations were shallow and 28-35/min. She was receiving 2L NC. Her peripheral pulses were very weak and you could hear the fluid in her lungs without even needing a stethoscope. On the second day of care she was even more lethargic and was no longer making any conversation and it usually took a few attempts to get her to respond to questions, sometimes she didn't respond at all. She did request water repeatedly through the day. Her heart rate and respirations were in the same ranges as the previous day and her peripheral pulses were barely palpable.

I've been looking at a few nursing diagnoses but for my case study I need to narrow down to the top three. The ones I'm considering are:

-Ineffective Tissue Perfusion

-Impaired Physical Mobility

-Risk for Aspiration

-Impaired Gas Exchange

-Impaired Cerebral Tissue Perfusion

-Risk for ineffective Airway Clearance

-Greiving

I'd love to hear from anyone who can help me narrow down this list!

Thanks,

Chelsea

[Clovery]

Since she is on "comfort care" I would probably use the risk for aspiration as one of the priorities. If she wants to eat & drink you want to be very careful that she doesn't get aspiration pneumonia. I just did a careplan with risk for aspiration for an elderly patient and I found a lot of good interventions in the Ackley care plan book under this diagnosis and also impaired swallowing.

If she's truly moving to hospice, then focus on the problems that are causing her discomfort. She sounds like she definitely is having impaired gas exchange and you could treat that with comfort measures such as oxygen and elevating the HOB. Aside from that, I would look at psychosocial dx like Grieving & Readiness for Enhanced Religiosity (if appropriate).

[Esme12, ASN, BSN, RN]

Whether or not someone is dying the priority doesn't change....... the treatment changes......ie:you won't intubate them but you don't want to kill them. Comfort is key and Clovery is right....Grieving & Readiness for Enhanced Religiosity and coping are good starts.

Just because someone is on hospice you don't want the to choke to death......think Maslows. these are prioritized according to think Maslow's hierarchy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

• self-actualization – e.g. morality, creativity, problem solving. (to be filled last)
  
• esteem – e.g. confidence, self-esteem, achievement, respect.
  
• belongingness – e.g. love, friendship, intimacy, family.
  
• safety – e.g. security of environment, employment, resources, health, property.
  
• physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis. (greatest need to be filled first)
  

assumptions

• maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.
  

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

• the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
  
• growth needs are the highest level, which is self-actualization, or the self-fulfillment.
  
• maslow suggested that only two percent of the people in the world achieve self actualization. e.g. Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor Roosevelt.
  
• self actualized people were reality and problem centered.
  
• they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
  
• they tended to be spontaneous and simple.
  

application in nursing

• maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.
  

[ChelseaSN]

Thanks for the help! I'm going to use impaired gas exchange (#1), risk for aspiration (#2), and grieving r/t impending death (#3). I think this all confused me because I've done care plans for stroke patients before and I have a difficult time ignoring the Ineffective Peripheral Tissue Perfusion and impaired physical mobility, both are applicable but in this situation I guess there are other more important priorities.

[Esme12, ASN, BSN, RN]

Not really....not getting a open painful decibitus is important......so her immobility can lead to skin breakdown pain and discomfort. Comfort and DIGNITY (big hint) are most important now. Most risks should be placed after actually present diagnoses.

Like......Readiness for enhanced Comfort

NANDA-I

Definition

A pattern of ease, relief and transcendence in physical, psychospiritual, environmental, and/or social dimensions that can be strengthened

Defining Characteristics

Expresses desire to enhance comfort; expresses desire to enhance feelings of contentment; expresses desire to enhance relaxation; expresses desire to enhance resolution of complaints

or........Risk for compromised Human Dignity

NANDA-I

Definition

At risk for perceived loss of respect and honor

Note: Honoring an individual's dignity is imperative and consists of the following elements:

• Physical comfort (bathing, positioning, pain and symptom relief, touch, and a peaceful environment). Encompasses aspects of privacy, respect, and autonomy. Also includes staff expertise, effectiveness, and safety of care
  
• Psychosocial comfort (listening, sharing fears, giving permission, presence, not dying alone, family support and presence). Includes elements of client participation and choice. Clients feel at ease, safe, and protected; neither intimidated nor threatened
  
• Spiritual comfort (sharing love and caring words, being remembered, validating their lives, praying with and for, reading scripture and Bible, clergy and referral to other providers [i.e., hospice]) (Touhy, Brown & Smith, 2005; Groenewoud et al, 2008)
  
• Risk Factors
  

Cultural incongruity; disclosure of confidential information; exposure of the body; inadequate participation in decision making; loss of control of body functions; perceived dehumanizing treatment; perceived humiliation; perceived intrusion by clinicians; perceived invasion of privacy; stigmatizing label; use of undefined medical terms

I hope this helps.