Client Story: A 60-year-old woman resides alone with her husband in a house.

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She suffered a stroke and is now unable to move her left arm or leg. The stroke left her speech slurry. She has hypertension and is obese. She currently takes no prescription medications.

Plan of Care: From the client story, identify two keystone issues (present state). The issues must be described in complete NANDA diagnostic statements. Provide a brief rationale as to why these two issues were identified as priorities. For each issue, identify at least one outcome and two tests to evaluate the stated outcome. Outcomes must be SMART (specific, measurable, achievable, realistic, and time-referenced).

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Specializes in ER, ICU, Medsurg.

Call me crazy but with all these posts, eas, I find it difficult not to think you are wanting us to do your homework for you. Why don't you try telling us what you have come up with so far and I'm sure we would all be happy to help.

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

Start by taking this information:

She suffered a stroke and is now unable to move her left arm or leg. The stroke left her speech slurry. She has hypertension and is obese. She currently takes no prescription medications.

and making a list of what is abnormal. That becomes a basis for your two (present state) keystone issues. Also look up the pathophysiology of a stroke. They will be turned into NANDA diagnostic statements. Without you doing that I will not provide any more assistance for you.

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Self care deficit related to Left-sided weakness 2nd to CVA AEB inability to purposefully move left arm or leg.

Impaired verbal Communication related to loss of left facial/oral muscle tone and control 2nd to CVA AEB slurred speech.

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

self care deficit related to left-sided weakness 2nd to cva aeb inability to purposefully move left arm or leg.

this diagnosis completely wrong. read the scenario again. there is nothing in there about an
"impaired ability to perform" adls
(the definition of self-care deficits).

impaired verbal communication related to loss of left facial/oral muscle tone and control 2nd to cva aeb slurred speech.

the diagnosis and evidence are correct, but the related factor is wrong. what in general terminology, because of the stroke, happens pathophysiologically to cause the slurred speech?

you can find lots of previous threads on allnurses about care plans and nursing diagnoses relating to stroke (cvas) .

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1) DIAGNOSES

- Impaired physical mobility, related to neurologic deficits 2nd CVA AEB inability to move left side

- Impaired verbal communication, related to cerebral injury 2nd CVA AEB slurred speech

OUTCOMES

- The client will participate in exercises necessary to maintain muscle strength and tone.

- The patient will practice and implement speech therapy activities while at the same time using alternative methods of communication.

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

she suffered a stroke and is now unable to move her left arm or leg. the stroke left her speech slurry. she has hypertension and is obese. she currently takes no prescription medications.

using the nursing process to problem solve. . .
step #1 assessment
(collect data, some of which has been provided for you)

  • unable to move her left arm or leg

  • slurred speech

also look up information about the pathophysiology, signs and symptoms and complications of strokes, hypertension and obesity

step #2 is to determine the nursing problem (nursing diagnosis)
based on the abnormal data that is present. the inability to move her left arm and leg and the slurred speech are evidence of nursing problems. the stroke, hypertension and obesity are causes that are contributing to these nursing problems (and the medical problem) and need to be considered as well.

the actual construction of the nursing diagnostic statement follows this format:
p-e-s

  • problem
    - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of
    taber's cyclopedic medical dictionary
    has this information.

  • etiology
    - also called the
    related factor
    by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.

  • symptoms
    - also called
    defining characteristics
    by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

so the correct diagnoses in
p-e-s
format for this client story will be this:

p
-
impaired physical mobility

e
- neurological impairment secondary to stroke

s
-
unable to move her left arm or leg

p
- impaired verbal communication

e
- neurological impairment secondary to stroke

s
-
slurred speech

and when written out look like this:

  • impaired physical mobility r/t neurological impairment secondary to stroke aeb inability to move her left arm or leg.

  • impaired verbal communication r/t neurological impairment secondary to stroke aeb slurred speech.

step #3 planning
involves writing measurable goals/outcomes and nursing interventions which are all based upon what was determined in step #2. there is continuity and cohesiveness to problem solving.

provide a brief rationale as to why these two issues were identified as priorities.

explained above. as for sequencing, it worked out that way it should. there were only 2 nursing issues you could get from the information provided. using maslow's hierarchy of needs (
http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
) the
impaired physical mobility
is a physiological need that must be addressed first. communication is a safety issue and is sequenced second.

for each issue, identify at least one outcome and two tests to evaluate the stated outcome.

outcomes must be smart (specific, measurable, achievable, realistic, and time-referenced).

there is very little we can do to cure the stroke, so our interventions will target and help her inability to move her left arm and leg and her slurred speech. outcomes are what you
predict
will happen as a result of the nursing interventions that you are going to order. you really haven't completed what you were asked to do. your outcomes are not specific, measurable or time-referenced. nor have you provided assessment data for how you will determine that they were met.

the client will participate in exercises necessary to maintain muscle strength and tone.

  • what exercises? no specific exercises are named. in the nursing interventions specific exercises would be mentioned.

  • how do we know and measure that exercises are being done successfully? 1 set of 10 of an exercise; 2 sets of 10 of the same exercise tolerated well? successful performance of some specific physical activity that helps compensate for the left sided paralysis? it has to be stated in the outcome statement.

  • the exercises and activities have to be ones that the patient will be able to do.

  • when will the patient be able to do these exercises--today, tomorrow, or next year?

the patient will practice and implement speech therapy activities while at the same time using alternative methods of communication.

  • what speech therapy activities?

  • what alternative methods of communication?

  • how will we know they are successful?

  • when will this happen?

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DIAGNOSES

- Impaired Physical Mobility R/T neurological impairment secondary to stroke AEB inability to move her left arm or leg.

Impaired Physical Mobility is a physiological need that must be addressed first.

- Impaired Verbal Communication R/T neurological impairment secondary to stroke AEB slurred speech.

Communication is a safety issue and is sequenced second.

OUTCOMES

- The client will lift left arm and leg for 5 to 10 seconds within 24 to 48 hours after the stroke.

- The patient will practice and implement speech therapy activities like singing, repeating lists, answering questions, and relearning the physical mechanisms of speech while at the same time using alternative methods of communication tomorrow.

TESTS

- The nurse will determine degree of mobility in relation to 0-4 scale, noting muscle strength and tone, joint mobility, balance, and endurance. The nurse will observe movement when client is unaware of observation to note any incongruency with reports of abilities.

- The nurse will determine degree of speech activities in relation to 0-4 scale. The nurse will observe speech activities when client is unaware of observation to note any incongruency with reports of abilities.

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

diagnoses

  1. impaired physical mobility r/t neurological impairment secondary to stroke aeb inability to move her left arm or leg.
    • definition: limitation in independent, purposeful physical movement of the body or of one or more extremities.

[*]impaired verbal communication r/t neurological impairment secondary to stroke aeb slurred speech.

  1. definition: decreased, delayed, or absent ability to receive, process or transmit and/or use a system or symbols.

outcomes

  • the client will lift left arm and leg for 5 to 10 seconds within 24 to 48 hours after the stroke.
    • we are not physical therapists. our aim, when the patient has impaired physical mobility, is to help them overcome their deficit (an inability to move her left arm or leg in this case) and carry on with their lives. lifting the left arm and leg for 5 to 10 seconds within 24 to 48 hours after the stroke is not going to do that. she can't do that. this person's left side is paralyzed. that is what "unable to move her left arm or leg" means. that is what happens when someone has a stroke. your nursing interventions will focus on how are you going to assist this patient who does not have movement of the extremities of their left side to move. the result of those interventions will be your outcome(s).

    [*]the patient will practice and implement speech therapy activities like singing, repeating lists, answering questions, and relearning the physical mechanisms of speech while at the same time using alternative methods of communication tomorrow.

    • when someone has a stroke they sometimes cannot make sense when they speak and people cannot understand what they say (http://www.stroke.org/site/pageserver?pagename=las - life after stroke). we are not speech therapists. our job as nurses is to help a patient who has a communication problem be helped to communicate. your nursing interventions will focus on how are you going to assist this patient who has slurred speech be understood by others. the result of those interventions will be your outcome(s).

i will say this once more. . .read about the pathophysiology, signs and symptoms and complications of strokes. you do not seem to understand what happens to a person who has a stroke and that is critical to this assignment.

tests

  • the nurse will determine degree of mobility in relation to 0-4 scale, noting muscle strength and tone, joint mobility, balance, and endurance. the nurse will observe movement when client is unaware of observation to note any incongruency with reports of abilities.
  • the nurse will determine degree of speech activities in relation to 0-4 scale. the nurse will observe speech activities when client is unaware of observation to note any incongruency with reports of abilities.
    • none of these are applicable because none of your outcomes are inappropriate.

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Daytonite...thanks so much.

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Daytonite, I really liked the P-E-S approach. I can usually write a dx pretty well but I will be sure to keep this in my toolbox AND share it with other students!

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day--you are awesome!! i hope your still surfing this site when i need help:)

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