confused with diagnosis

[nursing stud'nt]

Hi everyone,

I am currently studying my first case scenario for the term. We are expected to study the patient's disease then make a care plan out of it. It stated that the patient has Cerebral Palsy and has bouts of dysphagia. I am wondering if I should tackle dysphagia as a separate disorder or should I just include that as one of the complications of Cerebral Palsy?

According to my research, dysphagia is a medical term for "difficulty in swallowing" which could also have it's own symptoms. So that adds to my confusion. Can somebody please help me with this?

[Jolie, BSN]

If your information indicates that the patient's bouts of dysphagia are related to the CP diagnosis, then you should address it as part of that diagnosis. Look up the pathophysiology of CP to understand how dysphagia relates to that diagnosis.

If the dysphagia is a new problem, unrelated to CP, and under investigation as to its cause, then you can address it as a separate problem.

[Daytonite, BSN, RN]

you look up all the signs and symptoms of cerebral palsy as well as dysphagia since your scenario has told you that this patient has dysphagia. a care plan is first and foremost based on the actual problems a patient has and you are being told that dysphagia is one of them. it just happens to also be one of the complications of cerebral palsy. tough break for the patient. you will develop nursing interventions for the patient's responses to the symptoms of cerebral palsy and dysphagia in this care plan.

i strongly recommend that you follow the sequence of steps of the nursing process when writing care plans:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions based on the abnormal data collected)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)