i was hoping that someone would be able to confirm that i am on the right track with my nursing dx's for a situation that my teacher assigned me and i need help with the RTs AND AEBs.. so all feedback would be greatly appreciated!
Mr. Jones, aged 68, experienced a stroke 1 week ago that left him with right-sided weakness, aphasia and incontinence. His wife is eager to have him discharged from the hospital so that she can care for him at home. You have heard her tell Mr. Jones, "You don't need to worry about a thing, honey. I will take complete care of you and do everything for you. All you have to do is stay in bed and take it easy."
so far all i have:
Impaired swallowing RT aphasia secondary to CVA
Impaired verbal communication RT aphasia secondary to CVA AEB inability to communicate
Impaired physical mobility RT right sided weakness secondary to CVA AEB poor balance and weakness
Self care deficit RT acute disease process secondary to CVA AEB right sided weakness aphasia and incontinence
Risk for aspiration RT right sided weakness secondary to CVA
Risk for impaired skin integrity RT incontinence and right sided weakness
Knowledge deficit of caregiver of current dx and prognosis AEB ???
Risk for imbalanced nutrition: less than body requirements
the first thing i noticed is that you misdiagnosed the patient. aphasia is the inability to speak. aphagia is a problem with swallowing. unless you made a typo, this patient does not have a swallowing problem, so your diagnoses of impaired swallowing and risk for aspiration need to be removed.
in priority order, based on what you posted, i would diagnose the following:
total incontinence r/t neurological impairment secondary to stroke aeb (incontinence)
impaired verbal communication r/t neurological impairment secondary to stroke aeb aphasia
self care-deficits r/t neurological impairment secondary to stroke aeb (?)
caregiver role strain r/t inexperience and knowledge of caregiver aeb statement by wife "you don't need to worry about a thing, honey. i will take complete care of you and do everything for you. all you have to do is stay in bed and take it easy.
r/t's are the underlying cause of the problem; aeb's are always the symptoms that prove the existence of the problem.
- - - - - - - - - - - - - - -
impaired swallowing rt aphasia secondary to cva
aphasia is not difficulty swallowing.
impaired verbal communication rt aphasia secondary to cva aeb inability to communicate
aphasia is not the etiology, or underlying cause, of the
impaired verbal communication
(definition:
decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.
page 178,
nanda international nursing diagnoses: definitions and classifications 2009-2011
.) anyway, it is a medical diagnosis and should not be used in a nursing diagnostic statement. the cva is the cause of the aphasia, but must be stated in a more general way, such as neurological impairment or as alteration in central nervous system.
impaired physical mobility rt right sided weakness secondary to cva aeb poor balance and weakness
right-sided weakness is a
symptom
of the
impaired physical mobility
and not the underlying cause of it. again, the cva is the cause of it, but must be stated in a general way.
self care deficit rt acute disease process secondary to cva aeb right sided weakness aphasia and incontinence
self care deficit is the inability to perform adls. what acute disease process is going on to cause self-care deficits? the r/t factor is neuromuscular impairment secondary to the cva or possibly, in this case, the patient's inability to perceive a body part. insofar as the symptoms are concerned, right sided weakness, aphasia and incontinence are not self-care deficits. bathing, dressing, movement, eating, toileting, dressing and grooming fall into that category.
risk for aspiration rt right sided weakness secondary to cva
not applicable since aphasia is not a swallowing problem.
risk for impaired skin integrity rt incontinence and right sided weakness
this is a bit of a stretch, but ok.
knowledge deficit of caregiver of current dx and prognosis aeb ???
you can't diagnose the wife. the careplan is about the patient, not the wife. the focus has to be on the patient and what will happen to him, not his wife.
risk for imbalanced nutrition: less than body requirements
have no idea how you concluded this was a problem.
risk for injury rt right sided weakness
i wouldn't diagnosis this. interventions for this can be included with
impaired physical mobility
.
i figured i could include impaired swallowing because he has right sided weakness, so im thinking that his muscles are too weak for him to swallow safely
why wouldn i be able to use his wife in the care plan because to me she is a huge problem regarding his prognosis
*** I KNOW THat aphasia is not difficutly swallowing but because of a persons with aphasia inability to comprehend and/or communicate i figured that they would have trouble swallowing
Daytonite has forgotten that Nursing recently has evolved to more of a holistic model that encompasses the patient and family hence why NANDA has family, parent, and caregiver related diagnosis. By their very definition they refer to non patient issues that effect the patient in one manner or another.
Non direct patient careplans are considered extremely important, that is what seperates Nursing from Doctoring.
We care about what happens to our pts after the hospital.
Specializes in med/surg, telemetry, IV therapy, mgmt.
excuse me, students, but i haven't forgotten anything about nursing or its evolution. a care plan is still about the patient and if you read my post carefully i never said you can't do anything about non-patient issues. what i said was, "the focus has to be on the patient and what will happen to him. . ." that means as a result of what is going on with the family. use your thinking caps a little. the way you write these diagnoses up as well as your interventions is important. that is why you must know how to use the english language properly.
as for "because of a persons with aphasia inability to comprehend and/or communicate i figured that they would have trouble swallowing", do you have evidence to prove that? i've been a nurse for many years and can tell you that i've never seen that. these muscle groups are controlled by different cranial nerves. you don't know which ones might have been damaged by the stroke. how does speech work? are the same muscle groups used for speech involved with swallowing? check that out. never assume anything. right arm and leg weakness is affecting a different set of nerves.
SJH*SPN
10 Posts
i figured i could include impaired swallowing because he has right sided weakness, so im thinking that his muscles are too weak for him to swallow safely
why wouldn i be able to use his wife in the care plan because to me she is a huge problem regarding his prognosis
i know aphasia is not difficulty