Help with Care Plan for CVA client

you need to read the information on the first couple of posts of this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. you haven't posted enough information for me to even help you determine what this patient's nursing problems might be. all you have done is told us what their medical problems and medical treatments are. nurses help patients with how they are responding to their medical problems and that is why you are stuck. the first thing you need to do is assess how your patient is doing that. nursing assessment includes:

• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
  

out of all that information you are going to make a list of the things that are abnormal. think about what you do (they are probably normal) and the things that patient does or cannot do (many are not normal). the abnormal items are symptoms of their nursing problems. those nursing problems are then given names we call nursing diagnoses. we then treat those individual symptoms with nursing interventions and develop goals (anticipated reactions to our nursing treatments).

that is a care plan in a nutshell.

the correct sequence for your diagnoses is:

1. ineffective cerebral tissue perfusion r/t interruption of blood flow aeb changes in motor responses.
   
   • you should specify what those specific changes are
     

[*]ineffective airway clearance r/t retained viscous secretions aeb rhonchi on inspiration.

[*]impaired physical mobility r/t neuromuscular involvement aeb inability to purposefully move involved body parts

• you should name specific body parts and what they cannot do
  

[*]self-care deficit r/t neuromuscular impairment aeb inability to perform adl's.

• since you are combining all 4 diagnoses into one you should specifically list what these adls are in your aeb section
  

[*]impaired verbal communication r/t neuromuscular impairment aeb inability to produce verbal communication.

when someone comes along and reads a nursing diagnostic statement on a care plan, it is like a photograph. they should get a good mental picture of what is going on with that patient. saying something like self-care deficit r/t neuromuscular impairment aeb inability to perform adl's leaves me with a lot of questions. if i'm the director of nursing reading that, i shouldn't have to actually go into that patient's room and do an assessment myself to see what adls they can't do.

my supportive/assessment data for ineffective airway clearance r/t retained viscous secretions aeb rhonchi on inspiration.

• your diagnostic statement should include all the symptoms: ineffective airway clearance r/t retained secretions aeb rhonchi on inspiration and productive cough of yellow viscous secretions
  
• a tracheostomy and oxygen are medical treatments - not symptoms of the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway, the definition of ineffective airway clearance (page 308, nanda international nursing diagnoses: definitions and classifications 2009-2011).
  

my supportive/assessment data for ineffective airway clearance is

is

-trach in place

-oxygen at 10 l/min

-yellow viscous secretion produced by coughing

-rhonchi on inspiration

goal: client will maintain patent airway with breath sounds clear

interventions/rationales: (((i don't know this part yet....))))

• your nursing interventions target the patient's symptoms: the rhonchi and productive cough. so think about what you, nurse, are going to do for that cough and to help the patient clear those rhonchi (actually it's the secretions from their lungs).
  
• your goals are a prediction of what will happen when your nursing interventions are carried out
  
• here's an example of a goal and interventions for this diagnoses (warning: this may not apply to your patient and some are independent and some dependent on md order type interventions)
  

Airway is important and a patient will die rapidly with no oxygen, but brain cells start dying when the brain is deprived of oxygen at 4 minutes and at 7 minutes the brain is dead. Therefore, Ineffective cerebral tissue perfusion has to be sequenced before Ineffective airway clearance. A patient with breathing and airway problems takes longer to die.