Help with Care Plan for CVA client

[amandan08]

OK, so I went to clinical and now have my first care plan due tomorrow. I am utterly clueless on how to do this... I really need help..

Here is my client's information:

Medical Diagnosis: CVA

(other diagnoses include Hypertension, CAD, Hyperlipidemia, Angina, Dermatitis) She also has a trach and a peg tube.

She is practically non-responsive. She can't move her body or speak. She is a total care patient. She doesn't have a foley, her oxygen is at 10 l/min via trach. She has all nutrition via her PEG, doesn't have an IV.

I figure that one of the most important things is Ineffective Airway Clearance, but I don't have a r/t statement by it could be aeb SOB? I really don't know...

Any assistance would be helpful..

Thanks :):)

[Daytonite, BSN, RN]

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.

[amandan08]

Thanks!

I know I really didn't... I really don't know what else to tell you though! Here are the ones that I actually wrote:

1. Ineffective airway clearance r/t retained viscous secretions AEB rhonchi on inspiration.

2. Ineffective cerebral tissue perfusion r/t interruption of blood flow AEB changes in motor responses.

3. Impaired physical mobility r/t neuromuscular involvement AEB inability to purposefully move involved body parts

4. Self-care deficit r/t neuromuscular impairment AEB inability to perform ADL's.

5. Impaired verbal communication r/t neuromuscular impairment AEB inability to produce verbal communication.

Those are in the order of priority, and I hope that part is right....

My supportive/assessment data for Ineffective Airway Clearance 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....))))

And that's all I have :) Is that even right so far? What could some interventions be and I have to do the assessment data, goal, and interventions for another diagnosis...

[Daytonite, BSN, RN]

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)
  

short-term goal

(is what you predict will happen as a result of the interventions being performed): patient will demonstrate how to correctly cough and deep breath by the end of the day.

interventions

(they have to address the aebs and the r/ts):

- assess level of consciousness and orientation to person, place and time

- inspect the chest for abnormal movements with breathing

- inspect the extremities for cyanosis, edema and clubbing of the digits

- auscultate the lungs for diminished, absent and adventitious breath sounds q shift

- monitor for increasing lethargy

- have the patient sit upright to ease their breathing

- encourage the patient to drink plenty of fluids to stay hydrated and use humidification

- give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed

- explain the importance of coughing and deep breathing

- teach coughing and deep breathing exercises

o coughing

take a slow deep through the nose and expand the chest fully

breathe out through the mouth feeling the chest sink down and in

take a second slow breath through the nose expanding the chest fully and breathing out

take a third breath in the same way but hold it

the patient should now cough two or three times (once is usually not enough) and concentrate on using the diaphragm to force the air out

follow with several normal breaths exhaling slowly

do this every 2 hours

o deep breathing

lie supine with legs slightly bed at the knees; can also be done sitting and standing

take as deep breath as possible through the nose and allow the abdomen (not the chest) to rise

hold the breath for a count of five

exhale completely through pursed lips as if whistling allowing the ribs to sink downward and inward

rest several seconds and repeat 5 to 10 times every hour

- teach about the underlying diagnosis and treatment plan

[amandan08]

That makes a lot of sense. I'm going to make some revisions... Definately change the priority. I'm just so used to my instructors screaming AIRWAY! at me all of the time I always assume that would be the most important thing, but I suppose that with a CVA the tissue perfusion would be first.

I really appreciate your help! I really hope that one day I'll be a nurse as great as you! Thanks bunches!!

[Daytonite, BSN, RN]

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.

[Nara3105]

Hello,

my client also was diagnosed with CVA about a month ago. he has a Peg tube + oral reg. diet, R hemiplegia, L weakness, edema +2 on L hand and L extremities; R side skin is cool to touch. he can't move his body nor he can talk.

my priority diagnosis are: Ineffective tissue perfusion(cerebral) R/T decreased cerebral blood flow ST/ CVA AEB unable to turn and reposition; edema present +2. Two short terms goals are: 1) The client will maintain tissue perdusion AEB O2 Sat within defined limits and pink moucous membrane within my 8 hr shift. 2) The client will be turned and repositionned q1-2 hr and will have a strong peripheral pulses by the end of my shift.

Ineffective airway clearance R/T immobility and ineffective cough S/T CVA AEB R hemiplegia and pt'h an ineffective cough. The two short term goals are: 1) The client will maintan a clear airway AEB have increased fluid intake, turn and repositioend q1 -2 hr within my 8 hr shift. 2) the client will perform DB and C exercise during my 8 hr shift

Please I need your advice on these nrs dx and short term goals. your help will be appreciated

Nara