** Help with a Simple Care Plan **

well, this is very confusing. the nursing diagnosis you chose was: feeding self-care deficit related to muscular weakness on left side and cognitive deficit secondary to previous stroke (cva) as evidenced by inability to cut food or open packages.

i started looking at your broad goal: to maintain mobility on right side and to encourage use of call light. i had to go back to your diagnostic statement to see if i had read it correctly. the inability to cut food or open packages has absolutely nothing to do with maintaining mobility on the right side or using the call light! not only that, but the definition of the feeding self-care deficit is as follows: impaired ability to perform or complete feeding activities (page 185, nanda-i nursing diagnoses: definitions & classification 2007-2008). using a call light is not a feeding activity. mobility has to do with movement and the diagnosis of impaired physical mobility. it is inappropriate to use it with self-deficit.

outcomes are your predicted results based upon treating the cause of the problem as well as the symptoms of it and based upon the interventions that you order. i notice you are told the patient's deficit is due to muscular weakness and cognitive deficit because of a stroke. can these be reversed? or, are stroke residuals permanent? do you understand what a cognitive deficit means? it limits the patient's understanding because there was brain damage. not everything is curable. damage from strokes is not usually curable so we work to maintain whatever function the patient does have.

when care planning it is best to work with the nursing process. tear the nursing diagnosis down into its component parts:

• problem: feeding self-care deficit (inability to perform or complete feeding activities)
  
• etiology: muscular weakness on left side and cognitive deficit (this was due to a previous stroke)
  
• symptoms: inability to cut food or open packages
  

the symptoms are what were found during the assessment of the patient. knowledge about strokes is also what you would have learned during assessment as well

• http://www.strokecenter.org/prof/ems/ - stroke interactive tutorial
  
• http://www.merck.com/mmpe/sec16/ch211/ch211a.html
  
• http://www.stroke.org/site/pageserver?pagename=las - life after stroke
  

you need to be aware that people who have had strokes may also have issues not only with bringing the food up to their mouth physically (that's the left sided muscular weakness referred to in the "related to" part of the nursing diagnostic statement) but also with opening their mouth, and chewing since all these activities involve muscles of feeding that may be weakened or damaged from the stroke. if the patient cannot open their mouth wide enough food must be cut up so it is small enough for them to get it into their mouth. they may not be able to chew larger chunks of food enough to make them smaller before swallowing. rom exercises are not going to correct these problems, especially when the stroke happened "previously". what you are left with is to treat the symptoms

• can't cut up food
  
• can't open packages
  

we know there is a left side weakness, but how about the right side? can the patient hold utensils in the right hand? can we have the kitchen send food that is already chopped or soft so the patient merely needs to pick it up with a spoon? there are devices that can be placed around the edge of plates to help patients scoop food onto utensils so it doesn't get pushed off the dish when they are trying to get food onto a spoon or fork. we want to assist the patient to do as much for himself as possible and not do everything for them. we can ask the kitchen to put milk and fluids in a glass rather than send them in individual packages. yes, there are some things that will need to be opened. yes, we will need to make sure that utensils and glasses are placed at the patient's right side where he can reach them easily.

are you getting what i am saying?

outcome. . .patient will eat more at meals, will be more independent in eating, will eat safely

effectiveness. . .how do you know the interventions are working? assess for those symptoms or degree of them to continue occurring. is there still a problem with cutting up food? how much of a problem is it now? is there still a problem opening packages? to what extent?

do you see how we go from the problem to solutions to checking to see if the solutions are working? to come up with solutions you have to know what you are dealing with. go to mcdonalds and order something. put your hand behind your back and try to eat it. pretend that you are 6 years old and don't have the capacity to problem solve. take notes. try to eat a bowl of soup with one hand behind your back. again, pretend that you are brain damaged and don't have the capacity to figure out how to get the soup from the bowl to your mouth with your bad arm. take notes. you will get an idea of the kind of challenges a cva patient faces.

please, rewrite your interventions, outcomes and rationales. rationales are why we do something. when writing the rationales say to yourself, "the reason i am doing this intervention is because. . ."

nursing diagnosis: feeding self-care deficit related to muscular weakness on left side and cognitive deficit secondary to previous stroke (cva) as evidenced by inability to cut food or open packages.

broad goal: maximize independence of the patient when eating.

outcomes:

1) patient will eat food safely.

2) patient will be more independent when eating meals

3) patient will consume more food at meals

nic:

1. prepare food before patient begins eating by cutting it into smaller pieces that will fit into his mouth and opening all containers and placing them at the patient's right side.

- rationale: preparing items for the patient provides support while allowing patient the opportunity to do as much as possible for himself.

- effectiveness:

2. contact the dietician and ask that a mechanical soft diet be sent to the patient.

- rationale: mechanical soft foods allow for less energy expenditure required to cut up on the plate and to chew.

- effectiveness:

3) provide patient with adaptive devices for eating such as plate guards, nonspill cups and plate stabilizers.

- rationale: proper eating equipment increases the patient's independence.

- effectiveness: the addition of a plate guard helped patient be more successful in scooping food onto spoons and forks when eating.

4) make sure utensils and cups are within reach of the patient's right arm and encourage patient to eat using the right arm.

- rationale: this allows independence and increases a sense of self-esteem.

- effectiveness: patient felt comfortable eating, and was able to eat to his meal with more ease.