HELP! having trouble

athena55, BSN, RN · Jan 31, 2006

Dear Blondangl:

Geez, it has been a while since I last wrote a nursing care plan, but I have a great website you might want to check out: www.stroke.org

Why is your patient having trouble eating? Lack of adequate dentation? Dysphagia R/T his Hx of TIA or CVA? The risk would be immediate or actual, I would think. Does the hospital or health care facility (where your patient is located) have a stroke protocal in place? What kind of diagnostic exams has your patient endured or completed? What were the results?

My biggest question to you, though is: Why have you not had any instructors until this, your last week in school? Are you in a distance program of some type?

I wish I could have been of better help to you, but like I stated above, it has been about one hundred years since I was last in nursing school (graduated from nursing diploma program in 1975) - smile!

Rio, ASN, RN · Jan 31, 2006

As I read your assignment it reads as though you need to prioritize your care plan. For me, IMHO, I like the good old ABC's. Airway, breathing , circulation, disability (neuro). First, he has an airway, can he maintain it ? Breathing, big potential problem, look it up and cross reference resources. Circulation, hey something here, why are those extremities cold ? color ? Disabiltiy, there is a lot to work with here: actual, potential and collaborative.

The H/A ? 3 days ?

The scenario reads as a new presentation , such as in the emergency department. As in: patient presents (as you've written above) with complaint of the severe H/A for 3 days and onset of neuro deficits. So much not a R/O as a; is this an epidural bleed?

Your scenario is also inconsistent. You write it is a R/O CVA and then further down you write, "Esp with CVA being rulled out."

Good Luck

blondeangl · Jan 31, 2006

My instructor said R/O is rule out. I should've known is was risk or something. DARN! They apparentkly didn't have enough instructors to teach this class. our main instructor is great but she works full time administrative and only comes in certain times and dates. Hard class with this going on. We've had to go home like 4 times and this is a 5 week program! Good lordy! i still appreciate any help!!!!!!!!!! Finess

KatieBell · Jan 31, 2006

R/O usually means Rule out not risk of. Meaning they admitted to rule it out, not that it is already ruled out.

Rio, ASN, RN · Jan 31, 2006

blondeangl,

1. R/O is "rule out", BUT somewhere it could mean "risk of." That's why abbreviations are best avoided.

2. Please clarify the following conflicting statements in your scenario:

"we are suposed to R/O CVA" versus "Esp with CVA being rulled out"

Daytonite, BSN, RN · Feb 1, 2006

One of your first steps in developing a care plan is to look at the pathophysiology of the patient's medical problem and organize all the information you have about him. Although this patient's admitting diagnosis is R/O Stroke, it is most likely that he has indeed had one. This information can usually be found in the doctor's progress notes if you need to actually see the words "has had a stroke" written. However, from the way you describe the patient--he's had a stroke and been left with a left sided weakness. Next, think about what the doctor is going to order to evaluate whether or not this patient has had a stroke. What has he already ordered? What can you suggest that he hasn't already ordered? In the very early stages stroke patients are at risk for choking, depressed respirations leading to respiratory arrest, hypertension and arrhythmias. That nausea this patient is having may very well be related to whatever is going on in his head. It is possible that he has some vertigo that is causing this and that he is unable to articulate to you because his speech center may be compromised from the stroke. A headache can be a symptom of an intracranial bleed or swelling of the brain. It needs to be investigated.

A patient who is admitted for a stroke is usually kept NPO to avoid the possibility of aspiration, started on IV fluids to keep him/her hydrated, usually given oxygen and watched for temperature elevation. The most common causes of stroke are a thrombosis, embolis or hemorrhage and the doctors are going to want to diagnosis this ASAP since the immediate treatment of a thrombolytic stroke is to administer a clot buster. A CT of the head will be done to look for intracranial bleeding, a lumbar puncture to also evaluate for the presence of blood in the CS fluid that would indicate intracranial bleeding. Cardiac arrhythmias, particularly atrial fibrillation, can also lead to thrombosis formation. Complications of a stroke include hypertension or hypotension, seizures, and cerebral edema which could result in respiratory depression. Other complications that can occur are Inappropriate ADH Syndrome, pneumonia, UTI and pulmonary embolism. Treatment for a stroke by the doctor is going to include things starting oxygen, maintaining IV access, EKG monitoring, ordering labs such as a CBC, lytes, PT and PTT.

Organize your patients symptoms:

Is alert and oriented (?) and answers all questions appropriately. Asking why he can't move his left arm and leg
Severe, sharp headache in the occipital area (7/10)
Has unilateral weakness in the left arm and leg, right facial droop, difficulty speaking
Cold extremities
Nausea

The unilateral weakness and facial droop and difficulty speaking are typical in stroke patients. So, your plan of care must address these deficits.

The nausea and headache need to be investigated by the doctor. Is this patient receiving something for his nausea? Has the doctor been notified of the nausea? Is the patient receiving something to relieve his headache?

When a stroke patient is constantly asking why he can't move his left arm and leg you have to think that they are not able to process their thoughts very well since they are continually asking this. So, I think it's very likely that this patient is not really that oriented. Neuro checks should be done. His physical safety needs to be assessed and he needs protection from potential injury to himself.

Vital signs need watching, particularly temperature and blood pressure.

These are just a few things. Perhaps there are more you can come up with after reading up on strokes.

This patient's actual risks are complications of immobility, particularly in the affected side (left), fluid and/or electrolyte disturbances due to nausea and being NPO, safety due to left sided weakness and possibly cognitive disturbances.

His possible risks would be extension of the stroke, seizure, aspiration, pneumonia, loss of range of motion in affected extremities

With regard to wellness, this patient will need physical and occupational therapy as well as speech therapy (to evaluate swallowing and ability to handle oral food and fluids) in order to return to maximum functioning. Family or caregivers will need instruction on the lifestyle changes that are going to have to be made in the patient's life.

These are just the things I can think of off the top of my head. I will leave it to you to put together the nursing diagnoses and interventions.

All of this information should be in your nursing textbooks. In developing a nursing care plan you need to follow the nursing process. Assess the patient and collect data, develop a plan, implement it, and don't forget to include evaluate of the effectiveness of the nursing interventions you develop.