Looking for some feedback on careplan

do you read any of my posts on care plans? i get that you don't have to write out complete 3-part nursing diagnostic statements, but that doesn't relieve you of the responsibility of following the steps of the nursing process to write your care plan. you still have to know what the patient's symptoms are (the aeb stuff) because your outcomes and interventions are based upon them!

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

this is a list of her symptoms that i came up with as part of step #2 of the nursing process. when you look at them listed this way do you think maybe you missed a few important problems that this patient has?

• very sob as me and the cna were getting her up and dresses
  
• dysphagia
  
• wears briefs (does this mean she is incontinent at times?)
  
• scratches all over her arms from her scratching herself
  
• paralyzed on her right side
  
• wc bound
  
• requires assistance with all of her adl's
  
• not oriented to place or time
  
• pretty confused
  
• the speech therapist asked her what things she likes to eat and she said "arms,"
  
• smoker - altered health maint

first off, there's a whole bunch of symptoms for the nursing diagnosis of anxiety. check the list of defining characteristics for anxiety on this webpage: [color=#3366ff]anxiety. any outcomes and nursing interventions you develop for this anxiety should address her individual symptoms of it. her sob could be a symptom of the anxiety as well as her nervousness.

impaired swallowing [r/t neuromuscular impairment secondary to stroke aeb dysphagia] - focus of outcomes and nursing interventions should be on treating the dysphagia

impaired skin integrity [r/t abrasion forces aeb scratches all over arms] - focus of outcomes and nursing interventions should be on treating the scratches on her arms

impaired physical mobility [r/t neuromuscular impairment secondary to stroke aeb right sided paralysis and wc bound]

bathing/hygiene self-care deficit

dressing/grooming self-care deficit

feeding self-care deficit

toileting self-care deficit

chronic confusion [r/t dementia and cerebrovascular attack aeb disorientation to place and time and altered cognitive impairment]