Nursing Care Plan for CVA

[Daytonite, BSN, RN]

aphasia is the inability to speak.

aphagia is a problem with swallowing. this patient does not have a swallowing problem, so your diagnoses of impaired swallowing and risk for aspiration need to be removed.

in priority order, based on what was posted, i would diagnose the following:

• total incontinence r/t neurological impairment secondary to stroke aeb (incontinence)
  
• impaired physical mobility r/t neurological impairment secondary to stroke aeb right-sided weakness
  
• impaired verbal communication r/t neurological impairment secondary to stroke aeb aphasia
  
• self care-deficits r/t neurological impairment secondary to stroke aeb (?)
  
• caregiver role strain r/t inexperience and knowledge of caregiver aeb statement by wife "you don't need to worry about a thing, honey. i will take complete care of you and do everything for you. all you have to do is stay in bed and take it easy.
  

r/t's are the underlying cause of the problem; aeb's are always the symptoms that prove the existence of the problem.

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impaired swallowing rt aphasia secondary to cva

aphasia is not difficulty swallowing.

impaired verbal communication rt aphasia secondary to cva aeb inability to communicate

aphasia is not the etiology, or underlying cause, of the

impaired verbal communication

(definition:

decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.

page 178,

nanda international nursing diagnoses: definitions and classifications 2009-2011

.) anyway, it is a medical diagnosis and should not be used in a nursing diagnostic statement. the cva is the cause of the aphasia, but must be stated in a more general way, such as neurological impairment or as alteration in central nervous system.

impaired physical mobility rt right sided weakness secondary to cva aeb poor balance and weakness

right-sided weakness is a

symptom

of the

impaired physical mobility

and not the underlying cause of it. again, the cva is the cause of it, but must be stated in a general way.

self care deficit rt acute disease process secondary to cva aeb right sided weakness aphasia and incontinence

self care deficit is the inability to perform adls. what acute disease process is going on to cause self-care deficits? the r/t factor is neuromuscular impairment secondary to the cva or possibly, in this case, the patient's inability to perceive a body part. insofar as the symptoms are concerned, right sided weakness, aphasia and incontinence are not self-care deficits. bathing, dressing, movement, eating, toileting, dressing and grooming fall into that category.

risk for aspiration rt right sided weakness secondary to cva

not applicable since aphasia is not a swallowing problem.

risk for impaired skin integrity rt incontinence and right sided weakness

this is a bit of a stretch, but ok.

knowledge deficit of caregiver of current dx and prognosis aeb ???

you can't diagnose the wife. the careplan is about the patient, not the wife. the focus has to be on the patient and what will happen to him, not his wife.

risk for imbalanced nutrition: less than body requirements

have no idea how you concluded this was a problem.

risk for injury rt right sided weakness

i wouldn't diagnosis this. interventions for this can be included with

impaired physical mobility

.