Nursing care plan help!

Esme12, ASN, BSN, RN · Jun 16, 2012

CASE STUDY A 71 year old male was eating breakfast when he had an abrupt onset of visual loss in left eye and weakness in right arm and leg. There is some tingling of the right hand and right corner of mouth. He has difficulty standing and is taken to the emergency room where you are asked to initiate admission. On examining him, you find that his vision has recovered but he has weakness of the right arm involving the triceps, wrist and finger extensors and right leg involving hamstrings (lower leg flexors) and anterior tibial reflex.
He also has Babinski's sign.
Sensory examination reveals decreased sensation in right hand and arm and less sensation on the right side of face and leg. He has difficulty identifying objects placed in his hand by sensation alone. The patient has no difficulty understanding speech but speaks infrequently and does so with paucity of otherwise meaningful words.
General examination reveals left carotid bruit and a normal sinus rhythm.
From looking at the symptoms and doing some reading I found that most of the symptoms are present with a TIA. So these are the nursing diagnoses I have (was only required to have one actual and one potential diagnosis but I have two actual diagnoses to be critiqued):
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I dislike these fake scenario care plans The biggest thing about a care plan is the assessment. The second is knowledge about the disease process. First to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. It is difficult to assess a piece of paper.

Are you sure it is a TIA? Will a TIA give you a positive Babinski? What is a Babinski sign? Is a Babinski an sign of damage?

What do you think?

Esme12, ASN, BSN, RN · Jun 16, 2012

case study a 71 year old male was eating breakfast when he had an abrupt onset of visual loss in left eye and weakness in right arm and leg. there is some tingling of the right hand and right corner of mouth. he has difficulty standing and is taken to the emergency room where you are asked to initiate admission. on examining him, you find that his vision has recovered but he has
weakness of the right arm involving the triceps, wrist and finger extensors and right leg involving hamstrings (lower leg flexors) and anterior tibial reflex.
he also has babinski's sign.
sensory examination reveals decreased sensation in right hand and arm and less sensation on the right side of face and leg. he has difficulty identifying objects placed in his hand by sensation alone. the patient has no difficulty understanding speech but speaks infrequently and does so with paucity of otherwise meaningful words.
general examination reveals left carotid bruit and a normal sinus rhythm.

what would this patient need or potentially need? do the needs cahnge if this is a cva?

disturbed sensory perception r/t reduction in cerebral blood flow aeb decreased sensation on right side of face, right arm, hand and leg, decreased ability to identify objects placed in hand and patient's verbalization of abrupt visual loss in left eye and tingling in right hand and right corner of mouth.
desired outcome: patient will verbalize increased sensation in right hand, arm, leg and right side of face.
impaired verbal communication r/t decreased cerebral blood flow aeb impaired articulation.
desired outcome: patient will be able to form coherent sentences and speak fluently.
risk for trauma r/t decreased sensation in right leg and patient's verbalization of weakness in right leg and difficulty standing.
desired outcome: patient will remain free from injury.

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.

these may help

http://www.pterrywave.com/nursing/care plans/nursing care plans toc.aspx

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans

NikiCharles_01 · Jun 16, 2012

The reason why I gathered that it was a TIA was because of the symptoms and the left carotid bruit but I didn't take the Babinski sign into consideration. I'm seeing that is possible for a TIA to produce a positive Babinski and it's a sign that there is an upper motor neuron lesion present and mostly present in patient's who suffered from a stroke. Cerebral thrombosis can also be what it was since I've read that they are most likely suspected when there is carotid occlusion and that would take the bruit into account making it a stroke and not a TIA. This is some really tricky stuff :uhoh3:

Esme12, ASN, BSN, RN · Jun 16, 2012

Your thought process is good.......Part of doing a care plan is Looking at the patient. Knowing the disease is the other. What is it? What are it's Hallmark signs? How does my patient fit into the differential?

Look up CVA. Look up Babinski's Look up bruit. The one that tips the hat is the Babinski's sign. It is tricky, but if it was easy everyone could be a nurse....

Next....? :hug:

NikiCharles_01 · Jun 18, 2012

My lecturer only wanted neurological nursing diagnoses since the course it's for is management of neurological patients. Do you think these diagnoses will apply?

Esme12, ASN, BSN, RN · Jun 18, 2012

Yes they should....:) I would however include the positive babinskis sign

Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury AEB weakness of the right arm involving the triceps, wrist and finger extensors and right leg involving hamstrings (lower leg flexors), anterior tibial reflex and Babinski's sign.

Esme12, ASN, BSN, RN · Jun 18, 2012

Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae

Disturbed sensory perception related to altered sensory reception, transmission, and/or integration

Impaired verbal communication related to brain damage AEB aphasia

Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility AEB

NikiCharles_01 · Jun 18, 2012

Okay.... Thanks so much for your help :hug: .... This isn't for for another 3 weeks but thanks again for ensuring that I'm on the right track

nurseprnRN, BSN, RN · Jun 18, 2012

Remember that your nursing interventions are for the consequences of your nursing diagnoses. I don't know of any nursing interventions that will reverse a CVA. If your focus is less on the medical dx and plan of care and more on the nursing dx and plan of care, you will come to understand that.

Your pt is weak in one leg-- risk for falls. Your interventions decrease that risk, however you choose to do that, but you can't address it by curing his CVA.

He has tingling at the side of his mouth-- maybe he is at risk for aspiration. What assessments would you do, or have done, to eval his safety for oral intake? You cannot resolve that symptom or make it go away by nursing intervention. What could you do to make it less likely that he will aspirate?

Do you see where this is going?

NikiCharles_01 · Jun 23, 2012

I think I get what you're trying to say. For instance, since he cannot express himself in an appropriate manner verbally my aim should be to help him find other ways or another method of communicating just as effectively rather than saying that my goal would be for him to improve his verbal expression of thoughts and ideas. Am I understanding you correctly?

Katie71275 · Jun 24, 2012

I didn't read everyone's responses but for me, the big issue with CVA is safety! Aspiration, falls, They are at risk for atelectasis b/c they may not be able to move well enough to full expand lungs, etc. Risk for blood clots, again b/c they may not have full range of motion and could be immobile.