PLEASE HELP ME make an NCP on a CVA bleed patient

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i was assigned in ER.. and i had this patient, she was diagnosed with CVA bleed.. she's unconscious, with IVF, NGT, O2.. my prob is, since i only encounter her once, i dont know what are the proper actual and potential nursing diagnosis for her... huhuhuhuhu.. heeeeeeeeeeeeeeeeelp:cry:

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Ineffective tissue perfusion (cerebral) r/t bleeding, disturbed sensory perception r/t medically imposed restrictions, Anxiety r/r illness (or the unknown)? It really would depend on what interventions you have provided to this patient? These are just a few, there are a ton of dx's that you can use for this client.:wink2:

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Specializes in Nephrology, Cardiology, ER, ICU.

If you can show us what you have, we will be glad to try to add to it.

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Specializes in ICU/Critical Care.

I'm not against helping you with your careplan. Please show us what you have so far and we can provide assistance. We will not do your careplan for you.

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Specializes in ED, ICU, Heme/Onc.
i was assigned in ER.. and i had this patient, she was diagnosed with CVA bleed.. she's unconscious, with IVF, NGT, O2.. my prob is, since i only encounter her once, i dont know what are the proper actual and potential nursing diagnosis for her... huhuhuhuhu.. heeeeeeeeeeeeeeeeelp:cry:

Sounds like a patient I cared for this week. Frankly, I didn't have time for any nursing diagnosises. I was worried that he was going to herniate in front of me and despite everything, he did. In the ER, it's all about A,B,C's (airway, breathing and circulation) - write your careplan around that if it is ER specific. We don't have the patient long enough to address long term concerns.

Hope this helps as a starting point.

Blee

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Specializes in med/surg, telemetry, IV therapy, mgmt.

there is all kinds of information on how to write a care plan on the student forums of allnurses. you can see help and answers to other care plan questions and diagnosing on this thread:

you need to follow the nursing process. just as a doctor does an examination and testing before deciding on a patient's medical diagnosis, we must do similar before deciding on nursing diagnoses. nursing diagnoses are about patient's nursing problems. they focus on how patients respond to their medical conditions and their environment. each nursing diagnosis (there are officially 188 of them) have signs and symptoms just as medical diagnoses have signs and symptoms. so to determine a nursing diagnosis [example: some of the signs and symptoms of impaired physical mobility are jerky movements, limited rom in walking or moving of an arm or leg, tremors upon movement, slowed movement or uncoordinated movements] you must find those symptoms by starting off with doing an assessment of the patient. you would have done that when you did a physical exam on the patient. you would have also read what the er doctor and any emergency transportation personnel might have documented that they observed about the patient. anything abnormal is considered a sign or symptom--therefore, evidence of potential nursing problems which you can translate into nursing diagnoses. unfortunately, ivf, ngt, and o2 are medical treatments for this patients symptoms. what are the symptoms that the doctors are treating? that gets you closer to nursing diagnoses.

here are other student threads on care plans/nursing diagnoses pertaining specifically to stroke patients:

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i am really really confused right now... first, it's my first time to encounter patient with CVA.. she has history of hypertension, and i think that's one of the risk factors.. worst, i only had 2 hours monitoring her because, she died.. the worst part is that, my C.I insist that i should make an NCP out that patient.. when i first received the patient, she's unconscious, with IVF, NGT, O2 and she had a fever of 39.9..

i was just confused on what actual and potential nursing diagnosis i will make...

please help me, because if i have a nursing diagnosis, it will be easy for me to make the rest..

thank you very very very much,,,

please do help me...

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Specializes in Med-Surg/Tele, ER.

Yes, you are right. That would be easy.

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you can't think of nsg diagnoses r/t airway, breathing, circulation/perfusion, temp, nutrition, swallowing/aspiration?

think of your priorities here.

you can do this.

leslie

eta: read all those links daytonite provided.

my goodness, there's a wealth of information all within her 1 post.

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Specializes in Cardiac, Acute/Subacute Rehab.

Ummmm...you think hypertension is a risk factor for a CVA??

I am willing, and I'm sure others are willing, to help you tweak any diagnoses you may have come up with. What have YOU come up with?

EDITED TO ADD: My thoughts on care plans...they are busy work, yes. BUT, I think the ultimate goal of doing care plans is to force one to be able to immediately identify goals, outcomes and interventions for any given situation. A nurse getting report isn't going to be able to write a care plan for each patient they are assigned each shift (or ever). A nurse will need to be able to apply the nursing process as part of a daily routine. The End.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i am trying to help un-confuse you.

you say this patient had a "cva bleed". to me, that means a hemorrhagic stroke has occurred. did you look up what occurs during this kind of stoke physiologically?

hemorrhagic stroke.
this is the third most common type of stroke. a rupture occurs in an intracranial artery or vein as a result of hypertension, aneurysm, arteriovenous malformations, trauma, hemorrhagic disorders or a septic embolism. hypertension and ruptured aneurysms are the most common causes. it can occur at any age. as a result there is diminished blood supplied to the tissues fed by the ruptured artery and compression of the brain cells by accumulated blood. when hemorrhage has occurred the blood that has spilled among the brain cells acts as a space-occupying mass that exerts pressure on the brain tissue. at first, ruptured cerebral blood vessels may constrict to limit blood loss which further restricts blood flow to the area of stroke and promotes ischemia. blood cells can also migrate into the spaces where cerebral spinal fluid circulates and cause blockages of this fluid circulation resulting in hydocephalus.

when any type of stroke occurs, there is deprivation of oxygen and nutrients to the affected area of the brain. when blood flow in a blood vessel remains blocked for more than a few minutes, oxygen deprivation leads to infarction of brain tissue. the brain cells cease to function because they can neither store glucose or glycogen for use nor engage in anaerobic metabolism.

you said this patient had a history of hypertension. the above information indicates that hemorrhagic stroke is a result of hypertension. this kind of stroke causes oxygen deprivation in the brain and death of brain tissue, so your first nursing diagnosis would be ineffective tissue perfusion, cerebral r/t hemorrhage and cerebral swelling [that information was provided by you + the hemorrhage causes hydrocephalus] aeb unable to arouse patient to any level of alertness.

you need to put your thoughts and what happened during those two hours in some kind of order. all you keep saying is the following that is helpful:

  • she was unconscious (ineffective tissue perfusion, cerebral r/t hemorrhage and cerebral swelling aeb unable to arouse patient to any level of alertness)
  • she had a fever of 39.9 (nursing diagnosis: hyperthermia r/t cerebral trauma aeb fever of 39.9c. see this website hyperthermia)

but there would be more than that. what was her glasgow coma scale figure if you or someone else did neuro checks on her? what kind of movements did she make, if any? were there any peripheral sensations elicited? what else did you notice about her when you were with her for the two hours? what was her blood pressure? describe her heart rate and her heart sounds. what was the ekg showing? how was her output handled (catheter?)? describe her respirations and her lung sounds. and how much urine output did she have during those two hours? was she incontinent? was there any vomiting? what kind of labwork was done and what were the results? what x-rays/ct was done and what did it show? what people or family were at the bedside and what did they have to say and report? this information is needed in order to make other nursing diagnoses.

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thank you verrrrrrrrrrrrrry much.. actually i was done with my two NCP's before reading your reply.. i followed you're first advice... wooooow, you're sooooooo great, wish our C.I can explain thoroughly as good as you..

thank you very very much.. :yeah::bow:

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