Prioritizing stroke nursing diagnosis!

[ulcards25]

Hey hopefully you guys can help me in writing my synthesis paper on stroke. Here is a little background on my guy: he is a 79 year old white male with a diagnosis of acute ischemic stroke. He presented with right hand numbness for 24-36 hours, right facial droop, difficulty swallowing, slow gait, and difficulty with his thought processes. He has a history of diabetes type 2 which is not controlled well and carotid stenosis.

I need to identify nursing diagnoses for the population of stroke patients, which I have the following so far (I have to limit to 10) and then identify which are appropriate for my patient.

Finally I have to prioritize the top 3 nursing diagnoses for my patient and give rationale for my prioritizing....which is what I need the most help on.... Thanks to anyone who has advice

Ineffective cerebral tissue perfusion related to decreased cerebral blood flow; unilateral neglect related to perceptual disruption; impaired verbal communication related to cerebral speech center injury; impaired swallowing related to neuromuscular impairment; risk for aspiration; risk for infection; anxiety; compromised family coping related to critically ill family member; and deficient knowledge

I was thinking my top 3 should be:

1) Impaired swallowing related to weakness of affected muscles as evidenced by drooling and difficulty swallowing secondary to stroke; 2) impaired physical mobility related to generalized weakness and paresis as evidenced by flaccid upper extremity, limited range of motion, decreased muscle strength and decreased physical activity; and 3) risk for aspiration related to dysphagia, impaired swallowing, and depressed gag reflex.

But not sure on the prioritizing and rationale for why!

[C. Thinking]

I would list the following most important three..

1. Perfusion, ineffective cerebral

2. Aspiration, risk for

3. Swallowing, impaired

Because it's an actual problem

Because it's airway and is a potential problem...if the patient does actually have trouble with swallowing, then it would become actual and become "swallowing, impaired".

Because 2 and 3 are the difference between actual and potential and are of equal importance in maintaining airway...and then nutrition.

From there, I would address physical safety such as physical mobility, impaired.

[Daytonite, BSN, RN]

What is a synthesis paper? I've never heard that term before.

I care plan following the nursing process because a care plan is the determination of a patients nursing problems and the nursing process is the tool we use to solve problems. It is used in care planning like this:

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)

• A physical assessment of the patient
• Assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
• Data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
• Knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• Your instructors might have given it to you.
• You can purchase it directly from nanda. Nanda-I Nursing Diagnoses: Definitions & Classification
• Many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
• The nanda taxonomy and a medical disease cross reference is in the appendix of both Taber's Cyclopedic Medical Dictionary and Mosby's Medical, Nursing, & Allied Health Dictionary

Planning (write measurable goals/outcomes and nursing interventions)

• Goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  • improve the problem or remedy/cure it
  • stabilize it
  • support its deterioration

• Interventions are of four types

  • Assess/monitor/evaluate/observe (to evaluate the patient's condition) Note: Be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
  • Care/perform/provide/assist (performing actual patient care)
  • Teach/educate/instruct/supervise (educating patient or caregiver)
  • Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

Implementation (initiate the care plan)

Evaluation (determine if goals/outcomes have been met)

Prioritization is most often based on Maslow's Hierarchy of Needs, but also check with your instructors since sometimes they want certain other factors to take precedence.

1. Physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxygenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
   • the need for food and water
   • the need to eliminate and dispose of bodily wastes
   • the need to control body temperature
   • the need to move
   • the need for rest
   • the need for comfort
2. Safety and security needs (in the following order)
   • safety from physiological threat
   • safety from psychological threat
   • protection
   • continuity
   • stability
   • lack of danger
3. Love and belonging needs
   • affiliation
   • affection
   • intimacy
   • support
   • reassurance
4. Self-esteem needs
   • sense of self-worth
   • self-respect
   • independence
   • dignity
   • privacy
   • self-reliance
5. Self-actualization
   • recognition and realization of potential
   • growth
   • health
   • autonomy

I went through the information you posted about your patient and organized it.

Step 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 - acute stroke patients are at risk for breathing problems. Is this patient on oxygen or having any trouble breathing? I saw he drools, has a facial droop and you are concerned about aspiration. Did you assess his ability to perform his adls (bathing, dressing, mobility, eating. Toileting and grooming) and what kind of help and assistance is needed with those? How is he getting his food? How is he getting to the bathroom? Is he now incontinent? Does he have a foley catheter in place? How does he get in and out of bed, or is he bedridden? I saw the diagnosis of anxiety and unilateral neglect...what are the signs and symptoms that the patient has of these because you don't mention them? What knowledge is the patient lacking? Who in the patient's family is failing to provide supportive care that will support the compromised family coping diagnosis you want to assess here--no evidence supports this. What is going on with the patient's diabetes and is he receiving any kind of treatment for it? Is it influencing his diet? Do you think his stroke is a complication of the diabetes?

• acute ischemic stroke
• history of type ii diabetes not well controlled
• carotid stenosis

Step #2 Determination of the patient's problem(s)/nursing diagnosis part 1 - Make a list of the abnormal assessment data - this list is based on what I was able to pick out of everything you posted

• right hand numbness for 24-36 hours
• slow gait
• flaccid upper extremity
• limited range of motion - this needs more specific description
• decreased muscle strength - this needs more specific description
• decreased physical activity - this needs more specific description
• right facial droop
• difficulty swallowing
• drools
• difficulty with his thought processes - what does this mean? is he confused? yelling and screaming? this needs more specific description

Step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - Match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - all actual nursing problems have signs and symptoms. The nursing diagnosis is merely a shorthand label. The problem is more clearly described in the definition of the nursing diagnosis. There are also defining characteristics (signs and symptoms) which should be present as evidence to support the existence of the problem when you are assigning any diagnosis to a patient. This information is contained in the nanda taxonomy which should be used as a reference when assigning diagnosis. Based on the evidence you actually have, these are the diagnoses I know I can assign without hesitation:

• Impaired swallowing r/t neuromuscular impairment aeb right facial droop, difficulty swallowing and drooling - there are probably more symptoms if you were able to watch the patient eat or read an evaluation by a speech therapist.
• Impaired physical mobility r/t neuromuscular impairment aeb slow gait, flaccid upper [left?, right?] extremity, limited range of motion [this needs more specific description], and decreased muscle strength [this needs more specific description]

I took the 10 diagnosis you came up with and prioritized them by Maslow (gave you the Maslow Classification) and added comments about them. I think you need to add self-care deficits. Stroke patients require a lot of rehabilitation and the care plan should reflect that:

1. Ineffective cerebral tissue perfusion related to decreased cerebral blood flow (actual physiological need for oxygen to the brain)
   • The primary reason for hypoxia (the definition of this diagnosis) is what is leading to blood not getting to the cells of the brain. "Decreased cerebral blood flow" is the result. Interrupted blood flow was why.
   • Better: Ineffective tissue perfusion, cerebral r/t interrupted blood flow aeb difficulty swallowing, flaccid upper extremity and difficulty with thought processes
2. Impaired swallowing related to neuromuscular impairment - impaired swallowing related to weakness of affected muscles as evidenced by drooling and difficulty swallowing secondary to stroke (actual physiological need for nutrition)
   • addressed above
3. Impaired physical mobility related to generalized weakness and paresis as evidenced by flaccid upper extremity, limited range of motion, decreased muscle strength and decreased physical activity (actual physiological need for movement)
   • addressed above
4. Impaired verbal communication related to cerebral speech center injury (actual safety need from physiological threat)
   • The problem here is that you have no evidence to support the existence of this problem. read what the defining characteristic are on the webpage referenced above and find some evidence that you overlooked.
5. Unilateral neglect related to perceptual disruption (actual safety need from physiological threat)
   • I'm concerned that you don't know what this diagnosis is
     • impairment in sensory and motor response, mental representation, and spatial attention of the body and the corresponding environment characterized by inattention to one side and over attention to the opposite side. left side neglect is more severe and persistent than right side neglect.
   • The cause of this problem is not "perceptual disruption". "perceptual disruption" is what the problem is. injury to the brain from the cerebrovascular injury is the cause of this problem.
   • Better: unilateral neglect r/t brain injury from cerebrovascular accident aeb [evidence]
6. Anxiety (actual safety need for protection)
   • anxiety
   • its cause is probably due to the situation at hand
   • you have no evidence to support its existence
7. Deficient knowledge (actual safety need for protection)
   • Deficient knowledge (specify)
   • You must specify specific topics you say the patient needs to be provided with knowledge about
   • The related factor is why the patient lacks the information
   • You have no evidence to support the existence of this problem
8. Compromised family coping related to critically ill family member (actual love and belonging need for support)
   • Compromised family coping
   • The first thing I noticed was your related factor "critically ill family member". remember that this is a care plan about the patient--not the problems of the family. The family problems are only important when they affect the patient's responses or the patient's care. The related factor here is probably more importantly the situational crisis the stroke has put everyone in, but read the list of related factors on the webpage I posted above since you provided no other information.
   • Better: compromised family coping r/t situational crisis aeb [evidence; ex: wife not allowing nursing staff to turn patient every two hours as ordered stating "it's disturbing his rest."]
9. Risk for aspiration - risk for aspiration related to dysphagia, impaired swallowing, and depressed gag reflex (anticipated physiological need for nutrition)
   • Risk for aspiration
   • This is a problem that doesn't even exist yet so it carries very little priority

1. Risk for infection (anticipated physiological need for control of body temperature)
   • Risk for infection
   • Just as you had a reason for aspiration occurring above, you need to have a reason for an infection occurring as well.