Published May 17, 2010
Jess Oster
1 Post
Hiya. am doing my first major careplan for my degree, 2nd year in, in New Zealand.
My care plan is based upon a lady who has a Hx of CVA, TIA, HTN etc. She suffered another TIA recently and i am doing my careplan based upon her latest hospitalisation.
She only suffers mild weakness on her Left side, her obs are all withen normal range, GCS 15/15. I have to come up with 4 physical diagnoses and one psychosocial. I have come up with so far: Left sided neglect due to impaired perception of body secondary to neurological deficit; Potential for falls risk and injury due to impaired motor and sensory functions secondary to CVA; and I have my psych social.
Desperatly need help with some more physical ones, am struggling as i feel i have chosen a hard one being that i need to concentrate on her TIA not her prvious CVA.
Any ideas, all welcome!!
Cheers Jess
notmanydaysoff
199 Posts
one my trusty nrsg texts (Nurse's Pocket Guide) suggests the following for TIA:
tissue perfusion, ineffective cerebral
anxiety/fear R/T chg in health status, apprehension
RF ineffective denial R/T chg in health status, lifestyle
this little book is a gem. it describes the Dx, interventions and rationales for these nrsg Dx (which incidentally, is not my favorite thing....)
"Left sided neglect due to impaired perception of body secondary to neurological deficit"
We are supposed to start with a NANDA Dx. are you? I would reword this to say "Impaired mobility R/T TIA, AEB L-sided weakness" or something to that effect. The first statement is supposed to state the pt's (our) problem. In reading yours, it looks like the pt has chosen to ignore her L side due to a perceptual problem.
Mind you, I've just started doing these care plans in the past couple weeks so am hardly a pro...yet!