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Total Self Care Deficit Level 4 CARE PLAN HELP!!!!

Posted
gallika gallika (New) New

Hello all,

I need help figuring out what subjective data I can use for my NANDA. The patient is 52 yr/o female. Recent CVA, Intracranial Bleeding, hydrocephalus, Tracheostomy, G-Tube for feeding, NPO, non-rsponsive, only blinks once for yes twice for no, Patient can not even squeeze hand, mumble or show any kind of facial expression.

Objective data I am set. Its the subjective data I am struggling with. Thoughts please!!!!

Thank a ton in advance.

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown.

Well, your patient is unresponsive, therefore no patient comments. As you know. You could try reports from the family, close friends, or a spouse. Why do you absolutely need subjective information? Especially in this case. Doesn't seem practical having a patient who is unresponsive. You could try to ask closed ended questions and work out a communication system with the blinking. Only yes/no questions and using her blinking abilities. Maybe, keeping the questions simple and straight forward, you may be able to get some bits of information from her. I imagine communication this way would be frustrating and tiresome for the patient. Have pertinent questions. Maybe take breaks after 5 or so. Or, determine how many she handles before she is unable to communicate (i.e. frustrated or tired).

For example:

Assessing Neuros

Do you know where you are? Y/N

Are you at the hospital? Y/N

Is your name such and such? Y/N

Assessing Pain

Do you have pain right now? Y/N

If yes, is your pain here? Y/N

Here? Here? Here? etc.

Is your pain sharp? Y/N

Is your pain dull? Y/N

You can use this format for assessing each system. I'd be interested to here about how it worked as I haven't had a pt like this before. Gotta get creative sometimes. Maybe you could use pictures. For instance, point at the body and ask, "Do you have pain here, when you are pointing at the chest/abdomen/legs/arms? Tough situation. Good Luck!

Edited by AndrewCraigRN

blinking for yes/no is not "unresponsive."

impaired verbal communication looks like the winnah here. (page 275 in your nanda-i 2012-2014...which of course you have by now, available at your fave online booksellers.:smokin:) "decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols." you already have the defining characteristics, and the related-to. under subjective, all you can put is "unable to speak or use alternative forms of expression reliably." (how sure are you about that yes-no thing?)

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown.

blinking for yes/no is not "unresponsive."

impaired verbal communication looks like the winnah here. (page 275 in your nanda-i 2012-2014...which of course you have by now, available at your fave online booksellers.:smokin:) "decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols." you already have the defining characteristics, and the related-to. under subjective, all you can put is "unable to speak or use alternative forms of expression reliably." (how sure are you about that yes-no thing?)

good point. my mistake. impaired is better. thanks for the correction.

unresponsive implies no ability to communicate. oops, wording thing.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Great advice. The patient sounds locked in......are you sure they are responding to your questions or blinking randomly. Does she track movements with her eyes?