Question

Care Plan /homework please follow NANDA instructions

Maria J., an 86-year-old, has a history of cerebrovascular accident (CVA), 3 years ago. She has right sided weakness and expressive aphasia with minimal dysphagia. Maria J. also has a medical history of atrial fibrillation and hypertension. She lives with her daughter since the stroke. Since admission to an acute care facility 4 days ago, Maria J. has gained some strength, has become more oriented to person and place, and is anxious to start her rehabilitation program.

Below are instructions

The first Nursing process page ONLY. You will include

1) Subjective and objective Assessment data

2) 1 three-part NANDA Nursing diagnosis (please make sure your review the lesson on what a 3 part ND looks like). The Nursing diagnosis should pertain to a Physiologic issue.

Sample Nursing diagnosis you can use are:
Impaired Physical Mobility.
Impaired Verbal Communication.
Disturbed Sensory Perception.
Ineffective Coping.
Self-Care Deficit.
The risk for Impaired Swallowing.
Activity Intolerance.
Please note, Nursing diagnosis above is not a three-part diagnosis. The student is responsible for creating a three-part diagnosis using guidelines taught in week 3.
3) Two goals/outcomes (1 short term and one long term)

4) Six nursing interventions (3 for short term goal and 3 for long term goal)

5) Rationales for each intervention

6) Evaluation.
7) The reference page of your care plan should include all references used. (Please note the in-text citations used on the sample page and include in-text citations on your assignment page. A full reference should be provided on the bibliography/reference page)

Answer 1

1. Self care deficit related to weakness as evidenced by needs depends on the care given to meet the activities of daily living.

Outcome: short term:

* patient recognizes individual weakness or needs

Long term:

* patient demonstrates life style changes to meet self care needs.

Interventions with rationale:

Short term

* assess the patients strength cautiously to accomplish ADL as to find out how far the patient needs the assistance

* guide the patient in accepting the needed amount of dependence as were patient may require help in determining the safe limits of trying to be independent versus asking assistance when needed.

* present the positive reinforcement for the activities she does so as to encourage her to improve her independence

* provide the opportunity and encourage her to know her own strength and weakness in self care

* assist the patient to meet ADL and with assistive devices to help her to be more independent

Long term:

* rendering the supervision of each activity what she does in order to make that skill thorough and becomes independent so as to perform self care needs as it may change over time and needs regular assessment

* boost maximum independence by rehabilitation as it helps to achieve the highest independence.

* encourage to patient to involve in the social functioning so as to positively reinforce her to be more stable

Evaluation

The patient demonstrates to meet the ADL's with little assistance.

2. Activity intolerance related to generalized weakness as evidenced by imposed activity restriction

Outcome:

Short term:

* patient identifies the factors that aggravates activity intolerance

Long term

* patient identifies methods to reduce activity intolerance

Interventions with rationale

Short term

* investigate patients perception of causes of activity intolerance as to identify the temporary and permanent causative factors

* determine the patients routine as the fatigue may limit the patient activity

* encourage the patient nd motivate him to identify his strength in order to identify the relieving factors to alleviate the aggravating factors

Long term

* encourage the patient to actively participate in the rehabilitation in order to improve the social functioning

* provide the supervision for each activity and appreciate the methods used by patient to reduce the activity intolerance

* demonstrate the lifestyle changes according to patients needs to improve his activities

* help him with ambulation needs in order to make him mobile and limit the fatigue to improve his activities.

Evaluation

Patient demonstrates the methods to reduce the aggravating factors

3. Anxiety related to the rehabilitation programme as evidenced by patients verbalization

Outcome

Short term:

* patient verbalise her own anxiety and coping strategies

Long term

* the patient will relate an increase physiological and psychological comfort

Intervention with rationale

Short term

* encourage the patient to verbalise the anxiety and coping strategies in order to know her strength and weakness

* encourage the patients to ask the doubts regarding his concerns in order to know the factors which makes him anxious

* clear all the doubts of patient to reduce his anxiety

Long term

* assess patients complete physiological and psychological comfort

* demonstrate the coping mechanisms to reduce the anxiety

* encourage the patient to explore possible stressor and lifestyle changes she can adopt in order to help her with anxiety in life.

* encourage the patient to seek the assistance even the psychiatrist if possible to start with her anti anxiety drugs

Reference:

* http.registerednurses.com

* nurseslab careplans

* Black M. Joyes text book of medical surgical nursing elsevier publication.