Read the following case study, choose a nursing diagnosis and develop a care plan utilizing the steps of the nursing process. Remember to set 2 realistic goals for the client and develop nursing interventions that could help meet these goals, as well as the rationale for the interventions. You may consider a short-term goal and a long-term goal to work toward. Nursing interventions must be specific, and measurable.
Mrs. B an 86 year old female is a resident at the LTC facility. Diagnosis Left Sided CVA (Cerebrovascular Accident-Stroke) six months ago. You are the PN assigned to her for the day shift. The diet ordered for Mrs. B is a minced diet with thickened fluids. She requires partial assistance with her meals but requires constant supervision during mealtime as she is at risk for choking. She is unable to ambulate and refuses to get out of bed to even sit in the chair. She requires partial assistance with her bath. The RN has reported to you that she has a broken area to her coccyx- 1cm x 1 cm x 0.5 cm, during the bath you assess the area and now note a small amount of purulent drainage. No other new findings were noted. Her incontinence system (i.e. Depend, Tena) was wet, but no bowel movement. She had a bowel movement yesterday. Mrs. B was crying during her entire bath, when questioned she refused to elaborate on why she was crying.
Her vital signs at 1000 hours are B/P 140/90, Pulse 78, Respirations 16 and Temperature 36 °C. Oxygen saturation at room air is 90%.
Her intake for breakfast was as follows: 250 mls tea, 100 mls orange juice, 100 mls porridge and scrambled eggs.