THE CARE PLAN and NURSING DIAGNOSIS
             - The New Nurse
DEARNURSES.ORG
The Care Plan and Nursing Diagnosis

Preventing Post-op Pneumonia,
Preventing DVT (Deep Vein
Thrombosis)

Care Planning and Nursing Diagnosis.
The Stroke Patient
NURSING DIAGNOSES – THE CARE PLAN
( A WALK THROUGH )

Nursing diagnoses
and Care Planning are extremely  important
in the daily care of every patient who is admitted to the hospital.
When a patient is admitted to the hospital or other Healthcare
facility, a
history is taken from the patient or other responsible
party.

Whether a patient is admitted to the
surgical floor, ICU or ER, the
nurse does an
assessment and documents findings. Vital signs
are also taken and recorded.
The doctor also questions and
examines the patient and decides on a diagnosis based on
patient
history, physical and signs and symptoms.

The Care plan for each patient is a reflection of the information
provided about the history and
doctor’s diagnosis.






















Nursing Kardex – is used by nurses  to provide information
regarding
patient problems and the plan of care.

Here are some examples(only) of what might be found on the Care
Plan:

1)        
The Surgical patient-
Anxiety – related to surgery and family dynamics
Pain - potential for pain related to surgery
Dehydration- related to fluid/
blood loss related to surgery
Paralytic ileus – related  to anesthesia and surgical intervention

2)        The Stroke patient
Altered LOC ( level of consciousness)- related to stroke
Impaired mobility – related to prolonged bedrest
Seizures – related to brain injury
Fall prevention – related to impaired mobility
Related Topics and video:
Have you addressed Maslow's
Hierarchy of Needs in the clinical
setting? For more information click
on the video below:
Sessions for Nurses 39 on Youtube
Copyright DEAR NURSES. All rights reserved.
REHABILITATION
Following a stroke, a patient may
require PT/OT (
physical therapy,
occupational therapy). This is usually
ordered by the doctor.
A
stroke patient may require ICP
monitoring.
On admission to the hospital, a patient may be
anxious because of
family dynamics and
hospital admission.
Helpful Hint:
Anxiety should be included in the Plan of Care
CARE PLANNING -
NURSING DIAGNOSIS
An essential part of patient
admission to the hospital.
CRANIAL NERVE ASSESSMENT
OF THE STROKE PATIENT.

Following a stroke, the cranial
nerves 9 (Glossopharyngeal) and
10 (vagus) may be affected. A
patient may experience  
difficulty
with swallowing or gagging. Dietary
changes may become necessary.
These 2
cranial nerves are usually
assessed together.
THIS IS A SAMPLE OF
WHAT A CARE PLAN
MAY LOOK LIKE
HYPOTHERMIA
The Surgical Patient may be
at risk for hypothermia.

Hypothermia increases the
bodies need for
oxygen and
could possibly lead to a
cardiac event.

The surgical patient is also at
risk for
dehydration
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pics to enlarge
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