The reason I have chosen this nursing framework is that it can help nurses to remember the steps they need to take to care for the patient they are treating. It helps nurses to identify initial problems and develop solutions to overcome these problems. I have also chosen to use NANDA, which stands for, North American Nursing Diagnosis Association. The four types of nursing diagnosis used for NANDA are:
- Problem-Focused Diagnosis: This is also known as ‘actual diagnosis.’ This is focusing on the problems present at the exact time of the nursing diagnosis.
- Risk Diagnosis: This problem does exist at the time of the actual diagnosis but is likely to develop in time.
- Health Promotion Diagnosis: This is where the nurse will motivate the patient to become involved in their care if possible and try to achieve the best possible outcome.
- Syndrome Diagnosis: This is a concern with numerous problems that are likely to present because of a certain situation. (NANDA. 2015)
An ischemic stroke occurs when a blood vessel to the brain becomes blocked, depriving the brain of much-needed oxygen and nutrient-rich blood. It usually happens when fatty material, known as atherosclerosis, builds up in the artery and causes a blockage. Blood cells are then collected here and can cause a blood clot. This causes the brain cells to die. Ischemic strokes account for 80% of all strokes in Ireland (Hickey et al. 2011). The right side of the brain controls the left side of the body. So when a right-sided stroke happens, the left side of the body is affected, such as left-sided weakness or paralysis and sensory impairment.
Dysphasia is a common side-effect of a stroke. It is the medical term used for swallowing difficulties. It can cause problems trying to swallow certain foods or liquids. Common signs are coughing or choking while eating/drinking. The presence of dysphasia can increase pulmonary complications such as aspiration pneumonia. Aspiration is the term used to describe foreign objects such as food or liquids being inhaled into the airways (De Jesus et al. 2019). Orem’s self-care deficit theory describes a self-care deficit as the impaired ability to perform the activities of daily living, such as toileting, dressing, and/or feeding (Hartweg et al. 2016)
Upon admission of the patient, I have done a physical assessment and gathered the patient’s history at his bedside. I noticed he had weakness on his left side and was aphasic which means difficulty with talking. Aphasia is always caused by a brain injury such as a stroke (Charles et al. 2012). I asked the patient to take a small sip of water. I observed signs related to swallowing problems such as coughing, drooling, or choking. The patient began to cough after he took the first sip. To assess the patient’s left-sided weakness I asked him if he could raise or move his left-sided limbs. I also asked the patient to try unbuttoning his shirt with his right hand. The patient could not perform the tasks. I recorded his mobility as a 2 on the mobility scale, meaning the patient would need supervision or require assistance from another person (Maso et al. 2019). I assessed his emotional response to the limitation; although the patient was confused he said he understood that he may need assistance with self-care while admitted. I did a full set of vital signs to determine his baseline.
After assessing the patient’s swallow I documented my diagnosis as Impaired Swallowing. Due to the patient not being able to unbutton his shirt I also made a nursing diagnosis of a Self-Care deficit. The patient’s vital signs were within normal parameters. His Glasgow Coma Scale was 14/15; this was due to initial confusion upon arrival.
My priorities here were to prevent choking and/or aspiration and to help the patient safely perform self-care activities. The patient, his sister, and I spoke about the goals we would like the patient to achieve during his admission. I informed the patient and his sister that I would be making a referral to the speech and language therapist, physiotherapist, and occupational therapist. Both the patient and his sister were happy for me to do this.
To implement the plan of avoiding choking and/or aspiration I made sure the patient had the right amount of rest before each meal as fatigue can add to impaired swallowing. I made sure the patient was alert and awake before attempting to assist with eating. The patient was sat upright at a 90-degree angle; this position allows for easier swallowing and reduces the risk of choking and/or aspiration (Nichol et al. 2019). Oral care was performed both before and after mealtimes. Good oral care can prevent any residue from being left in the mouth afterward which can cause choking and/or aspiration. The speech and language therapist decided with the patient and me that it was best for the patient to be on a minced-moist diet. The food had to be soft, and moist and not have any hard lumps. With the patient’s liquids, the speech and language therapist thought it was best that one scoop of Nutilis Clear be added to any liquids. Nutilis Clear is a thickening powder that is added to food or liquids. The patient was happy with this. I encouraged the patient to take small amounts each time and to do it at a slow pace. I explained the importance of chewing food to avoid choking and also to intake drinks frequently throughout mealtimes to make sure no residue was left in his mouth. The patient was left in an upright position after each meal. An upright position makes sure that the food stays in the stomach until it is ready to be digested; this decreases the risk of aspiration. I made sure to observe for signs of aspiration after each meal. The sound of new crackles or wheezing could indicate food or liquid has been aspirated. I made sure to praise the patient each time as this promotes positivity and encourages the patient (Nurselabs, 2010).
When it came to assisting the patient with his self-care, I allowed the patient to do as much as he could for himself and I allowed sufficient time for this. I assisted when it was necessary. This promotes recovery and independence. Assisting when needed allows the patient to avoid frustration. I placed everything he needed on the right side of his table, such as cutlery and other essential items so that he could use his right hand to pick things up himself and use them as necessary. Encouraging the patient to do as much as possible for himself re-establishes his sense of self-worth and promotes the rehabilitation process. The rehabilitation process helps the patient to relearn skills that are lost when the brain was damaged from the stroke.