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This Concept Map, created with IHMC CmapTools, has information related to: Untitled 3, is related to ???? is related to, Key Problem #__1___ Abcess to PEG site ND: Infection DATA: -previous absess around PEG site present in April 2011 (resolved). -upon assessment, small amount of bloody drainage and small amount of green discharge was present on drain sponges. -vitals upon assessment: temp: 36.4C(97.5F), Pulse 79, Resp. 18, O2 100% on room air -no labs/culture done at this time Outcomes: -S.S. will be free of infection within one week of finishing Keflex -S.S. will remain free of infection from around her PEG tube site Interventions: -Keflex 250mg four times a day for 10 days via PEG tube -Skin assessment every shift and as needed, recording peg tube characteristics and drainage. Health Care Need: Medical Diagnosis: Abdominal Abcess Key Assessments: Pain Abdominal Distension Bowel Sounds I & O Wound & Drainage Skin, Key Problem #__3___ Incontinence of bowel and bladder ND: Urinary Incontinence, Total; Bowel Incontinence, Risk for Impaired Skin Integrity DATA: -S.S is totally incontinent of bowel and bladder due to cerebral palsy. -She currently wears incontinent briefs Outcomes -S.S.'s breif will be checked for incontinence every 2 hours -S.S. skin will remain free of breakdown due to urinary and fecal incontinence Interventions: -Keep skin clean and dry in the folds and creases -Change diaper frequently as needed -Observe and report for signs and symptoms of skin irritation -Apply Desitin Cream prn diaper rash is related to Key Problem #__2___ Immobility ND: Mobility Impaired, Wheelchair DATA: -quadriparetic spastic cerebral palsy -Scoliosis -X-Ray done on 8/11 showed mild to diffuse osteopenia, right hip dislocation with poor acetabular developmenent (dislocation now resolved) Outcomes: -Reduce spasticity with the use of the baclofen pump. -Prevent further complications of osteopenia Interventions: -Manual wheelchair, TSLO brace in the daytime for scoliosis -Diazapam 2mg TID spasticity -Botox injections approximately every 4 months to upper and lower extremities for spasticity -Baclofen pump for spasticity -Passive ROM to upper and lower extremities every 2 hours. Regular movement of the joints through the full range of motion via passive exercise conducted by another person can prevent contractures from occuring (Falvo, 2009)., Key Problem #__3___ Incontinence of bowel and bladder ND: Urinary Incontinence, Total; Bowel Incontinence, Risk for Impaired Skin Integrity DATA: -S.S is totally incontinent of bowel and bladder due to cerebral palsy. -She currently wears incontinent briefs Outcomes -S.S.'s breif will be checked for incontinence every 2 hours -S.S. skin will remain free of breakdown due to urinary and fecal incontinence Interventions: -Keep skin clean and dry in the folds and creases -Change diaper frequently as needed -Observe and report for signs and symptoms of skin irritation -Apply Desitin Cream prn diaper rash ???? Health Care Need: Medical Diagnosis: Abdominal Abcess Key Assessments: Pain Abdominal Distension Bowel Sounds I & O Wound & Drainage Skin, Key Problem #__3___ Incontinence of bowel and bladder ND: Urinary Incontinence, Total; Bowel Incontinence, Risk for Impaired Skin Integrity DATA: -S.S is totally incontinent of bowel and bladder due to cerebral palsy. -She currently wears incontinent briefs Outcomes -S.S.'s breif will be checked for incontinence every 2 hours -S.S. skin will remain free of breakdown due to urinary and fecal incontinence Interventions: -Keep skin clean and dry in the folds and creases -Change diaper frequently as needed -Observe and report for signs and symptoms of skin irritation -Apply Desitin Cream prn diaper rash is related to Key Problem #__4___ Cognitive impairment due to cerebral palsy ND: Growth and Development, altered DATA: -Spastic cerebral palsy -Based on S.S.'s medical shart, she has the cognitive impairment of an infant 6 months old. Outcomes -The overall goal is to help individuals attain and maintain an optimal level of health and function throughout the lifespan within the range of their capacity(Falvo, 2009). Interventions: -Provide for S.S's physical care needs -S.S. goes to special education Monday -Friday from 8am-1pm in a classroom setting in order to promote cognitive development., Key Problem #__2___ Immobility ND: Mobility Impaired, Wheelchair DATA: -quadriparetic spastic cerebral palsy -Scoliosis -X-Ray done on 8/11 showed mild to diffuse osteopenia, right hip dislocation with poor acetabular developmenent (dislocation now resolved) Outcomes: -Reduce spasticity with the use of the baclofen pump. -Prevent further complications of osteopenia Interventions: -Manual wheelchair, TSLO brace in the daytime for scoliosis -Diazapam 2mg TID spasticity -Botox injections approximately every 4 months to upper and lower extremities for spasticity -Baclofen pump for spasticity -Passive ROM to upper and lower extremities every 2 hours. Regular movement of the joints through the full range of motion via passive exercise conducted by another person can prevent contractures from occuring (Falvo, 2009). ???? is related to, Health Care Need: Medical Diagnosis: Abdominal Abcess Key Assessments: Pain Abdominal Distension Bowel Sounds I & O Wound & Drainage Skin ???? ????, Key Problem #__2___ Immobility ND: Mobility Impaired, Wheelchair DATA: -quadriparetic spastic cerebral palsy -Scoliosis -X-Ray done on 8/11 showed mild to diffuse osteopenia, right hip dislocation with poor acetabular developmenent (dislocation now resolved) Outcomes: -Reduce spasticity with the use of the baclofen pump. -Prevent further complications of osteopenia Interventions: -Manual wheelchair, TSLO brace in the daytime for scoliosis -Diazapam 2mg TID spasticity -Botox injections approximately every 4 months to upper and lower extremities for spasticity -Baclofen pump for spasticity -Passive ROM to upper and lower extremities every 2 hours. Regular movement of the joints through the full range of motion via passive exercise conducted by another person can prevent contractures from occuring (Falvo, 2009). ???? ????, Health Care Need: Medical Diagnosis: Abdominal Abcess Key Assessments: Pain Abdominal Distension Bowel Sounds I & O Wound & Drainage Skin Patient Information Patients Initials: S.S Gender:Female Age: 8 years old Weight: 20.5 kg History: congenital cytomegalovirus, encephalopathy, microcephaly, quadriparetic cerebral palsy, developmental delay, seizures, visual impairment, GERD, PEG tube placement, fractured left clavicle, failure to thrive, botox injections, baclofen pump placement, scoliosis, unable to walk Pregnancy was noted to have intrauterine growth retardation in the first 6 months and was a stressful pregnancy due to an abusive father. S.S was being raised by a foster family before they moved her to St. Mary's home for disabled children for better nursing care. Her foster family are still very involved in her life and active in her treatment plan., Health Care Need: Medical Diagnosis: Abdominal Abcess Key Assessments: Pain Abdominal Distension Bowel Sounds I & O Wound & Drainage Skin ?? Key Problem #__2___ Immobility ND: Mobility Impaired, Wheelchair DATA: -quadriparetic spastic cerebral palsy -Scoliosis -X-Ray done on 8/11 showed mild to diffuse osteopenia, right hip dislocation with poor acetabular developmenent (dislocation now resolved) Outcomes: -Reduce spasticity with the use of the baclofen pump. -Prevent further complications of osteopenia Interventions: -Manual wheelchair, TSLO brace in the daytime for scoliosis -Diazapam 2mg TID spasticity -Botox injections approximately every 4 months to upper and lower extremities for spasticity -Baclofen pump for spasticity -Passive ROM to upper and lower extremities every 2 hours. Regular movement of the joints through the full range of motion via passive exercise conducted by another person can prevent contractures from occuring (Falvo, 2009).