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This Concept Map, created with IHMC CmapTools, has information related to: Peds 6, II. Pathophysiology of Cerebral Palsy 1. Cerebral palsy is caused when the premature brain in the baby is abused either before birth, during the birth process or in the hospital period. 2. When the higher brain centers are abused it leads to cerebral palsy, abuse to the cerebral cortex/ corticospinal tracts cause spastic cerebral palsy. 3. Abuse to the cerebral cortex leads to contractions of the muscles and if the basal ganglia are abused, posture of a person and the automatic movements of the body are affected (Lemone & Burke, 2008) leads to III. Focused Assessment 1. VS: pulse: 85 Resp: 20 BP: 132/86 Temp: 97.0 ax SaO2 96% Pain 0 2. Assessed strength in the arms and legs. Good strength in both arms and legs. Able to walk with assistance. 3.Active Range of Motion in all limbs 4. Incontinence X2. Continence not obtained., V. Expected Outcomes 1. The patient will maintain skin integrity aeb no signs of redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will maintain absences of pain in the extremities aeb making no facial signs of pain or pulling away due to sensitivity by 1300 on 6/27/09. 3. The patient will ingest foods adequate to promote skin integrity aeb nutritional tube feedings and the patient not being deficient in any nutrients by 1300 on 7/6/09. Interventions & Rationals VI. Interventions 1. The nurse will assess for risk factors that may lead to skin breakdown by 1000 on 6/25/09. Early recognition of risk factors helps prevent skin breakdown from occuring. 2. The nurse will monitor skin surfaces for redness or lesions, especially if the client's activity is greatly reduced q2h starting at 0600 on 6/25/09. Systematic inspection can identify impending problems early. 3. The nurse will monitor the client's skin care practices, noting type of soap or other cleansing agents used, and temperature of water every night during bath time starting on 6/25/09. Individualize plan according to the client's skin condition, needs, and preferences. 4. The nurse will implement a written prevention plan by 1300 on 6/25/09. A written plan ensures consistency in care and documentation. 5. The nurse will assess the client's nutritional status by 1300 on 6/25/09 and again by 1300 on 7/6/09. The National Pressure Ulcer Advisory Panel endorses the application of reasonable nutritional assessment and treatment for clients at risk for and/or with pressure ulcers. (Lemone & Burke 2009), I.Patients Info & Medical Diagnosis IR, age 9 year old arabic ethnicity Medical Diagnosis: 1. Cerebral Palsy 2. Chromosomal syndrome 3. S/P VSD Repair 4. Heart Valve Replacement 5. G-Tube 6. Developmentally Delayed 7. Premature 8. S/P Bilat 9. Orchiectomy affects II. Pathophysiology of Cerebral Palsy 1. Cerebral palsy is caused when the premature brain in the baby is abused either before birth, during the birth process or in the hospital period. 2. When the higher brain centers are abused it leads to cerebral palsy, abuse to the cerebral cortex/ corticospinal tracts cause spastic cerebral palsy. 3. Abuse to the cerebral cortex leads to contractions of the muscles and if the basal ganglia are abused, posture of a person and the automatic movements of the body are affected (Lemone & Burke, 2008), IV. Priority Nursing Diagnosis Risk for Impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers. Define: At risk for skin being adversely altered. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will maintain skin integrity aeb no signs of redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will maintain absences of pain in the extremities aeb making no facial signs of pain or pulling away due to sensitivity by 1300 on 6/27/09. 3. The patient will ingest foods adequate to promote skin integrity aeb nutritional tube feedings and the patient not being deficient in any nutrients by 1300 on 7/6/09., V. Expected Outcomes 1. The patient will maintain skin integrity aeb no signs of redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will maintain absences of pain in the extremities aeb making no facial signs of pain or pulling away due to sensitivity by 1300 on 6/27/09. 3. The patient will ingest foods adequate to promote skin integrity aeb nutritional tube feedings and the patient not being deficient in any nutrients by 1300 on 7/6/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient maintained skin integrity aeb no signs of redness, inflammation, or break in skin integrity by 1300 on 6/27/09.Goal Met 2. The patient maintained absences of pain in the extremities aeb making no facial signs of pain or pulling away due to sensitivity by 1300 on 6/27/09. Goal Met 3. The patient ingested foods adequate to promote skin integrity aeb nutritional tube feeding through g-tube and not being deficient in any nutrients by 1300 on 7/6/09. Goal Met, III. Focused Assessment 1. VS: pulse: 85 Resp: 20 BP: 132/86 Temp: 97.0 ax SaO2 96% Pain 0 2. Assessed strength in the arms and legs. Good strength in both arms and legs. Able to walk with assistance. 3.Active Range of Motion in all limbs 4. Incontinence X2. Continence not obtained. Generate Nursing Diagnosis IV. Priority Nursing Diagnosis Risk for Impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers. Define: At risk for skin being adversely altered. (Wilkenson & Ahern 2009), IV. Secondary Nursing Diagnosis 2. Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. 3. Total Urinary Incontinence r/t neurological dysfunction secondary to cerebral palsy. 3. Bowel Incontinence r/t neurologiacal dysfunction secondary to cerebral palsy. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Risk for Impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers. Define: At risk for skin being adversely altered. (Wilkenson & Ahern 2009), III. Focused Assessment 1. VS: pulse: 85 Resp: 20 BP: 132/86 Temp: 97.0 ax SaO2 96% Pain 0 2. Assessed strength in the arms and legs. Good strength in both arms and legs. Able to walk with assistance. 3.Active Range of Motion in all limbs 4. Incontinence X2. Continence not obtained. Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis 2. Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. 3. Total Urinary Incontinence r/t neurological dysfunction secondary to cerebral palsy. 3. Bowel Incontinence r/t neurologiacal dysfunction secondary to cerebral palsy. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis IR, age 9 year old arabic ethnicity Medical Diagnosis: 1. Cerebral Palsy 2. Chromosomal syndrome 3. S/P VSD Repair 4. Heart Valve Replacement 5. G-Tube 6. Developmentally Delayed 7. Premature 8. S/P Bilat 9. Orchiectomy assess III. Focused Assessment 1. VS: pulse: 85 Resp: 20 BP: 132/86 Temp: 97.0 ax SaO2 96% Pain 0 2. Assessed strength in the arms and legs. Good strength in both arms and legs. Able to walk with assistance. 3.Active Range of Motion in all limbs 4. Incontinence X2. Continence not obtained.