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This Concept Map, created with IHMC CmapTools, has information related to: Peds 5, V. Expected Outcomes 1. The patient will demonstrate intact skin in the perianal/ perineal area aeb no redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will 3. Evaluation VII. Evaluation of expected Outcomes 1. 2. 3., 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 is 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., 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. Risk for impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers. Prioritized to IV. Priority Nursing Diagnosis Bowel Incontinence r/t neurological dysfunction secondary to cerebral palsy. Define: Change in normal bowel elimination habits characterized by involuntary passage of stool. (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., 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 Bowel Incontinence r/t neurological dysfunction secondary to cerebral palsy. Define: Change in normal bowel elimination habits characterized by involuntary passage of stool. (Wilkenson & Ahern 2009), IV. Priority Nursing Diagnosis Bowel Incontinence r/t neurological dysfunction secondary to cerebral palsy. Define: Change in normal bowel elimination habits characterized by involuntary passage of stool. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will demonstrate intact skin in the perianal/ perineal area aeb no redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will 3., 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. Risk for impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers., 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 is affected (Lemone & Burke, 2008), V. Expected Outcomes 1. The patient will demonstrate intact skin in the perianal/ perineal area aeb no redness, inflammation, or break in skin integrity by 1300 on 6/27/09. 2. The patient will 3. Interventions & Rationals VI. Interventions 1. 2. 3. 4. 5. (Lemone & Burke 2009)