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This Concept Map, created with IHMC CmapTools, has information related to: Peds 2, III. Focused Assessment 1. VS: pulse: 92 Resp: 20 BP: 95/60 Temp: 98.6 SaO2 98% Pain 0 2. Assessed strength in the arms and legs. Weak in legs, rt arm had good strength, left arm weaker. 3.Passive Range of Motion in all limbs by PT 4. Incontinence X3 . 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. 3. Social Isolation r/t cognitive, sensory, and motor impairment secondary to cerebral palsy. 4. Risk for Injury r/t inability to protect self from injury and has no self perservation skills. (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. 3. Social Isolation r/t cognitive, sensory, and motor impairment secondary to cerebral palsy. 4. Risk for Injury r/t inability to protect self from injury and has no self perservation skills. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. Define: At risk for experiencing vascular, cellular, or intracellular dehydration. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis DH, age 10 year old white male Medical Diagnosis: 1. Cerebral Palsy-Quadriplegic 2. Convulsion Disorder 3. Legal Blindness assess III. Focused Assessment 1. VS: pulse: 92 Resp: 20 BP: 95/60 Temp: 98.6 SaO2 98% Pain 0 2. Assessed strength in the arms and legs. Weak in legs, rt arm had good strength, left arm weaker. 3.Passive Range of Motion in all limbs by PT 4. Incontinence X3 . Continence not obtained., V. Expected Outcomes 1. The patient will maintain urine output of at least 30 ml/hour aeb at least 30 ml (1oz) in his diaper by 1300 on 6/19/09. 2. The patient will maintain normal blood pressure, pulse, and body temperature aeb keeping all vs within normal limits by 1300 on 6/19/09. 3. The patient will maintain hydration aeb elastic skin turgor and moist tongue and mucous membranes by 1300 on 6/19/09. Evaluation VII. Evaluation of Expected Outcomes 1. Goal met. The patient maintained a urine output of at least 30 ml an hour by 1300 on 6/19/09. 2. Goal met. The patient maintained normal bp, pulse, and body temperature by 1300 on 6/19/09. 3. Goal met. The patient maintained elastic skin turgor and moist tongue and mucous membranes by 1300 on 6/19/09., III. Focused Assessment 1. VS: pulse: 92 Resp: 20 BP: 95/60 Temp: 98.6 SaO2 98% Pain 0 2. Assessed strength in the arms and legs. Weak in legs, rt arm had good strength, left arm weaker. 3.Passive Range of Motion in all limbs by PT 4. Incontinence X3 . Continence not obtained. Generate Nursing Diagnosis IV. Priority Nursing Diagnosis Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. Define: At risk for experiencing vascular, cellular, or intracellular dehydration. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis DH, age 10 year old white male Medical Diagnosis: 1. Cerebral Palsy-Quadriplegic 2. Convulsion Disorder 3. Legal Blindness 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), 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: 92 Resp: 20 BP: 95/60 Temp: 98.6 SaO2 98% Pain 0 2. Assessed strength in the arms and legs. Weak in legs, rt arm had good strength, left arm weaker. 3.Passive Range of Motion in all limbs by PT 4. Incontinence X3 . Continence not obtained., V. Expected Outcomes 1. The patient will maintain urine output of at least 30 ml/hour aeb at least 30 ml (1oz) in his diaper by 1300 on 6/19/09. 2. The patient will maintain normal blood pressure, pulse, and body temperature aeb keeping all vs within normal limits by 1300 on 6/19/09. 3. The patient will maintain hydration aeb elastic skin turgor and moist tongue and mucous membranes by 1300 on 6/19/09. Interventions & Rationals VI. Interventions 1. The nurse will monitor weight daily for sudden decreases, especially in the presence of decreasing urine output or active fluid loss by 1300 on 6/19/09. Body weight changes reflect changes in body fluid volume. 2. The nurse will monitor for the existence of factors causing deficient fluid volume by 1800 on 6/18/09. Early identification of risk factors and early interventions can decrease the occurrence and severity of complications from deficient fluid volume. 3. The nurse will monitor for inelastic skin turgor, thirst, dry tongue and mucous membranes, longitudinal tongue and furrow, dry skin, sunken eyeballs, and weakness q2h starting at 0600 on 6/19/09. These are symptoms of decreased body fluids. 4. The nurse will monitor total fluid intake and output q4h starting at 0600 on 6/18/09. Ongoing assessments are necessary for early detection of deficient fluid volume. 5. The nurse will check orthostatic blood pressures with the client lying, sitting, and standing q8h starting at 0600 on 6/18/09. A 20 mm Hg drop when upright or an increase of 15 beats/min. in the pulse rate is seen with deficient fluid volume. (Lemone & Burke 2009), IV. Priority Nursing Diagnosis Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. Define: At risk for experiencing vascular, cellular, or intracellular dehydration. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will maintain urine output of at least 30 ml/hour aeb at least 30 ml (1oz) in his diaper by 1300 on 6/19/09. 2. The patient will maintain normal blood pressure, pulse, and body temperature aeb keeping all vs within normal limits by 1300 on 6/19/09. 3. The patient will maintain hydration aeb elastic skin turgor and moist tongue and mucous membranes by 1300 on 6/19/09.