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This Concept Map, created with IHMC CmapTools, has information related to: Pediatrics 5, V. Expected Outcomes 1. The patient will maintain a rectal area free of irritation aeb no signs of redness, or inflammation by 1300 on 6/27/09. 2. The patient will maintain skin turgor and weight at usual level aeb no weight change or tenting of the skin by 1300 on 6/27/09. 3. The client maintain electrolyte balance within normal limits aeb lab test results and/or no signs of electrolyte imbalance such as tetany by 1300 on 6/27/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient maintained a rectal area free of irritation aeb no signs of redness or inflammation by 1300 on 6/27/09. Goal Met. 2. The patient maintained skin turgor and weight at usual level aeb no weight change or tenting of the skin by 1300 on 6/27/09. Goal Met. 3.The client maintained electroyle balance within normal limits aeb lab tests results and no signs of electrolyte imbalance such as tetany by 1300 on 6/27/09. Goal Met., 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 a rectal area free of irritation aeb no signs of redness, or inflammation by 1300 on 6/27/09. 2. The patient will maintain skin turgor and weight at usual level aeb no weight change or tenting of the skin by 1300 on 6/27/09. 3. The client maintain electrolyte balance within normal limits aeb lab test results and/or no signs of electrolyte imbalance such as tetany by 1300 on 6/27/09. Interventions & Rationals VI. Interventions 1. The nurse will assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue q2h starting at 0600 on 6/25/09. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness. 2. The nurse will measure specific gravity of urine if possible and observe the color of the urine when the client voids. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume. 3. The nurse will monitor the rectal area for any signs of irritation such as redness or inflammation q2h starting at 0600 on 6/25/09 or whenever changing the child. Early signs of irritation can prevent the area from getting worse with proper treatment in a timely manner. 4. The nurse will note the rate of infusion, and prevent contamination of feeding by rinsing container after every use and replacing it every 24 hours starting at 0600 on 6/25/09. Rapid administration of tube feeding and contaminated feedings have been associated with diarrhea. 5. The nurse will observe for signs of electrolyte imbalance such as muscle spasms, twitches, and cramping q2h starting at 0600 on 6/25/09 or whenever in contact with the patient. Early recognition of electrolyte imbalance can prevent more serious complications from occuring and can begin treating the imbalance quickly. (Lemone & Burke 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. Risk for impaired skin integrity r/t limited mobility, incontinence, gastrostomy tube is at risk for pressure ulcers. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Diarrhea r/t tube feedings. Define: Passage of loose, unformed stool. (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. Priority Nursing Diagnosis Diarrhea r/t tube feedings. Define: Passage of loose, unformed 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. 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. (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 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 Diarrhea r/t tube feedings. Define: Passage of loose, unformed stool. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will maintain a rectal area free of irritation aeb no signs of redness, or inflammation by 1300 on 6/27/09. 2. The patient will maintain skin turgor and weight at usual level aeb no weight change or tenting of the skin by 1300 on 6/27/09. 3. The client maintain electrolyte balance within normal limits aeb lab test results and/or no signs of electrolyte imbalance such as tetany by 1300 on 6/27/09.