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This Concept Map, created with IHMC CmapTools, has information related to: Peds 1, II. Pathophysiology 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 be treated as normally as possible by family to avoid overdependence aeb speaking with him like they would anyone else by 1300 on 6/19/09. 2. The patient will participate in the development of the plan of care to the best of his ability aeb deciding if he wants to take a nap in the afternoon or listen to T.V. by 1300 on 6/19/09. 3. The patient will experience an increase in the number of visits by his family members aeb having them visit three times a week by 1300 on 6/25/09. Evaluation VII. Evaluation of expected Outcomes 1. Goal Met. The patient was treated as normally as possible which prevented him from becoming overdependent by 1300 on 6/19/09. The parents kept communicating with the patient very well. 2. Goal Met. The patient participated in the development of his care plan by nodding yes to watching T.V. instead of sleeping by 1300 on 6/19/09. 3. Goal Met. The patient experienced an increase in the number of visits from his family members by 1300 on 6/25/09. They visited three times that week., 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 be treated as normally as possible by family to avoid overdependence aeb speaking with him like they would anyone else by 1300 on 6/19/09. 2. The patient will participate in the development of the plan of care to the best of his ability aeb deciding if he wants to take a nap in the afternoon or listen to T.V. by 1300 on 6/19/09. 3. The patient will experience an increase in the number of visits by his family members aeb having them visit three times a week by 1300 on 6/25/09. Interventions & Rationals VI. Interventions 1. The nurse will establish rapport with families by providing accurate communication by 1800 on 6/18/09.Family care can be improved by focusing on building rapport and communication problems and concerns between families and health professionals. 2. The nurse will involve family members in the care, information, and client teaching sessions with the client by 1800 on 6/18/09. Family-focused activities can help families cope better with the long-term care facility experience. 3. The nurse will encourage family to visit the client frequently by 1800 on 6/18/09. Having the family involved and around is healthy for the client physically and mentally. 4. The nurse will assist the client in the development of his care plan by 1300 on 6/18/09. Involving the client with the development of his care plan give him a sense of independence. 5. The nurse wil document all contact with family by 1300 on 6/25/09. Keeping track of the amount of times the family visits keeps an accurate record if the patient is meeting his goal. (Lemone & Burke 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 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), 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 Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. Define: Change in family relationship or functioning. (Wilkenson & Ahern 2009), 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. Social Isolation r/t cognitive, sensory, and motor impairment secondary to cerebral palsy. 3. Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. 4. Risk for Injury r/t inability to protect self from injury and has no self perservation skills., IV. Priority Nursing Diagnosis Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. Define: Change in family relationship or functioning. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will be treated as normally as possible by family to avoid overdependence aeb speaking with him like they would anyone else by 1300 on 6/19/09. 2. The patient will participate in the development of the plan of care to the best of his ability aeb deciding if he wants to take a nap in the afternoon or listen to T.V. by 1300 on 6/19/09. 3. The patient will experience an increase in the number of visits by his family members aeb having them visit three times a week by 1300 on 6/25/09., IV. Secondary Nursing Diagnosis 2. Social Isolation r/t cognitive, sensory, and motor impairment secondary to cerebral palsy. 3. Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. 4. Risk for Injury r/t inability to protect self from injury and has no self perservation skills. Prioritized to IV. Priority Nursing Diagnosis Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. Define: Change in family relationship or functioning. (Wilkenson & Ahern 2009)