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This Concept Map, created with IHMC CmapTools, has information related to: Peds 3, V. Expected Outcomes 1. The patient will practice social skills needed to interact with others aeb not yelling when someone trys to interact with him by 1300 on 6/19/09. 2. The patient will participate in activities and programs at level of ability and desire aeb helping with the cooking activity on 6/19/09 by 1300. 3. The patient will interactions with others aeb playing basketball with someone by 1300 on 6/19/09. Interventions & Rationals VI. Interventions 1. The nurse will observe for barriers to social interactions by 1800 on 6/18/09. Causes of social isolation may be different for each individual; therefore adequate information must be gathered so that appropriate interventions can be planned. 2. The nurse will note risk factors such as specific illnesses by 1800 on 6/18/09. Clients with certain risk factors may be at risk for social isolation. Young adults with mental illness identify social isolation as their main concern. 3. The nurse will establish therapuetic relationship and spend time with the client by 1300 on 6/19/09. Being truly present was listed as one behavior that demonstrated caring. Presence and caring communication is important. 4. The nurse will promote social interactions with the idea of the cooking activity on 6/19/09 at 1000. Social interactions helps to make friends and to participate in a fun activity. 5. The nurse will encourage the client to not yell or make any inappropriate gesters to other people by 1300 on 6/19/09. Yelling or making inappropropriate faces towards people tends to keep them away or it may really hurt their feelings. Upseting people is not a way of making a good relationship. (Wilkenson & Ahern2009), 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.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. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Social Isolation r/t cognition, sensory, and motor impairment secondary to cerebral palsy. Define: Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state. (Wilkenson & Ahern 2009), 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., 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 Social Isolation r/t cognition, sensory, and motor impairment secondary to cerebral palsy. Define: Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state. (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. 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.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. (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., 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), IV. Priority Nursing Diagnosis Social Isolation r/t cognition, sensory, and motor impairment secondary to cerebral palsy. Define: Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will practice social skills needed to interact with others aeb not yelling when someone trys to interact with him by 1300 on 6/19/09. 2. The patient will participate in activities and programs at level of ability and desire aeb helping with the cooking activity on 6/19/09 by 1300. 3. The patient will interactions with others aeb playing basketball with someone by 1300 on 6/19/09., V. Expected Outcomes 1. The patient will practice social skills needed to interact with others aeb not yelling when someone trys to interact with him by 1300 on 6/19/09. 2. The patient will participate in activities and programs at level of ability and desire aeb helping with the cooking activity on 6/19/09 by 1300. 3. The patient will interactions with others aeb playing basketball with someone by 1300 on 6/19/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient yelled at some people when they tried to interact with him, but not everyone by 1300 on 6/19/09. Goal partially met. 2. The patient attended the cooking activity on 6/19/09 at 1000 but did not participate and only stayed for about 5 min. and then we had to leave because he was upset and crying. Goal not met. 3. The patient did play basketball with the nurse for about 20-30 minutes on 6/19/09 by 1300. Goal met