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This Concept Map, created with IHMC CmapTools, has information related to: Peds 4, IV. Secondary Nursing Diagnosis 2. Socail isolation r/t cognition, sensory, and motor impairment secondary to cerebral palsy. 3. Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. 4.Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs. Prioritized to IV. Priority Nursing Diagnosis Total Urinary Incontinence r/t neurologic dysfunction secondary to cerebral palsy. Define: Continuous and unpredictable loss of urine. (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. Secondary Nursing Diagnosis 2. Socail isolation r/t cognition, sensory, and motor impairment secondary to cerebral palsy. 3. Interrupted Family Process r/t client's diagnosis and placement in a long term facility secondary to cerebral palsy, convulsion disorder, and legal blindness. 4.Risk for Deficient Fluid Volume r/t lack of ability to access to convey fluid needs., 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), 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 adequate skin integrity aeb no signs of skin breakdown such as redness, inflammation, or break in skin integrity by 1300 on 6/19/09. 2. The patient will have absence of urinary tract infection aeb no signs of a fever or an increase in WBC count by 1300 on 6/19/09. 3. The patient will keep his pants dry aeb wearing a diaper to catch any of his body fluids and no moisture present on the pants by 1300 on 6/19/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient maintained adequate skin integrity aeb no signs of skin breakdown such as redness or break in skin integrity by 1300 on 6/19/09. Goal Met 2. The patient did not receive a UTI aeb no signs of an infection such as a fever an elevated WBC count by 1300 on 6/19/09. Goal Met. 3. The patient kept his pants dry aeb no type of moisture on the pants by 1300 on 6/19/09. Goal Met., IV. Priority Nursing Diagnosis Total Urinary Incontinence r/t neurologic dysfunction secondary to cerebral palsy. Define: Continuous and unpredictable loss of urine. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will maintain adequate skin integrity aeb no signs of skin breakdown such as redness, inflammation, or break in skin integrity by 1300 on 6/19/09. 2. The patient will have absence of urinary tract infection aeb no signs of a fever or an increase in WBC count by 1300 on 6/19/09. 3. The patient will keep his pants dry aeb wearing a diaper to catch any of his body fluids and no moisture present on the pants by 1300 on 6/19/09., V. Expected Outcomes 1. The patient will maintain adequate skin integrity aeb no signs of skin breakdown such as redness, inflammation, or break in skin integrity by 1300 on 6/19/09. 2. The patient will have absence of urinary tract infection aeb no signs of a fever or an increase in WBC count by 1300 on 6/19/09. 3. The patient will keep his pants dry aeb wearing a diaper to catch any of his body fluids and no moisture present on the pants by 1300 on 6/19/09. Interventions & Rationals VI. Interventions 1. The nurse will assess the patient for skin breakdown q2h starting at 0600 on 6/18/09. Assessing for skin breakdown will provide for early recognition and treatment if one occurs. 2. The nurse will teach the family the S&S of UTI by 1300 on 6/18/09. Knowing the S&S helps with early detection and treatment that will prevent the UTI from becoming more severe. 3. The nurse will ensure the client is adequately dry when changing a wet diaper or anytime the client gets moisture on him by 1300 on 6/19/09. Maintaining a dry environment prevents bacteria or organisms from growing. Bacteria likes to grow in moist, warm, dark areas increasing the chance of impaired skin integrity. 4. The nurse will monitor the patient's vital signs for any indication for an infection q2h starting at 0600 on 6/18/09. If an infection is present the client demonstrate a fever, have some type of pain, and/or have an increase in respirations. 5. The nurse will assess the clients pants for any kind of wetness q2h or whenever changing the client starting at 0600 on 6/18/09. Wetness on the client's pants could indicate a large accident and provide for an environment of bacterial growth which could result in skin breakdown. (Lemone & Burke 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. Priority Nursing Diagnosis Total Urinary Incontinence r/t neurologic dysfunction secondary to cerebral palsy. Define: Continuous and unpredictable loss of urine. (Wilkenson & Ahern 2009)