care plan
TRANSCRIPT
Amy Mantel
Nursing Care Plan
Pediatrics
University of Chicago
3/25/11
History of Patient
Patient is a sixteen year old female admitted on 2/5/11 for right leg pain and respiratory
distress. Assessment was performed on 2/11/11. Vitals were BP-124/88 taken in the lower left leg, T-
97.1, HR-139, R-28 clear and diminished (which is normal for patient’s baseline), O2-95% on room air.
An x-ray was done which showed a fractured femur and fibula. A long leg cast was applied to the right
leg. Mechanical chest physiotherapy was performed for respiratory distress. Patient has a history of
cerebral palsy, hypoxia, and seizure disorder, asthma with exacerbation, pneumonia, and scoliosis.
On assessment nurse stated patient was brought in for pain to the right leg. Pain was noticed
upon daily assessment when patient moaned and became disturbed when leg was touched. Patient is
nonresponsive to questioning, and unable to speak. All pulses were present, although pedal pulses were
weak. Capillary refill was less than three seconds. Skin was moist and clean, with no lesions apparent.
Range of motion was performed. Patient did not tolerate this activity well and became agitated. Patient
has complete feeding done by J-tube. Bowel sounds present in all four quadrants. Pupils were equal
and reactive to light. Neurological status was not able to be assessed. Patient had no IV access and J-
tube was set on continuous feed. Urinary catheter was in place. Urine is clear, yellow, and free of odor.
Developmental status is severely diminished due to advanced cerebral palsy. Support systems in place
are complete care living facility, and a grandfather that visits and helps with care.
Pathophysiology of a fracture
If Ca and vitamin D levels are adequate and bone tissue is healthy and the fracture edges are
kept reasonably close to each other and with little or no relative motion, most fractures heal within
weeks or months via remodeling. New tissue (callus) is produced within weeks, and bone reshapes at
variable rates during the first weeks or months. Ultimately, optimal remodeling requires gradual
resumption of normal motion and load-bearing stress. However, remodeling can be disrupted and
refracture can occur if force is applied or the joint moves prematurely; thus, immobilization is usually
needed. Serious complications are unusual. Arteries are injured occasionally in closed supracondylar
fractures of the humerus and femur but rarely in other closed fractures. Compartment syndrome or
nerve injury may occur. Open fractures predispose to bone infection (see Infections of Joints and Bones:
Osteomyelitis), which can be intractable. Fractures of long bones may release fat (and other marrow
contents) that embolizes to the lungs and causes respiratory complications (see Sidebar 1: Pulmonary
Embolism: Nonthrombotic Pulmonary Embolism). Fractures that extend into joints usually disrupt
articular cartilage; misaligned articular cartilage tends to scar, causing osteoarthritis and impairing joint
motion. Occasionally, fractures do not heal (called nonunion); rarely, nonunion occurs even when
treatment is expeditious and correct. If the vascular supply is injured by the initial injury (such as a
scaphoid fracture), aseptic necrosis may ensue even if the fracture was properly immobilized.
http://www.merckmanuals.com/professional/sec21/ch309/ch309b.html
Pathophysiology of cerebral palsy
Cerebral palsy can be termed as a static encephalopathy caused by an insult to the brain of the
newborn baby during the prenatal, perinatal, or postnatal period. Cerebral palsy is a group of chronic
disorders impairing control of movement. Cerebral palsy is generally caused by the faulty development
or damage to motor areas in the brain that disrupts the brain's ability to control movement and posture.
The symptoms of the cerebral palsy vary in terms of severity. The main symptoms of the cerebral palsy
include difficulty with normal motor tasks such as writing or using scissors, difficulty in walking and
imbalanced pasture. Cerebral palsy normally do not get worsen over the time. Cerebral palsy can lead to
global dysfunction but always includes motor problems. There are mainly four types of cerebral palsy
based on the movement dysfunction. First is Spastic cerebral palsy in which the sudden, involuntary
movements are seen in the patient. These movements are stiff and difficult. The second is Athetoid
characterized with uncontrolled, slow, writhing movements. The third type is Ataxic cerebral palsy in
which irregular muscle coordination and lack of balance can be noticed. The fourth and final type is
mixed cerebral palsy, which is a combination of two or more types. The cerebral insults have a wide
range and include vascular, hypoxic-ischemic, metabolic, infectious, traumatic, and genetic causes.
There may be some other causes also. The spasticity results because of too much facilitatory input from
the spinal reflex arc. This spinal reflex arc is generated by a stretch put on the muscle spindle. The
spindle sends information to the spinal cord that generally is controlled by the descending tracts. If
these tracts are injured, then an uncontrolled facilitation occurs that causes the muscle to contract. The
muscle takes up the length on the spindle. The basal ganglia are a contributor to the extra pyramidal
system of the muscles. It is an important center for movements related to posture, automatic
movements and skilled volitional movements. Injuries or insults in this area often results in the difficulty
in stopping motion, rigidity, tremor or chorea. These symptoms are medically known as akinesia.
Inability to control the range of motion in an activity also results due to the insult to cerebellum.
http://www.zimbio.com/Cerebral+palsy/articles/L8mP2BicNxh/
Pathophysiology+cerebral+palsy+General+Information
Pathophysiology of seizure disorder
Seizures are the result of an electrical misfiring of the brain. "Classic" seizures involve falling to the
ground and flailing uncontrollably, but seizures can be as mild in appearance as feeling confused or
looking distracted. These symptoms occur because the brain sends signals to the body through electrical
pulses. When there's a misfire, the pulses are nonsensical to the muscles, resulting in an unpredictable
reaction. Biochemicals called neurotransmitters---which elicit moods, hunger, thirst, lust and other
feelings---can influence electrical impulses sent out by your brain. The neurotransmitters are either
absent or present in abnormal amounts due to disease. Some medications and poisons lead to the
depletion of neurotransmitters, causing seizures in some cases.
Congenital conditions such as hydrocephaly---which occurs when cerebrospinal fluid pressure is higher
than normal---keep the brain from fully developing and leave a fluid-filled space in the cranium. The
undeveloped brain then moves freely within the cranium, unable to regulate its electrical impulses to
the body like a healthy brain could.
http://www.ehow.com/about_5711802_pathophysiology-seizure-disorders.html
Pathophysiology of Asthma
Asthma commonly results from hyperresponsiveness of the trachea and bronchi to irritants. Allergy
influences both the persistence and the severity of asthma, and atopy or the genetic predisposition for
the development of an IgE-mediated response to common airborne allergens is the most predisposing
factor for the development of asthma.
http://nursingcrib.com/case-study/asthma-case-study/
Pathophysiology of Scoliosis
Scoliosis is an abnormal sideways curvature of the spine that is typically found in children and
adolescents. In most cases, scoliosis is painless. However, it can become gradually more severe if left
untreated, resulting in chronic back pain. In young children, severe cases can cause deformities, impair
development and be life-threatening. In most cases, scoliosis is painless and develops gradually. It often
worsens during growth spurts in children and teens. Scoliosis patients who wear a back brace over an
extended period of time can usually prevent further curvature of the spine. The cause of most cases of
scoliosis cases is unknown (idiopathic). Suspected causes of scoliosis include connective tissue disorders,
muscle disorders, hormonal imbalance and abnormality of the nervous system. Spinal cord and
brainstem abnormalities may also contribute to scoliosis. The condition can also be hereditary.
Nonstructural scoliosis. Also known as functional scoliosis, this involves a spine that is structurally
normal yet appears curved. This is a temporary curve that changes, and is caused by an underlying
condition such as difference in leg length, muscle spasms or inflammatory conditions such as
appendicitis. Physicians usually treat this type of scoliosis by addressing the underlying condition. The
term nonstructural scoliosis has also been used to describe cases involving a side–to–side curvature.
Structural scoliosis. This is a fixed curve that is treated individually according to its cause. Some cases of
structural scoliosis are the result of disease, such as the inherited connective tissue disorder known as
Marfan’s syndrome. In other cases, the curve occurs on its own. Other causes include neuromuscular
diseases (such as cerebral palsy, poliomyelitis or muscular dystrophy), birth defects, injury, infection,
tumors, metabolic diseases, rheumatic diseases or unknown factors. The term structural scoliosis has
also been used to describe cases involving a twisting of the spine in three dimensions rather than a
sideways curvature.
http://arthritis-symptom.com/scoliosis/pathophysiology-scoliosis.htm
Websites for patient/family
http://www.cerebralpalsysource.com/Education_and_Patients/index.html
This is a website about cerebral palsy. I chose this site because it seems to be very informative
about the information patients and family would want to know. I also feel this site is very self
explanatory, and easy to navigate thru.
http://www.cpirf.org/
This is the international cerebral palsy research foundation. This site also has great information
about the illness. I also chose this site because I was able to find information on the special
circumstances of children with cerebral palsy and bone fractures.
Med Sheets
Ibuprofen
Class: Anti-inflammatory
Indications: relief of mild to moderate pain and inflammation, reduction of fever
Routes Available: PO
Common dose: up to 800 mg in divided doses
Contraindications/Precautions: Hypertension, history of GI ulceration, diabetes, impaired renal function,
history of CAD, angina, chronic renal failure, and patients with SLE
Adverse reactions/Side effects: headache, dizziness, light-headedness, anxiety, fatigue, drowsiness
Nursing responsibilities:
o Monitor for therapeutic effectiveness
o Observe patients with history of cardiac decompensation closely
o Baseline and periodic evaluations of Hgb, renal and hepatic function
o Monitor for GI distress and S&S of GI bleeding
Patient teaching:
o Notify doctor is dark tarry stools are present or other evidence of GI distress is noted
o Do not self medicate if taking other prescription drug without notifying doctor
o Do not take with aspirin
o Avoid alcohol while taking this medication
Budesonide
Class: Anti-inflammatory
Indications: Prophylaxis for asthma
Routes Available: PO
Common dose: 9mg
Contraindications/Precautions: Concomitant administration of systemic oral steroids, tuberculosis,
infections of the respiratory tract, fungal, bacterial, or systemic viral infections, diabetes, seizure
disorders
Adverse reactions/Side effects: fatigue, fever, hyperkinesis, myalgia, asthenia, tremor, dizziness, facial
edema, hypertension, abdominal pain, and cramps
Nursing responsibilities:
o Monitor for S&S of hypercorticism
o Lab test should be periodic serum potassium levels
Patient teaching:
o Notify doctor of signs of itching, skin rash, fever, swelling of face and neck, difficulty
breathing
o Do not drink grapefruit juice
o Avoid people with infections, especially chicken pox or measles
Valproic Acid
Class: Anticonvulsant
Indications: management of seizures
Routes Available: PO
Common dose: 250mg bid
Contraindications/Precautions: History of kidney disease or renal failure, history of liver disease,
congenital metabolic disorders, severe epilepsy, use alone
Adverse reactions/Side effects: breakthrough seizures, sedation, drowsiness, dizziness, aggression,
nausea, vomiting, and indigestion
Nursing responsibilities:
o Monitor for therapeutic effectiveness
o Monitor patient’s alertness
o Monitor patient carefully during dose adjustments
Patient teaching:
o Do not discontinue therapy without doctor order
o Notify doctor if spontaneous bleeding occurs
o Avoid alcohol
o Consult doctor before using OTC drugs
o Notify doctor of following symptoms: visual disturbances, rash, jaundice, light colored
stools, protracted vomiting, and diarrhea
Lansoprazole
Class: Antisecretory
Indications: treatment of duodenal ulcer and erosive esophagitis, and GERD
Routes Available: PO
Common dose: 15mg
Contraindications/Precautions: Hepatic disease
Adverse reactions/Side effects: fatigue, dizziness, headache, nausea, diarrhea, constipation, anorexia,
thirst, and rash
Nursing responsibilities:
o Monitor CBC, kidney and liver function test
o Monitor for therapeutic effectiveness
Patient teaching:
Inform doctor of significant diarrhea
Glycopyrrolate
Class: Anticholinergic
Indications: Management of peptic ulcer and other GI disorders, also used to reverse neuromuscular
blockade
Routes Available: PO
Common dose: 1mg tid
Contraindications/Precautions: Autonomic neuropathy, hepatic or renal disease, cardiac arrhythmias
Adverse reactions/Side effects: decreased sweating, weakness, dizziness, drowsiness, muscle weakness,
blurred vision
Nursing responsibilities:
o Monitor I&O and watch for urinary hesitancy and retention
o Monitor vital signs and report change in heart rate.
Patient teaching:
o Avoid high temperatures
o Do not drive
o Use good oral hygiene and rinse mouth with water frequently
Levetiracetam
Class: Anticonvulsant
Indications: treat certain types of seizures
Routes Available: PO
Common dose: 500mg bid
Contraindications/Precautions: renal impairment, renal disease, renal failure, history of depression
Adverse reactions/Side effects: drowsiness, weakness, unsteady walking, coordination problems,
headache, pain, forgetfulness, anxiety, agitation or hostility, dizziness, moodiness, nervousness,
numbness, burning, or tingling in the hands or feet, loss of appetite, vomiting, diarrhea, constipation,
changes in skin color
Nursing responsibilities:
o Monitor individuals with a history of depression
o Monitor difficulty with gait or coordination
o Periodic CBC with differential should be done
o Monitor for changes in blood levels
Patient teaching:
o Monitor for S&S of depression
o Do not drive or engage in hazardous activity
o Do not abruptly discontinue medication
Metoclopramide
Class: Prokinetic agent
Indications: treatment of gastroesophageal reflux
Routes Available: PO
Common dose: 10-15mg
Contraindications/Precautions: Gastrointestinal bleeding or perforation, A gastrointestinal blockage,
Pheochromocytoma, Seizures or epilepsy, Depression (or a history of depression), Parkinson's disease,
High blood pressure (hypertension), Congestive heart failure (CHF), Cirrhosis of the liver
Adverse reactions/Side effects: Decreased energy; diarrhea; dizziness; drowsiness; headache; nausea;
restlessness; tiredness; trouble sleeping.
Nursing responsibilities:
o Report onset of restlessness and involuntary movements
o Monitor for possible hypernatremia and hypokalemia
o Electrolytes lab test should be done periodically
Patient teaching:
o Avoid driving while on this medication
o Avoid alcohol
o Report S&S of acute dystonia, such as trembling hands and facial grimacing
Lab tests and results
Glucose: 109 Normal value: 70-110
Sodium: 142 Normal value: 135-145
Potassium: 4.2 Normal value: 3.5-5.3
Chloride: 101 Normal value: 95-105
Carbon Dioxide: 30 Normal value: 22-30
BUN: 17 Normal value: 5-25
Creatinine: 0.3 Normal value: 0.4-1.2
Abnormal result-Lower than desired- Decreased creatinine levels may be seen in: the elderly, persons
with small stature, decreased muscle mass, or inadequate dietary protein. Muscle atrophy can also
result in decreased serum creatinine level. If muscle atrophy is suspected, assessment of serum creatine,
an important enzyme necessary for normal muscle function, is done.
Calcium: 8.8 Normal value: 4.5-5.5
Alk Phos, Serum: 98 Normal value: 50-230
PTH, Intact: 50 Normal value: 11-24
Nursing Diagnosis 1
Risk for Injury R/T physical disability, perceptual and cognitive impairment, seizures, and lack of
knowledge regarding injury prevention
Desired Goal
Child remains free from signs and symptoms of injury. Parents verbalize accurate knowledge about how
to provide a safe environment for their child.
Interventions
Educate family about bed safety in the lowest position with side rails up
o This information reduces child’s risk for injury
Teach families ways in which to institute seizure precautions
o This information helps prevent injury caused by seizures
Teach family how to secure child properly in wheelchair, positioning devices, and motor vehicles
o The decreases the chances of injury by falling as a result of spasticity, posturing, or lack
of muscular control
Evaluation
Family showed evidence of understanding way to prevent injury by explaining specific procedures to
use to avoid falls. Continue with plan of care.
Nursing Diagnosis 2
Impaired Physical Mobility R/T neuromuscular impairment
Desired Goal
Within one month after intervention, child demonstrates improved mobility, and parents demonstrate
correct use of physical therapy techniques.
Interventions
Reinforce use of physical therapy exercises
o These exercises facilitate optimum muscular development by strengthening and
promoting muscle coordination
Encourage rest before locomotion activities
o Spasticity and abnormal posturing increase when child is tired. Being rested before
attempting locomotion improves chance of accomplishing goals
Instruct parents in correct use of orthoses
o Orthoses help prevent contractures, protect skin, and maintain or improve function
Evaluate child’s response to therapy on a regular basis
o Ongoing evaluation of effectiveness of current plan increases chance of success because
modifications or changes can be made in a timely manner, as necessary
Evaluation
Evaluation for this particular diagnosis could not be done during the clinical time frame. Patient was not
able to be analyzed for outcome
Nursing Diagnosis 3
Self-Care Deficit: Bathing/Hygiene, Dressing/Grooming, Toileting R/T neuromuscular impairment
Desired Goal
Family and caretakers will demonstrate adequate knowledge of proper care prior to discharge
Interventions
Teach caregivers specific techniques on oral care and bathing
o Proper oral care and bathing techniques can avoid bacteria from forming and
spreading , and also prevent skin breakdown.
Teach caregivers proper perinatal care techniques
o Cleaning perinatal area thoroughly after child voids is very important to avoid skin
breakdown and discomfort to child.
Encourage parents to have realistic expectations of what the child can do
o Stress will be reduced if caregivers understand the child’s limitations and accepts them.
Evaluation
Caregivers were able to demonstrate proper techniques to care for hygiene of child.
Nursing Diagnosis 4
Impaired Verbal Communication R/T neuromuscular impairment
Desired Goal
Within one month of interventions, child’s ability to communicate needs to caregiver will improve
Interventions
Speak slowly and clearly when speaking with child
o This gives child time to understand speech
Listen closely to what child says
o Ignoring or not listening to child increases frustrations with failure to communicate
Use assistive devices such as pictures or flash cards
o These devices promote child’s communication ability and mutual understanding of what
is being said
Evaluation
Child was unable to be evaluated for effectiveness due to not having enough clinical time
Nursing Diagnosis 5
Ineffective Airway Clearance R/T presence of tracheobronchial secretions secondary to infection
Desired Goal
Child will demonstrate effective cough.
Interventions
Inspect sputum for quantity, odor, color, and consistency, and document
o This will help you see if patients conditions is worsening or improving
Assist child into position of comfort, usually semi-fowlers position
o This will facilitate ease and promote expansion of lungs
Provide respiratory therapy treatments as ordered
o This will help loosen sputum so it can be excreted properly
Evaluation
After respiratory treatments patient was able to cough more effectively and produce sputum. Continue
with plan of care.