Cerebral Palsy Care Plan

NURSING PROGRAM CLINICAL CARE PLAN ASSESSMENT Data -Severity of CP -Muscle tone -Reflex -Spasm -Posture -Balance -Gross motor function -Fine motor function -Oral motor function -Behavior / cognition -Nutrition -Seizure/tremor -ADLs -Family/social support -Hx/meds/ milestones -Risks DIAGNOSIS Nursing Diagnosis PLANNING Goal(s) (Related to) 1.) Impaired physical mobility r/t muscle weakness and poor muscle control 1.) Pt. will maintain maximum movement during hospitalization -Altered growth and development r/t neuromuscular disorder / reduced intake / -Risk for injury -Altered communication levels IMPLEMENTATION Nursing Interventions Rationale & References 1.)-Contact PT/rehab therapists assistance mobile walkers, wheelchair, braces -Plan activities to use gross and fine motor skills (toys)allow times -Reposition q2hrs -ROM 2-4 hrs -Monitor for pain  Administer pain/muscle spasm medication -Knowledge deficit -Caregiver strain -Utilize parents -interrupted family process r/t level of care required in caring for chonically ill child STRENGTHS: - risk of aspiration -Enhance gross and fine motor skills that have most likely been affected. Allow time as it might be difficult -mobility, circulation, decreases risk of contractures - Rest periods -Observe child  developmental milestones? -Imbalanced nutrition: less than body requirements r/t decreased intake and uncoordinated oral motor fxn -Help build and strengthen “good” and “bad” sides. Promote some level of independence in ambulation -Pain may limit mobility and motivation -Need rest periods b/c what may seem easy for someone w/o CP may actually be overexerting a pt. that does have CP -Children with CP often miss developmentally milestones (a common sign that parents notice in their child). Noting significant behavioral cues may allow for early treatment. -Parent is the child’s expert! EVALUATION Evaluation Modification r/t uncoordinated oral motor fxn resulting in swallowing difficulty and muscle spasticity