Pediatric Care Plan

Pediatric Care Plan* STUDENT NAME: PATIENT DEMOGRAPHICS: Patient Initials DOB Family Assessment Lives with Mother Susan, Father Jason, and Brother Hayden Primary Health Care Provider Diagnosis Cerebral Palsy, general spasticity, mental impairment, impaired vision and hearing, hydrocephalus, intrathecal spasticity control. PATHOPHYSIOLOGY OF DIAGNOSIS Cerebral Palsy Cerebral Palsy CP affects the ability to balance and maintain posture. According to the CDC, “Cerebral Palsy is the most common motor disability in childhood.” There are multiple types of CP the most common type is Spastic Cerebral Palsy. Characterized by muscle stiffness in the lower extremities, upper extremities are rarely affected. The legs often turn inward and cross at the knee, as well as tightness in the hip. This makes it difficult for the patient to walk, they often need assistance and require wheelchairs. Diagnosis Looking at laboratory values can be helpful to determine a person’s overall health. A creatine phosphokinase or CPK can help detect injury within the brain, heart, and skeletal muscles. High levels of CPK3 indicate muscle injury and can help with the diagnosis of CP. Cerebral Palsy can be screened through genetic testing. Diagnosis may take a few months after birth. The child’s development will need to be monitored and assessed. Often the patient is referred to a specialist such as a neurologist, a developmental specialist, and or rehabilitation specialist. CP often affects vision and hearing 1 and the child will need to have these evaluated. Medications Muscles are stiffness if often treated with a muscle relaxant such as baclofen, or tizanidine. Pain medications may also be needed to help relieve chronic pain experienced by CP patients. Some specific muscles can be injected every 3 months with Botox to help relieve muscle tightness. Patient and family teaching Cerebral palsy is a lifetime diagnosis, the caregivers will need education and support to live with the diagnosis. Physical therapy is an important factor in the care of CP patients, it will help strengthen and increase range of motion for the patient. Occupational therapy will help teach the child to do daily activities on their own. Speech and language therapies will help the child communicate. Explaining the importance of all the therapies is extremely important for the child to have the best outcome with the diagnosis of CP. BRIEF HISTORY Pamela Souza, 6 years old, was born with cerebral palsy. Pamela suffers from general spasticity, mental impairment, impaired vision and hearing, and hydrocephalus. She has been admitted to the pediatric unit for evaluation of intrathecal spasticity control. Pamela uses a wheelchair for mobility. Smoking History: No exposure to secondhand smoke. 2 Hx of Drug Abuse: N/A Hx of Alcohol Abuse: N/A Hx of Sexual/Emotional/Physical Abuse: N/A Lifestyle Risk Factors: N/A Any Concerns: Cerebral Palsy, general spasticity, mental impairment, impaired vision and hearing, hydrocephalus, intrathecal spasticity control. ALLERGIES Food: Peanut, anaphylaxis. VITAL SIGNS Blood pressure: Heart Rate: Respirations: SpO2: Oxygen Delivery Method: Temperature: Left upper arm, sitting, 112/76 95 18 97% Room air Temporal, 37.1°C PHYSICAL ASSESSMENT HEENT Head: Rounded, normocephalic and symmetrical Eyes: Conjunctiva normal and clear; vision impairment. Ears: Hearing impairment, Pain not present; Drainage not present; Interior normal; Tympanic membrane landmarks well visualized Nose: Symmetrical; No obstruction present; Septum is intact; No abnormalities present; No discharge Mouth/Throat: Moist and pink with no lesions or sores. Thyroid not palpable; no masses Developmentally delayed Growth & Development Neurological Moderate neurological deficit, alert and conscious, sitting up in bed. Cardiovascular Pulses are equal and strong in all extremities. Heart sounds S1, S2 heard. Respiratory Clear sounds in all lobes, chest rises equal and bilaterally with no difficulty. Gastrointestinal Bowel sounds heard in all quadrants. Abdomen is round and soft. No masses palpated. Genitourinary Urine is pale yellow in color. Patient wears brief. Musculoskeletal Wheelchair bound, able to stand with assistance for short periods. Mental Health Happy 6 year old. Pain Faces pain Scale: 0 Pain goal: 0-1 No intervention needed at this time. Smooth with no scars, rashes, nor lesions. Integumentary (include a Braden Braden Scale: 2, 3, 2, 2, 3, 2 Scale) Braden Score: 14 Moderate risk. 3 Vascular Access 22 gauge IV in left forearm, Tegaderm dressing clean dry intact. No redness or swelling at site. NURSING DIAGNOSES Impaired Physical Mobility Nursing Diagnosis: Diagnosis Type: Actual Diagnosis Category: Physiological Related to: Cerebral Palsy As evidenced by: Limited range of motion, and muscle spasms. Expected outcomes: Achieve maximum movement ability and absence of contractures. Short-term goals: Identify and implement ROM exercises to increase lower extremities movement and strength, within 24 hours. Patient will maintain pain control while implementing new ROM exercises. Long-term goals: Improve strength of lower extremities, within 3 months. Improve ROM of lower extremities, within 3 months. Nursing Interventions: Assess the type of auditory, visual, motor, or intellectual deficit. Facilitate activities in using fine and gross motor skills. Encourage the child to rest between activities that are tiring. Rationale: Knowing the type of deficit will aid in planning interventions appropriate for the child. Activities of daily living and play exercises increase physical development. Given the limitations of the child’s ability, rest periods are given to maintain energy. Evaluation Child is able to participate in ROM activities as ordered. NURSING DIAGNOSES Nursing Diagnosis: Risk for deficient fluid volume Diagnosis Type: Potential Diagnosis Category: Physiological Related to: NPO status pre procedure. As evidenced by: Not applicable. Expected outcomes: Maintain adequate fluid volumes. Caregiver will explain how to maintain a healthy fluid volume and Short-term goals: Include time range why it is important by the end of nursing shift. After 8 hours of nursing interventions, the patient will maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output. Client will drink 7 cups of fluid each day, within 2 weeks of Long-term goals: Include time range discharge. The patient lab value will be within normal limits prior to discharge. Nursing Interventions: Maintain accurate intake and output record. Monitor vital signs as appropriate. 4 Rationale: Evaluation Give fluids as appropriate. Administer IV therapy as prescribed Maintains urine output of 30ml per hour per kg of body weight. Maintains normal blood pressure, pulse, and body temperature. Maintains elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, time. Explains measures that can be taken to treat or prevent fluid volume loss. Child is able to maintain adequate fluid volume without IV support by discharge. NURSING DIAGNOSES Risk for developing constipation Nursing Diagnosis: Diagnosis Type: Potential Diagnosis Category: Physiological Related to: Impaired physical mobility, use of pain medication post procedure. As evidenced by: Cerebral Palsy, Opioid use after procedure. Expected outcomes: Able to pass stool and avoid constipation. Short-term goals: Patient will take Colace daily while using pain medication, within 1 day of procedure. Patient will have adequate fluid intake to avoid constipation, before discharge. Long-term goals: Patient will take medications as prescribed and stop taking when no longer needed, within 4 weeks of procedure. Patient will increase fiber in diet, within 1 week of procedure. Nursing Interventions: Educate caregivers and patient on proper use of pain medication. Educate caregivers and patient on importance of adequate fluid intake and adequate fiber in diet. Rationale: To maintain normal stooling pattern. Evaluation Caregiver and patient will be able to explain how to properly use narcotic medication. Caregiver and patient will state understanding of adequate fluid and fiber intake. Lab Test Patient Value Normal Range Complete Metabolic Panel Sodium (Na) Potassium (K) Chloride (Cl) Carbon Dioxide (C02) Glucose 138 3.8 104 25 80 Blood Urea Nitrogen (BUN) Creatine Total Bilirubin 18 0.9 0.24 136 - 145 3.7 - 5.2 96 - 106 20 - 29 70-125 Nonfasting 7 – 20 0.8 – 1.4 0.2 – 1.0 Rationale for Abnormal Value 5 Total Protein Albumin Calcium CBC White Blood Cells (WBC) Red Blood Cells (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plts) 7.1 3.8 9.2 6.4 – 8.2 3.4 – 5.0 8.5 – 10.1 8.9 4.8 13.8 38.7 199 5.0 – 10.0 4.5 – 5.90 13.3 – 16.7 35.9 – 44.6 140 - 400 RECENT, CURRENT, AND PRESCRIBED MEDICATIONS Medication & Classification Dosages, Reason Side Effects Patient and/or Routes & for Family Teaching Frequency Taking Baclofen 10mg Muscle Nausea Take with milk or Therapeutic class: Skeletal Tablet spasticit Constipatio food. muscle relaxants PO y n Avoid OTC Pharmacologic class: TID Agitation antihistamines while Gamma-aminobutyric acid Insomnia taking drug. derivatives Rash Teach patient and Urticaria caregivers about the Dyspnea signs and symptoms of overdose and what to do if an overdose occurs. 10mg Pain Drowsiness Explain assessment Morphine Sulfate Therapeutic class: Opioid Capsule Headache and monitoring analgesics PO Constipatio process to patient and Pharmacologic class: Opioids PRN Q4 n family. Instruct them hours Nausea to immediately report Vomiting difficulty breathing or Respiratory other signs or arrest symptoms of a Diaphoresis potential adverse opioid-related reaction. 6