Care plan

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


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


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


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



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


Common dose: 15mg

Contraindications/Precautions: Hepatic disease

Adverse reactions/Side effects: fatigue, dizziness, headache, nausea, diarrhea, constipation, anorexia,

thirst, and rash


o Monitor CBC, kidney and liver function test


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


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


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


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


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


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.


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.

Documents

Care plan