Question

Scenario: Romel Jones is an 11-month-old infant who was seen this week at the developmental pediatrician’s office and was diagnosed with spastic cerebral palsy. The pediatrician’s office referred him because he is not rolling over or attempting to sit. He has hypertonia of the lower extremities. Romel is the fourth child of a 26-year-old single mother, who developed preeclampsia. He was born at 24 weeks’ gestation with a birth weight of 1 pound 4 ounces, and spent 3 months in the neonatal ICU, where his treatment included mechanical ventilation and tube feedings. When he was discharged home 8 months ago, he was on an apnea monitor, receiving bronchodilator medication via nebulizer, and was taking bottle feedings. His weight gain has been slow but steady, and currently he weighs 15 pounds and is 26 ½ inches long. Romel is seen monthly by a public health nurse, who has been assessing his health status and development, and teaching his mother about using a nebulizer. Romel’s mother is very upset at hearing his diagnosis. She states she knew they were going to follow him for possible developmental problems, but that she had not heard anything about cerebral palsy before. Intial Discussion Post: Using the Nursing Process and information from your textbooks, develop a nursing plan of care for the above client. Your plan of care must include: One (1) priority NAND-I nursing diagnosis (must be an actual nursing diagnosis) based on the information presented. Include the related factor and the rationale for the selected nursing diagnosis. One (1) measurable patient outcome. Two (2) nursing interventions. Remember: the intervention moves the client toward the outcome. Provide a rationale for each of the nursing interventions. Identify one (1) interprofessional health care team member to include in the plan of care. Include your rationale for this choice.

Answer 1

Impaired physical mobility related to decrease muscle control in cerebral palsy.

desired outcome- Infant will achieve maximum ability to move and absence of contractures.

Nursing intervention:

Assess the type of visual, auditory, motor or intellectual deficit

Assess the developmental milestones like sitting, stand with help etc

Rationale

Knowing the deficits help in planning the appropriate interventions

Cerebral palsy has delayed developmental milstones. if the child attain one skill , will plan the intervention for the suceeding one

Interprofessional healthcare team member- physiotherapist

Rationale- Cerebral palsy child have muscle weakness and little activity. physiotherapist greatly help in assisting the baby.