Question

Cerebral palsy has been described as a group of permanent disorders of the development of movement and posture. In addition to motor disorders, the condition often involves disturbances of sensation, perception, communication, cognition, and behavior. After completing the reading, develop a nursing plan of care for the client and family in the following scenario.

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

Priority nursing diagnosis :

Impaired physical mobility related to hypertonia of the muscles As evidenced by observation ( not rolling over and not attempting to sit)

Rationale: if hypertonia is not treated it will lead to twisting or repetitive movements of abnormal posture.

Patient outcome: child will develop a maximum movement ability.

Nursing intervention :

1. Examine the range of motion of the joints and also look for muscle tone.

Rationale: to avoid the development of muscle contractions and to plan the necessary exercise regimen.

2.reposition the child every 2hours once.

Rationale: to avoid pressure sore and to ensure blood circulation.

The physiotherapy department or a physiotherapist should be included in the plan of care to ensure improvement of motor skills and to prevent movement problems getting worse.