Question

Nursing care plan for: Chapter 44: Nursing Care of the Child With a Neuromuscular Disorder 1. 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. (Learning Objectives 2, 3, 4, and 6)

Answer 1

Nursing care plan :-

1. Nursing diagnosis - Ineffective airway clearance related to weakness of throat muscles AEB dysphagia , pulmonary secreations , decreased breath sounds .

Nursing Interventions :-

Auscultate heart and lung sounds every 5-10 min, to serve as abaseline.

- Assess LOC every 5-10 min, Increasing confusion, restlessness, andirritability are signs of cerebral hypoxia.

-Assess vital signs every 5-10 min, Tachycardia and hypertensionmay be related to increased work of breathing or hypoxia. Fever maydevelop in response to retained secretions or atelectasis

- Monitor arterial blood gases and pulse oximetry continuously,Increasing PaCO2 and decreasing PaO2 and pulse oximetry readingsare signs of respiratory failure.

- Administer IVF/oral fluids as indicate, helps to mobilized secretions.- Suction the patient as ordered to ensure an airway clearance. Haveintubation tray at bedside.

- Apply oxygen as ordered to ensure perfusion.

- Position the pt in fowler’s position to avoid aspiration and to facilitatebreathing.

- Give meds as per MD orders.

2. Nursing diagnosis - Ineffective breathing pattern related progressive weakness and respiratory weakness .

Nursing Interventions :-

- Obtain medical history and ask if any viral infection within 1-4 weeks?

- Assess/monitor changes in vital signs

-Assess respiratory rate, character, and use of accessory muscle

-Assess/review of ABG, pulse Ox

-Asses for pain/discomfort that may restrict or limit respiratory effort- Assist with necessary testing (chest x-ray, spinal tap)

-Elevate HOB

-Suction if necessary to clear any secretions- Monitor for changes in vital capacity- not enough air in lungs (working too hard)- Monitor for negative inspiratory force (helps determine the need of early intervention)- Promote the use of incentive spirometer and slower/deeper respirations, use of pursedlip technique- Chest physiotherapy- to loosen secretions

-Provide patient with comfortable environment and teach relaxation techniques

-Administer oxygen as ordered

-Administer medications as ordered

-Teach patient about disease process

3. Nursing diagnosis - Risk for injury related to impaired sensory functions

Nursing interventions :-

- orient the patient to the environment

- keep all articles needed by the patient close to them

- keep the floors dry

- provide adequate lighting

- provide speech therapy to assist them to speak

- interact with the patient using borads ,pictures if they can't speak

- don't leave the patient alone .