Question

Pt. initials H.C Rm. # 206 ge 11 y/oWt.163lbs Gender M Diagnosis: Chiari Malformation General Health Hx Hydrocephalus Autism Cerebral Palsy Allergies: kiwi, pineapple, red dye HPI: VP shunt malfunction (infected shunt) Safety: X ID band X Allergy band X Falls Risk Intravenous (I Type: Fluids Site: L arm Saline Lock: yes Flush: yes IV Solution: Sodium Chloride Rate:70cc/hr X Seizure Precaution Security Monitor Vital Signs 4/1 Isolatioin Type: Standard 02 sat Time Temp BP 8:00a | 98.4° | 109/71mmH | 18bp | 94% Vitals within normal range for age? Yes Activit OOB ad lib X Amb assist X Bedrest Pain Assessment Time (every 4hr &PRN) 800 Pain Scale Used: 1-10 Pain scale Pain Score 6 Clinical Signs/Characteristics: ROM aching, constant headache Turn & position Pain Intervention: Acetaminophen
I have a patient with Chiari malformation, make 3 learning needs and .............. 3 nursing diagnosis (then pick one nursing diagnosis) and have an expected outcome, intervention, and then evaluation. then a nurses note. provide rational and etc (THESE NEED TO BE THOROUGH) provide references if needed

Answer 1

Chiari Malformation is a structural defect of the skull and cerebellum where the part of cerebellum protrudes into the spinal cord (extends past foramen magnum). It can develop when part of the skull is either smaller than should be or mishap. The protrusion causes pressure on the cerebellum and brain stem and CSF can also be blocked.

In the present scenario, the patient is an 11-year-old baby suffered with

*Hydrocephalus

*Autism

*Cerebral Palsy

*Allergies to Kiwi, Pineapple and red dye

*Learning needs of the patient:

The cognitive and physical ability of the child is impaired for the present condition.

We have to improve the physical activity of the child by physical therapy – This therapy can help in improving the coordination, balance and posture.

We have to improve the articulation, language and vocabulary development and word comprehension through a speech therapy

We can help the child in everyday activities and functions such as eating, dressing and using the bathroom by a proper occupational therapy

*Acute pain related to headache

*Impaired physical mobility due to neuromuscular impairment

*Impaired verbal communication related to neurologic impairment

*Care Plan:

Nursing Diagnosis Statement	Expected outcome	Intervention	Rationale	Evaluation
Acute pain related to headache	*After 2-4 hours there is a reduction of pain due to the effective interventions	*Assess for the type of pain, duration, frequency, and intensity *Assess for the provocative factors for pain *Provide a calm and quiet environment for the child * Provide any diversional therapy for relaxation *Administer the drug as prescribed	*To get the baseline data *provide more comfort *Promote relaxation *Enhance mind deviation *Releive from pain	After 2-4 hours the assessment scale shows there is a reduction of pain from 6/10 to 3-4

Nursing diagnosis statement	Expected outcome	Intervention	Rationale	Evaluation
Impaired physical mobility due to neuromuscular impairment	The child will achieve maximum movement ability and absence of contractures.	*Assess the type of auditory, visual, motor, or intellectual deficit. *Allow the child to perform activities or care routines at his or her own pace. *Encourage the child to rest between activities that are tiring. *Perform range-of-motion exercises every 4 hours for the child unable to move body parts.	Knowing the type of deficit will aid in planning interventions appropriate for the child. *A child may have difficulty completing tasks in time compared to normal children. *Given the limitations of the child’s ability, rest periods are given to maintain energy. *ROM exercises promote movement and minimize the risk of contractures.	The child range of motion has been improved to a satisfactory limit

Nursing Diagnosis statement	Expected outcomes	Intervention	Rationale	Evaluation
Impaired verbal communication related to neurologic impairment	The child will verbally make essential needs known to health care providers and family members.	Learn patient needs and pay attention to nonverbal cues. *Maintain a calm, unhurried manner. Provide ample time for the child to respond. *Remove all distractions while talking with the child *Provide an alternative means of communication *Coordinate the child with a speech therapist as indicated.	The nurse should set aside enough time to attend to all of the details of patient care. *Hurrying up the child’s speech will make it less clear and communications will be impaired. *Removing such distractions maintain the focus of the child, and decreases stimuli going to the brain for interpretation. *Hand signs or a picture board allows the client to express oneself if speaking is difficult to obtain. learning how to speak slowly and how to coordinate their lips and tongue	The child is trying to respond by a mode of verbal communication