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 18-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 standing or walking and is having difficulty swallowing table food that has not been pureed. 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. His weight gain has been slow but steady, and Romel is currently at the 10th percentile on the standard growth charts for both height and weight. Romel is seen monthly by a public health nurse, who has been assessing his health status and development. 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) NAND-I nursing diagnosis (must be an actual nursing diagnosis, not an "at risk for" 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.

Answer 1

Nursing Diagnosis :

Imbalanced nutrition less than body requirements related to inability to ingest food evidenced by difficulty in swallowing,underweight,inadequate calorie intake.

Desired outcome:

Child takes adequate amount of calories or nutrients needed for normal growth.

Nursing Interventions

1. Monitor and record height and weight.

Rationale: These anthropomorphic assessments are vital that they need to be accurate. These will be used as a basis for caloric and nutrient requirements.

2. Assess the infant sucking and swallowing ability.

Rationale: Infants with cerebral palsy often suck poorly due to the uncoordinated movements of the lips, tongue, and jaw and tongue thrusting make them push food out of their mouth.

3. Offer small frequent meals more throughout the day.

Rationale: Adequate time is required between meals to allow for natural swallowing.

4. Position the child upright during feedings.

Rationale: To prevent aspiration of food. Aspiration pneumonia is a risk for a child with poor swallowing.

5. Provide soft and blended foods.

Rationale: Foods can be softened by combining it with milk, juice, or broth to avoid aspiration. Liquids can be thickened to facilitate safety and ease in swallowing.

6. Encourage adequate fluid intake and high fiber foods such as wholegrain cereals, fruit, and vegetables.

Rationale: High fiber diet and increase fluid intake avoid constipation.

7. Offer high protein supplements based on individual needs and capabilities.

Rationale: Such supplements can be used to increase calories and protein and meet the body requirement.

8. Teach the family regarding proper enteral tube feeding as appropriate.

Rationale: Enteral tube feeding is indicated to this child as he is unable to meet nutritional requirements orally.