Peds Patient Profile

8/8/2019 Peds Patient Profile

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ORLANDO TECH

PRACTICAL NURSING PROGRAM

PATIENT PROFILE

Diana Ariza

Olukayode Saseyi



Patient Initials: AV DOB: 01/16/2002 Sex: Female

Age: 8 Yrs Hgt: 41.8 in/106 cm Wgt: 40.5 lbs

Diagnoses:

Cerebral Palsy- Spatic Squad

Patient acquired the cerebral trauma due to misdiagnosis and wrong drug treatment used. Cerebral palsy is

the name given to those cerebral traumas that result in a specific family of symptoms. The spastic form of

Cerebral Palsy is characterized by abnormal control of voluntary limb muscles and by exaggerated reflexes,

sometimes in association with a reduction in muscle tone in the trunk of the body. The muscles are stiffly and

permanently contracted. Making movement awkward and difficult to varying degrees depending upon

severity.

With Full Body Involvement, there are additional complications having to do with eating and breathing due to

the lack of muscle control or the inability of muscles to work together in the normal patterns or rhythms of

contraction.In the pts case, she is not able to be fed due to the lack of muscle tone, therefore she has to be fed

by the feeding pump. Also due to the spasm of muscles, she has breathing problems, which usually leads to an

increase amount of secretions.

The symptoms associated with the spastic form of Cerebral Palsy lessen during sleep and are exacerbated by

stress or voluntary movement .

Developmental Delay

Child development refers to the process in which children go through changes in skill development during

predictable time periods, called developmental milestones. Developmental delay occurs when children have

not reached these milestones by the expected time period. For example, if the normal range for learning to

walk is between 9 and 15 months, and a 20-month-old child has still not begun walking, this would beconsidered a developmental delay.

Developmental delays can occur in all five areas of development or may just happen in one or more of those

areas (to read about the five areas of development). Additionally, growth in each area of development is

related to growth in the other areas. So if there is a difficulty in one area (e.g., speech and language), it is likely

to influence development in other areas (e.g., social and emotional).

Seizure Disorder

brain disorder involving repeated, spontaneous seizures of any type. Seizures ("fits," convulsions) are

episodes of disturbed brain function that cause changes in attention or behavior. They are caused by

abnormally excited electrical signals in the brain.

Seizures ("fits," convulsions) are episodes of disturbed brain function that cause changes in attention or

behavior. They are caused by abnormally excited electrical signals in the brain.

Sometimes a seizure is related to a temporary condition, such as exposure to drugs, withdrawal from certain

drugs, a high fever, or abnormal levels of sodium or glucose in the blood. If the seizure or seizures do not

happen again once the underlying problem is corrected, the person does NOT have epilepsy.



In other cases, permanent injury to or changes in brain tissue cause the brain to be abnormally excitable. In

these cases, the seizures happen without an immediate cause. This is epilepsy. Epilepsy can affect people of

any age.

Epilepsy may be idiopathic, which means the cause cannot be identified. These seizures usually begin

between ages 5 and 20, but they can happen at any age. People with this condition have no other neurological

problems, but sometimes have a family history of seizures or epilepsy.

Almost all seizures are relatively brief, lasting from a few seconds to a few minutes. Most seizures last 1 to 2

minutes. When a seizure stops, people may have a headache, sore muscles, unusual sensations, confusion, and

profound fatigue. These after-effects are called the postictal state. In some people, one side of the body is

weak, and the weakness lasts longer than the seizure (a disorder called Todd's paralysis). Most people who

have a seizure disorder look and behave normally between seizures.

PHYSICAL ASSESSMENT

V/ST:95.0 Axillary

P: 70

R: 22

spO2: 93

Weight: 40.5 lbs

NEURO

Orientation: Alerted, active, hypertonic per norm

Reflexes: no deficits in reflexesPosturing: Chair fast Pupils :PERRL

GENITAL

Female: No signs of menarche

RESPIRATORY Symmetrical

Rate: 22 breaths per min

Retractions: none

Sounds: Labored breathing, Rhonchi and rales

Cough: Active & productive

Secretions: Active- 5 mL

SKINTemperature: Warm

Hydration: Well hydrated & well nourished

Intact: Yes

Jaundiced,Puritis: No

Pain: Pt cant verbally express pain, she shows

uncomfortable facial expressionsWell perfused

CARDIACNo edema present

Rate and quality: Regular HR

Radial p :3+Femoral p: 3+

Color: Pink

Capillary Refill: < 2 sec

Skeletal/MuscleReflexes: No deficits

Range of motion: Limited

Contractures or posturing : present in hands and feet Scoliosis: no present

No acute changes in spasticity

GIAbdomen: Flat

Bowel Sounds: Hypoactive

Feeding Tube: Mic 16 Fr/ 2.5

G/UIncontinent

Color: Amber

Odor: Normal



Eyes, Ears, Nose, Throat:

Cornea clear

Color of sclera: White

Evidence gingival hyperplasia: No

Face: symmetrical

Ears lowest? No

ENDOCRINE

Hx of DM, DI, hypothyroid, adrenal insufficiency?

No

PAST MEDICAL HISTORY

Aspiration Pneumonia Aspiration pneumonia is inflammation of the lungs and airways to the

lungs (bronchial tubes) from breathing in foreign material.

Aspiration pneumonia is caused by breathing foreign materials (usually

food, liquids, vomit, or fluids from the mouth) into the lungs. This may

lead to:

y A collection of pus in the lungs (lung abscess)y An inflammatory reaction

y A lung infection

Aspiration pneumonitis represents chemical damage to the

tracheobronchial tree caused by acute, often witnessed, inhalation of

regurgitated gastric contents in patients with an acute change in mental

status. Aspiration pneumonia results from chronic, usually unwitnessed,

inhalation of small amounts of oropharyngeal contents leading to an

infectious process.

Small Bowel Obstruction A small-bowel obstruction (SBO) is caused by a variety of pathologicprocesses. The leading cause of SBO in developed countries ispostoperative adhesions (60%) followed by malignancy, Crohn'sdisease, and hernias.SBOs can be partial or complete, simple (ie, nonstrangulated) or strangulated. Strangulated obstructions are surgical emergencies. If notdiagnosed and properly treated, vascular compromise leads to bowelischemia and further morbidity and mortality. Because as many as 40%of patients have strangulated obstructions, differentiating thecharacteristics and etiologies of obstruction is critical to proper patienttreatment.

Obstruction of the small bowel leads to proximal dilatation of the

intestine due to accumulation of GI secretions and swallowed air. This

bowel dilatation stimulates cell secretory activity resulting in more fluid

accumulation. This leads to increased peristalsis both above and below

the obstruction with frequent loose stools and flatus early in its course.

Hiatal Hernia condition in which a portion of the stomach protrudes upward into the

chest, through an opening in the diaphragm. The diaphragm is the sheet

of muscle that separates the chest from the abdomen. It is used in

breathing.



The goals of treatment are to relieve symptoms and prevent

complications.

Reducing the backflow of stomach contents into the esophagus

(gastroesophageal reflux) will relieve pain. Medications that neutralize

stomach acidity, decrease acid production, or strengthen the lower

esophageal sphincter (the muscle that prevents acid from backing upinto the esphagus) may be prescribed.

Bowel/ Bladder Incontinence Fecal incontinence is the inability to control your bowels. When

you feel the urge to have a bowel movement, you may not be ableto hold it until you get to a toilet. Or stool may leak from the

rectum unexpectedly, sometimes while passing gas.

Fecal incontinence can be caused by injury to one or both of the

ring-like muscles at the end of the rectum called the anal internaland external sphincters. The sphincters keep stool inside. When

damaged, the muscles aren¶t strong enough to do their job andstool can leak out. In women, the damage often happens when

giving birth. The risk of injury is greatest if the doctor uses forcepsto help deliver the baby or performs an episiotomy, which is a cut

in the vaginal area to prevent it from tearing during birth.Hemorrhoid surgery can also damage the sphincters.

Myringotomy tubessurgical procedure in which a small incision is made in the eardrum (the

tympanic membrane), usually in both ears. The English word is derived from

myringa, modern Latin for drum membrane, and tome, Greek for cutting. It is

also called myringocentesis, tympanotomy, tympanostomy, or paracentesis of

the tympanic membrane. Fluid in the middle ear can be drawn out through the

incision.

Ear tubes, or tympanostomy tubes, are small tubes open at both ends that are

inserted into the incisions in the eardrums during myringotomy. They come in

various shapes and sizes and are made of plastic, metal, or both.

y GT care with soap and water once per day and PRN

y Nasopharyngeal suction PRN with red rubber cathetery Utilize AFOs & splints as directed by Doctor and therapist

Upper Gastrointestinal Bleed

6/16/2009

The underlying mechanisms of nonvariceal bleeding involve either arterial

hemorrhage, such as in ulcer disease and mucosal deep tears, or low-pressure venous hemorrhage, as in telangiectasias and angioectasias. In

variceal hemorrhage, the underlying pathophysiology is due to elevatedportal pressure transmitted to esophageal and gastric varices and resulting

in portal gastropathy.



Duodenal ulcer disease is strongly associated with Helicobacter pylori

infection. The organism causes disruption of the mucous barrier and has a

direct inflammatory effect on gastric and duodenal mucosa. Eradication of

H pylori has been demonstrated to reduce the risk of recurrent ulcers and,

thus, recurrent ulcer hemorrhage.

Allergies: Not Known Drug Allergies

What Immunizations should have at this age?

y rotavirus vaccine- 2 or 3 doses 2 months, 4 months, 6 months.

y Influenza vaccination

y Haemophilus influenzae type b (Hib) conjugate vaccine- Vaccine: 3 or 4 doses 2

months, 4 months, 6 months, 12-15 months

y Hepatitis B - 3 doses Birth, 1-2 months, 6-18 months

y DTaP-Diphtheria, Tetanus & Pertussis- 5 doses 2 months, 4 months, 6 months, 15-

18 months, 4-6 years

y Pneumococcus - 4 doses 2 months, 4 months, 6 months, 12-15 months

y Polio- 4 doses 2 months, 4 months, 6-18 months, 4-6 years

y Meningococcal

y Hepatitis A- 12-23 months of age

y Measles, mumps, and rubella- 12-15 months of age

y Chicken Pox

y Varicella

GROWTH AND DEVELOPMENT

How the disease affects the normal G&D

Stage according to Ericksons stages of development

Where she should be?

Long term effect on the future of this child

SURGICAL AND DIAGNOSTIC PROCEDURES

Name of Procedure Description of Procedure Procedure Results Nursing Interventions & Pt

education (2)

X-RAY Sound waves are sent toward the

organ through a handheld device

that a technician glides over the

Shows a mass and

surgical clips noted

Education about the procedure isgiven to the patient. It is a non-invasive procedure with sound



Why was this ordered? abdomen. The sound waves

bounce off the organs, and their

echoes make electrical impulses

that create a picture - called a

sonogram - on a video monitor. If

there is any hernias or bowel

obstructions, it will bounce off theimage.

behind the heart.

Related to Hiatal

Hernia

Small bowel

obstruction

waves imaging to scan the pancreassize.It is a painless test where a machinewill move while taking the imagesnecessary.

Patient has to remove jewelry,

glasses, and any metal objects.

FUNDOPLICATION

Why was this ordered?

Decompression done

but SBO persisted,

Laparotomy

16 french for Nissan-

type fundoplication

Pre-procedure

Post Procedure

ABNORMAL LAB WORK

Lab Test 1st

Abnormal Most Recent Values Normal ValuesHemoglobin 12.7 15.7 34-40

Hematocrit 39.5 45.9 9.4-14.3

Platelet 313CRP 16.3

Serum Creatinine 0.34 mg/dLNa 131 135-145 mmol/L

K 4.2 3.5-5.0

Ca 9.2 8.5-10.5

Cl 102 98-110

Glucose 148 70-100

BUN 11 5-25

Creatinine 0.37 0.2-0.7

Albumin 3.6 3.2-5.5 WBC 10.7 5.5-15.5

RBC 5.38 4.11-5.59

TREATMENTS AND RATIONALE

Treatments RationaleDIET:Pediasure 5 cans per dayBolus over 1& ½ -2 hrsFlush 180 cc with H2O

Main goal is to give nutritional supplements since patient is not able to eatregular meals.

Also due

Vital Signs: q 4 Hrs Assess any symptoms of Hypertension, any signs or symptoms of distress. Assess for any symptoms of hypoxia by checking the O2 sat and make suresuctioning is done PRN. CPT and postural drainage ABI Vest used to drainsecretions and prevent O2 <90%

I&O Intake and output are important measures to take, to prevent any edema or pulmonary edema due to the inactivity. Also to prevent any dehydration due tothe lack of Liquid intake.

Activity Level Patient is wheelchair bound but any increase of activity level will help with thedecrease of edema or prevent any pulmonary problems due to secretions. It



will help move secretions and let her breath better. It helps with the cognitivelevel as well as her psychological well-being.

PositioningEvery 2 hrsrepositioning

Helps patient to move secretions to prevent a relapse of aspiration pneumonia.Prevents any edema since pt is chair fast. Helps with Range of motionexercises needed to prevent contraction and further level of spasticity.

Catheters N/A

Blood Glucose/Accuchecks everyphysical

Blood glucose level determines the need for insulin and how the Pediasureand medicine might affect her glucose levels.

Special mattresses N/A for Children¶s carePt sleeps for 1 hr in an elevated mattress, restrained to not fall, and positionedon left side, to help move secretions.

Rehab P.T.- activities and education to improve flexibility, strength, mobility, and function. Cognitive skills and fine motor coordination therapy implemented to increaseher level of control. Standing frame, ROM and gait trainer has been used.O.T.- helps to learn physical skills she needs to function and become as independent as possible. Occupational therapy uses people's strengths to help them cope with their disabilities. Pt. is developing head and neck control when she wants. She

responds to verbal directions to reposition herself. Exercises to help her control her extremities without any help and with self-determination has beenimplemented.Botox injection applied to help with the muscle spasticity; pt showedimprovement so further therapy will be used.Speech Therapy- enable pt to make maximum use of their communication skills inexpressing their ideas and understanding those expressed by others Pt has class witha teacher to increase her cognitive level. Pt has not been able to say any word.Her way to communicate is by pressing buttons or choose cards that say ³Yes´or ³No´Resp. Therapy- Pt is evaluated for medicine prescribed for removal of secretions. Chest therapy and ABI Vest used to help move secretions andprevent any pneumonia. Suctioning is scheduled every 2 hours or PRN with

nebulizer medicine to improve asthma symptoms as well as bronchodilator.Play Therapy Improves emotional and social development; reduce aggression; improvecooperation with others. Helps pt to improve cognitive level as well as tointeract with the outside environment. Pt responds well to play therapy andenjoys listening to music. Most of the treatment is to influence the music in her therapy in order to see improvement. Play also induces laughter, which we allknow is the best medicine. Playing also increases hand-eye coordination, canaid in developing fine motor skills, and as they get older, can aid in developingtheir gross motor skills

School Patient goes to class at 9:30 a.m. for 1 hour with a one-to-one contact toincrease cognitive level. Pt responds well to the teacher and the learningmaterials offered, such as colors, figures and music to implement newvocabulary words. Although patient doesn¶t speak, pt is able to show with armsand with facial expressions the likes and dislikes of material. She is able tofollow commands and follow objects and persons when hiding. Teacher implements a lot of exercises for her to recognize when something is in front of her or not. Pt has been showing improvement.

AGE & DIAGNOSIS APPROPRIATE PLAY ACTIVITY & EDUCATIONAL ACTIVITIES

Play activities-



Voice Instructional Equipment with buttons:

Pt likes to hear the voice of a person with the instructions of what she has to do. Pt seems to be able to

press buttons and loves to be able to be independent to do so. Therefore we think it is important to

improve her independency level during class. We can record certain activities explaining what she has

to do, and she is able to pick and choose what she is able to do next, by having different color and

figures in each figure that has the recording. For example, we can use a 4 color table that has 4 different

recording with instructions to choose the color she would like to learn that day. In the color she chooses,

we can describe certain objects and places she can find those colors.While she listens to it, we can give

her the objects so she is able to touch them and play with her hands. This will introduce the touching

and listening activities to improve her vocabulary as well as to learn how to follow instructions.

Since she is choosing the buttons, she will feel a sense of independence and will motivate her to keep

learning and playing. By choosing the different instructions and colors, it also helps with the

neurological development.

Music-

Pt loves and recognize music as an enjoyment time. Not only she is able to recognize the sounds and

follow them but she also move her extremities in order to show enjoyment. This can help her with her

motor development as well as cognitive. It will be great to implement new words and rhythms into her

play therapy so she can increase her cognitive level. "Play permits the child to resolve in symbolic form

unsolved problems of the past and to cope directly or symbolically with present concerns. It is also his

most significant tool for preparing himself for the future and its tasks." Bruno Bettelheim . Therefore it is

important to implement music that helps her interact with other classmates and learn their ways tomove. She tries to imitate their moves, which are important to her physical development and

improvement. Although the pt is not able to move like she would like to, she feels secure trying to move

her extremities and following the example that kids or any person who is playing with her is doing. This

help with her self-expression, adjustability, and potential for interaction.

Music helps the patient to feel secure around sounds and different voices. It will help her to get used to

different directions by different voices, rather than to focus on the everyday people she interacts with.

Also it will help with her motor skills, balance and coordination, by following the rhythm and anyone

around her.

School- Pt receives classes in the morning in the Children¶s care Campus. She is currently ingrade _____. The main activities during her class days are the implementation of new words

into her vocabulary. They used figures that are used everyday (such as fruits, paper and

geometrical figures) to relate it to the colors as well as toys that she can touch. Pt seems to be

able to recognize the colors, once she is able to feel them or associate them in any way with

touch.



Pt reacts positively to music, therefore teacher implements music into the learning activities

such as learning the colors and the rules of behavior while in class. Pt is able to move her head

and hands (even though is not completely in control) following the songs. She follows the

teacher around and gets excited when she hears the music she likes. She enjoys the music

where she sees her classmates dance and the ones that she is able to move her arms to follow

their movements.

Equipment or assistive devices

Patient has to be wheelchair bound in order to move around. In her wheelchair she has to carry

a portable suctioning machine to clear up secretions. She carries her Feeding tube pump in

order to have her feeding every 2 hours at least.

The personnel that go with the child should be somebody who knows the scheduled feeding,

medicines and suctioning. Also somebody who knows to look for Oxygen needs and who knows

that any accumulation of secretions should be avoided as much as possible. They should be

instructed in how to use the suctioning machine as well as the feeding pump.

MEDICATIONS

Medication and doseordered

Safe range ascalculated from

drug guide

Is the Dose safe? If it is outside the

therapeutic rangewhy is it still given?

Why was it ordered?

Albuterol 2.5mgnebulizer tid by

updraft

By dilating the bronchii itwill help patient open theairways and allowsecretions to be coughedout easily

Pulmicort 0.5mgnebulizer bid by

updraft

This is a locally actingsteroid for inhalation, itwill reduce the associatedinflammatory reactiongoing on in the lungs,reduce the amount of secretions and edemathereby improving air entry.

Foradil I caps for inhalation bid byupdraft

Causes bronchodilation inthe patient improvingbreathing

Keppra 500mg bid viang tube

This is an anticovulsantused to reduce frequencyand severity of seizuresthereby helping the childto be quiet and relaxed.

Robinul 1mg qid viang tube

It is used to reducesecretions in therespiratory tract and theGI tract, reducedsecretions promotes air



way patency.

Zantac 200mg at bedtime via ng tube

An anti ulcer drug thatworks by inhibiting protonpumps in the stomachthereby reducing acidity,patient is post

fundiplication, medicationwill help reduce impact of acid on the esophagus

Miralax 8.5mg via ngtube prn

This is used to evacuatethe GI, because mosttimes children withcerebral have problemswith elimination due to uncoordinated and in -effective peristalsis

CARE PLAN

DATE ASSESSMENT/NURSINGDIAGNOSIS

GOAL INTERVENTIONS/NURSING MEASURES &RATIONAL

10/25 /10 Nsg. Dx : : Ineffective air

way clearance, as

evidenced by noisy

breathing, ineffective cough,

decreased air entry in both

lung fields, presence of

crackles, rhonchi and rales

sounds , SPO2<92%

Related to abnormal

voluntary and involuntary

motor performances due to

cerebral palsy

Stmt:Child will have a patent airway

in the next 30 mins

She will have good air entry in

both lung fields in the next 3

mins

Her lung sounds will be

vesicular in the next 3 mins

She will produce less secretions

in the next 2 days

All secretions produced will be

expelled or removed promptly

SPO2 will remain at 96% or

above at all times.

1. Position child in an upright or head

position, or on the side when lying do

at all times, the rationale is that thes

position help prevent blockage of airw

by accumulated secretions.

Suction nasopharynx and oropharynx

necessary as prescribed this will remo

accumulated secretions and eventually

clear the airway.

AEBO2 sat check every 4 hrs suctioning PRN

2. Administer bronchodilator, inhalatio

corticosteroids, prescribed by doctor in

updraft breathing mask, the rationale

that updraft breathing treatment

containing bronchodilators and



corticosteroids help loosen secretions

bring them upward in the bronchioles

be expectorated.

3. Administer anticholinergic as prescr

the rationale is that this class of medication reduces the amount of

secretions produced

Administer chest physiotherapy treatm

through an ABI vest, as prescribed, th

will help loosing secretions, thereby

making easily available for suctioning.

Nsg. DxDelayed growth and

development as

evidenced by

delayed milestones,

[ child is 7 years

old, but she is still

non verbal,

minimally controls

neck muscles, no

cordinations in all

limbs, child cannot

grasp or hold any

object, child cannot

recognize or smile

to a familiar face or

objects, child is

totally in continent

of urine and feces],

as related to

cerebral palsy.

Stmt:child will progressively be able

to demonstrate some form of communication pattern, that is

within the scope of her

functional development that is

appropriate for age and present

capabilities in the next 6 months

Child will be able to show

recognition of familiar of familiar

objects or faces in the next 2

months

Child will be able to participatein a learning program

Child will be involved in play

activities with other children

Child will be able to initiate

some vocal sounds

1.

C ollaboratively provide physical thera

to help child gain some control of

muscular coordination and movement

Collaboratively provide occupational

therapy to help child develop ability t

use hands to grasp objects

Collaboratively provide speech therap

help child have some verbal means

means of expressing self

2. Administer medications as prescribe

to decrease muscle spasticity eg baclo

Encourage communication and

interaction with another child at her

developmental level, this will help her



learn from the other child and help in

setting limits and internal guidance

3. Provide a quiet and calm

environment for child to observe her

surroundings this will lessen distractioand allow child to focus on other thin

in the environment

Provide appropriate toys for the child

developmental level, this will serve as

ritual objects to which the child can t

to sometimes for comfort and reducti

of anxiety

Measure developmental level using

age appropriate tests such as DENVER

DEVELOPMENTAL SCREENING TEST, no

alteration in functional level, this will

provide comparative baseline and bas

for choosing developmentally appropri

interventions.

Nsg. DxRisk for injury and falls

related to muscular

spasticity and spontaneousseizures AS EVIDENCED BY

last episodes througho put

the year. Medical history

proves risk for falls during

seizures due to w/c bound

Stmt: child will be able to move

from one point to the other

without sustaining any injury or

falls.

1. When in upright position provide

wheel chair restraint as ordered at al

times this will prevent child from bolt

out of chair without warning,

Provide mattress restraints when lying

down, this will prevent her from rollin

off the mattresss on to the floor

Place childs mattress on the floor, t

will minimize injury incase she rolls of

the mattress

2. Administer anticonvulsant as ordere

this will reduce the reduce the freque

and severity of seizures

Provide a safe environment by remov

sharp objects from childs immediate

vicinity



Do not leave child unattended when

without restraints at any time.

3. Provide information regarding suppo

services and community agencies.

Review home situation for safety

hazards, ascertain parent or caregiver

knowledge of safety needs and injury

prevention in home setting this will

promote a safe environment, reduce t

impact of repeated concussion which

might have been underestimated

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