Saturday, March 3, 2012

Nursing Diagnosis and Interventions for Cerebral Palsy

Cerebral Palsy is a condition lasting damage to brain tissue and not progressive, occurring in a young (since birth) and hinder normal brain development with clinical manifestations may change throughout life and showed abnormalities in the attitude and movement, accompanied by neurological abnormalities in the form of spastic paralysis, ganglia disorders, basal, cereblum and mental disorders.

Nursing Diagnosis for Cerebral Palsy

a. Risk for injury r/t spasms, uncontrolled movements and seizures

b. Impaired Physical mobility r/t spasms and muscle weakness.

c. Changes in growth and development r/t neuromuscular disorders.

d. Impaired verbal communicationr/t difficulty in articulation.

e. Risk for aspiration r/t neuromuscular disorders

f. Changes in thought processes r/th cerebral injury, learning disabilities.

g. Self-care Deficit r/t muscle spasms, increased activity, cognitive changes.

h. Deficient Knowledge r/t home care and therapeutic needs.

Goal :
a. Children will always be safe and free from injury.
b. Children will have a maximum movement ability and not have contractures.
c. Children will explore how to learn and participate with other children in doing some activities.
d. Children will express their needs and develop a body weight within normal limits.
e. Children do not have aspirations.
f. The child will demonstrate an appropriate level of learning ability.
g. Daily needs of the child tetpenuhi.
h. Parents / family demonstrate understanding of the needs of child care that is characterized by taking an active role in child care.
i. Children do not show a marked impairment of skin integrity with intact skin.


Nursing Interventions for Cerebral Palsy

a. The increasing need for security and prevent injury

1) avoid children from harmful objects, for example can be dropped.
2) watch the children during activity.
3) give the kids a break when tired.
4) use safety equipment when necessary.
5) when a seizure; install a safety device in the mouth so that the tongue is not bitten.
6) do suction.
7) the provision of anti-seizure in the event of a seizure.

b. Improve the physical mobility

1) examine the movement of the joints and muscle tone.
2) do physical therapy.
3) do repositioning every 2 hours.
4) evaluation of the needs of special equipment for eating, writing and reading and activities.
5) teach the use of a walker.
6) teach how to sit, crawl in young children, walking, and others.
7) teaches how to reach for objects.
8) taught to move the limbs.
9) teach appropriate ROM.
10) provide a rest period.

c. Increases the need rumbuh flowers in the optimum level

1) examine the growth and development.
2) teaching for early intervention with therapeutic recreation and school activities.
3) Provide appropriate activities, withdrawal and can be done by a child

d. Improve communication

1) examine the response to communication.
2) use the cards / pictures / whiteboards to facilitate communication.
3) Involve the family in training a child to communicate.
4) refer to a speech therapist.
5) teach and assess non-verbal meaning.
6) trained in the use of the lips, mouth and tongue.

e. Improve the nutritional status needs

1) examine the diet of children.
2) Weigh weight every day.
3) provide adequate nutrition and food preferences, lots of protein, minerals and vitamins.
4) Give extra foods that contain lots of calories.
5) Help your child meet their daily needs with the ability

f. Prevent the occurrence of aspiration

1) do immediately when there is suction secretions.
2) provide an upright position or semi-sitting while eating and drinking.
3) examine the pattern of breathing

g. Increase the need for intellectual

1) review the child's level of understanding.
2) teach in understanding conversations with verbal or non verbal.
3) teach writing using whiteboards or other devices that can be used according to the ability of parents and children.
4) teaching reading and writing according to his needs

h. Meet the daily needs

1) examine the level of children's ability to meet daily needs.
2) assist in meeting the needs; eating and drinking, elimination, personal hygiene, dress, play activities.
3) Involve families and for children who are cooperative in meeting their daily needs.

i. Enhance the knowledge and the role of parents in meeting child care needs

1) examine the level of parental knowledge.
2) teach parents to express their feelings about the child's condition.
3) teach parents in meeting child care needs.
4) teach about the conditions experienced by children and are related to physical therapy and exercise needs.
5) emphasize that parents and families have an important role in helping meet the needs.
6) explain the importance of play and socialization needs of others.

j. Prevent to impaired skin integrity

1) examine the area that is attached ancillary equipment.
2) use a skin lotion to prevent dry skin.
3) do the massage in a depressed area.
4) provide a comfortable position and provide support with pillows.
5) ensure that ancillary equipment or dressing appropriately and fixed.

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