Melanie Carlson

4/5/04

PERSON
Name: Melanie Carlsons patient (rm 304)
Current Medical/Surgical Diagnoses: Cerebral Palsy w/ mental retardation and chronic seizure disorder;
type 1 diabetes mellitus w/ gastroparesis; osteomyelitis of the left heel; chronic heel ulcers; benign prostatic
hyperplasia
Age: 54 Code Status: Full LEO
Admit Date: 3/23/2004
Transfer Date to LTAC: 4/2/2004
Date of Care: 4/1/2004
P NEED:
This patient is a 54-year-old, 208-pound, 64, single, white male who is well known to the facility. He
has cerebral palsy with mental retardation and seizures. He was admitted on March 23rd, 2004, after an
episode in his doctors office of altered mental status. He apparently had a 15-minute episode of decreased
alertness with unresponsiveness. He recalls being at his doctors office, but does not remember anything
else until the emergency room.
The patient was recently in the hospital (discharged on 3/12/04) for DKA and Dilantin toxicity. His
anticonvulsive regimen was rearranged by discontinuing Dilantin and adding Keppra and Depakote. Upon
admission on 3/23/04, his Depakote level was a bit low and required adjustment while hospitalized. The
patient has not had a recent history of any seizures. On 4/1/04, the patients level of consciousness was
diminished somewhat from the previous day, and the doctor ordered a repeat blood level of valproic acid
(Depakote).
The patient is a resident of Southwood Care Center, but has been evaluated by Cornerstone Hospital and
approved for LTAC on 3/31/04. His physician is currently waiting for approval from his sisters for the
transfer, and for a bed to become available at Cornerstone.
He is a nonsmoker and nondrinker. He is insured by Medicaid and Medicare Part A and B. He has
sisters who are supportive and help to look after him. One sister has told the hospital staff that he often
pretends to understand more than he really does. He was oriented times three upon admission. He has
remained lucid of his location and knows what day it is because he reads the newspaper each morning.
He is able to voice his wants/needs, make simple decisions, and follow simple verbal commands. His
memory is impaired, supported by his lack of name recall of staff (he asked my name 7 times on 4/1/04),
lack of ADL recall (he often doesnt remember getting up to sit in the chair or being assisted to the
bathroom), and his lack of recall of simple activities (how to order a newspaper to his room was explained
each morning). Because of this impairment, it was difficult to obtain a thorough Review of Systems or Past
Medical History from him.
He is not anxious or upset, and told the attending physician upon admission that he felt like he was in his
usual state of health.
Diagnostics: Upon admission, a CT brain scan was performed and revealed atrophy, but no evidence of
acute abnormality.
Meds: Keppra 1500 mg po b.i.d.; Depakote 1500 mg po b.i.d.
Labs: Depakote WNL (50-100) during hospital stay, except elevated on 3/24/04 to 113.4; Depakote level for
4/1/0/4 pending.
E NEED:
Patient has a past medical history of benign prostatic hyperplasia. This can lead to urinary retention and
acute pain, but the patient complains of neither symptom. He is eliminating without difficulty on a regular
basis. He has not had N/V, fever or chills.
Upon admission, the patient complained of chronic constipation. While hospitalized, his medications
have improved this infirmity and caused soft, loose stools. He has a large bowel movement every day; on
4/1/04, it was very soft, orange and odorous. He is often incontinent of urine even though a urinal is at his
1

bedside. He doesnt remember to use it. Because of erythema and scaling on his scrotum, the patient is
lying on an absorbent pad, but does not wear adult diapers for the incontinency. Protective ointment is
being applied to his scrotal area to prevent further skin breakdown.
Meds: Demadex 40 mg po q.am.; Flomax 0.8 mg po q.d.; Colace 100 mg po b.i.d.; Reglan 10 mg po
a.c./h.s.; Os-Cal 500 mg po b.i.d.
Labs: On 3/31/04, BUN 24.0 H; creatinine 0.9.
Diagnostics: On 3/29/04, a urinalysis was performed. Sp gr 1.005; pH 5.0; 1+ leuk esterase; negative for
nitrite, protein, glucose, ketone, bilirubin or WBC; urobilinogen .2; blood 1+; and yeast rare.
R NEED:
The patient does not complain of any pain, and is unable to use a 1-10 pain scale. He has not requested
any pain medication during his hospital stay. Past medical history includes microvascular type 1 diabetes
mellitus with gastroparesis and peripheral vascular disease. Upon admission, his blood sugar was slightly
elevated, but no evidence of DKA or acidosis in spite of acetone being present. He is to continue his Lantus
and be covered with sliding scale insulin (Humalog). Accucheck a.c./h.s. The patient has a past medical
history of hypothyroidism and takes Levothroid to maintain it.
Meds: Actos 15 mg po q.d.; Lovenox 40 mg SQ q.d.; Humalog a.c./h.s. (sliding scale) SQ; Levothroid 0.1
mg po q.d.
Labs: Blood glucose is very sporadic, ranging from 78 to the high 200s. On 4/1/04, morning Accucheck
was 78 (no Humalog admin.); noon was 283 (10 units of Humalog admin.).
S NEED:
ALLERGIES: NKDA
CODE STATUS: Full LEO
The patient has glasses and dentures and needs assistance with ambulation from caregiver and a walker.
When attempting to stand, the patients arms shake and he has difficulty holding his weight on the walker.
While standing, patient has a tendency to lean forward with head down as if tipping over. Upon verbal
reminders, he is able to lift his head and straighten his body. Patient has no IV, with only a heplock at his
left wrist that was started on 3/23/04; CDI. Patient has cerebral palsy with a chronic seizure disorder and
muscle spasticity.
Skin examination reveals numerous sites of skin breakdown. He has Elastogels on both elbows to
prevent pressure ulcers at that site. He has a duoderm on his coccyx, where skin breakdown has already
occurred with signs of erythema and epidermal skin peeling off. It would classify as a Stage I on the verge
of becoming a Stage II pressure ulcer. He has Kerlex dressings to bilateral heels of his feet, along with
cushioned boots to prevent further pressure points. He has a Stage IV pressure ulcer with resolving
osteomyelitis in the left heel. According to wound care physician, granulation buds continue to increase and
there is a small amount of serous yellow drainage. In the right heel, there is a Stage III pressure ulcer with
black hard eschar, green drainage, pitting edema, and surrounding erythema. A podiatrist was being
consulted because the wound care doctor was unable to debride the wound because of the hard eschar. The
right heel is worrisome for infection, and Ceftin is being administered. The right leg has erythema
surrounding the ulcer and coming up the anterior aspect to below the knee. The admitting physician
reported that the patient had what seems like a ruptured bullous lesion on the posterior aspect of the right
calf. Osteomyelitis of the right heel was ruled out on 4/1/04.
Labs: 3/31/04 WBC 7.2; RBC 3.23 L; Hgb 10.1 L; Hct 29.7 L; platelets 269. These values have remained
as such during his hospital stay, with WBC & platelets WNL, and RBC, Hgb & Hct values remaining low
secondary to infection.
Diagnosics: An MRI of the right foot was performed on 3/31/04 to rule out osteomyelitis (bone
involvement). It came back negative for bone involvement.
Meds: Ceftin 500 mg po q.12h.
O NEED:
2

The patients vital signs were stable during his entire hospital stay, with no signs of acute respiratory
distress or fever. The patient does have bilateral edema of his lower extremities, 3+ on the right and 2+ on
the left. A Doppler was done in January to rule out DVTs. However, admitting physician feels his edema is
much worse and has reordered it to be sure he has not developed a clot. (See S NEED for description of
skin.) Bilateral pedal pulses are +1; radial pulses are +3. Heart sounds are regular, with no murmur or
gallop. He has mild rhinitis, with clear drainage from his nose. This could be secondary to Flomax or
Keppra medications.
Blood pressure upon admission was 163/94. During my time with this patient, his blood pressure was
not highly abnormal, ranging in the 150-160s for systolic and 80-90s for diastolic. I did not find evidence in
his chart of a past medical history of hypertension, but he was taking Demadex, a loop diuretic and
antihypertensive agent.
Labs: 3/31/04 CO2 34.0 H; MCV 92; MCH 31.2 H; MCHC 33.9. His MCH has been elevated throughout
his hospital stay.
Meds: Aspirin E.C. 81 mg po q.d.; Demadex 40 mg q.am.; Allegra 180 mg po q.d.; folic acid 1 mg po q.d.;
Flonase 2 puffs q.d.; Trental 400 mg po t.i.d. w/ meals
Diagnostics: Doppler of lower extremities pending.
N NEED:
No recent weight loss; patient is 64, 208 pounds. Appetite is normal. Patient has upper and lower
dentures. Current diet is CHO diabetic diet of 1500 calories. The patients fine motor skills are impaired
and he needs assistance cutting his food and opening containers. He is able to feed himself with only minor
difficulties, and has no trouble swallowing.
Current diagnoses include mild hyponatremia and hypomagnesemia.
Meds: Zinc Sulfate 220 mg po q.d.; Vitamin C 500 mg po b.i.d.

MEDICATIONS
Name: Actos (pioglitazone hydrochloride)
Dosage: 15 mg po q.d. (1 tab)
Classification: antidiabetic; thiazolidinedione
Action: increases insulin sensitivity by affecting insulin receptors; decreases hepatic glucose output and
increases insulin-dependent muscle glucose uptake in skeletal muscle and adipose tissue
Indication: This patient has type-1 DM, with blood glucose levels that vary sporadically.
Side Effects: upper respiratory tract infection; edema & fluid retention; hypoglycemia; mild anemia
Nursing Considerations: This medication states it is contraindicated in type 1 diabetes or treatment of DKA,
which I thought was interesting. It also has a cautious use for patients with hypertension or edema.
Therefore, it is important to closely monitor the patients blood glucose levels, any changes in his lower
extremity edema, and response to medication (peak is at 2 hours).
Name: Aspirin E.C. (acetylsalicylic acid)
Dosage: 81 mg po q.d. (1 tab)
Classification:
Action:
Indication: The anti-inflammatory actions of aspirin should help prevent spreading of his lower bilateral
edema. He also has a risk for DVT in his lower extremitities due to his impaired mobility (aspirin inhibits
platelet aggregation and reduces ability of blood to clot).
Side Effects: N/V; heartburn; stomach pains; hemolytic anemia; bronchospasm, anaphylactic shock
Nursing Considerations: Review diagnostic test interferences that occur with aspirin administration. Give with
food or fluid to minimize gastric irritation. Monitor for loss of tolerance to aspirin. Observe patient for signs of
bleeding or other adverse effects.
Name: Demadex (torsemide)
Dosage: 40 mg po q.am. (2 20 mg tabs)
Classification: loop diuretic
Action: Inhibits reabsorption of Na and Cl primarily in the Loop of Henle and also in the proximal and distal
renal tubules. Has lower potassium-wasting effects than furosemide, and a longer half-life.
Indication: My patients blood pressure is borderline hypertensive. I could not find confirmation in the chart of
a past medical history of hypertension, nor do I know the exact reason for this medication.
Side Effects: hypokalemia, hyponatremia, orthostatic hypotension, headache
Nursing Considerations: This medication states a cautious use warning for diabetes patients. Monitor blood
pressure often and assess for orthostatic hypotension. Monitor serum electrolytes, uric acid, blood glucose,
BUN and creatitine during course of therapy.
Name: Flomax (tamsulosin hydrochloride)
Dosage: 0.8 mg po q.d. (2 capsules)
Classification: alpha-adrenergic antagonist; autonomic nervous system agent
Action: Blockage of alpha-adrenergic receptors can cause smooth muscles in the bladder outlet and prostate
gland to relax, resulting in improvement in urinary blood flow and reduction in symptoms of BPH.
Indication: My patient has benign prostatic hyperplasia. This medication improves his ability to void by
decreasing bladder outlet obstruction.
Side Effects: headache, dizziness;, orthostatic hypotension (w/ first dose), rhinitis, abnormal ejaculation
Nursing Considerations: Monitor for signs of orthostatic hypotension.

Name: Levothroid (levothyroxine sodium)

Dosage: 0.1 mg po q.d. (100 mcg tablet)
Classification: thyroid agent; hormone & synthetic substitute
Action: Synthetically prepared monosodium salt and levo-isomer of thyroxine. T3 and T4 serum levels
increase, and improves diuresis, weight loss and puffiness.
Indication: This patient has hypothyroidism and requires replacement therapy for diminished thyroid function.
Side Effects: insomnia; weight loss; palpitations; irritability
Nursing Considerations: This patient has likely been on this medication for an extended period of time with the
dosage already adjusted to the most effective level. Most adverse effects occur during early adjustment or with
first doses. Baseline and periodic tests of thyroid function are necessary.
Name: Allegra (fexofenadine)
Dosage: 180 mg po q.d.
Classification: H1-receptor antagonist; non-sedating antihistamine
Action: Antagonizes histamine at the H1-receptor site to inhibit antigen-induced bronchospasm and histamine
release from mast cells.
Indication: The patient has rhinitis with drainage.
Side Effects: headache, nausea, fatigue, dyspepsia
Nursing Considerations: Monitor effectiveness; assist patient with proper usage.
Name: Colace (docusate calcium)
Dosage: 100 mg po b.i.d.
Classification: stool softener
Action: anionic surface-active agent w/ emulsifying and wetting properties
Indication: The patient complained of constipation upon admission, but of loose stools by 4/1/04. Miralax was
discontinued on that day, but this medication was not.
Side Effects: diarrhea
Nursing Considerations: Assess patients stools for improvement in symptoms of constipation. This
medication states a cautious use for patients with edema or diabetes mellitus, so edematous sites and blood
glucose levels need to be closely monitored.
Name: Os-Cal (calcium carbonate)
Dosage: 500+ D tabs (1 tab po b.i.d.)
Classification: antacid
Action: Rapid-acting antacid with high neutralizing capacity and relatively prolonged duration of action.
Decreases gastric acidity, thereby inhibiting proteolytic action of pepsin on gastric mucosa. Also increases lower
esophageal sphincter tone.
Indication: This patient has gastroparesis (failure of the stomach to empty) likely caused by diabetic autonomic
neuropathy.
Side Effects: Constipation, flatulence, hypomagnesemia, polyuria
Nursing Considerations: This could be causing his hypomagnesemia. Monitor lab values closely and replete
magnesium as ordered.
Name: Folic Acid
Dosage: 1 mg po q.d.
Classification: vitamin B9
Action: Vitamin B complex essential for nucleoprotein synthesis and maintenance of normal erythropoiesis.
Indication:
Side Effects:
Nursing Considerations:
5

Name: Lovenox (enoxaparin)

Dosage: 40 mg SQ q.d.
Classification: low molecular weight heparin
Action: Antithrombitic properties with effect on TT and aPTT values.
Indication: Due to severe impaired mobility secondary to ataxia and pressure ulcers, this patient is a high risk
for DVT.
Side Effects: hemorrhage, angioedema arthralgia, dyspnea, allergic reactions, pain & inflammation at injection
site
Nursing Considerations: Report signs of unexplained bleeding immediately. Monitor platelets, hct, and hgb
closely.
Name: Zinc sulfate
Dosage: 220 mg po q.d.
Classification: nutrional supplement, mineral
Action: Antithrombitic properties with effect on TT and aPTT values.
Indication: Diabetes mellitus with gastroparesis increases the bodys need for folic acid. Skin disorders (in this
case pressure ulcers) also increase the need for folic acid.
Side Effects: very few adverse effects unless taking large doses or overdosed
Nursing Considerations: Space doses of folic acid 2 hours apart from fiber-containing foods, phosphoruscontaining foods and whole-grain breads & cereals to get full benefit of supplement.
Name: Flonase (fluticasone)
Dosage: 2 puffs per nares q.d.
Classification: adrenal corticosteroid; anti-inflammatory
Action: Antithrombitic properties with effect on TT and aPTT values.
Indication: Due to severe impaired mobility secondary to ataxia and pressure ulcers, this patient is a high risk
for DVT.
Side Effects: transient nasal irritation, burning, sneezing
Nursing Considerations: Usually prescribed for a maximum of four days. Monitor nasal tissue for irritation.
Name: Keppra (levetiracetam)
Dosage: 1500 mg po b.i.d.
Classification: anticonvulsant; CNS agent
Action: Precise mechanism is unknown. It is a broad spectrum antiepileptic which does not involve GABA
inhibition.
Indication: The patient has a history of chronic seizure disorder associated with his cerebral palsy.
Side Effects: Asthenia, headache, infection, somnolence, ataxia, amnesia, rhinitis, cough
Nursing Considerations:
Name: Vitamin C (ascorbic acid)
Dosage: 500 mg po b.i.d.
Classification: low molecular weight heparin
Action: Increases protection mechanism of the immune system, thus supporting wound healing. Necessary for
wound healing and resistance to infection. Must be consumed daily.
Indication: Pressure ulcers, skin breakdown, and risk for infection in the bilateral heel ulcers strongly indicates
a need for vitamin C.
Side Effects: headache, N/V (most adverse effects dont occur until administering high dosage)
Nursing Considerations: Be aware of diagnostic test interferences that may occur when taking vitamin C,
including false-negative tests for occult blood in stools.

Name: Reglan (metoclopramide hydrochloride)

Dosage: 10 mg AC/HS po
Classification: GI agent; prokinetic agent; ANS agent; direct-acting cholinergic (parasympathomimetic);
antiemetic
Action: Exact mechanism of action not clear but appears to sensitize GI smooth muscle to effects of
acetylcholine by direct action. Increases resting tone of esophageal sphincter, and tone and amplitude of upper
GI contractions. As a result, gastric emptying and intestinal transit are accelerated with little effect, if any, on
gastric, biliary, or pancreatic secretions.
Indication: The patient has a past history of gastroparesis associated with his diabetes mellitus.
Side Effects: mild sedation, fatigue, restlessness, diarrhea, hypertensive crisis (rare)
Nursing Considerations: Report immediately the onset of restlessness, involuntary movements, facial
grimacing, rigidity, or tremors. Monitor serum electrolytes.
Name: Trental (pentoxiphylline)
Dosage: 400 mg po t.i.d. w/ meals
Classification: hemorrheologic agent; antiplatelet agent
Action: Useful in restoration of blood flow through nutritive capillary microcirculation that has been
compromised by structural and flow dynamic changes in cerebral and peripheral vascular disorders. Action
mechanism unclear, but drug action interrupts the vicious cycle of tissue hypoxia, sludging and stasis of
capillary blood flow, microthrombotic activity, reduced oxygen delivery to ischemic cells.
Indication: The patient has been diagnosed with microvascular diabetes mellitus with peripheral vascular
disease. He has edema of his lower extremities, and improved blood flow to the feet would greatly improve
healing of the ulcers. Also, due to impaired physical mobility, patient is at risk for DVT.
Side Effects: dizziness, dyspepsia, N/V, angina
Nursing Considerations: Monitor therapeutic effectiveness. Monitor BP because patient also on
antihypertensive treatment. Drug may slightly decrease an already stabilized BP, necessitating a reduced dose of
the hypotensive drug.
Name: Humalog (insulin lispro)
Dosage: sliding scale Accucheck done before meals and h.s.
Classification: antidiabetic agent; hormone & synthetic substitute
Action: Human insulin that is a rapid-acting, glucose-lowering agent that works by increasing peripheral
glucose uptake (esp. skeletal muscle and fat tissue) and by inhibiting liver from changing glycogen to glucose.
Indication: This patient has type-1 diabetes mellitus. Often, before lunch and bedtime, his blood glucose level
is in the 200s.
Side Effects: nausea, tremulousness, palpitation, confusion, ataxia, profuse sweating, and coma
Nursing Considerations: Monitor patient for hypoglycemia from 1-3 hours after injection. Be aware that
insulin injections can cause interference in thyroid and liver function tests, and may decrease serum potassium
and calcium.
Name: Depakote (valproic acid)
Dosage: 1500 mg po b.i.d.
Classification: anticonvulsant; GABA inhibitor
Action: May be related to increased bioavailability of the inhibitory neurotransmitter gamma-aminobutyric acid
(GABA) to brain neurons. Depressesabnormal neuron discharges in the CNS, thus decreasing seizure activity.
Indication: The patient has cerebral palsy with chronic seizure disorder.
Side Effects: N/V, drowsiness, sedation, deep coma & death, liver failure, pancreatitis, bone marrow
depression, prolonged bleeding time,
Nursing Considerations: Be aware that Depakote can cause interference in many serum and diagnostic tests.
Because this patient is on multiple drugs for seizure control, there is an increased risk of hyperammonemia,
7

marked by lethargy, anorexia, asterixis, increased seizure frequency, and vomiting. Report such symptoms
promptly to physician.
Name: Ceftin (insulin lispro)
Dosage: 500 mg po q.12h.
Classification: antibiotic; 2nd-generation cephalosporin
Action: Preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of
susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the
bacterium. Effectively treats bone and joint infections, and skin & soft-tissue infections.
Indication: Due to osteomyelititis in the left heel, and risk for infection in other present pressure ulcers, this
medication is a good choice.
Side Effects: diarrhea, antibiotic-associated colitis
Nursing Considerations: Determine history of hypersensitivity reactions to cephalosporins, penicillins, and
history of drug allergies before therapy is initiated. Perform culture and sensitivity tests before initiation of
therapy and periodically during therapy if indicated. Monitor and report onset of loose stools and/or diarrhea.
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LIST OF APPLICABLE NURSING DIAGNOSES

1. Self care deficit: toileting, bathing, hygiene, instrumental related to general debilitation and
perceptual/cognitive impairment
2. Thought processes, disturbed related to loss of cells/brain atrophy and cerebral palsy
3. Skin integrity, impaired related to inadequate tissue perfusion, prolonged pressure to skin & SQ tissue, and
diminished sensation in lower extremities secondary to peripheral polyneuropathy
4. Urinary elimination, impaired related to impaired ability to recognize bladder cues secondary to cerebral
palsy and diabetic neuropathy
5. Physical mobility, impaired related to ataxia, muscle rigidity and weakness secondary to cerebral palsy,
ulcers on bilateral heels
6. Injury, risk for: Falls related to sensory loss and weakness of lower extremities secondary to pressure ulcers;
ataxia and chronic seizure disorder secondary to cerebral palsy, and lack of awareness of environmental
hazards
7. Infection, risk for related to osteomyelitis of left heel, cellulitis of right lower extremity, and incontinence

CEREBRAL PALSY
Mosbys Dictionary p. 324
Online sources:
http://gait.aidi.udel.edu/res695/homepage/pd_ortho/clinics/c_palsy/cpweb.htm
http://www.neurocarecenter.com/conditions/cp.html
http://www.about-cerebral-palsy.org
Cerebral palsy is a motor function disorder caused by a permanent, nonprogressive brain defect or lesion
present at birth or shortly thereafter. The neurologic deficit may result in spastic hemiplegia, monoplegia,
diplegia, or quadriplegia; athetosis or ataxia; seizures; paresthesia; varying degrees of mental retardation; and
impaired speech, vision and hearing. The disorder is usually associated with premature or abnormal birth and
intrapartum asphyxia, causing damage to the nervous system.
Risk Factors:
highest risk is premature, very small baby who does not cry in the first five minutes after delivery, who
needs to be on a ventilator for over four weeks, and who has bleeding in his brain
babies wtih congenital malformations in systems such as the heart, kidneys, or spine are also more likely to
develop CP, probably because they also have malformations in the brain
Seizures in a newborn also increase the risk of CP
Clinical Manifestations:
Symptoms of the condition vary from mild to severe. Mild symptoms might include speech impairment, fine
motor coordination problems, or mildly awkward movement. More severe symptoms include inability to walk,
speak, or control their own movements. Depending on the type and location of damage to the brain, a child may
have additional problems such as mental retardation, seizures, or language, learning, vision, and hearing
problems. Cerebral Palsy does not get better or worse with time. For most patients, whatever their challenges
are as a child will remain with them throughout their adult life.
Diagnostic Studies:
When an infant or child has brain damage, a variety of symptoms can lead doctors and parents to suspect
that something is wrong, including lethargy, poor feeding abilities, abnormal posture and seizures. During the
first six months of life, other signs of brain injury may also appear in an infants muscle tone and posture. Once
a baby with brain damage reaches six months of age, it usually becomes quite apparent that he or she is picking
up movement skills slower than normal. Infants with cerebral palsy are more often slow to reach certain
developmental milestones, such as rolling over, sitting up, crawling, walking and talking. Parents are more
likely to notice these developmental delays and abnormal behaviors, especially if this is not their first child.
Sometimes when they express their concerns to their physicians, their child is immediately diagnosed as having
cerebral palsy.
More often, however, medical professionals hesitate to use the term "cerebral palsy"at first. When
diagnosing cerebral palsy, doctors must rule out other disorders that can cause abnormal movements. Magnetic
resonance imaging (MRI) and Computed Tomography (CT) scans are often ordered and may provide evidence
of hydrocephalus (an abnormal accumulation of fluid in the cerebral ventricles), or they may be used to exclude
other causes of motor problems. A diagnosis of cerebral palsy cannot be made on the basis of an x-ray or blood
test, though the physician may order such tests to exclude other neurologic diseases.
In conclusion, to make a diagnosis of cerebral palsy, the most meaningful aspect of the examination is the
physical evidence of abnormal motor function, and most children display a defininite and permanent
abnormality by 18 months of age.

Nursing Dx & Support Data

Skin integrity, impaired related to
inadequate tissue
perfusion, prolonged
pressure to skin & SQ
tissue, and diminished
sensation in lower
extremities secondary to
peripheral
polyneuropathy
Support Data
Bilateral pressure ulcers in
heels
Skin breakdown (stage 1) at
coccyx
Mild erythema at elbows;
elastogels applied as protection
Cellulitis & erythema of right
leg
Impaired physical mobility
Need to turn patient q.2h. or
get out of bed to chair
Diabetes mellitus with
peripheral vascular disease

Goal/Outcome
& Outcome
Attainment
1) The patient
will demonstrate
progressive
healing of tissue.

Outcome
Attainme
nt
As I was only
present for one
day, I was unable
to determine
improvement in
the healing of
tissue. However,
interventions
were in place to
prevent further
breakdown and
promote healing.

Nursing Interventions
1a) Cover open pressure
ulcers with sterile dressings
or protective barrier.
1b) Consult with specialist
for treatment of stage IV
pressure ulcers.
1c) Implement measures to
prevent further breakdown.

1d) Perform actions to

prevent infection in wound.
1e) Encourage client to wear
immobilization device.

Scientific Rationale
1a) May reduce bacterial contamination
and promote healing.
1b) MRI may be necessary to determine
bone, muscle or supporting structure
involvement. Wound care specialist has
knowledge of how to promote healing of
stage IV pressure ulcer.
1c) Friction, maceration, shearing and
skin surface abrasion can cause pressure
ulcers. Pressure-reducing/relieving
measures can prevent these.
1d) Infection will delay healing and
increase involvement of underlying
tissues, bone, muscle and supportive
structures.
1e) Reduces risk for trauma to pressure
points.

10

Evaluation
1a) Patient has sterile dressings to bilateral
heel ulcers that are changed and inspected
daily by Wound Care.
1b) Wound care physician comes every day to
inspect the wounds, debride, and apply new
duoderm to coccyx, elastogel to elbows, and
dressings to feet.
1c) The patients linens were changed and his
perineal area washed thoroughly each time he
was incontinent of urine or feces. He was
assisted to a bedside chair, or turned q.2h.
Feet cushioned on pillows at all times.
Protective ointment applied to the scrotal area.
1d) Patient was instructed to avoid touching
dressing or open wounds. Sterile technique
used during dressing changes and wound care.
Ceftin 500 mg q.12h. given to fight infection.
1e) The patient wore bilateral boots in bed and
when in chair. Boots only removed for
dressing changes, wound care and shower.

Nursing Dx & Support

Data
Injury, risk for (Falls)
related to sensory loss and
weakness of lower
extremities secondary to
pressure ulcers and edema
of lower extremities; ataxia
and chronic seizure
disorder secondary to
cerebral palsy, and lack of
awareness of
environmental hazards
Support Data
cerebral palsy with
chronic seizure disorder
ataxia, mucle
weakness & rigidity
spastic arm muscles
while trying to use walker
and get into standing
position
pressure ulcers on feet
and associated decrease in
sensation of lower
extremities
edema of lower
extremities
mental retardation

Goal/Outcome &
Outcome
Attainment
1) Patient will be free
of injury during
hospitalization.

Outcome
Attainme
nt
The goal was
successfully attained
during the patients
hospital stay, before
his transfer to
Cornerstone Hospital.

Nursing Interventions

Scientific Rationale

Evaluation

1a) Change position slowly

to prevent orthostatic
hypotension.

1a) Each time patient was helped into chair or to bedside

commode, his feet were dangled at bedside and he was
asked if dizzy.

1b) Explain importance of

using call light to ask for
assistance before getting up;
keep bedside rails up.

1a) Orthostatic hypotension may

occur as result of venous
pooling, or as a side effect of
medication admin.
1b) Bed side rails help remind
patient to call for help, and
prevent accidental falls from the
bed.

1c) Administer seizure

medication as prescribed.

1c) Prevention of seizure activity

minimizes risk for injury.

1d) Assess functional ability

and extent of impairment.

1d) Identifies potential risks in

the environment and heightens
awareness of risks so caregivers
are more alert to dangers.

1e) Assist/instruct patient

with use of mobility aids.

1e) If patient is knowledgeable

and confident in the usage of a
mobility aid, there will be less
risk for fall.
1f) If patient begins to fall,
caregiver is able to move behind,
slip hands under arms, and assist
patient to a chair or slowly slide
patient to floor.

1f) Stand slightly behind

patient with hands on
patients arms when patient
is ambulating.

11

1b) Patient had no difficulty using his call button, and

understood the importance of asking for assistance to get
out of bed. However, he very seldom asked for assistance
to go to the bathroom and was often incontinent.
1c) Depakote and Keppra are prescribed for the patients
seizures. They are effective on this patient, but it was
necessary to assess his degree of alertness due to their
side effects of somnolence, dizziness, ataxia and fatigue.
1d) Before each task, I usually asked a staff member or
the patient concerning his ability or extent of impairment.
For example, I asked him if he needed help cutting his
food. I asked the nurses if he needed help getting into the
upright position because he was 208 pounds (and I could
not lift him alone).
1e) The patient used a walker to transfer from the bed to
the commode or chair. Due to his memory impairment,
he did not recall how to use it properly and was instructed
each time.
1f) Because of the patients size, I got help each time
before ambulating the patient. On one occasion, when
patient was trying to stand up from bedside commode to
return to bed, he began to fall. As I was behind him and
another nursing student was in front of him, we were able
to catch him and return him to the commode until he felt
more stable.