a list of the signs and symptoms of cerebral palsy are listed here at the website below. if you patient has any of these, then use them for your aeb items to support your nursing diagnoses:
- information on cerebral palsy including the pathophysiology and symptoms.
- another article from emedicine on cerebral palsy
- this is a site within emedicine written for the health consumer so is a little easier to read. there is a link to an 18-page (not long pages) write up about the symptoms as well as for treatment and therapies. well worth reading.
you should probably use diagnoses like this (i have sequenced them in order of priority by maslow's hierarchy of needs):
- imbalanced nutrition: less than body requirements r/t feed and swallowing difficulties due to spasticity aeb body weight 20% below ideal for a 60 inch tall female, patient reports that it is difficult to physically feed herself, and patient reports of difficulty swallowing [physiological - food]
- impaired physical mobility r/t neuromuscular impairment aeb by spastic movements and poor balance aeb observed unstable posture while standing and attempting to perform adls, observed limitation in gross motor movements of arms and legs, spastic gait, swaying while standing and walking and difficulty beginning a step [physiological - movement]
- impaired verbal communication r/t facial muscle spasticity aeb physical difficulty forming words, slurring of words and drooling [safety] http://www1.us.elsevierhealth.com/me...ex.cfm?plan=11 http://www1.us.elsevierhealth.com/ev...replan_015.php
- risk for injury r/t inability to control spasticity [anticipatory problem - safety] http://www1.us.elsevierhealth.com/ev...replan_043.php
i've only given you items for your diagnostic statements that i think might apply to your patient. they are based on my experiences over the years with patients who have cerebral palsy. of course, only you know what your patient was like and capable of doing or not doing. it's very hard at first to put down on paper what we observe with our eyes so very quickly. so, it helps to look at some written resources. that is why i've given you four websites to go to for information about cerebral palsy. as you read through those sites think back to what you observed in your patient. if she had one of those signs or symptoms, then write it down immediately before you forget it again. that will be usable information for your care plan. feel free to change anything i've given you as this is your patient.
you should address your nursing interventions to the items that follow the aeb part of each of your nursing diagnoses. these are the actual signs and symptoms (abnormal data) that you observed in your patient. these are the things that as a nurse you will assist in helping her with. you may need to do some hunting around in nursing and other textbooks to find appropriate interventions. if you have to develop outcomes, the websites for the nursing diagnoses i've listed for you have outcomes listed for them.
for all your subsequent patients, go through their charts. take down information from the doctor's history and physical, any consultant's reports, labwork results, x-ray results, physical therapy evaluations (would have been very helpful in writing this patient's care plan), dietary evaluations, speech therapy evaluations, respiratory therapy notes, the nursing admission history items especially those things addressing the patient's ability to perform adls, medications being taken, treatments ordered, and the doctor's progress notes. this is all data that is going to prove important to use when putting together a care plan for a patient. just because you weren't the person who got this information from the patient doesn't mean you can't use it. it's in her chart, it's up for grabs to be used. you don't have to duplicate their work with the exception of your own review of systems and physical examination.
hope this gets you moved along farther in completing this care plan. good luck. you can always feel free to private message me for help with a care plan.