NURSING CARE PLANS

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1. Ineffective cerebral tissue perfusion 2. Decreased intracranial adaptive capacity 3. Imbalanced nutrition: less than body requirement 4. Delayed Growth and Development 5. Risk for impaired skin Integrity

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Problem No. 1: Generalized weakness (December 7, 2011)

Cues: Subjective: hindi siya gaanong magalaw, nakahiga lang siya diyan, tahimik. As verbalized by the mother. Objective: Generalized weakness, irritability, weak cry, lethargy, visible and dilated scalp veins, bulging of the soft spot on top of the head, head circumference of 39 cm, Papilloedema
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Papilloedema

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visible and dilated scalp veins

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Nursing Diagnosis:

Ineffective cerebral tissue perfusion related to decreased arterial or venous blood flow secondary to vascular impeding from increase ICP due to fluid congestion.

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NOC: Neurological status, Tissue Perfusion: Cerebral, Circulation status

Short-term goal: After 8 hours of nursing intervention, client will not manifest further CNS deterioration as evidenced by maintenance of level of consciousness as evidence by normal N/V signs, improvement of alertness, feeding and cry. Long-term goal: After 2 days of nursing intervention, client will be able to maintain CNS stabilization as evidenced by maintenance of level of consciousness as evidenced by normal N/V signs and improvement of alertness, feeding and cry.
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NIC: Cerebral Perfusion promotion

INDEPENDENT: Monitored vital signs noting: a. Heart and rhythm, auscultated for murmurs Changes in rate, especially in bradychardia, can occur because of brain damage. b. Respirations Irregularities can suggest location of cerebral insult or increased intracranial pressure

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2. Evaluated pupils, noting size, shape, and equality, and light reactivity Pupil reactions are regulated by the Oculomotor (III) cranial nerve are useful in determining whether the brainstem is intact. 3. Positioned head slightly elevated (30 degrees)and in neutral position. Reduces arterial pressure by promoting venous *drainage and may improve cerebral circulation and perfusion. 4. Maintained rest and provided a quiet environment. Continual stimulation can increase Intra-cranial pressure and cerebral edema.
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 Collaborative: 1. Administered supplemental oxygen as indicated Reduces hypoxemia 2. Administered acetazolamide specific dose, frequency, route as prescribed by the physician. Drug action: Acetazolamide was known to decrease production of cerebrospinal fluid that would decrease intra cranial pressure. Given 120 mg. pptab..

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Evaluation:
Short term goal: GOAL MET: After 8 hours of nursing intervention, client have not manifested further CNS deterioration as evidenced by maintenance of level of consciousness as evidenced by normal N/V signs, improvement of alertness, feeding and cry. Long-term goal: GOAL MET: After 2 days of nursing intervention, client was able to maintain CNS stabilization as evidenced by maintenance of level of consciousness as evidenced by normal N/V signs and improvement of alertness, feeding and cry. Page 11

Problem no.2: Bulging fontanels, lethargy (November 8, 2011)

Cues: Subjective: Parang and daming tubig sa ulo nya, lumalaki at bumibigat ulo nya as verbalized by the mother Objective: Scalp shiny, bulging fontanels, veins on head are visible, immobility of the head, lethargy, head circumference of 39cm , Glasgow coma scale score of 12, Papilledema.

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Nursing Diagnosis:

Decreased intracranial adaptive capacity related to compression of the brain tissue due to increased cerebrospinal fluid secondary to increased intracranial pressure

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NOC: Tissue Perfusion : Cerebral, Neurologic Status

Short-term goal: After 8 hours of nursing interventions, patient will be free from sign and symptoms of increased intracranial pressure as evidenced by increased score of GCS to 13 ,free from alteration of level of consciousness and decreased head circumference of at least .5 to 1cm. Long-term goal: After 2 days of nursing interventions, patient will be able to maintain improved adaptive capacity as evidenced by further enhancement of the level of consciousness and alertness, GCS score of 15 and continuous decrease of head circumference.

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NIC: Cerebral Perfusion Promotion

Independent: 1. Monitored vital signs noting: a.Heart and rhythm, auscultated for murmurs Changes in rate, especially in bradychardia, can occur because of brain damage. b. Respirations Irregularities can suggest location of cerebral insult or increased intracranial pressure c. Pupils, noting size, shape, and equality, and light reactivity Pupil reactions are regulated by the Oculomotor (III) cranial nerve are useful in determining whether the brainstem is intact. Page 15

3. Performed neurologic assessments at least q2h, including the Glasgow Coma Scale, pupillary response, and strength. Allows for continuous monitoring of the patients condition and allows for early detection of complications and capacity for the adaptive response. 4. Measured the infants head daily To monitor and assess the increase of intracranial pressure. 5. Firm, soft, pillow was placed under the infants head To reduce pressure of the increasing weight to the thin skin of the infant preventing pressure ulcers to develop. 6. Repositioned the head of the infant every two hours as permitted. To decrease the risks of developing pressure ulcer on the side where the infant rests. Page 16

6. Kept the infants head and linens clean and dry To prevent further skin infections 7. Promoted precaution in handling the infants head To prevent the occurrence of further injuries 8. Positioned head slightly elevated (30 degrees) and in neutral position. Reduces arterial pressure by promoting venous damage and may improve cerebral circulation and perfusion.

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Collaborative:
Administered acetazolamide specific dose, frequency, route as prescribed by the physician. Drug action: Acetazolamide was known to decrease production of cerebrospinal fluid that would decrease intra cranial pressure. 120 mg. pptab.

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Evaluation:
Short-term goal: GOAL MET: : After 8 hours of nursing interventions, patient was
free from sign and symptoms of increased intracranial pressure as evidenced by increased score of GCS to 13 ,free from alteration of level of consciousness and decreased head circumference of at least .5

Long-term goal: GOAL MET: After 2 days of nursing interventions, patient was able
to maintain improved adaptive capacity as evidenced by further enhancement of the level of consciousness and alertness, GCS score of 15 and continuous decrease of head circumference.

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Problem no.3: Difficulty in feeding (November 8, 2011)

Cues: Subjective: Nahihirapan siya dumede, kaya ayan payat niya tuloy as verbalized by the mother. Objective: Weight of 2.4 kg, difficulty in feeding, difficulty of swallowing, lethargy, generalized weakness. Amount of intake is 120 cc of bottle-fed milk breastfeeding of 4 times for 20 minutes per shift.

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Nursing Diagnosis:

Imbalanced nutrition: less than body requirement related to inability to ingest feedings secondary to compression of cerebellum.

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NOC: Nutritional Status: Food and fluid intake, Nutritional status: nutrient intake
Short-term goal: After 1 hour of health teaching, mother will be able to demonstrate appropriate breastfeeding techniques and positioning. Within the shift, Patient will be able to tolerate expected feeding of breast milk 30 minutes every 2 hours or . Long-term goal: After 2 days of nursing interventions, patient will not manifest further weight loss will manifest weight gain from 2.4 kg to 3 kg

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NIC: Nutrition management, Nutrition monitoring

1. Monitored vital signs every four hours or as required. Allows early detection of further complications 2. Obtained the infants weight at same time each day, using the same scale To ensure early recognition of excessive weight loss. 3. Monitor hydration status Insufficient intake can lead to dehydration.
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4. Feed the infant on a regular schedule that offers nutrients appropriate to metabolic needs. The stomach capacity and digestive concerns for each patient must be considered to realistically plan for weight gain over a slow, steady, incremental time frame. 5. Recorded frequency of feeding as well as ingestion of any supplement To aid in early recognition of inadequate caloric and fluid intake 6. Elevated the head of the bead and if necessary, hold the infant during breastfeeding Facilitates digestion and provides interactive times with the caregiver (parents) Page 24

7. Assessed parents knowledge of feeding techniques. Early detection of knowledge deficits and appropriate instruction help eliminate misconception. 8. Taught appropriate breastfeeding/ formula feeding position and techniques Enhances feeding and prevents difficulty of swallowing. 9. Warmed foods and formula as needed, and test on wrist before feeding the infant or child. Safety for potential hyperthermic injury

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Collaborative:
1. Collaborated with the dietitian in planning and teaching diet Gives baseline from which to plan better nutrition 2. Administered Vitamins and minerals as prescribed by the physician To add nutritional supplements necessary for weight gain.
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Evaluation:
Short term goal: GOAL: After 1 hour of health teaching, mother was able to demonstrate appropriate breastfeeding techniques and positioning. Within the shift, Patient was able to tolerate expected feeding of breast milk 30 minutes every 2 hours. Long term goal: GOAL: After 2 days of nursing interventions, patient have not manifested further weight loss and has gained weight from 2.4 kg to 3 kg.
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Problem No. 4: Underweight, Lethargy (December 7, 2011)

Cues: Subjective: Maliit talaga siya, tahimik lang, at di nagkikilos-kilos as verbalized by the mother Objective: Infants current weight of 2.4 kg, lethargic, generalized weakness, deterioration of gross motor skillcomplete head lag, regression of reflexes manifested by weak grasp reflex, cries whenever he was being touched, has difficulty in swallowing.

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Nursing Diagnosis:
Delayed Growth and Development related to impaired ability to achieve developmental tasks secondary to CNS deterioration and poor stimulation due to hospitalization

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NOC: Child development: 2 months

Short-term goal: After 2 hours of health teaching, primary caregiver will understand the cause of developmental delay by explaining the cause with his/her own words and enumerate 3 ways to stimulate patient to promote developmental advancement. After 8 hours of nursing interventions, patient will be able to manifest enhanced growth and development as evidenced by improvement of level of consciousness Long-term goal: After 2 days of nursing interventions, the primary care provider will adhere to stimulation activities and the patient will be able to maintain or improve from present condition.
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NIC: Developmental Enhancement- child

1. Positioned infant with proper support. Promotes neurobehavioral integration 2. Obtained daily weights. To determine if feeding pattern is sufficient to promote adequate growth. 3. Provided experiences that add to security, such as soft sounds and touch. To form a sense of trust to the child.
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4. Promoted strategies to facilitate infant attachment Parents may be facing issues relating to long term care or quality of life that decreases their attachment to the infant. 5. Educated the parents about the normal developmental milestones and associated behaviors. Provides anticipatory guidance and allows the parents to participate in the infants care 6. Educated mother about appropriate breastfeeding or bottle-feeding To inform the mother of what to expect in normal feeding pattern
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Collaborative:
1. Collaborated with physical therapists and Nutrition and dieticians to develop a plan of care. It provides opportunities for optimizing the development potential and reinforcing the plan of care

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Evaluation
Short term goal GOAL MET: After 2 hours of health teaching, the primary caregiver have understood the cause of developmental delay by explaining the cause with his/her own words and enumerating 3 ways to stimulate patient to promote developmental advancement. Long term goal GOAL MET: After 2 days of nursing interventions, the primary care provider had adhered to stimulation activities and the patient was able to maintain or improve from present condition.
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Problem No. 5: Shiny scalp with visible dilated veins and redness on pressure area (November 8, 2011)

Cues: Subjective: Halatang halata yung mga ugat niya sa ulo at hindi nya masyadong maigalaw yung ulo niya, as verbalized by the mother. Objective: Shiny scalp, bulging fontanels, veins on head are visible, immobility of the head, placed on just one side, redness on pressure area, head circumference: 39cm

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Nursing Diagnosis:

Risk for impaired skin Integrity related to pressure on scalp from decrease physical mobility and expansion of skull due to fluid accumulation.

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NOC: Tissue integrity: skin and mucous membranes

Short-term goal: After 30 minutes of health teaching, primary caregiver will be able to change the infants position as scheduled. After 8 hours of nursing interventions, patient will be free from skin breakdown as evidenced by absence of lesions and further redness of pressure area. Long-term goal: After 2 days of nursing interventions, patient will be able to maintain skin integrity as evidenced by absence of pressure ulcers.

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NIC: Skin surveillance

Independent: 1. Firm, soft, pillow was placed under the infants head To reduce pressure of the increasing weight to the thin skin of the infant preventing pressure ulcers to develop. 2. Repositioned the head of the infant every two hours as permitted. To decrease the risks of developing pressure ulcer on the side where the infant rests. 3. Taught parents on how to properly reposition the head of the infant every two hours. To ensure proper and timed positioning.
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4. Kept the infants head and linens clean and dry To prevent further skin infections 5. Promoted precaution in handling the infants head To prevent the occurrence of further injuries 6. Shampooed and bathed the infant daily To decrease risk of further infections and for hygienic purposes.
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Collaborative:
1. Collaborated with the physician and physical therapists on plan for skin breakdown prevention Provides opportunities for optimizing and reinforcing the plan of care

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Evaluation:
Short term goal: GOAL MET: After 30 minutes of health teaching, primary caregiver was able to change the infants position as scheduled. After 8 hours of nursing interventions, patient was now free from skin breakdown as evidenced by absence of lesions and further redness of pressure area. Long term goal: GOAL MET: After 2 days of nursing interventions, patient was able to maintain skin integrity as evidenced by absence of pressure ulcers.
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GCS score
Eye response: 4-opens spontaneously Verbal Response: 3-inconsistent, inconsolible moaning Motor: 5-withdraws for touch

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