Lakeview College of Nursing
N308 Nursing Care of the Childrearing Family
Swann Center Case Study

Student: 					

1. Pathophysiology	(8 points)							
2. Family, Activity/Mobility, Medications, &
therapeutic interventions (12 points)						
3. Problem list (5 points)								
4. Nursing Diagnosis (5 points)							
5. Assessment data, goals, expected outcomes, interventions,
	rationales, & evaluation. (Care plan 10 points)				

6. Well prepared for presentation, knowledgeable of subject (5 points)		

7. Write up complete, sources cited & reference list included in 
	APA format					(5 points)			

					Total	(50 points)				

Comments: 

Evaluator: 							Date: 				

Lakeview College of Nursing
N308 Nursing Care of the Childrearing Family
Swann Center Case Study- Presentation and Write up

Student- Weruche Uzoaru		Date: 	6/20/2011 

Pt. initials:  A.L   Age:   7 years  Gender: 	 Code Status: 	Resuscitate 	

Primary Medical Diagnosis: 	Profound Mental Retardation		

Co-Morbid Conditions: Spina Bifuda (surgically repaired), myelomeningocele, Fetal Valproate Syndrome, Pyelonephritis, Seizure disorder(controlled), Chronic constipation. 	

Pathophysiology: From birth she was diagnosed with neural tube defects namely myelomeningocele which is the protrusion of the membranes that cover the spine and part of the spinal cord through a bone defect in the vertebral column. This is due to failure of closure during embryonic life of bottom end of the neural tube, the structure which gives rise to the central nervous system. This further resulted in significantly sub average general intellectual function with concurrent deficits in functional life skills. The diagnosis of MR/ID requires an intelligence deficit of at least 2 standard deviations (SDs) below the mean IQ. This generally translates into an intelligence quotient (IQ) score of 70-75, given a population mean of 100.  In her case as she got older tests have been attempted the last one on January of this year which was the Binet Intelligence Scale Form and she hasn’t been able to register at all during the testing process solidifying her rating and diagnosis as profoundly mentally retarded.

Etiology: None has been definitely identified in her history but might be related to her preterm status as she was born at 34 weeks via caesarean. She does a family history of fetal death syndrome at 6 months and neurological disorders from her father’s side. She was born diagnosed wit neural tube defect namely myelomeningocele which was surgically repaired when she was 3 days old. Finally she does have fetal valproate syndrome, which put her at a higher risk for neurological disorders at birth. 
Pathophysiology: What is happening at the cellular, organ, and systems level? Put this into your own words; do not copy it from a textbook. It is not the definition of a syndrome but the pathophysiology.	- 
Here the body’s cell doesn’t communicate, as it should due to the possible non-transmissions from the brain to the rest of the body. Although her Spina Bifuda was repaired the damage was done and currently as she is being revaluated every year there has been no improvement 
Clinical manifestations (typical ones and star or underline those of your patient) 
•	Delays in oral language development
•	Deficits in memory skills
•	Difficulty learning social rules
•	Difficulty with problem solving skills
•	Delays in the development of adaptive behaviors such as self-help or self-care skills
•	Lack of social inhibitors
Since she is severely or profoundly mental retarded she will need more intensive support and supervision his or her entire life. At most she might learn some activities of daily living but will require full-time care by an attendant.
Family dynamics: her parents were married at the time of her birth but are currently divorced. Her mother was granted custody. Her father can visit but only under supervision and cant take her off the premises. Her grandparents from her mother are very involved in her care and visit her from time to time. Her mother is also very involved in her care and leaves instruction on how her wants her hair done with picture in the binder in her room and also attends her evaluation meetings.  

Medications: (Complete the medication form, know why they are being given to your patient.)

Therapeutic interventions: (dressing changes, trach care, G-tube, turning, ROM, special formulas, PT, OT, etc.) and the reason why these are being done. 

Occupational therapy - She has no dressing changes but needs to always have a pair of shorts on as she formed the habit of Coprophagia and had to be retrained not to do that anymore by being chastised when she did and making sure she had a pair of shorts all the time. She is also learning how to do a couple of her ADLs like brushing her teeth and hair. Her last evaluation done in may of this year showed no improvement in these activities yet.

Physical therapy- She is currently at a 9-10 months old level of physical coordination
- She has to be turned or moved around if on her wheel chair. 
- She has to have mat time for at least 2 hours everyday. 
- To transition to a different position (rolling from laying down to sit)
- Learning to sit unsupported (improving trunk control) 
 She also has to be assessed for her scoliosis, which was corrected from a 70 degree deviation to a 30 degree deviation and also had her hip contractures released April of 2010. So it’s very important to do her range of motion exercises to prevent further contractures and strengthen her trunk to carry her weight.  
Activity/Mobility Level: She is considered a level 1 activity here at Swann center, which means that she is unable to participate in a full activity program with the other residents 
Problem List (List all problems you see that could be addresses- physical, emotional, social, etc.)
Sensory deprivation
Impaired verbal communication
Impaired social interaction
Risk of injury 
Self care deficit
Risk of skin impairment
Delayed growth and development

Nursing Diagnosis (see attached) List three and write in complete format.

1.) Impaired physical mobility related to muscle weakness, and poor coordination secondary to congenital neurologic defects as evidenced by an inability to ambulate or move without limitations and existing skeletal disorders (contractures and scoliosis).

2.) Self-care deficit related to neuromuscular impairments and cognitive deficits as evidenced by an inability to perform hygiene care and transfer self independently.

3.) Risk of delayed development related to impaired ability to achieve developmental tasks secondary to cerebral palsy and as evidenced by 
Inability to perform skills typical of her age group ( motor, cognition)  and altered physical growth (2 standard deviations lower).

Choose one diagnoses you see as a high priority and explain why. Write one goal, two expected outcomes, five interventions with scientific rationale for the diagnoses. Be prepared to discuss this with your group and know how you would evaluate if care was effective.

Name, dose & frequency of administration for this patient. Plus usual dose and frequency of prescription.
     
Levetiracetam 100mg/ml
150mg P.O B.I.D

Oyster shell 
Cal 500mg w/ D
Once daily

Divalproex 250mg P.O
125mg 2tabs T.I.D

Phenobarbital P.O
15mg ,1 tabs T.I.D 

Infant Saline Drop
1-2 nasal drops T.I.D

Miralax powder P.O
7.5gms T.I.D

	Classification & mechanism of action. [Use your drug guide!]

Anticonvulsant 
Works by decreasing abnormal excitement in the brain.

Multivitamin 
Works to increase bone density and the vitamin D increases the absorption of vitamin C.

Anti epileptic
Drug works by affecting sodium channels in the brain and increasing the amount of a certain brain chemical

Barbiturate
It works by slowing down brain activity.

Nasal decongestant
Clears and irrigates sinuses.

Osmotic laxative 
Works by pulling water to the stool making it softer and easier to pass. 	Why is medication ordered for THIS patient?

To control her seizures

To treat her calcium deficiency and reduce her risk for low bone density from the seizure medications she is on.

To help control her seizures.

It is also helping to control her seizures.

To improve her breathing by clearing her nasal passageway. 

To treat constipation caused by her anti seizure medications and calcium.	 Nursing Precautions/ Considerations with this medication. 

Medication should be measured exactly to prevent complications. Will watch for vomiting, angioedema or a rash 

Make sure patient doesn’t have kidney disease and watch for fainting, irregular heart rate or vomiting. 

Make sure patient has no kidney problems. Watch for vomiting, dark urine, fever, jaundice, as they might be signs of liver failure.

Should be carefully measured out and given as prescribed as it is addictive. Don’t stop abruptly also watch for dizziness, muscle twitching, seizures, vomiting or new uncontrollable shaking of a body part. 

Should be inserted gently and squeezed. Watch for bleeding.

Watch for diarrhea, hives or nausea and vomiting. 	 Evaluate medication effectiveness for THIS patient (patient response).

Medication is effective as the patient’s seizure is controlled.

Medication might be effective, as she hasn’t had a fracture. Proper bone density scans are the correct way to evaluate this medication.

Medication has been effective and patient’s seizures are controlled. Also there is no sign of liver dysfunction or pancreatitis. 

Medication is effective as her seizure is controlled with no relapse. 

Medication is effective, as her breathing sounds clearer after administration. Although it only last for about 3 hours at a time.

Medication is effective as she has regular bowel movements. 	

Nursing Diagnosis: As explained previously. List all relevant assessment data for the diagnosis (objective, subjective, labs, etc.) under AEB
-	History of neurological disorders
-	Self care deficit
-	History of contractures
-	Present scoliosis

Patient Goal(s): (long term) an objective to be achieved by discharge or near future – refers back to the R/T statement and AEB data
Examples: Client will demonstrate effective cough and ↑ air exchange in lungs by                               date
	      Client will describe way to decrease tenacious secretions by date
	      Pulse rate will be ….
	      Lung sounds will be …
Must be measurable and realistic

Nursing Interventions: Plan individualized care to patient. Include: assessment, treatment & procedures, teaching/guidance, case management (referrals, consultations, follow-up, etc.)

Rationale: Scientific rationale for nursing interventions – reason for the intervention. Document sources using APA format.

Evaluation: Goal met, unmet, partially met? List supporting data. If unmet, what is the plan? Modification needed? Continue plan as is until discharge? Don’t forget to evaluate expected outcomes as met, unmet, partially met, etc. and if not met, tell what plan is. 

What is the subjective & objective data that helped you determine a nursing diagnosis?
NURSING DIAGNOSIS
Impaired physical mobility related to muscle weakness, and poor coordination secondary to congenital neurologic defects as evidenced by an inability to ambulate or move purposefully without limitations and existing skeletal disorders (contractures and scoliosis).
	What does the patient/client need to accomplish?
GOALS/OUTCOMES
Nurse or client perspective

Client will show improvement in mobility for her disability-imposed restrictions.
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions

-Will perform range of motion exercise with her both passive and active before my shift end. 

-Will help facilitate motor development by increasing tactile stimulation especially touches as she responds positively to them especially when she is on the mat for her mat time before my shift end.

- Will participate in ADL care especially those that involve motion (teeth brushing) to strengthen her muscles as well as stimulate her before my shift end.

- Will praise her on completion of tasks or good behavior to provide positive reinforcement to emphasize good behavior before my shift end.

- Will utilize information provided by physical and occupational therapy and provide activities equal to a 1-3 year olds level to stimulate her cognitively and physically before my shift end.

- Will turn her every two hours on her wheel chair to prevent skin break down before my shift end.	Why will the nurse do these actions?
SCIENTIFIC RATIONALE
Be sure to include source using APA format 

-To prevent contractures and facilitate joint mobility. (Ricci and Kyle, 2009) 

- Touch has been proven to relieve anxiety and staying on the mat helps build upper body strength and improve circulation too (Ricci and Kyle, 2009).

- Performing ADLs with the client helps provide a steady ritual and improve her motor development (Ricci and Kyle, 2009).

- Positive reinforcement is great as it builds confidence and emphasizes the child’s abilities making it more likely she will repeat behaviors that are praised (Ricci and Kyle, 2009).

- Collaborating with the other teams creates a stronger intervention and makes it more effective (Ricci and Kyle, 2009). 

-Two hour turns are the standard of care for clients with impaired mobility. It improves circulation prevents contractures and skin break down. (Ricci and Kyle, 2009). 

	EVALUATION
Client Response, Status of Goals & Outcomes, Modifications to Plan

- Patient was able to move all extremities so goal was met. 

- Patient really enjoyed physical interaction and responded positively to it. Didn’t get to do mat time with her though so goal was partially met.

- I didn’t get to do ADL’s with the patient as she was already groomed before I came so goal was not met.

- She reacted to praise by repeating whatever motions she just made. I think it’s a good tool for teaching and encouraging positive behavior so I feel the goal was met. 

- Collaborating with the other care team helped provide a framework to work with although I didn’t get to spend a lot of time doing activities as she went to school so the goal was not met.

- The goal was met as I repositioned her every two hours as long as I had her before she left for the school.