CEREBRAL PALSY
Medications
Prescribed
Patient
Diagnoses
Acute pain r/t orthopedic surgery as manifested by agitation, restlessness, frowns and whines
Impaired physical mobility r/t surgical femoral osteotomy and stabilization of hip joints as evidenced by bilateral spica casts and inability to ambulate
Goal: Patient will experience pain at a level less than 3 to 4 on a 0 to 10 rating scale.
Diazepam (Valium)
Lamotrigine (Lamictal)
Baclofen (Lioresal)
T.M. 
3 yo boy
Admitted for surgical femoral osteotomy and stabilization of hip joints
Assessments
Subjective
Objective
Speech impairment
Seizure disorder
Poor weight gain
Feeding issues
Skin-level feeding device
Cannot ambulate without braces and wearsankle-foot orthotics
Physical, occupational, speech therapy
12 kg
Verbal and can answer questions with simple phrases and responds to commands
Periods of agitation and restlessness post op
RR 25 bpm
Bilateral breath sounds equal, clear, good air exchange
O2 98%, room air
HR 85 bpm
Temp 36.8 C axillary
Peripheral IV to right forearm
Positive bowel sounds
Mic-key site clean
8 in foley catheter intact and secured
yellow clear urine
Bilateral spica cast to legs with hip abductor bar intact
Toes warm to touch, able to move
Unable to palpate pedal pulses
Capillary refill <2 seconds
PCA is connected to IV and infusing
Occasionally frowns and whines
Comforted by parents bedside active in care
Diet as tolerated, NPO for solids and hold tube feedings at midnight
Question this order due to seizure history
Data Gaps
What are all of his lab values?
Has he had any surgeries prior to this admission?
Does he go to daycare or school?
Autonomy vs Shame and Doubt
encourage to become more independent while at the same time protecting him so that constant failure is avoided
Impaired vision corrected with glasses
Goal:Patient will use safety measures to minimize potential for injury
Outcome/ Intervention: Patient and family will learn the FLACC pain scale and understand its use by October 10th.
Nurse will educate the family and patient on the FLACC pain scale and complete an assessment of pain with every vital sign assessment during stay in the hospital.
Outcome/ Intervention: Patient and family will learn non-pharmacological methods to help pain levels(e.g., relaxation,
guided imagery, music therapy, distraction, and massage) by October 10th.
Nurse will educate the patient and family on the use of non-pharmacologic pain relievers and the benefits they can have to his healing process by October 10th.
Outcome/ Intervention: Patient and family will adhere to the PCA and pharmacological regiment by October 10th.
Nurse will educate patient and family on the PCA and proper use by October 10th.
Outcome/ Intervention: Patient and family will understand the importance of regular pressure area care and repositioning every 2 hours to alleviate pressure and keep skin intact by October 10th. Nurse will educate the family on repositioning and reposition every 2 hours placing the patient supine, prone, or on their side making sure to support with pillows by October 10th.
Outcome/ Intervention: Patient and family will understand the importance of keeping the cast clean and dry, ensuring changing and cleaning of diaper area by October 10th. Nurse will educate the patient and family on keeping the cast clean and dry and ensure diaper is changed when soiled and patient is properly cleaned by October 10th.
Outcome/ Intervention: Patient and family will understand the importance of neurological checks with every vital sign assessment to ensure there is no neurological compromise and the signs and symptoms such as altered sensation, paralysis, pallor, excessive pain by October 10th. Nurse will assess the neurological status of the legs by inspecting the color of the toes, capillary refill, movement, sensation, warmth and pulses and ensure findings are compared bilaterally then document findings on appropriate limb observation flowsheet by October 10th.
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Evaluation: Patient and family understand the importance of neurological checks. Nurse performed neurological checks with every vital sign assessment. Patient and family understand the importance of regular pressure area care and repositioning. Nurse repositioned the patient every 2 hours and supported him with pillows. Patient and family understand the importance of the cast care. Nurse ensured the cast is kept clean and dry with regular diaper changes and cleaning. Goal met. Nurse will continue with these measures until discharge.
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Evaluation: Patient and family are adhering to the PCA and pharmacological regiment. Nurse educated the patient and family on the PCA and proper use. Patient and family were educated on the FLACC pain scale and stated an understanding of its use. Nurse educated the family and completed proper assessments of pain with each vital sign check. Patient and family were educated on non-pharmacological methods to help relieve pain. Nurse educated the patient and family on non-pharmacological pain relief methods. Patients pain has not been over a 4. Nurse will continue with these interventions until discharge. Goal met.
Diaper to spica cast opening
FLACC pain scale of 4