Patient- 15y/o Female

Medical Dx- Cerebral Palsy, nonketotic Hyperglycinemia

Risk for contractures R/T Immobility: as evidence by Hx of percutaneous hamstring lengthening. 1. Use passive range of motion exercises 6 times a day 2 times q shift on all extremities. Use ROM on bilateral shoulders, elbows, wrists, hips, knees, and ankles. -Due to patients complete immobility, passive range of motion must be done on a regular basis to avoid future contractures. 2. Abduction pillow or multiple pillows placed between patients legs at bed time to reduce the risk of permanent adduction of leg due to contractures while sleeping. Monitor patient on evening shift (3-11) and night shift (11-7) to make sure patient is placed in proper positioning. -When immobile patient is laying on their side in bed, the legs naturally fall into adduction position. If adduction pillow or multiple pillows are placed in between her legs at night contractures into that position can be avoided. 3. Reposition patient q2h on night shift to avoid extremities remaining in one position throughout the night. -The patient is unable to move body on command, and the body may remain in one position for 8 hours unless it is manipulated by a care taker. Movement every 2 hours will keep the muscles from contracting into one position. Risk for Impaired Skin Integrity R/T Immobility, Incontinence, and continuous use of Boston Brace for Scoliosis. 1. Tilt the patients wheel chair from 90 degrees to 45 degree angle q2 hours to move pressure points. Reposition the patient q2hours while laying in bed from left side, to middle, to right side. -With Immobility, the patient may remain on one pressure point for hours. By tilting the wheel chair at different degrees, you are able to relieve pressure points every 2 hours. Also repositioning in bed will allow for patient to come off of boney prominences. 2. Check the patients brief q 2 hours for incontinence. Change brief when wet or q5 hours if dry. Add moisture barrier cream every morning with morning care, after every change, and before bed time. -The brief should be check for wetness every 2 hours to avoid change of pH on the skin that will promote skin breakdown. Change to a fresh brief every 5 hours so the patients

skin is not wet due to sweat. Moisture barrier will protect the skin from breaking down due to incontinence. 3. Check positioning of brace and skin integrity under the brace q shift. If there is any redness of the skin due to pressure points loosen and readjust the brace. Keep the brace on 20-22 hours a day, removing for 2 to 4 hours while in bed. -The skin under the brace must be observed for pressure points which would cause skin breakdown. Loosening and readjusting will help maintain skin integrity.

Risk for Depression R/T Decreased Brain Stimulation: as evidence by sitting in a wheel chair in an immobile position at the end of the hallway. 1. Sit with the patient 15 minutes every shift. Talk to patient in a high pitch voice using touch as main source of communication. -Patient reacts positively to touch and high pitch voices because patients developmental level is the functioning of an infant. One on one communication will help the child to feel attachment to a caretaker. 2. Have patient attend activities that involve music and visual stimuli at least twice a day. -Patient reacts positively to music and visual stimuli, decreasing risk of depression. 3. Install a mobile over the head of the bed for visual and musical stimuli to sooth the patient before falling asleep. -A mobile will fit the patients functional age, giving visual and auditory stimuli, helping the patient sooth and relax along with getting a form of sensory input.