Pediatric Nursing Care Plan - Mental Retardation

Pediatric Nursing Care Plan - Mental Retardation Nursing Assessment

Assessment can be done through:

1. Neuroradiology can find abnormalities in the structure of the cranium, such as classification or increased intracranial pressure.
2. Echoencephalography can show the tumor and hematoma.
3. A brain biopsy is only useful on a small number of children retardasii mentally. Not easy for parents to accept the role in brain tissue making even small amounts because they add to the brain damage is inadequate.
4. Bio-chemical research to determine the metabolic rates of various materials which are known to affect brain tissue if not found in large quantities or small, such as hyperglycemia in preterm neonates, accumulation of glycogen in muscles and neurons, fat deposits in the brain and high levels of phenylalanine.

Or can perform the following assessments:

• Assessment of physical
• Assessment for growing up
• Family history assessment, especially regarding mental retardation and hereditary disorders in which mental retardation is one of the main species.
• Medical history to obtain evidence of trauma to prenatal, perinatal, postnatal, or physical injury.
• Prenatal maternal infection (eg, rubella), alcoholism, drug consumption.
• Inadequate nutrition.
• Environmental deviations.
• Psychiatric disorders (eg, Autism).
• Infections, particularly those involving the brain (eg, meningitis, encephalitis, measles) or high body temperature.
• Chromosome abnormalities.
• Assist with diagnostic tests such as: analysts chromosomes, metabolic dysfunction, radiography, tomography, electro ensephalography.
• Perform or assist with intelligence tests. Stanford Binet, Wechsler intellence, Scale, American Assiciation of Mental Retardation Adaptive Behavior Scale.
• Observation of an early manifestation of mental retardation:
  • Not responsive to contact.
  • Poor eye contact during breastfeeding.
  • Decrease in spontaneous activity.
  • Decreased awareness of sound vibrations.
  • Sensitive stimuli.
  • Breast-feeding is slow.

Pediatric Nursing Care Plan Mental Retardation Nursing Diagnosis and Interventions 

1. Altered Growth and Development related to damage to cognitive function.

Expected results:

• Children and families actively involved in infant stimulation program. 
• Families applying these concepts and continue the child care activities at home. 
• Children perform activities of daily living at optimal capacity. Family ~ find out about educational programs. 

Nursing interventions :

• Involve children and families in early infant stimulation program. Rational: to help maximize growth in children.
• Assess the progress of the child's development with regular intervals, for which detailed records to distinguish subtle changes in function. Rational: so the treatment plan can be repaired as needed.
• Help families set goals for the child's reality. Rationale: to encourage the successful achievement of goals and self-esteem.
• Provide positive reinforcement / specific tasks to the behavior of children. Rational: as this can improve motivation and learning.
• Provide information on adolescent social practices and codes of behavior that is concrete and well defined. Rational: because of the ease and lack of assessment of the child persuasion can make children are at risk of dangerous.

2. Altered family processes related to having a child with mental retardation.

Expected results:

• Family expresses feelings and concerns about the birth of a child with mental retardation and its implications.
• Family members indicate acceptance of the child.
• Family members indicate acceptance of the child.

Nursing Interventions:

•  Provide information on the family as soon as possible during or after birth. Rational: In order for families able to receive the actual circumstances.
•  Encourage both parents to be present at the conference giving information. Rational: In order for parents to get lots of information about mental retardation.
•  Discuss with family members about the benefits of home care, give them a chance to investigate all residential alternatives before making a decision. Rationale: So that they can take the best decision for them and their children.
• Encourage the family to meet with other families who have the same problem. Rational: so they can receive additional support.

Care Plan Nursing Read more »

Self-Care Deficit Nanda Nursing Diagnosis

Self-care deficits

When an individual is very unable to meet their own self-care requisites, a "self-care deficit" occurs. It is the job of the Registered Nurse to determine these deficits, and define a support modality.

Self-care deficit nursing theory is a grand nursing theory that was developed between 1959 and 2001 by Dorothea Orem. It is also known as the Orem model of nursing. It is particularly used in rehabilitation and primary care settings where the patient is encouraged to be as independent as possible.

Self-Care Deficit

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

Defining Characteristics:

• Inability to feed self independently
• Inability to dress self independently
• Inability to bathe and groom self independently
• Inability to perform toileting tasks independently
• Inability to transfer from bed to wheelchair
• Inability to ambulate independently
• Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :

• Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
• Musculoskeletal disorder such as rheumatoid arthritis
• Cognitive impairment
• Energy deficit
• Pain
• Severe anxiety
• Decreased motivation
• Environmental barriers
• Impaired mobility or transfer ability

Expected Outcomes

• Patient safely performs (to maximum ability) self-care activities.
• Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Self-Care: Eating
• Self-Care: Bathing
• Self-Care: Dressing
• Self-Care: Grooming
• Self-Care: Hygiene
• Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Self-Care Assistance: Bathing/Hygiene
• Self-Care Assistance
• Dressing/Grooming
• Self-Care Assistance: Feeding
• Self-Care Assistance: Toileting
• Environment Management

Care Plan Nursing Read more »

Impaired Physical Mobility Nanda Nursing Diagnosis

Nanda Definition:

Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.


Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

Impaired physical mobility - Related factors arising from within the person include pain or fear of discomfort, anxiety or depression, and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system.

Defining Characteristics:

• Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
• Reluctance to attempt movement
• Limited range of motion (ROM)
• Decreased muscle endurance, strength, control, or mass
• Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination
• Inability to perform action as instructed

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Ambulation: Walking
• Joint Movement: Active
• Mobility Level

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Exercise Therapy: Ambulation
• Joint Mobility
• Fall Precautions
• Positioning
• Bed Rest Care

Expected Outcomes

• Patient performs physical activity independently or with assistive devices as needed.
• Patient is free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, and normal bowel pattern.

Care Plan Nursing Read more »

Imbalanced Nutrition More than Body Requirements Nanda Nursing Diagnosis

Imbalanced Nutrition More than Body Requirements Definition :


Imbalanced nutrition : more than body requirements refers to a caloric intake / excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when BMI is between 25 and 29.9 kg/m2 and obese when BMI is >30 kg/m2 . Factors that affect weight gain include genetics, sedentary lifestyle, and emotional factors associated with dysfunctional eating. Medical conditions associated with this problem are as follows: diabetes mellitus, severe hypertension, and Cushing’s syndrome. Cultural or ethnic background also influences eating habits. Overall nutritional requirements of geriatric patients are similar to those of younger patients, except that calories should be reduced because of their leaner body mass. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and decrease weight.


Related Factors :

• Cultural preferences
• Excessive intake in relation to metabolic need
• Lack of knowledge of nutritional needs, food intake, and/or appropriate food preparation
• Metabolic disorders
• Poor dietary habits
• Psychosocial factors
• Sedentary lifestyle
• Socioeconomic status
• Use of food as coping mechanism

Nursing Interventions Classification (NIC)

• Nutrition Counseling
• Nutritional Monitoring
• Weight Reduction Assistance

Nursing Outcomes Classification (NOC)

• Nutritional Status: Food and Fluid Intake
• Weight Control
• Knowledge: Diet

Goal and Objectives

• Patient will articulate actions essential to attain weight reduction.
  
  • Patient will cemonstrate change in eating patterns and participation in individual exercise program.
• Patient will commence an appropriate program of exercise.
  
• Patient will demonstrate proper selection of meals or menu planning toward the goal of weight reduction.
  
• Patient will exhibit weight loss with optimal continuation of health.
  
• Patient will recognize inappropriate behaviors and consequences related with overeating or weight gain.

Care Plan Nursing Read more »