- Imbalanced Nutrition less than Body Requirements related to difficulty in swallowing, chewing, or sucking and food intake less than recommended daily allowances as evidenced by decreased muscle tone and inability to control the tongue
- Impaired Physical Mobility related to decrease in muscle strength or control and neuromuscular impairment as evidenced by muscle weakness and decrease in fine or gross motor skills‘
- Impaired Verbal Communication related to impaired motor function of muscles for speech and impaired comprehension, or language as evidenced by use of incomprehensible words or sounds to express wants/needs and difficulty expressing verbally
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes difficulty in swallowing Objective Data: -Body weight 20% or more below the ideal weight range -Decreased muscle tone -Inability to control the tongue -Reduced subcutaneous fat or muscle mass | Imbalanced Nutrition less than Body Requirements related to difficulty in swallowing, chewing, or sucking and food intake less than recommended daily allowances as evidenced by decreased muscle tone and inability to control the tongue | Patient will demonstrate gradual and safe weight gain toward their target weight. Patient will display safe chewing and swallowing without gagging or coughing. | 1. Facilitate strategies that promote the patient’s appetite. Determining food preferences, eliminating offensive odors and sights, and providing a relaxing atmosphere help boost appetite, promoting more food intake. 2. Collaborate with a dietitian or nutritionist in creating a meal plan. Consultation with a dietitian or nutritionist ensures an optimal nutritional intake. 3. Assist the patient in using utensils for feeding. Patients with CP may have decreased spontaneous upper arm movement, making feeding difficult. An occupational therapist can recommend tools and utensils that allow the patient to feed themselves 4. Elevate the patient’s head when eating. Some patients may have poor head control and difficulty swallowing. Keep the patient upright while eating to prevent aspiration pneumonia. 5. Consider a feeding tube. A large number of children with CP require a feeding tube and enteral nutrition to meet their nutritional needs. Nurses can train parents to use a feeding pump and care for the child’s tube. | Patient demonstrated gradual and safe weight gain toward their target weight. Patient displayed safe chewing and swallowing without gagging or coughing. |
| Subjective data: Expression of pain and discomfort with movement Refusal to move Objective data: -Limited range of motion -Uncoordinated movements -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Decreased muscle strength | Impaired Physical Mobility related to decrease in muscle strength or control and neuromuscular impairment as evidenced by muscle weakness and decrease in fine or gross motor skills | Patient will maintain or increase muscle strength and function of the affected extremity. Patient will demonstrate independence in certain activities of daily living (ADLs). | 1. Perform passive or active ROM exercises. Active ROM increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. Passive ROM improves joint mobility and circulation and decreases the likelihood of contractures. 2. Position in alignment to prevent complications. Patients with severe subtypes of cerebral palsy need to be repositioned frequently in bed and chairs to prevent complications. Maintaining proper alignment prevents foot drops and contractures that may worsen the patient’s condition. 3. Teach how to ambulate with adaptive equipment. Safe and effective use of ambulatory aid equipment such as braces, walkers, and wheelchairs will maximize physical mobility and prevent injury. 4. Collaborate with PT/OT. Physical and occupational therapists are a significant part of the care team for a patient with CP. PT programs can improve muscle strength and balance, and OT can recommend ways to complete everyday activities. 5. Consider a baclofen pump. An intrathecal baclofen pump implanted near the spine delivers a muscle relaxant to reduce muscle spasticity. | Patient maintained or increase muscle strength and function of the affected extremity. Patient demonstrated independence in certain activities of daily living (ADLs). |
| Subjective Data: Facial expression shows his inability to communicate Objective Data: -Use of incomprehensible words or sounds to express wants/needs -Difficulty expressing verbally -Difficulty understanding and maintaining a communication pattern | Impaired Verbal Communication related to impaired motor function of muscles for speech and impaired comprehension, or language as evidenced by use of incomprehensible words or sounds to express wants/needs and difficulty expressing verbally | Patient will demonstrate an increased ability to express themself. Patient will demonstrate effective alternative methods of communication. | 1. Establish therapeutic nurse-patient relationships through active listening. Nurses should take time to learn their patient’s individual abilities through active listening, observation, and patience. 2. Make eye contact. Eye contact shows that one is interested in what the patient would like to convey. This is necessary, especially for patients who also have hearing deficits. 3. Keep the communication slow and relaxed yet distinct and straightforward. Speaking clearly assists in promoting comprehension and improved overall communication. Patients may respond ineffectively to shouting and high-pitched sounds because they amplify vowels and obscure consonant sounds. 4. Provide alternative methods of communication. Nurses may use other creative measures such as alphabet boards, picture charts, lip reading, sign language, writing, etc. Alternative forms of communication ease anxiety and alienation and promote the patient’s sense of control and safety. 5. Refer to speech and language therapy. A speech-language pathologist can help improve the child’s ability to speak and instruct on using communication devices. | Patient demonstrated an increased ability to express themself. Patient demonstrated effective alternative methods of communication. |