Comprehensive Assessment 1 Comprehensive Assessment Maranda McCray-Dixon Dr. Chris Nelson Nursing 470L October 12, 2006 Comprehensive Assessment 2 Comprehensive Assessment D.B. is a 9 year old Biracial (black father, white mother) male who resides at a Pediatric Long Term care facility because of the long term diagnosis of a traumatic brain injury. D.B. is totally dependent on the staff for all ADLs. A typical day for D.B. would be waking up around 7:00am for morning care, morning feedings and meds through a PEG tube, and being dressed for school. He attends Heritage, a special education school from 9-2:30 pm where he responds to environmental stimuli and learns in a nontraditional way. After D.B arrives home at about 3:00 pm, he is taken out of his wheelchair and his school clothes, put in more comfortable clothes and he is and placed in bed watching cartoons. He usually sleeps until bath time which is every other day, or until 6:00pm feeds and meds. After this he usually lays in bed listening to cartoons until he falls asleep. The goals and expectations for the future are not to rehabilitate D.B. but to habilitate him. With his brain injury being so devastating the goal is to keep him at his current level of function. The admitting diagnosis for D.B. was Intentional Traumatic Brain injury with Intracranial Hemorrhages. Health History and History of present illness was obtained by the nurses and the charts because he could not be a historian. Prior to admission to the facility, he was essentially healthy. There are no long standing diseases from prior to the injury save for a Tonsil and Adenoid removal. D.B. started out as a typical child with a normal developmental childhood, but at the age of 8 he was subjected to extreme physical abuse from a mother’s boyfriend. The sequele of the injuries is that he is unable to communicate effectively (grunts and moans), partially blind, unambulatory, suffers from Comprehensive Assessment 3 seizure disorders, Renal Kidney Hydronephrosis, Resolved Decompression Craniotomy, Scoliosis, Severe Kyphosis, Encephalopathy, Incontinence, and Malnutrition. The physical examination reveals a rectal Temperature of 99.0, Pulse 80 right radial, regular rhythm, Blood Pressure 106/70 right arm supine, Respirations 19, Chest expansion symmetric. Though D.B. is unresponsive it is assumed that his pain scale is low because there are no visible signs of pain such as grimacing or crying. Assessment of the lymph nodes revealed no large swollen or tender masses. Pupils are equal round and react to light. Inspection of the nose reveals no large or tender masses, there is a septum present. Inspection of the oral mucosa yields some hyperplasia of the gums especially by the molars. There are still some teeth that have not yet erupted. Inspection of the external ear revealed intact skin with no pain or lesions. The patients skin is smooth with no breaks, there is no erythema, edema, or decubitus sores to note. D.B. does have a gastrostomy tube, which the incision is healed well around the tube. When the hair is separated the scars from the injury can be seen. Nail beds are pink with a normal capillary refill. During examination of the musculoskeletal system kyphosis and extreme scoliosis is noted. D.B. also has hand splints for both of his hands to keep them from balling up and excoriating himself. While listening to his lungs they were equal bilaterally with symmetric rising. When palpating the stomach it felt firm and upon auscultation there were infrequent high pitched sounds. The genetalia is appropriate size and development for his age. D.B.’s legs are usually flexed in the fetal position when Comprehensive Assessment 4 placed in his bed. There are no lesions or breaks in skin noted on the lower extremities of the body. There were no recent diagnostic tests to note in the chart. D.B.’s current medication includes: Carbamazepine (Anticonvulsant) 200 mg/11ml via Gtube three times a day Action: Decreases synaptic transmission in the CNS by affecting Na channels in neurons. Side effects: ataxia, drowsiness, fatigue, psychosis, vertigo, blurred vision, corneal opacities, pneumonitis, CHF, hyper or hypo tension, syncope, hepatitis, urinary retention, photosensitivity, rashes, urticaria, SIADH Agranulocytosis, Aplastic anemia, Thrombocytopenia, eosinophilia, leucopenia, chills fever and lymphadenopathy. Clonazepam (Benzodiazepine) 0.25 mg via Gtube twice a day Action: Anticonvulsant effects may be due to presynaptic inhibition. Side effects: Abnormal eye movements, aphonia, choreiform movements, coma, diplopia, dysarthria, dysdiadochokinesis, "glassy-eyed" appearance, headache, hemiparesis, hypotonia, nystagmus, respiratory depression, slurred speech, tremor, vertigo, Confusion, depression, amnesia, hallucinations, hysteria, increased libido, insomnia, psychosis, suicidal attempt (the behavior effects are more likely to occur in patients with a history of psychiatric disturbances). Chest Comprehensive Assessment 5 congestion, rhinorrhea, shortness of breath, hypersecretion in upper respiratory passages. Palpitations. Hair loss, hirsutism, skin rash, ankle and facial edema. Anorexia, coated tongue, constipation.diarrhea, dry mouth, encopresis, gastritis, hepatomegaly, increased appetite, nausea, sore gums. Dysuria, enuresis, nocturia, urinary retention. Muscle weakness, pains. Dehydration, general deterioration, fever, lymphadenopathy, weight loss or gain. Anemia, leukopenia, thrombocytopenia, eosinophilia. Transient elevations of serum transaminases and alkaline phosphatase. Clonidine Patch (antiHypertension)0.2mg topical once a week Action: Stimulates alpha adrenergic receptors in the CNS; Which results in the decreased sympathetic outflow inhibiting cardio acceleration and vasoconstriction centers. Side Effects: drowsiness depression dizziness, nervousness, nightmares, bradycardia, hypotension, palpitations, dry mouth constipation, vomiting, nausea, impotence rash, sweating, Na retention, weight gain. Dantrolene (antispasticity)10mg/2ml via Gtube three times a day Actions: acts directly on skeletal muscle causeing relaxation by decreasing calcium release from sarcoplasmic reticulum in muscle cells. Side effects: Drowsiness, muscle weakness, hepatotoxicity, diarrhea. Comprehensive Assessment 6 Diazepam (anticonvulsant) 2mg via gtube three times a day Action: Depresses the CNS, produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways. Side Effects: dizziness, drowsiness, lethargy, blurred vision, respiratory depression, constipation, diarrhea, nausea, rashes, physical dependence. Lansoprazole suspension (Gerd) 30mg/10ml once a day Action: Binds to an enzyme in the presence4 of acidic gastric pH, Preventing the f inal transportof H+ ions into the gastric lumen Side Effects: dizziness, headache, diarrhea Methylphenidate (Tx of ADHD, symptomatic Tx of Narcolepsy)5mg via Gtube once a day Action: Produces CNS and respiratory stimulation with weak sympathomimetic activity, increases attention span in ADHD. Side effects: hyperactivity, insomnia, restlessness, tremor, dizziness, headache, irritability, hypertension, palpitations, tachycardia, anorexia. Polyethelyne Glycol Powder (laxative)8.5mg via Gtube in 8oz h2o once a day Action: In a solution acts as an osmotic agent drawing water into the lumen of the GI tract. Side effect: abdominal bloating, cramping, flatulence, nausea. Comprehensive Assessment 7 Rantidine (H2 antagonist) 30mg/2ml via Gtube twice a day Action: Inhibits action of histamine at the H2 receptor site located primarily in the Gastric Parental Cells resulting in inhibition of gastric acid secretion. Reuteri Primadophilus (herbal supplement)5ml oral twice a day prior to feeds Action: recolonizes the stomach with normal bacteria in order to help stool to Breakdown. Side effects: none listed Acetaminophen Liquid (pain reliever/fever reducer) 380/11.8ml via Gtube as Needed. Action: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS Side Effects: hepatic failure, hepatoxicity, renal failure, rash, uticaria Albuterol (Bronchodilator) inhalant as needed every four hours Actions: Binds to beta 2 adrenergic receptors in airway smooth muscle and leads to vasodilation. Side effects: nervousness, restlessness, tremor, headache, insomnia, chest pain, palpitations, angina, arrythmias, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, and tremor. Comprehensive Assessment 8 Bisacodyl Suppository (laxative) every third day as needed Action: Stimulates Peristalsis, produces fluid accumulation in colon. Side Effects:abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia, muscle weakness, protein losing enteropathy tetany. Guaifenesen (expectorant) 75mg/3.75ml via Gtube every four hours Action: reduces viscosity of tenacious secretions by increasing respiratory tract fluid. Side effects: dizziness, nausea, headache, diarrhea,stomach pain, nausea, rashes, urticaria. Ibuprofen Liquid (nonopiod analgesic)250mg/12.5ml via Gtube Action: Inhibits prostaglandin synthesis Side Effects: headache, constipation, dyspepsia, nausea, vomiting Nutritional Assessment According to the determine tool D.B. is at a high nutritional health risk. D.B. diet consists of 240 mls Kindercal Junior formula administered by G tube three times a day. This diet is adhered to by the facility workers and the special school workers during the day. D.B’s height and weight is 53” and 85 pounds. Some of the problems related to dietary intake is D.B.s gingival hyperplasia and under erupted teeth. Comprehensive Assessment 9 Teaching Plan/ Nursing Care Plan No family is present to teach, D.B. is cognitively incapable to learn from a teaching plan, and the nurses already have specific plans for D.B. The primary nursing care plan is to turn and position D.B. frequently to prevent skin breakdown. Most of the psychosocial Dimension does not apply to D.B. because he is unable to show cognition to his surroundings aside from pain he rarely shows emotion. It may be noted that he is somewhat attached to his nurses and he does enjoy the stimulation of school. Based on my assessment of the client and your analysis of the data I feel D.B. is in a state of adaptive equilibrium. Prioritized list of client’s current and potential problems 1) Risk for impaired nutrition 2) Risk for skin breakdown Client’s strengths 1) D.B. is well care for by skilled nurses 2) D.B. is seen by a team of other healthcare providers including MDs, Dietitians, Dentists, and Physical Therapy.