NAME: RUSNANEE RADAENG

NIM: 21114081

NURSING CARE PLAN: CEREBRAL PALSY

Nursing Diagnoses

1. Impaired Physical mobility related to spasms and muscle weakness.

2. Impaired verbal communication related to difficulty in articulation.
3. Risk for injury related to spasms, uncontrolled movements and seizures

NO Nursing Goals and results criteria Intervention

. Diagnoses

1. Impaired NOC NIC

Physical
mobility related Joint Movement : Exercise therapy:
to spasms and Active ambulation
Mobility Level
muscle Monitor vital sign
Self Care : ADLs
weakness. before and after
Client outcomes: activity.
Provide assistive
Increases physical
devices if the client
activity
requires
Verbalizes feeling
Teach client to use
of increased
assistive devices
strength and ability
such as a cane, a
to move
walker, or crutches
Demonstrates use
to increase mobility.
of adaptive
Consult with
equipment (e.g.,
physical therapist
wheelchairs,
for further
walkers) to
evaluation, strength
increase mobility
training, gait
training, and
 development of a
mobility plan.
If the client is
immobile, perform
passive range of
motion (ROM)
exercises at least
twice a day unless
contraindicated;
Repeat each
maneuver three
times.

2. Impaired verbal NOC NIC

communication
related to sensory function : Communication
difficulty in hearing & vision Enhancement
fear self-control
articulation. examine the response
Client outcomes: to communication.
use the cards /
Able to control the
pictures /
response of fear whiteboards to
and anxiety to facilitate
speech communication.
impairment Involve the family in
Able to
training a child to
communicate
communicate.
needs with the refer to a speech
social
therapist.
environment teach and assess non-
 verbal meaning.
trained in the use of
the lips, mouth and
tongue

3. Risk for injury NOC NIC

related to
spasms, Risk control Environment management
uncontrolled Client outcomes: Identification of
movements and environmental factors
seizures no physical injury
that allow the risk of
to the client
injury.
client is in a safe Keep objects that
condition
could cause injury to
no bruises
the patient during a
no fall seizure.
Install the barrier the
patient's bed.
Place the patient in a
low and flat.
Together with the
patient in some time
after the seizure.
Prepare a soft cloth to
prevent biting the
tongue occurs during
seizures.