1. Activity Intolerance
1.1. Assessments -generalized muscle weakness in lower extremities -out of breath going from bed to toilet -refusing to get up and walk with PT -shakiness of the legs when standing
1.1.1. Interventions -work on ROM exercises daily -encourage play around the room when patient's siblings are present -medicate patient for pain as needed
2. Impaired Neurological Status
2.1. Assessments -increased ICP -patient lethargic throughout the day -pupils reactive, but sluggish -confused -complains of headache -high fevers (100.9 and 100.4)
2.1.1. Interventions -reorient patient as needed -give prescribed Tylenol for headache as needed -give Tylenol for fever as needed -monitor for changes in ptosis of eye -seizure precautions
3. Fluid and Electrolytes
3.1. Assessments -patient unable to eat or drink on his own -before this clinical shift, patient had not had a BM in 2 days -soft stools related to antibiotics -only ate 15% of breakfast meal for the entire shift
3.1.1. Interventions -IV fluids running -frequent hydration assessment (skin turgor) -strict I & Os -have mom help with feedings when at bedside -order food the patient likes to eat -monitor electrolyte lab levels for changes from baseline
4. Impaired Gas Exchange
4.1. Assessments -labored breathing during shift change -O2 saturation dipped to 86% in the AM -starting to get a cough
4.1.1. Interventions -turn, cough, deep breath to get air into the lungs -continuous O2 saturation monitoring -frequent auscultation of lung fields to monitor for change