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Concept Map JS, Labs CBC, Barium Swallow Study #2 Priority Nutrition Imbalance less than Body Requirements r/t insufficient Calorie intake 1600 Kcal/day Rationale: The body requires fuel to provide energy for cellular metabolism, repair, organ function, growth, and body movements (Potter & Perry, 2005, p.1273) S: Mother states, "He loves to eat" "I'm worried about how many calories he is getting" "He moves around so much" O: Patient has high risk of aspiration as evidenced by swallow study 4/13/06 History of weight loss of 27 pounds Current body weight 97 lbs. Current BMI 21. New PEG tube administration NPO status 1600 Kcal/day enteral nutrition by Ensure Plus Patient has continuous non purposeful body movement Labs: RBC low at 3.07 Hct low at 27.9 % Hgb low at 9.5 Protime high at 13.9 APTT high at 50.4 sec. Goal: Patient will tolerate increased calorie intake as evidenced by normal BMI of 18.5-24.9 or weight of 92-115 pounds by May 20, 2006, Left Pleural Effusion Respiratory, Labs Chest x-ray, Valproate Sodium 625 mg in 12.5 ml via ft bid Epilepsy, CBC #2 Priority Nutrition Imbalance less than Body Requirements r/t insufficient Calorie intake 1600 Kcal/day Rationale: The body requires fuel to provide energy for cellular metabolism, repair, organ function, growth, and body movements (Potter & Perry, 2005, p.1273) S: Mother states, "He loves to eat" "I'm worried about how many calories he is getting" "He moves around so much" O: Patient has high risk of aspiration as evidenced by swallow study 4/13/06 History of weight loss of 27 pounds Current body weight 97 lbs. Current BMI 21. New PEG tube administration NPO status 1600 Kcal/day enteral nutrition by Ensure Plus Patient has continuous non purposeful body movement Labs: RBC low at 3.07 Hct low at 27.9 % Hgb low at 9.5 Protime high at 13.9 APTT high at 50.4 sec. Goal: Patient will tolerate increased calorie intake as evidenced by normal BMI of 18.5-24.9 or weight of 92-115 pounds by May 20, 2006, Impaired Verbal Communication r/t inability to speak clearly S: "He doesn't really talk" O: Says, "Mom" Blinks for "No" Responds to name Cerebral Palsy Cognitive disorder Cognitive Disability, Pneumonia Respiratory, Coagulation Studies #2 Priority Nutrition Imbalance less than Body Requirements r/t insufficient Calorie intake 1600 Kcal/day Rationale: The body requires fuel to provide energy for cellular metabolism, repair, organ function, growth, and body movements (Potter & Perry, 2005, p.1273) S: Mother states, "He loves to eat" "I'm worried about how many calories he is getting" "He moves around so much" O: Patient has high risk of aspiration as evidenced by swallow study 4/13/06 History of weight loss of 27 pounds Current body weight 97 lbs. Current BMI 21. New PEG tube administration NPO status 1600 Kcal/day enteral nutrition by Ensure Plus Patient has continuous non purposeful body movement Labs: RBC low at 3.07 Hct low at 27.9 % Hgb low at 9.5 Protime high at 13.9 APTT high at 50.4 sec. Goal: Patient will tolerate increased calorie intake as evidenced by normal BMI of 18.5-24.9 or weight of 92-115 pounds by May 20, 2006, Medications Valproate Sodium 625 mg in 12.5 ml via ft bid