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Assessment 3 N450- Autism (1)
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Assessment 3 N450- Autism (1)
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Assessment 3 N450- AutismDefinition - ANS-a disorder that appears in childhood and is marked by:
1. significant deficiencies in communication and social interaction
2. Rigidly fixated interests and repetitive behaviors
Both are needed for diagnosis
Most clear cut symptom of Autism - ANS-Delayed or abnormal speech development
Other symptoms - ANS-- Lack of eye contact
- Lack of responding (flat effect/monotone)
- Developmental delay
- Cognitive impairment
- Self injurious acts (biting, head banging)
- Repetitive movements (hand clapping, spinning around)
- Lack of play
- Lack of imitation of others
Impairment to social interaction - ANS--They have an aversion to affection and physical contact
-Attachment to significant adult is either absent
-In childhood, there is failure to develop cooperative play, imaginative play, friendships and
imitation phases
Impairment in communication and imaginative activity - ANS--Language is totally absent
-Responses are flat and monotone
-Nonverbal communication such as facial expressions or gestures are absent or socially
inappropriate
Restricted activities and interests - ANS--Routine becomes an obsession and any minor
changes in the environment are often met with resistance or hysterical responses
-Repetitive body movements (hand clapping, rocking, whole body swaying) and verbalizing
repeated words are typical
, -Diet abnormalities may include only eating a few specific foods or consuming an excessive
amount of fluids
*-Behaviors that are self injurious such as head banging or biting own hands or arms occur
THIS IS OF PRIORITY*
*Risk for self-mutilation* r/t neurological alterations; hx of self mutilative behaviors; hysterical
reactions to changes in the environment - ANS-*Goal/ Outcome- Client will not harm self*
Interventions:
-Nurse will determine if the harmful to self behavior is in response to anxiety; if so, to what the
anxiety may be attributed to
-Nurse will protect the child when harmful to self behavior occurs such as applying a helmet,
hand mitts, arm covers
*Impaired social interaction* r/t inability to trust; neurological alterations aeb lack of
responsiveness to or interest in people - ANS-STG-Client will demonstrate trust in one caregiver
STG
LTG- Client will initiate in social interactions with caregiver
*Intervention:*
-Assign a limited # of caregivers to child
-Provide child with familiar toys and objects
-Give positive reinforcement for eye contact with something acceptable to the child (food,
familiar object) Gradually replace with social reinforcement (touch, smiling, hugging)
Impaired verbal communication r/t withdrawal into the self aeb inability or unwillingness to
speak; lack of nonverbal expression - ANS-Goal- Client will establish means of communicating
needs and desires to others
Interventions:
-Maintain consistency in assignment of caregivers
-Give positive reinforcement when eye contact is used to convey nonverbal expressions.
Positive reinforcement increases self esteem and encourages repetition
What nursing interventions would you implement when caring for an ASD child? - ANS--Follow
routines
-Decrease stimulation
-Helmets PRN
-Keep family present
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