disease condition with medical and nursing management

1. Presented to: Mrs. Vinay Kumari
Associate Professor (MMCON)
Presented By: Amandeep Kaur
Msc. (N) 2nd year
1915703

2. CEREBRAL PALSY (CP)
 In 1860s, known as
"Cerebral Paralysis” or
“Little’s Disease”
 After an English surgeon
wrote the 1st medical
descriptions
 William John Little
(1810-1894)

3. CEREBRAL PALSY (CP)
 Cerebral“- Latin Cerebrum;
 Affected part of brain
 “Palsy " -Gr. para- beyond,
lysis – loosening
 Lack of muscle control

4. CEREBRAL PALSY (CP)
 A motor function disorder
 caused by permanent, non-progressive brain
lesion
 present at birth or shortly thereafter.
 Non-curable, life-long condition
 Damage doesn’t worsen
 May be congenital or acquired

5. CEREBRAL PALSY (CP)
A Heterogenous Group of
Movement Disorders.
– An umbrella term
– Not a single diagnosis

7. CPAffects
Movements
Coordination
Muscle
Strength
Balance
Posture

8. In CP
 Muscles are unaffected.
 Brain is unable to send
the appropriate signals
necessary to instruct
muscles when to
contract and relax.

10. An insult or injury to the brain
– Fixed, static lesion(s)
– In single or multiple areas
of the motor centers of the
brain
– Early in CNS deviation.

11. Cont…
 Development Malformations
 The brain fails to develop correctly.
 Neurological damage
 Can occur before, during or after delivery
 Rh incompatibility, illness, severe lack of oxygen
* Unknown in many instances

12. Cont…
 Severe deprivation of oxygen or blood flow to the
brain
– Hypoxic-ischemic encephalopathy or intrapartal
asphyxia

14. RISK FACTORS
 Prenatal factors
 Before birth
 Maternal characteristics
• Perinatal factors
– at the time of birth to 1month
• Postnatal factors
– In the first 5 mos of life

15. Prenatal factors
 Hemorrhage/bleeding
 Abruptio placenta
 Infections
 Rubella, cytomegalovirus,
toxoplasmosis,
 Environmental factors
 Maternal Characteristics

16. Maternal Characteristics
 Age
 Difficulty in conceiving or holding a
baby to term
 Multiple births
 History of fetal deaths/miscarriages
 Cigarette smoking >30 sticks per day
 Alcoholism and drug addiction
 Social status; mother with MR
 Mother’s medical condition

17. Perinatal Factors
 High or low BP
 Umbilical cord coil
 Breech delivery
 Over sedation of drugs
 Trauma i.e. forceps or vacuum
delivery
 Complications of birth

18. Postnatal Causes
 Trauma, head injury
 Infections
 Lack of oxygen
 Stroke in the young
 Tumor, cyst

19. CP Cases
Before
Birth
75%
During
Birth,
5-15%
After
Birth,
10-20%

20. TYPES OF
CEREBRAL PALSY

21. Classification of CP
According to:
1. Neurologic deficits
2. Type of movement involved
3. Area of affected limbs

22. Acc. to Neurologic Deficits
 Based on the
- extent of the damage
- area of brain damage
 Each type involves the way a person moves

23.  3 MAIN TYPES
1. PYRAMIDAL
- originates from the motor
areas of the cerebral cortex
2. EXTAPYRAMIDAL
- basal ganglia and
cerebellum
3. MIXED

24. 2. Acc. to Type of Movement

25.  4 MAIN TYPES
PYRAMIDAL 1. Spastic CP
EXTAPYRAMIDAL 2. Athethoid CP
3. Ataxic CP
MIXED 4. Spastic & Athethoid CP

26. TYPES

27. Spastic CP
 Increased muscle tone, tense and
contracted muscles
 Have stiff and jerky or awkward
movements.
 limbs are usually underdeveloped
 increased deep tendon reflexes
 Most common form 70-80% of all
affected.

28. Types of Spastic CP
According to affected limbs:
* plegia or paresis - meaning paralyzed or weak:
 Paraplegia
 Diplegia
 Hemiplegia
 Quadriplegia
 Monoplegia –one limb (extremely rare)
 Triplegia –three limbs (extremely rare)

29. Diplegia/ Paraplegia
• Both legs with slight
involvement elsewhere
• both legs

30. Diplegia
May also have
Contractures of hips and
knees and
talipes equinovarus
(clubfoot).

31. Hemiplegia
 Limbs on only one side
 Hemiplegia on right side
 Hip and knee contractures
 Talipes equinus (“tip-toeing”
- Sole permanently flexed)
 Asteriognosis may be present.
(Inability to identify objects by touch)

32. Quadriplegia

33.  Spastic Quadriplegia
Characteristic “scissors” positions of lower limbs due to
adductor spasms.

34. Dyskinesia
 Dyskinetic movement of
mouth
 Grimacing, drooling and
dysarthria.
 Adductor spasm

35. Movements may become choreoid
(rapid, irregular, jerky)
and
dystonic
(disordered muscle tone, sustained
muscle contractions)
especially when stressed and during the
adolescent years.

36. Ataxic CP
 Poor balance and lack of
coordination
 Wide-based gait
 Depth perception usually affected.
 Tendency to fall and stumble
 Inability to walk straight line.
 Least common 5-10% of cases

38. MIXED CP
 A common combination is
spastic and athetoid
 Spastic muscle tone and involuntary movements.
 25% of CP cases, fairly common

39. DEGREE OF SEVERITY
1. Mild CP- 20% of cases
-Not require self help for assisting their impaired
ambulation capacity.
2. Moderate CP- 50%
- Require self help for assisting their impaired
ambulation capacity.
3. Severe CP- 30%;
-Totally incapacited and bedridden and they always
need care from others.

40. Pathophysiology

42. Signs & Symptoms

43. a.
b.
c.
d.
e.
f.
g.
h.

44. • Stiff or floppy posture
• Weak suck/ tongue thrust/ tonic bite/ feeding
difficulties
• Poor head control
• Excessive lethargy or irritability/
High pitched cry
Infancy (0-3 Months)
Early Signs

45.  Abnormal or prolonged primitive reflexes
Moro’s reflex
Asymmetric tonic neck reflex
Placing reflex
Landau reflex
Early Signs

46. CHILD with CP

47.  Inability to perform motor skills as indicated:
 Control hand grasp by 3 months
 Rolling over by 5 months
 Independent sitting by 7 months
 Abnormal Developmental Patterns:
 Hand preference by 12 months
 Excessive arching of back
 Log rolling
 Abnormal or prolonged parachute response
Late infancy

48.  “W sitting” – knees flexed,
legs extremely rotated
 “Bottom shuffling” Scoots along the floor
 Walking on tip toe or hopping
Abnormal Developmental Patterns
after 1 year of age:

49. Behavioral Symptoms
Poor ability to concentrate,
unusual tenseness,
 Irritability

50. Cerebral Palsy
 Main problem:
 Mentation and thought processes are not always
affected;
 Trapped in their bodies with their disabilities
 Ability to express their intelligence may be
limited by difficulties in communicating.

51. ASSOCIATED
PROBLEMS

52. Cont…
 Hearing and visual problems
 Sensory integration
problems
 Failure-to-thrive, Feeding
problems
 Behavioral/emotional
difficulties,
 Communication disorders
 Bladder and bowel control
problems, digestive problems
 (Gastroesophageal reflux)
 Skeletal deformities, dental
problems
 Mental retardation and
learning disabilities in some
 Seizures/ epilepsy

53. Diagnosis
A USEFUL diagnosis is when the specific type,
affected limb, severity and cause, if known, are
identified.

54. DIAGNOSIS
 Physical evaluation, Interview
 MRI, CT Scan EEG
 Laboratory and radiologic work up
 Assessment tools
 i.e. Peabody Development Motor Skills, Denver Test
II

55. The Peabody Development
Motor Scales
 In-depth assessment
 6 Subtests include:
 Reflexes
 Stationary
 Locomotion
 Object Manipulation
 Grasping,
 Visual-Motor
Integration.
 The subtests yield a
gross motor quotient
 A fine motor quotient
 A total motor
quotient.
 Ages covered: from
birth through five years
of age

56. Denver Test II
 Developmental Screening Test
 Cover 4 general functions:
 Personal social (eg. Smiling),
 Fine motor adaptive (eg. Grasping & drawing)
 Language (eg. Combining words)
 Gross motor (eg. Walking)
Ages covered: from birth to 6 years

57. Denver Test II

58. ASSESSMENT

59. - INTERVIEW

60. a. History Taking
Include all that may predispose an
infant to brain damage or CP
Risk factors
Psychosocial factors
Family adaptation

61. b. Child’s Health History
 Often admitted to hospitals for corrective surgeries and
other complications.
 Respiratory status
 Motor function
 Presence of fever
 Feeding and weight loss
 Any changes in physical state
 Medical regimen

62. - Physical Examination
2. OBJECTIVE

63. CRITERIA
P osturing / Poor muscle control and strength
O ropharyngeal problems
S trabismus/ Squint
T one (hyper-, hypotonia)
E volutional maldevelopment
R eflexes (e.g. increaseddeep tendon)
*Abnormalities 4/6 strongly point to CP

64. Posturing / Poor muscle
control and strength
 Test hand strength by lifting the child off the ground while the
child holds the nurses hands.
 Observe for presence of limb deformity, as decreased use of
extremity leads to shortening.
 Upon extension of extremities on vertical suspension of the
infant,
 If infant back bend backwards like
and arch may indicate CP is severe

65. Oropharyngeal problems
Speech,
swallowing
breathing,
drooling,
feeding poorly

66. Strabismus
 Squint  Tone
 Hypertonia - rigid, tense
 Hypotonia – floppy or
flaccid

67. Evolutional mal development
 Delays in motor skills
 such as rolling over, sitting, crawling, and
walking
 Size for age.
 Persistence of primitive reflexes or parachute
reflex fail to develop

68.  Present at birth, normally disappears after 3 or
4 months (some say 6months)
Alternative Names:
Startle response; Startle reflex; Embrace reflex

69. Asymmetric tonic neck reflex
"fencing position“
-- head to one side, arm & leg on that side extended,
opposite limbs flexed.

70. Athetosis
and
persistent asymmetric tonic reflex.

71. Placing Reflex
 When the dorsal (back) side of the hand or foot is placed on the
edge of a surface, such as a table, the infant will lift the
extremity and place it on the flat surface.

72. Landau Reflex
 When the infant is held in a horizontal prone position, the infant will lift head
and extend the neck and trunk. When the neck is passively flexed, the entire
body will flex. This reflex is present by 6 months and hypotonicity (low
tone) indicates motor system deficits.

73. Parachute Reflex
 When held around the waist in a horizontal prone position and then lowering
the infant slowly, head first to the surface. By age 6 to 8 months the infant
should respond by extending the arms and hands to break the “fall”. If this
response is asymmetrical it indicates an unilateral motor abnormality.

75. Reflexes
Eg. Increased/ exaggerated deep tendon

76. Treatment

77. - No treatment to cure cerebral palsy.
- Brain damage cannot be corrected.
 Crucial for children with CP:
 Early Identification;
 Multidisciplinary Care; and
 Support

78. I. Nonphysical Therapy

79. A. General management
- Proper nutrition and personal care
B. Pharmacologic
Botox, Intrathecal, Baclofen
- control muscle spasms and seizures,
-Delivered directly to the spinal fluid
-Using a pump to avoid brain effects
Glycopyrrolate -control drooling
Pamidronate -may help with osteoporosis.

80. C. Surgery
-To loosen joints,
-Relieve muscle tightness,
- Straightening of different twists or
unusual curvatures of leg muscles
- Improve the ability to sit, stand, and walk.

81. Selective posterior rhizotomy
 Is used to improve
spasticity (muscle
stiffness) in cerebral
palsy. In some cases
nerves need to be severed
to decrease muscle
tension of inappropriate
contractions.

82. Procedure
 A major operation, takes approximately four hours to
complete.
 The sensory nerve fibers in the spinal cord, usually
between the bottom of the rib cage and the top of the
hips are divided
 The nerve fibers are then stimulated and the responses
of the leg muscles are observed.
 Those that have an abnormal or excessive response
are severed.
 Those with a normal response are left intact.
 Intensive rehabilitation is required after the surgery,
usually up to six weeks, followed by physical therapy
on an ongoing basis.

83. Cont…

84. Cont…

85. D. Physical Aids
Orthosis, braces and splints
- Keep limbs in correct alignment
- Prevent deformities.
Positioning devices
-Enable better posture
Walkers, special scooters, wheelchairs
- make it easier to move about.

86. E. Special Education
- To meet the child's special needs
- Improve learning.
- Vocational training can help prepare young
adults for jobs

87. F. Rehabilitation Services-
Speech and occupational therapies may improve
the ability to speak, and perform activities of
daily living and to do some suitable works to
have their own income.

88. G. Family Services
- Professional support helps a patient and
family cope with cerebral palsy.
- Counselors help parents learn how to
modify behaviors.
- Caring for a child with cerebral palsy can
be very stressful.
- Some families find support groups helpful.

89. H. Other Treatment
- Therapeutic electrical stimulation,
- Acupuncture,
- Hyperbaric therapy
- Massage Therapy might help

90. II. Physical Therapy
 'The ultimate long-term goal is realistic independence.
To get there we have to have some short-term goals.
Those being a working communication system,
education to his potential, computer skills and, above
all, friends'.

91. A. Sitting
- Vertical head control and
control of head and trunk.
B. Standing and walking
- Establish an equal distribution of
weight on each foot, train to use steps or inclines
C. Prone Development
D. Supine Development
-Head control on supine and positions

92. RESEARCH
INPUT

93. The impact of Kinesio taping technique on
children with cerebral palsy.
 Shamsoddini A
 Abstract
 Cerebral palsy (CP) is the most common movement disorder in
children that is associated with life-long disability and multiple
impairments. The clinical manifestations of CP vary among
children. CP is accompanied by a wide range of problems and
has a broad spectrum. Children with CP demonstrate poor fine
and dross motor function due to psychomotor disturbances.
Early rehabilitation programs are essential for children with CP
and should be appropriate for the age and functional condition
of the patients.

94. Cont…
 Kinesio taping (KT) technique is a relatively new
technique applied in rehabilitation programs of CP.
 The author reviews the effects of KT techniques on
improving motor skills in children with CP. In this study,
we used keywords "cerebral palsy, Kinesio Tape, KT and
Taping" in the national and international electronic
databases between 1999 and 2016. Out of the 43 articles
obtained, 21 studies met the inclusion criteria.

95. Cont…
Findings:- There are several different applications about KT
technique in children with CP. Review of the literature
demonstrated that the impact of this technique on gross and fine
motor function and dynamic activities is more effective than
postural and static activities. Also this technique has more
effectiveness in the child at higher developmental and motor
stages.
The majority of consistent findings showed that KT technique as
part of a multimodal therapy program can be effective in the
rehabilitation of children with CP to improve motor function and
dynamic activities especially in higher developmental and motor
stages.

98. NURSING
RESPONSIBILITIES

99.  Nursing Diagnosis
a. Risk for injury r/t spasms, uncontrolled movements and seizures.
b. Impaired Physical mobility r/t spasms and muscle weakness.
c. Changes in growth and development r/t neuromuscular disorders.
d. Impaired verbal communication r/t difficulty in articulation.
e. Risk for aspiration r/t neuromuscular disorders.
f. Changes in thought processes r/t cerebral injury, learning disabilities.
g. Self-care Deficit r/t muscle spasms, increased activity, cognitive
changes.
h. Deficient Knowledge r/t home care and therapeutic needs.

100.  Goals :
a. Children will always be safe and free from injury.
b. Children will have a maximum movement ability and not
have contractures.
c. Children will explore how to learn and participate with other
children in doing some activities.
d. Children will express their needs and develop a body weight
within normal limits.
e. Children do not have aspirations.
f. The child will demonstrate an appropriate level of learning
ability.
g. Parents / family demonstrate understanding of the needs of
child care that is characterized by taking an active role in
child care.

101. Nursing Interventions
a. The increasing need for security and prevent injury
1. Avoid children from harmful objects, for example can be
dropped.
2. Watch the children during activity.
3. Give the kids a break when tired.
4. Use safety equipment when necessary.
5. The provision of anti-seizure in the event of a seizure, When a
seizure; install a safety device in the mouth so that the tongue
is not bitten.
6. Do suction, if necessary.

102. b. Improve the physical mobility
1. Examine the movement of the joints and muscle tone.
2. Do physical therapy and repositioning every 2 hours.
3. Evaluation of the needs of special equipment for eating,
writing and reading and activities.
4. Teach the use of a walker, how to sit, crawl in young
children, walking, and others.
5. Teach how to reach for objects, how to move the limbs,
appropriate ROM.
6. Provide a rest period.

103. c. Improve communication
1. Examine the response to communication.
2. Use the cards / pictures / whiteboards to facilitate
communication.
3. Involve the family in training a child to communicate.
4. Refer to a speech therapist.
5. Teach and assess non-verbal meaning.
6. Trained in the use of the lips, mouth and tongue.

104. d. Improve the nutritional status needs
1. Examine the diet of children.
2. Weigh weight every day.
3. Provide adequate nutrition and food preferences, lots of
protein, minerals and vitamins.
4. Give extra foods that contain lots of calories.
5. Help your child meet their daily needs with the ability

105. e. Prevent the occurrence of aspiration
1. Do immediately when there is suction secretions.
2. Provide an upright position or semi-sitting while eating
and drinking.
3. Examine the pattern of breathing

106. f. Increase the need for intellectual
1. Review the child's level of understanding.
2. Teach in understanding conversations with verbal or non
verbal.
3. Teach writing using whiteboards or other devices that
can be used according to the ability of parents and
children.
4. Teaching reading and writing according to his needs

107. g. Meet the daily needs
1. Examine the level of children's ability to meet daily
needs.
2. Assist in meeting the needs; eating and drinking,
elimination, personal hygiene, dress, play activities.
3. Involve families and for children who are cooperative in
meeting their daily needs.

108. h. Enhance the knowledge and the role of parents in
meeting child care needs
1. Examine the level of parental knowledge.
2. Teach parents to express their feelings about the child's condition.
3. Teach parents in meeting child care needs.
4. Teach about the conditions experienced by children and are related
to physical therapy and exercise needs.
5. Emphasize that parents and families have an important role in
helping meet the needs.
6. Explain the importance of play and socialization needs of others.

109. i. Prevent to impaired skin integrity
1. Examine the area that is attached ancillary equipment.
2. Use a skin lotion to prevent dry skin.
3. Do the massage in a depressed area.
4. Provide a comfortable position and provide support with
pillows.
5. Ensure that ancillary equipment or dressing
appropriately and fixed.

111. REFERENCES
1. “CEREBRAL PALSY” on SlideShare [Internet]. [cited 2017 May 2].
Available from:
https://www.slideshare.net/search/slideshow?searchfrom=header&q=CERE
BRAL+PALSY
2. Moro reflex - Google Search [Internet]. [cited 2017 May 2]. Available from:
https://www.google.co.in/search?q=moro+reflex&source=lnms&tbm=isch&
sa=X&sqi=2&ved=0ahUKEwim05n8vM_TAhXGkZQKHYOvBUgQ_AUI
BigB&biw=1366&bih=659

112. Thank you