CASE STUDY:PATIENT WITH CEREBRAL PALSY

GENERAL OBJECTIVES:This case study aims to collect

signinficant information that helps us to plan and to provide nursing interventions to a patient with Cerebral Palsy.

SPECIFIC OBJECTIVES:conduct an interviewassess patient from head to toeprovide health education to patient's S.Oimplement a nursing care plansimplement a discharge plan

DEMOGRAPHIC DATA:

NAME: Jeffrey DancesAGE: 2 years oldADDRESS: Guadalupe, Maasin CityBIRTHDATE: July 27, 2009BIRTHPLACE: SOYMPHNATIONALITY: FilipinoRELIGION: Roman CatholicTIME OF ADDMISSION:PHYSICIAN: Dr. Jocelyn Verano

HEALTH HISTORY

CHIEF COMPLAINTS:the pt. is a 2 y.o boy with diarrhea, fever

and experienced seizure

HISTORY OF PRESENT ILLNESS:According to the pt. s.o, the pt.

experienced diarrhea, fever and seizure in the past 2 days. The parents gave the pt. Sodium for dehydration and herbal medicine like avocado for diarrhea. But there's no improvement so they decided to seek medical attention to their pediatrician.

PAST HEALTH HISTORY:

According to the pt's. Mother, before she used IUD to prevent from pregnancy since they already had 7 children. But they decided to stop it because the doctor told them that she has ovarian cyst (myoma). Three months after, the doctor administered medicine for ulcer w/o knowing that she is 3 months pregnant. She also experienced vaginal bleeding that lasted for 2 days. She was 41 y.o when she gave birth to her baby, weighing 4,070 grams. When her baby was 3 mos. Old, he accidentally fell into the ground and hit his head by a stone that caused swelling to his right forehead, the mother also observed that he cannot identify colors, and had no reaction (smile, laugh) so she brought him to the doctor and said that the baby has blurred vision.

Six months after, the baby had an epilepsy which the mother believed that it was due to max. volume of music, since they live near the gym where discos were held. The following day, the baby had fever so they decided to bring him to the hospital. The pt. was able to consume all necessary immunization w/c makes him fully immunized child. No allergies were noted.

FAMILY HISTORY OF ILLNESS:

the patient's paternal side has a history of epilepsy, arthritis, hypertension. While on the maternal side has breast cancer, hypertension and polio.

PHYSICAL ASSESSMENT

GENERAL APPEARANCE:pt. Is conscious, has fair complexion, with IV on her left

hand.

SKINPoor hygien, dry skin

HEAD, NECK and FACE:flat on the left back side of the headrashes on the neck

EYEsclera is clear , unable to focusreactive and sensitive to light

EARpresence of earwax, unable to hear

MOUTHdental cavities noted, upper and lower teeth

ABDOMENrounded abdomenno tenderness noteddry skin noted

MUSCULOSKELETAL and NEUROLOGICunable to respondunable to walkunable to hold thingshas difficulty in speech

GENOGRAM

Emiliana Reyes71 y.o

Crisanto Reyes70 y.o

Hypertension

Rosana 40 y.oBreast Cancer

Ruby R. Dances40 y.o

Cita Dances

died 2009Epilepsy

Simplicio Dances83 y.o

Simplicio Dances Jr.54 y.o

Arthritis & Hypertension

Rodrigo Reyes48 y.o

polio since 3 y.o

Jeffry Dances2 y.o

Cerebral Palsy

Floe Marie12 y.o

Kyptosis

MyleneDance

s22 y.o

RobertsonDances21 y.o

Rellanie

Dances18 y.o

GORDON’S FUNCTIONAL

HEALTH PATTERN

Nutritional and Metabolic Patternevery meal, he drinks milk, eat rice, vegetable soup

and papaya. Sometimes, mashed potato with soup. He eats 3 times a day, eat snacks before lunch and before dinner. During hospitalization, he had soft diet.

Elimation Patternbefore hospitalization, the pt. defecates every

morning. while when he was admitted, he defecates twice a day.

Activity Pattern as stated by the mother, the pt. stays only in the

house the whole day, lying on bed as he cant walk and no exercise. During hospitalization he did the same thing but after discharged, mother spend time to exercise his child by using the walker.

Sleep and Rest Patternthe pt has no exact sleeping pattern, sometimes

he sleep 7 hours at night during hospitalization he keep on sleeping.

Cognitive PerceptualUnable to focus,

Role and Relationshipthe member of the family treated him special

despite his condition because according to them, he is a gift from God. They don't want to mingle others, especially their neighbors because they were hurt everytime they hear a negative feedback (gossips) about their son's condition.

DEFINITION and MANGEMENT OF DISEASE

Cerebral palsy is an umbrella-like term used to describe a

group of chronic disorders impairing control of movementthat appear in the first few years of life and generally do notworsen over time. The term cerebral refers to the brain'stwo halves, or hemispheres, and palsy describes any disorderthat impairs control of body movement. Thus, thesedisorders are not caused by problems in the muscles ornerves. Instead, faulty development or damage to motorareas in the brain disrupts the brain's ability to adequatelycontrol movement and posture.

Cerebral Palsy Causes

Cerebral palsy results from damage to certain parts of the developing brain.

Medical mistakes can cause cerebral palsy or brain damage.Bleeding during pregnancyNutritional deficiency( anemia)Unkown cause Mechanical trauma during deliveryHead Traumatoxin ( contaminated fish)

Cerebral Palsy SymptomsThe signs of cerebral palsy are usually not noticeable in early infancy but become more obvious as the child’s nervous system matures. Early signs include the following:

*Delayed milestones such as controlling head, rolling over, reaching with one hand, sitting without support, crawling, or walking.

*Problems and disabilities related to CP range from very

mild to very severe. Their severity is related to the severity of

the brain damage. They may be very subtle, noticeable only to

medical professionals, or may be obvious to the parents and

other caregivers.

*Abnormal movements: Movements may be unusually jerky or

abrupt, or slow and writhing. They may appear uncontrolled or

without purpose.

*Abnormal muscle tone: Limbs may be held in unusual or

awkward positions. For example, spastic leg muscles may cause

legs to cross in a scissor-like position.

*Skeletal deformities- may have shortened limbs on the affected

side.

*Seizures - Seizures may appear early in life or years after the

brain damage

*Speech problems:*Swallowing problems

*Hearing loss: Partial hearing loss is not unusual, may not

respond to sounds or may have delayed speech.

*Vision problems - This is due to weakness of the muscles that

control eye movement.*Dental problems- This results from both defects in tooth enamel

and difficulties brushing the teeth.

Cerebral Palsy Treatment

There is no cure for cerebral palsy. With early and ongoing treatment, however, the disabilities associated with cerebral palsy can be reduced. Many different therapies are available, most under the supervision of a medical specialist or other allied professional. Not all of these therapies are right for every person with cerebral palsy. The therapy regimen for a specific individual with cerebral palsy should be tailored to meet the needs of that individual. A treatment may work for one child but not for another. The parents and the child’s care team work together to choose only those treatments that offer some benefit to the child.

HOME MANAGEMENT OF CHILD WITH CEREBRAL PALSY

ANATOMY

AND

PHYSIOLOGY

The brain is a highly specialized organ. It

serves as the control center for functions of the

body and allows us to cope with our

environment. Words, actions, thoughts, and

feelings are centered in the brain. It is so

complex that some theorists believe we will

never be able to fully understand it. We do,

however, know that each part of the brain has a

specific, important function, often a profoundly

important function, and each part contributes to

the healthy functioning of our body.

Cerebrum is the largest part of the brain and is associated with conscious thought, movement and sensation. It consists of two halves, each controlling the opposite side of the body. The halves are connected by the corpus callosum, which delivers messages between them. Four lobes make up the cerebrum: the frontal, temporal, parietal, and occipital lobes.

Having to do with memory,emotion, hearing, andlanguage

having to do with decision-making

problem solving and planning

concerned w/ the reception and processingof sensory information from the body

concerned w/ vision

Brain Stem controls many vitally important

functions including motor and sensory

pathways, cardiac and respiratory functions,

and reflexes.

Cerebellum controls complex motor functions

such as walking, balance, posture, and general

motor coordination.

PATHOPHYSIOLOGY

CEREBRAL PALSY

PRENATAL PERINATAL POSTNATAL

BleedingNutritional deficiences( anemia)unkown cause

Mechanical trauma during delivery

Head traumaEnvironmental toxin

Breech deliveryHypoxia/ asphyxia

Cause edema in the brain

Cebral swelling & CNS damage

Brain trauma leads to infarction,intraventicular & subarchnoid hemorrhage.

CNS damage

LABATORY EXAM

LABORATORY EXAM

NORMAL FINDINGS

PATIENT’S RESULTS

SIGNIFICANCE

FECES EXAMINATION

PHYSICAL CHARACTER: Soft

COLOR: Greenish

OVA OF PARASITES: None seen

LABORATORY EXAM

NORMAL FINDINGS PATIENT’S RESULTS SIGNIFICANCE

HEMATOLOGY

The science dealing with the formation, composition, functions and diseases of the morphology of the blood forming organs

* Leukocyte # cone : 4.5 - 11.0 x 109 / L

* Different Counts

→ Segmenters : 0.31 - 0.76 % → Lymphocytes : 0.14 - 0.44 %

* Erythrocyte vol. fraction : 0.40 – 0.52 x 1011 /L

LEUCOCYTES# CONC:7.4 x 109/L

Segmenters: 0.90

Lymphocytes: 0. 10

Erythrocyte vol. Fraction : 0.40

DRUG SUMMARY

Brand Name: Biogesic

Generic Name: ParacetamolRoute: OralDossage: 500mg, 1 tab ( prn for fever)Classes: Analgesic

Antipyretics

Indication: Relief for fever

Therapeutic action: reduces fever by acting directly on the hypothalmia heat- regulating center to cause vasolidation & sweating which help disspate heat.

Adverese effects:Head achedyspneaacute renal failure

Contraindication:contraindicated in hypersensitivity, analgesic nephropathy, renal hepatic impairement

Brand Name: Phenobarbital

Drug Classes: AntiepilepticBarbiturateHypnotic

Therapeutic actions:General CNS depressant; depress the

cerebral cortex, alter cerebellar function, depress motor output, has anti- seizure activity, making it suitable for long term use as an antiepileptic.

Indications:Oral: Emergency control of certain acute seizures (those associated w/ status epilepticus)

Contraindications:* Contraindication w/ hypersensitivity to barbiturats.* Seizure disorder ( abrupt discontinuation of daily doses can result in status epilepticus)

Dossages:OralAntiepileptic : 3-6 mg/kg/day

Pharmacokinetics:

Route Onset DurationOral 30-60 min 10-26 hr

Excretion: Urine

Adverse Effect:CNS depression, nausea, vomiting, constipation, diarrhea, epigastric pain, dizziness, anxiety

Interactions:*Increased serum level and therapeutic and

toxic effect with valproic acid.*Increased risk of neuromuscular excitation

and hypotension with barbiturate anesthetic.

Nursing Intervention:

Monitor pt responses, Monitor blood levels

Nursing Care Plan

Asessement

S- “ wa siya’y kusog maam, dili gani siya makatindog” as verbalized by S.O.O- Temp. PR. RR Poor muscle strength noted

Nursing Diagnosis

Impaired Physical Mobility r/t decreased muscle strength and control

PLANNING

After 4 hrs of nursing interventnion the pts, S.O will be able to use the mobility devices such as walker.

1. Plan activities to use gross and fine motor skills (holding pen toys positioned to encourage reaching and rolling over.

2. Teach the pt. to perform range-of-motionexercise every 4 hrs for the child unable tomove body parts. Position the child to promote tendon stretching ( foot plantarflexion instead of dorsiflexion).

3. Encourage parents to keep appointment w/a therapist.

4. Perform development assessment and record the achievement to maintain

joint flexibility.

5.Teach the family to maintain appropriate brace wear.

•Many activities of daily living & play activities promote physical development.

2. Promote mobility and Increased circulationand decreases the risk of contractures.

3. A regular and frequently re evaluated rehabi-litation program assists in promoting

development.

4.Delayed development milestones are common w/ this condition. Once a one mile stone is achieved assist in the next skill necessary.

5. Adaptive devices are often necessary tomaximize physical mobility.

NURSING INTERVENTION RATIONALE

ASSESSMENTS- “ wala man me kabalo ug unsay angay buhaton aron siya makalihok unta”

O- temp. PR RR

DIAGNOSISIneffective management of therapeutic regimen r/t to lack of knowledge

PLANNING

1. Allow opportunites for parents toverbalize the impact of cerebral palsy on the family.

2. teach the families skills neededto manage childs care.( physicalrehabilation, seizure).

3. teach case management techqnues.

4. Involve siblings in the care for the children w/ cerebral palsy. Review for parents the needs of all childrenin the family.

The family needs an opportunity toexplore the emotional & social impactof the child care to integrate the grow from the experience.

The childs achievements are positive reinforcement of the family'seffort.

Parents become case manager to coordinate care.

Special efforts contribute to meetingthe developmental needs of allthe family members.

NURSING INTERVENTION RATIONALE

ASSESSMENT

S- “ dili man tingali siya kadungog kay dili man maminaw ug storyahan, di sad ka kita kay wala man reaction kung tagaan ug butang, dili ganiniya kuhaon” as verbalized by S.O.

O- Temp.PRRRdeafness notedblurred vission

DIAGNOSIS

Visual / auditory alteration r/t cerebral damage

PLANNING

After 4 hrs of nursing Intervention, the pt. S.O will be able to use technique to know wether their child has impaired vision and hearing & to improve his condition.

NURSING INTERVENTION RATIONALE

1. Promote the use of adaptive devices such as hearing aide.

2. encourage for further evaluation.

3. encourage in visits to some specialist.

4. describe verbally the surounding

to a child of poor vision.

5. allow touching of objects

6. provide visual materials to enhance learning.

A daptive devices often enhance sensory input. These devices needfrequent changes to child grows.Just to make sure what is his condition.

Other senses can compensate for these that are impaired.

Disharge Plan

Name: Jeffrey DancesAge: 2 y.oSex: MDiagnosis: Cerebral PalsyHospital: SoymphRm/ ward: Rm. 12Physician : Dr. Jocelyn Verano

Objectives:

Medication* pt. must continued medication as advised* pt should not miss a dose of midication.

Environmental & Exercise:* pt should perform, ROM exercises to their child to

improve the unsual movement.* pt's enviroment should be safe & comfortable during

rest time.* provide enjoyable environment for the pt to

communicate others.* provide a safe physical environment* keep sharp instrument away from reach of the child

Treatment:* promote exercise to circulate blood and to serve as a

therapy.* pt should continue home medications.

Health Teachings:* explain to pt's S.O the disorder and the treatment

plan.

* teach pt's S.O how to do ROM exercises.* provide written & oral instruction about

medication, recommended activities.

Out patients* consult a doctor if problem or complication

occured.

Diet* pt. Should have a soft diet for him to digest

easily.* Give milk and other nutritious foods.

Spritual* Assisting pt. & pt's S.O w/ prayer* support them for their religious activities* providing presence