I.

INTRODUCTION

Neurologic disorders encompass a wide array of problems resulting from congenital disorders, acquired dysfunction, infection, or trauma. Many of these disorders can cause severe illness. Others can result in life-threatening [Link] possible, prevention must be the highest priority for keeping the nervous system healthy. If degeneration has already occurred, nursing care must focus on helping the child and family develop strategies for dealing with the associated loss in mental or physical functioning, making the child comfortable, and providing an environment conducive to the childs development and self-esteem.

II.

CONTENT A. What is Cerebral Palsy?

Cerebral palsy is a non-progressive disorder of motion and posture resulting from brain injury or insult during a period of early brain growth. It is not in itself a disease but a condition that may result from numerous diseases that damage those parts of the brain responsible for voluntary muscular coordination. Such causes may include pressure on the brain or oxygen deprivation to the brain before or during birth (cerebral anoxia), direct injury, embolus or hemorrhage, arrested hydrocephalus, and infection or toxicity occurring any time after birth. Cerebral palsy is usually diagnosed in infancy, since it is commonly caused by events associated with the prenatal or perinatal period. Treatment is directed toward limiting the disability and may continue throughout the affected person's life. The disorder may be limited, mild or severe and far-reaching, involving many body functions. There are approximately 1.3 cases of cerebral palsy per 1000 persons in the general population. The child with the disorder of movement called cerebral palsy may have injuries to the brain involving other functions. Some patients with cerebral palsy have associated seizures, mental insufficiency, behavior problems, and special sensory difficulties, especially related to vision or hearing, and learning disturbances. The muscles of the mouth, tongue, and throat may be affected, influencing the ability to receive, chew and swallow food, as well as speech and language.

B. Clinical Manifestations/ Features in: i. SPASTIC TYPE

It is the most common form, affecting 65% of cerebral palsy patients. It is characterized by increased muscle stiffness or tone, exaggerated contraction of affected muscle groups when stimulated (stretch reflex), jerky motions, and a tendency to have contractures. The lower extremities are most often involved. A scissors gait is common. PATTERNS OF SPASTICITY The following body patterns of spastic cerebral palsy are: 1. Hemiplegia A child with spastic hemiplegeia will typically have spasticity (muscle stiffness) on one side of the body - usually just a hand and arm, but may also involve a leg. The side that is

affected may not develop properly. The child may have speech problems. In the majority of cases intelligence is not affected. Some children will have seizures. 2. Double Hemiplegia Involves arms and legs on both sides, with one side more severely involved 3. Quadriplegia The child's legs, arms, and body are affected. This is the severest from of spastic cerebral palsy. Children with this kind of cerebral palsy are more likely to have mental retardation. Walking and talking will be difficult. Some children have seizures. 4. Diplegia The lower limbs are affected, and there is no or little upper body spasticity. The child's leg and hip muscles are tight. Legs cross at the knees, making walking more difficult. The crossing of the legs when the child is upright is often referred to as scissoring (scissors gait).

ii. EXTRAPYRAMIDAL (nonspastic type)comprising about 15% of cases,

are characterized by a variety of emotional, postural, and sleep states. This type includes the following:

a. b.

Athetoid, characterized by involuntary, uncoordinated, purposeless movements involving joint motion rather than single muscle action (The upper extremities are often involved.) Ataxic, characterized by loss of a sense of balance and problems in evaluating spatial relationships and the relative positions of body parts

iii. MIXED TYPE of cerebral palsy combines features of types 1 and 2 and
represents about 20% of affected patients GENERAL SIGNS & SYMPTOMS A person with cerebral palsy will generally show symptoms during the first three years of life. A child/baby with cerebral palsy may have some of the signs and symptoms below: o o o o o o o o Achieves developmental milestones, such as crawling, walking, or speaking, later than his/her peers. Crawls in an unusual way. Has abnormal muscle tone - the child will slouch while sitting. Has difficulty feeding and sucking. Lies down in awkward positions. Can be easily startled. Favors one side of the body over the other. Has overdeveloped or underdeveloped muscles (has floppy or stiff movements).

o o o o o o o o o o

Has bad coordination and balance (ataxia). Has involuntary, slow writing movements (athetosis). Muscles are stiff and contract abnormally (spastic paralysis). Has hearing problems. Has problems with eyesight. Has bladder control problems. Has bowel movement control problems. Has seizures. Has problems swallowing. Range of movements are limited.

C. Risk Factors of Cerebral Palsy

Risk factors can be associated with the parents, as well as the child. The following are risk factors related to parents that can increase the risk of cerebral palsy: y Mother 40 years or older y Mother 20 years or younger y Father 20 years or younger y African-American ethnicity. The following are risk factors related to the child that can increase the risk of cerebral palsy: y A first child or child born fifth or later in the family y One of a pair of twins, especially if one twin dies y Low birth weight, less than 3.5 pounds y Premature infant, less than 37 weeks. The following are other known risk factors that can increase the risk of cerebral palsy: y Rh or ABO blood type incompatibility between mother and infant y Infection of the mother with German measles or other virus in early pregnancy y Attack by microorganisms on the central nervous system of the infant. More than one risk factor can be present at the same time, such as low birth weight and being a twin. Such combinations can further increase the risk of cerebral palsy occurring.

D. Nursing Considerations
The care of children with cerebral palsy and their families requires a multidisciplinary team approach including: the nurses in the hospital, home, and primary care settings, the pediatrician, orthopedist, physical therapist, occupational therapist, speech pathologist, audiologist, psychologist, medical-social worker, public health workers, nurses and educators.

i.

For the Child

When children with cerebral palsy are hospitalized, it is very important that the hospital staff know their capabilities as individuals. Information regarding successful feeding and dressing techniques, toileting practices, communication aids, and special challenges saves

hours of frustration and distress. The care of children whose total neuromuscular involvement is slight requires little modification. The care of others requires considerable study and adjustment. Children with a history of seizures or upper extremity or head involvement should not have their temperature taken orally until the safety of the procedure is evaluated. Each child's diet must be evaluated to ensure that it is appropriate for his or her age, nutritional needs, and ability to handle and swallow. Although self-feeding may take considerable time and cause some disorder, these children should feed themselves as much as possible, using techniques they have been taught. Aids, such as swivel spoons, plate guards, training cups, and rocker knives, are invaluable. Special weights can be attached to the child's arms to help control involuntary motion. Children may need patient, caring assistance with feeding. Since severely affected children may require the occasional use of suction, an apparatus should be readily available. During feedings, the nurse should hold the child in such a way that the child's arm closest extends behind him or her. This often causes the child's head to rotate comfortably to the same side (tonic neck reflex). Gentle support of the chin or stroking the neck on either side of the esophagus may help lip closure and swallowing. Some children who have difficulty swallowing find carbonated drinks a problem. Stirring until the carbonation is minimal or serving other types of liquid is helpful. Excessive stimulation, sudden jarring movements, and the pressure of "having to hurry" induces greater tenseness and makes performance of relatively simple tasks arduous. These children find it very difficult to relax, and they become fatigued easily. The simplest kind of controlled movement may require a tremendous amount of concentration and energy. When possible, the child with cerebral palsy should have contact with other children and should not be socially deprived. Contact with other youngsters is frequently limited. However, even those who have moderately severe muscular involvement often enjoy working with modeling clay, finger paints, large blocks, and hand puppets. Many enjoy music, television, and reading. An occupational therapist can work with the children to improve skills needed to meet everyday needs. These are presented to the young child in the form of games or special projects. Progress, though at times seemingly small, should be recognized and praised. The child usually responds to this recognition and continues efforts to improve.

ii. For the Family

These children and their families often have considerable emotional problems, which may be expressed in the way the parents treat the child and in their aspirations for the child's future. Parents may be overprotective and do too much for their child, making it difficult for him/her to master the skills of which they are capable. On the other hand, they may expect too much and cause painful frustrations. Parents may need help in establishing realistic goals and in providing an environment conducive to positive mental and physical health. That the problem is not inherited should be clarified early to decrease parental feelings of guilt. Informational and emotional support provided by other parents and health care providers is invaluable. A hopeful aspect of cerebral palsy is that the initiating cause is not progressive in character, and so the neuromuscular involvement, with treatment, does not worsen. Cerebral palsy is not a degenerative disease like muscular dystrophies, and

considerable improvement can usually be gained. Through physical and occupational therapy, surgical techniques, and medication, children with cerebral palsy are able to meet their daily personal needs and, in some cases, to prepare for self-supporting occupations. Special public programs geared to meet the needs of disabled children are available in most communities. Children may attend regular school classes as well as special sessions designed to meet their individual needs during their school years. The school nurse plays an important role in coordinating their care.

E. Prevention
There are some things people can do to minimize the risk. However, in many cases cerebral palsy cannot be prevented. The pregnant mother should: y y y y y y y Make sure all her vaccinations are up-to-date Go to all her antenatal appointments Abstain from drinking alcohol throughout the whole pregnancy Abstain from smoking throughout the whole pregnancy Take regular exercise throughout the whole pregnancy (check with the doctor what you can do) Eat a healthy diet throughout the whole pregnancy Identify potential Rh incompatibility (usually for second and subsequent pregnancies)

F. Diagnostic Evaluation
The neurologic examination and history are the primary modalities for diagnosis of CP.A through knowledge of normal variations of motor development is required for detecting abnormal progress and careful history is elicited to detect possible etiologic factors. The childs spontaneous movements and behavior are observed, including posture; attitude; and muscle size, function and tone. Persistence of primitive reflexes may be of value and two of these aids in the diagnoses: the asymmetric tonic neck reflex and the crossed extensor reflex. Supplemental diagnostic tests may be employed such as electroencephalography, tomography, screening for metabolic defects and serum electrolyte values. The possibility that the manifestations are those of slowly progressive degenerative disease or early-onset, slowly growing brain tumors must be ruled out.

G. Management
Management involves multiple disciplines, including a primary physician, specialty physicians such as a neurologists and orthopedic surgeons; nurses, physical therapists, speech therapists, dietician, psychologist, counselors, teachers, and parents.

i.

Therapeutic

Spasticity management will be a primary concern and will be a determined by clinical findings. There is no standard treatment for all children. The overall focus of therapeutic management will be to assist the child to gain optimal development and function within the limits of the disease. Treatment is mainly symptomatic, preventive and supportive. Medical management is focused on promoting mobility through the use of therapeutic modalities and medications. Multiple corrective surgeries may be required; usually are orthopedic or neurosurgical. Contractures that limit movement may also be surgically corrected. Common orthopedic procedures include tendon lengthening, correction of hip and adductor muscle spasticity and spinal deformity correction. Common neurosurgical procedures are placement of shunt in hydrocephalic patients.

PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY

The use of such therapies will be essential in promoting mobility and development in the child with CP. Physical Therapy Physical therapists work with children to assist in the development of gross motor movements such as walking and positioning and they help the child develop independent movement. They also assist in preventing contractures and they instruct children and caregivers in the use of assistive devices such as walkers and wheelchairs. Occupational therapists may be responsible for fashioning orthotics and splints. AFOs (ankle-foot orthotics) are the most common orthotic used by children with cerebral palsy. AFOs help prevent deformity from conditions such as contractures and help reduce the effects of existing deformities. They can help improve a childs mobility by assisting in control of alignment and helping to increase the efficiency of the childs gait. Spinal orthotics such as braces are used in young children with cerebral palsy to combat scoliosis that develops due to spasticity. These braces are used to delay surgical management of the scoliosis until the child reaches skeletal maturity. Splinting is used to maintain muscle length. Serial casting may also be used to increase muscle and tendon length. Occupational Therapy Occupational therapy also assists in the development of the fine motor skills and will help the child to perform optimal self-care by working on skills such as activities of daily living. Speech Therapy Speech therapy assists in the development of receptive and expressive language and addresses the use of appropriate feeding techniques in the child who has swallowing problems. Speech therapists may teach augmented communication strategies to children who are nonverbal or who have articulation problems. Many children may not communicate verbally but can use alternative means such as communication books or boards to make their desires known or to participate in conversation.

ii. Pharmacological
Various pharmacologic opinions are available to manage spasticity. Medications are also used to treat seizure disorders in children with cerebral palsy. Oral medications used to treat spasticity include baclofen and diazepam. Patients with athetoid cerebral palsy may be given anticholinergics to help decrease abnormal movements. Parenterally administered medications such as botulin toxins and baclofen are also used to manage spasticity. Botulinum toxin is injected into the spastic muscle to balance the muscle forces across joints and to decrease the spasticity. It is useful in managing focal spasticity in which the spasticity is interfering with the function, producing pain, or contributing to a progressive deformity. Botulinum toxin injection is performed by the physician or advanced practitioner and can be done in the clinic or outpatient setting, Intrathecal administration of baclofen has been shown to decrease tone but it must be infused continuously due to its short half-life. Surgical placement of a baclofen pump will be considered in children with general spasticity that is limiting function, comfort, activities of daily living and endurance. To test whether it is a suitable option, an intrathecal test dose of baclofen will be administered. If the trial is successful, a baclofen pump will be implanted. Once inserted, delivery of the drug can be individualized to meet the patients unique needs. The pump needs to be replaced every 5 to 7 years and must be refilled with medication approximately every 3 months, depending on the type of pump. Complications with baclofen pump placement include infection, rupture, dislodgment or blockage of the catheter.