Identifying nursing diagnoses for patients with cerebral palsy will help us determine what specific issues should be the focus of our nursing care.
Some examples of priority nursing diagnoses for CP:
Readiness for enhanced mobility / related to willingness to work with physical and occupational therapists, and potential for development of muscle control
Risk for injury /related to muscle spasms and lack of coordination
Impaired verbal communication / related to facial muscle spasms, possible co-morbid cognitive impairments
Readiness for enhanced family coping / related to family investment in care for the child
Self-care deficit / related to impairments in feeding, mobility, and communication
And to create a more detailed care plan, we would create nursing interventions and expected outcomes-- or goals-- for each diagnosis.
Nursing Diagnosis
Intervention
Expected Outcome
Readiness for enhanced mobility r/t willingness to work with healthcare team, and potential for development of muscle control
Assess patient for current physical mobility and assess patient and/or family for current goals
Engage the patient in daily exercises, focusing on range of motion, flexibility, and muscle coordination
Provide positive reinforcement for small changes
Patient and/or family will identify goals for increased mobility
Patient will demonstrate greater range of motion, flexibility, and muscle coordination
Patient and/or family will recognize progress and identify successes
First of all, I want to share an incredible story about an older man with cerebral palsy who creates truly incredible works of art using only a typewriter. Paul is unable to hold a paintbrush, pen, or pencil, but he's found ways to create shading, shape, and depth using his symbol keys.
Access to quality healthcare and therapy during childhood can greatly increase the motor control, coordination, independence, and ability to communicate for people with CP. Normally, an interdisciplinary team-- including physicians, occupational therapists, physical therapists, speech and language therapists, and nurses-- will work with an individual to meet their and their families' needs.
Nursing care goals for children with CP:
Child will remain safe and free from injury or skin breakdown.
Child's movement, coordination, communication, and independence will be optimized.
Child will demonstrate their optimal level of learning ability.
Child will participate in activities with other children.
Parents/caregivers will demonstrate understanding of childcare needs and actively participate in care.
The nursing care plan will integrate these goals, prioritizing safety while encouraging activities that foster muscle control, coordination, communication skills, independence in activities of daily living, and bonding with other children and family members. The parents or caregivers will be included in the care process, and will be engaged in the process of creating a care plan for their child.
OHSU has provided excellent Guidelines of Care for children and adolescents with CP-- they include interview questions for the family, a template for a plan of care, and critical evaluations and procedures for each age group.
One common thread runs through all of the research on treating cerebral palsy-- the sooner the better. The earlier treatment starts, the more likely the child is to find ways to overcome their motor disabilities, or find other means of achieving their goals.
The goal of treatment for CP is to improve quality of life for the client by optimizing mobility, pain control, independence, self-care, communication and learning abilities, and social interaction.
Multiple therapies are usually used together-- physical, occupational, recreational, and speech and language therapists will often all work as a team with one child. These professionals provide the child with exercises, activities, and opportunities to practice motor control, balance, communication, and whatever other skill development the child needs support in. These therapists will frequently introduce assistive devices, such as walkers, braces, and voice synthesizers, depending on their client's needs.
In the video below, Noreen Scott, a physical therapist at Tender Ones Therapy Services in Georgia, talks about how she approaches the incredibly varied needs of her young clients with cerebral palsy.
In addition to these therapies, in some cases drugs are prescribed to relax chronically contracted muscles. Oral medications are most frequently used, starting with diazepam, baclofen, dantrolene sodium, and tizanidine. In more severe cases, botulinum toxin may be injected into a contracted muscle in order to relax its contractions, or baclofen might be pumped into the area surrounding the spinal cord for a more widespread muscle relaxant.
Orthopedic surgery is also sometimes used to lengthen muscles or tendons that might be restricting movement. Surgery is also sometimes done to cut nerves that are contributing to spastic movement.
More information on the treatment of cerebral palsy can be found at CerebralPalsy.org
Cerebral palsy looks different for every person living with it. Some infants with CP are easily identified-- some may even be suspected of having CP at birth. Others may not show clear signs until they're two years old. The signs a healthcare provider will look for areissues with muscle tone, gross and fine motor developmental delays, and difficulties with control, coordination, balance, reflexes, and posture. People with CP may also have trouble swallowing, eating, and speaking. The video below has a great deal more information on looking for signs of CP--
In addition to individual differences, CP is also divided into categories, which will each present differently. Athetoid, or dyskinetic, cerebral palsy affects 25% of people with CP. It is characterized by difficulty controlling and coordinating limb movements. The child below is showing early typical signs of athetoid CP.
A more severe example is Emma, in the video bellow Her mother explains that in addition to living with quadriplegic athetoid CP, meaning she has difficulty controlling both arms and both legs, Emma also has intermittent spastic CP, which in her case makes it difficult for her to speak or form sounds.
Signs and symptoms of cerebral palsy vary widely-- but a common thread is a sense among parents of children with CP that something is different about their child. The intuitions of caregivers have led to many early diagnoses of CP, which make a huge difference in providing effective treatment.
Before I dig into the difficulties of diagnosing cerebral palsy -
This an incredible story about two parents, Adele and her husband Laurence, both diagnosed with CP. Even if you only have time to watch the first couple minutes, the video brings up some really interesting issues. Parents with disabilities face a lot of stigma and a lot of logistical complications as they navigate the healthcare system and the physical demands of raising a child.
There isn't just one diagnostic test to determine whether a child has CP or not. At regular well-child checks, a child's healthcare provider will monitor their development, and at certain ages (9, 18, and 24 or 30 months) will do a series of tests to see how the child's motor skills, language, and social skills compare to other children their age. Through these tests, the difficulty with muscle control that defines CP can be identified.
Providers will look at things like a baby's height and weight, posture, reflexes, muscle tone, and interaction with parents.
Some children are more difficult to diagnose than others. I've highlighted the diversity of experiences and issues faced by people living with CP, and that diversity is even present in infancy. Some people with CP may have gross motor development delays that are large enough to be seen by a caregiver at 9 months. Others might have mild movement delays that aren't clear until the child is two years old.
It's also important to remember that a diagnosis of cerebral palsy does not mean anything certain about a child's future. Adele says in the documentary above that the doctors her family worked with told them she would never walk-- and yet as an adult woman, she walks smoothly with a cane, and is an adept mother.
Before we get into the inner workings of cerebral palsy, this week's story is from Victoria Conrad. It's been inspiring to read and listen to so many portraits of people living with CP. Each person is affected so differently, and has different strategies for adapting to their lack of muscle control.
Cerebral palsy is a set of muscle control disorders that are thought to be caused by a lack of oxygen to the brain of a fetus or newborn-- CP is tied to a number of different risk factors, including some infections during pregnancy, lung immaturity (especially in premature newborns), seizures shortly after birth, a knot in the umbilical cord, or the newborn breathing in some of its first bowel movement during labor. The many different potential causes of CP are still being researched.
This research is crucial. Cerebral palsy affects many different parts of a child's life, and the lives of their loved ones.
There is a great deal of research into medical malpractice and cerebral palsy cases, as well-- some groups blame medication and delivery errors. These concerns make it even more crucial for the specific causes of CP to be identified.
This week I want to let Jamaul Thomas and his family have the first word.
According to the Centers for Disease Control and Prevention (CDC), cerebral palsy (CP) is the name for a number of disorders that all affect a person's balance, posture, and ability to move. The CDC estimates that in the U.S., an average of 1 in 323 children have a CP disorder-- making CP responsible for the most common childhood motor disabilities.
In the U.S., the CDC states that CP is more common among Black children than Latino, Asian, or White children. It is also more common in boys than in girls. Children with CP also commonly have another disorder-- the most common co-occurring disorders are epilepsy and autism spectrum disorder.
Cerebral palsy is linked to the lack of oxygen in the brain of a fetus, newborn, or infant-- but there are many different ways that oxygen can be blocked. Some children with CP were affected by a traumatic birth, in which there was a problem with their umbilical cord or with blood flow to the placenta. Others suffered strokes or hemorrhages as newborns.
The more we know about the root causes of a disorder, the easier it is to decrease the number of people it affects. With a group of disorders like CP, there are so many potential causes that its occurrence is difficult to control-- but there are some things that women can do to increase their fetus' access to oxygen, and to decrease their child's risks of experiencing CP.
In a study from 1996 to 2008, researchers found that women were significantly more likely to deliver a baby with CP if they had had, during pregnancy, vaginal infections (especially untreated infections) or fever, or had smoked 10 or more cigarettes per day. 81,066 mothers and their newborns participated. By accessing prenatal care, getting treatment for infections and illnesses, and cutting down on or stopping smoking, women can decrease their risk of giving birth to a child with CP. However, these services are much harder to access for some women than for others-- for example, women living in rural areas, women unable to get time off of work for prenatal visits, and women with traumatic experiences from dealing with the healthcare system may not get the care, education, or support they need to make these changes.
There is still a great deal of research to be done on the causes and risk factors of cerebral palsy-- and there are many situations in which a child's CP was unavoidable by either the parents or by healthcare providers. It is clear, however, that providing easy access to quality prenatal care and education for all women is a good place to start in reducing the high rates, and discrepancies, in children with CP.
