Athetosis

DEFINITION

Cerebral palsy is a non-specific term applied to disorders characterized by early onset and impaired movement and posture. It is non-progressive and may be accompanied by perceptual problems, language deficits and intellectual involvement. It is the most common permanent physical disability of childhood. (Marlow)

INCIDENCE

2-4/1000 live Births, since mild cases are likely to be missed in survey, the prevalence may well be higher than the estimation (Marlow).

ETIOLOGY

* Developmental and structural disorder of brain or injury to the brain

* Fetal asphyxia and hypoxia

* Acid base imbalance

* Indirect hyper-bilirubinemia

* Metabolic disorder and

* Intra-uierine or acquired infection

(These factors may operate Pre-natally, during delivery or in the postnatal period)

CLASSIFICATION OF CP

1. Spastic: May involve one or both sides

* Hypertonicity with poor control of posture, balance and coordinated movement

* Impairment of fine and gross motor skills

2. Athetoid: Abnormal involuntary movement

* Athetosis - Slow, Worm like, Writhing neck,

* Leads to drooling and dysarthria

* Involuntary, irregular, jerking movement and disorder muscle tone

3. Ataxic: Wide based gait, rapid repetitive movement performed poorly

4. Mixed: Combination of Spasticity & Athetosis

PATHOLOGY

Wide Spread Cerebral Atrophy Cavity Formation in Sub Cortical White Matter- Atrophy of Basal Ganglion and Porencephalitis Severe Cerebral palsy

General Therapeutic Interventions:

* Physical Therapy

* Occupational Therapy

* Speech/ Language therapy

* Special Education

* Surgical Intervention

* Medication Therapy

Associated Problems / Needs:

1. Self care deficit: Skin care, Dental /oral care, Feeding and eating, Bowel and Bladder, Safety, Locomotion

2. Communication : Language/ Speech, Vision and Hearing

3. Seizure disorder : Prevention of Injury, Support to Family

4. Behavioural and Emotional : Lack of psychosocial adjustment, Loss of self concept

5. Parents and family Anxiety : Diagnosis & Prognosis, During Crisis

HOME MANAGEMENT OF CHILD WITH CEREBRAL PALSY

1. Self Care Deficit

i) Self Care Support related to Skin Care

Objective : a) Maintain Skin Integrity

Management

* Maintain skin hygiene

* Reposition every 2-3 hrs, if needed

* Keep skin dry and clean

* Use lotion for dry skin

* Use special mattress and pillows

b) Prevent contractures

* Maintain good alignment with pillows

* Use high back chair with chest strap

* Place a foot rest under the feet

* Apply braces in day times and splints at night

* Perform active and passive stretching exercises

ii) Self Care Support related to Dental/Oral Care

a) Prevention of Dental caries

* Teach correct technique

* Advice brushing twice a day

* Watch for loose teeth

* Give calcium rich food

b) Maintain oral Hygiene

* Mouth rinse after each feed

* Avoid sweets after brushing

* Watch for oral infections

* Watch gums for any bleeding

iii) Self Care Support related to feeding and Eating

a) Identify problems associated with feeding and eating

Assess for:

* Difficulty in sucking & swallowing

* Persistent bite reflex

* Hyper active gag reflex

* Poor lip and tongue control

* High arched palate

* Chewing difficulties

* Abnormal intra oral sensation

* Delayed hand to mouth co-or-dination and self-feeding

* Refer the child for further management

b) Maintain adequate nutrition and hydration

* Recognize, caloric needs in Spastic, Athetoid, and Atoxia

* Provide oral care frequently

* Offer foods that child can eat

* Serve food in attractive manner

* Maintain food hygiene

* Small and frequent food

* Allow long time period for meal

* Reduce stress during mealtime

* Maintain intake/output chart

iv) Self Care Support related to Bowel and Bladder functioning

a) Maintain normal bowel and bladder pattern

* Take child to bath room every 2-3 hrs

* Diaper the child if needed

* Use intermittent catheterization

* Encourage the child to maintain bowel and bladder habits

* Evaluate the possibility of bowel / bladder training programme

* Maintain hygiene

* Provide perennial care

b) Prevent constipation

* Give diet with high roughage

* Provide lots of oral fluids

* Encourage regular bowel habit

* Enema if necessary

v) Self Care Support related to Safety

a) Promote safety to Prevent accidents.

* Teach child to obey rules and regulations

* Select age appropriate toys and activities

* Provide protective head gear (helmet)

* Provide safe physical environment

* Keep sharp instruments away form reach of the child

* No sharp edged furniture

* No open electrical systems

vi) Self Care Support related to Initiate Self care activities

a) Develop skill in self-care activities gradually

* Parents need to encourage child for self care and ADLs

* Boost child's ability in self-care activities

* Modify utensils and cloths for self-help

* Modify equipment and activities

vii) Self Care Support related to Locomotion

a) Improve & strengthen locomotor function

* Encourage sitting, crawling

* Provide incentives to get up

* Incorporate play into motor

* Have supportive aids available to encourage locomotion

2. FACILITATING COMMUNICATION

a) Develop skill in communication with limitations

* Talk slowly to the child

* Ask one question at a time

* Use signals

* Find out the signals which the child uses

* Provide an opportunity for initiation in communication

* Allow time for child to express ideas

* Explore other non verbal methods

* For vision /hearing/ language/speech problems refer to specialists

3. BEHAVIORAL AND EMOTIONAL CARE

a) Build a positive self-concept

* Accept the child as an individual

* Understand child's strengths and competencies

* Expect best possible response

* Provide feedback

* Give support and encouragement

* Adhere to the limits

* Keep records of child's progress

* Recognize the child's needs

* Encourage child to have his own thoughts, and attitude

* Recognize problems with self-concept

b) Adjust to psychosocial problems related to limitations

* Parents need to be supported for care

* Recognize child's skills and abilities

* Acknowledge limitations

* Set and maintain expectations

* Support and encourage the child's attempts for independence

* Provide a variety of experience in the child's area of strength

* Provide reasonable discipline

3. Seizure Care

a) Prevent injuries during seizure

* Child need to be aware of the aura

* Place the child on flat surface

* Be with the child throughout

* Turn the head of the child to one side

* Observe and prevent tongue bite

* Do not hold the child too tightly

* Avoid over crowding

* Good ventilation

* Provide calm and quiet environment

Nurses' Role in Home Management of patient with CP in the Community

1. Identification of Child With CP at Home

a) Assessment of the Child with suspected CP

Activities

* A 'quiet' sleep for long & cry often

* Difficulty in sucking & eating

* Delayed milestones

* Persistent adoption of the posture

* Exaggerated Stretch Reflexes

* Co-contraction of Muscles

* Dystonia

* Refer and follow up

2. Helping the parents in accepting the diagnosis

a) Provide support to family members

* Reassure the parents & family members

* Explain need for the long term treatment

* Allow them to express their feelings

* Provide emotional support

* Medications should be continued as advised

* Educate about-the care during the fit and after the fit

* Work with parents

* Encourage parents to educate the child for self-care

3. Supporting the family members for home care

a) Help the parents and the family to accept the diagnosis

* Allow family members to express feelings and emotions

* Explain about the condition

* Remember that coping styles vary

* Be patient in clarifying doubts

* Reassure the parents

4. Educating the parents for early detection and care for anticipated crisis

a) Early detection and care for anticipated crisis

* Recognize the four common crisis periods

* time of diagnosis child starting time of school

* child leaves school needs to achieve independent role

* Provide anticipatory guidance

* Help in decision making

5. Assist the family for identifying the community resources

a) Assist the family identity and use the community resources

* Arrange meetings with good coping parents of children with CP

* Explain parents about the benefits available for handicap children

* Inform about educational options available

4. Educating Parents About Signs of CP for Referral

Physical Signs:

Poor head control after 3 months

Stiff or rigid arms or legs, pushing way or arch back

Ploppy or lip body posture

Cannot sit up without support by 8 months

Use only one side of the body or only the arms to crawl

Behavioural Signs:

Extreme irritability or crying,

Failure to smile by 3 months

Feeding difficulties

CONCLUSION

The goal of nursing care for the child with cerebral palsy should be developed in consultation with the family. For home care the nurse reinforce the therapeutic plan and assist the family in designing and modifying equipments and activities to continue the therapy programme at home.

Reference:

1. Gupfe Suraj, "The Short Text Book of Pediatrics", 8th edn, (1998) Jaypee Brothers.

2. Hazinski Mary Fran, "Nursing care of the critically ill child", 2nd Edn, (1992).

3. Marlow Dorothy and Redding Barbara, "Text Book of Pediatric Nursing", 6th edn, (1988), W.B. Sounder Co.

4. Partha Sarathy Etal, "IAP text book of pediatrics", (1999), 1st edn. Jaypee Brothers.

5. Waechter Eugenia, Philips Jane & Holanday Bonnie, "Nursing care of children", 10th edn, 1985, Luppincott.

1Nagarajappa D. and 2Dr. (Mrs) Laxmi Rana

AUTHORS :

1. M.Sc. Nursing Student, Community Health Nursing, M.S. Ramaiah Institute of Nursing Education, & Research, Bangalore-54. &

2. Prof and HOD, Dept. of Community Health Nursing, M.S. Ramaiah Institute of Nursing Education & Research, Bagalore-54.

Copyright Trained Nurses' Association of India Oct 2003
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