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 interview assess patient from head to toe provide health education to patient's S.O implement a nursing care plans implement a discharge plan
DEMOGRAPHIC DATA: NAME: Jeffrey Dances AGE: 2 years old ADDRESS: Guadalupe, Maasin City BIRTHDATE: July 27, 2009 BIRTHPLACE: SOYMPH NATIONALITY: Filipino RELIGION: Roman Catholic TIME 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.
SKIN Poor hygien, dry skin
HEAD, NECK and FACE: flat on the left back side of the head rashes on the neck EYE sclera is clear , unable to focus reactive and sensitive to light presence of earwax, unable to hear
EAR
MOUTH dental cavities noted, upper and lower teeth ABDOMEN rounded abdomen no tenderness noted dry skin noted MUSCULOSKELETAL and NEUROLOGIC unable to respond unable to walk unable to hold things has difficulty in speech
GENOGRAM
Emiliana Reyes 71 y.o
Crisanto Reyes 70 y.o Hypertension Cita Dances died 2009 Epilepsy Simplicio Dances 83 y.o
Rosana 40 y.o Breast Cancer
Rodrigo Reyes 48 y.o polio since 3 y.o
Ruby R. Dances 40 y.o
Simplicio Dances Jr. 54 y.o Arthritis & Hypertension
Mylene Dances 22 y.o
Rella nie Danc es 18 y.o
Robertson Dances 21 y.o
Floe Marie 12 y.o Kyptosi s
Jeffry Dances 2 y.o Cerebral Palsy
GORDONS FUNCTIONAL HEALTH PATTERN
Nutritional and Metabolic Pattern every 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 Pattern before 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 Pattern the pt has no exact sleeping pattern, sometimes he sleep 7 hours at night during hospitalization he keep on sleeping. Cognitive Perceptual Unable to focus, Role and Relationship the 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 movement that appear in the first few years of life and generally do not worsen over time. The term cerebral refers to the brain's two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement. Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or damage to motor areas in the brain disrupts the brain's ability to adequately control 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 pregnancy Nutritional deficiency( anemia) Unkown cause Mechanical trauma during delivery Head Trauma toxin ( contaminated fish)
Cerebral palsy are usually not noticeable in The signs of cerebralPalsy Symptoms early infancy but become more obvious as the childs 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 childs 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
co n cer n e d w / th e rece p tio n a n d p o f se n s o r y in fo r m a tio n fro m th e b
having to do w ith decisio n- m aking pro blem so lving and planning
c o n c e r n e d w / v is io
H aving to do w m ory ith em , em otion hearing, and , language
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.
Brain Stem functions
controls many vitally important 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
Bleeding Nutritional deficiences ( anemia) unkown cause
Mechanical trauma during delivery
Head trauma Environmental toxin
Hypoxia/ asphyxia
Breech delivery
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
PATIENTS RESULTS
SIGNIFICANCE
FECES EXAMINATION
PHYSICAL CHARACTER: Soft COLOR: Greenish OVA OF PARASITES: None seen
LABORATORY EXAM
NORMAL FINDINGS
PATIENTS 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: Paracetamol Route: Oral Dossage: 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 ache dyspnea acute renal failure
Contraindication: contraindicated in hypersensitivity, analgesic nephropathy, renal hepatic impairement
Brand Name: Phenobarbital Drug Classes: Antiepileptic Barbiturate Hypnotic
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: Oral Antiepileptic : 3-6 mg/kg/day
Pharmacokinetics: Route Oral Onset 30-60 min Duration 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 siyay 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.
NURSING INTERVENTION
RATIONALE
Plan activities to use gross and fine motor skills (holding pen toys positioned to encourage reaching and rolling over. Teach the pt. to perform range-of-motion exercise every 4 hrs for the child unable to move body parts. Position the child to promote tendon stretching ( foot plantar flexion instead of dorsiflexion). Encourage parents to keep appointment w/a therapist. Perform development assessment and record the achievement to maintain joint flexibility.
Many activities of daily living & play activities promote physical development. 2. Promote mobility and Increased circulation and 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 to maximize physical mobility.
Teach the family to maintain appropriate ace wear.
ASSESSMENT S- wala man me kabalo ug unsay angay buhaton aron siya makalihok unta O- temp. PR RR
DIAGNOSIS Ineffective management of therapeutic regimen r/t to lack of knowledge
PLANNING
NURSING INTERVENTION
RATIONALE
Allow opportunites for parents to verbalize the impact of cerebral palsy on the family. teach the families skills needed to manage childs care.( physical rehabilation, seizure). teach case management techqnues. Involve siblings in the care for the children w/ cerebral palsy. Review for parents the needs of all children in the family.
The family needs an opportunity to explore the emotional & social impact of the child care to integrate the grow from the experience. The childs achievements are positive reinforcement of the family's effort. Parents become case manager to coordinate care. Special efforts contribute to meeting the developmental needs of all the family members.
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 gani niya kuhaon as verbalized by S.O. O- Temp. PR RR deafness noted blurred 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 need frequent 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 Dances Age: 2 y.o Sex: M Diagnosis: Cerebral Palsy Hospital: Soymph Rm/ ward: Rm. 12 Physician : 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
