Care of the Patient with Cerebral Palsy

It is estimated that more than 764,000 children and adults in the United States have at least one symptom of cerebral palsy (United Cerebral Palsy, 2015).    Furthermore, there is a worldwide prevalence of 1.5 to 4 cerebral palsy cases per 1000 live births, and it is the most common motor disability in childhood (CDC, 2015). Although there is no known cure, research has provided many ways in which to help these patients live productive lives.  Healthcare workers need to have an understanding of the various symptoms of cerebral palsy as well as what can be done to help these patients.

Cerebral palsy is a motor control disorder that is caused by injury or abnormalities in an immature brain. This is a permanent disorder that is non-progressing and occurs during fetal or infant brain development (Hockenberry & Wilson, 2014). Motor disorders can include sensory, perception, communication, cognition, behavioral, musculoskeletal, seizures, and epilepsy. Symptoms vary by which part of the brain is affected. Abnormal muscle tone and coordination are the primary problems seen (Hockenberry & Wilson, 2014). The patient often presents with problems affecting muscle control, coordination, muscle tone, reflex, posture, and balance as well as fine motor skills, gross motor skills and oral motor functioning (“Types of cerebral palsy,” 2016).

There are different types of cerebral palsy that describe affected body parts and severity of symptoms. Spastic cerebral palsy is characterized by increase muscle tone. Non-spastic cerebral palsy is identified by a lack of muscle tone. Furthermore, muscle tone is described as being either hypertonic, which is increased muscle tone resulting in stiff limbs or hypotonic which is decreased muscle tone resulting in the loose, floppy limbs (“Types of cerebral palsy,” 2016).

Symptoms or brain injuries occurring before birth or during birth are called congenital cerebral palsy. Approximately 85% to 90% of cerebral palsy cases are congenital. However, injury can occur post birth up to two years of age (Sorrentino & Remmert, 2016). There are different types of cerebral palsy. Each form describes the various symptoms. Spastic cerebral palsy represents approximately 70% of all cases and can be corrected most times with surgery (Sorrentino & Remmert, 2016). Spastic cerebral palsy is characterized by increased muscle tone and hyperreflexia resulting in awkward and restrictive movements. Spastic cerebral palsy can be broken down further to describe which parts of the body is affected. These are hemiplegia, diplegia, and quadriplegia.

Spastic hemiplegia describes limited movement on one side of the body. One hemisphere or side of the brain controls the opposite side of the body (“Spastic diplegia cerebral palsy,”2014). If the right side of the brain experiences damage the symptoms will appear on the left side of the body and vice versa. The affected side is usually shorter and thinner than the other side, and an abnormal curvature of the spine can also develop called scoliosis (Cerebral palsy: Hope through research,” 2016).

Those affected with spastic cerebral palsy can have a wide range of difficulties (“Spastic cerebral palsy”, 2016). But, not all patients experience every problem. Symptoms may be mild and others severe. Furthermore, some symptoms may be temporary (Cerebral palsy: Hope through research,” 2016). For example, a patient may have trouble walking due to difficulty with their balance. Once they are given aids to help with their balance, walking becomes much easier.

Children with spastic hemiplegia may also have developmental delays (“Spastic diplegia cerebral palsy,”2014). This is usually seen as not being able to sit up, crawl, walk, or talk the same time as other children. Some of these patients may experience seizures as well. This form of cerebral palsy may affect intelligence. However, only about a quarter of all children with this type of cerebral palsy have an IQ below 70 (Brainandspinalcord, 2016). This type of cerebral palsy can lead to limb deformities. There can be problems with normal flexing of affected body parts such as the foot not flexing normally causing toe walking. Children do not outgrow this problem. Therefore, it can lead to difficulty walking as well as problems with hip joints and falling. Another related problem is foot drop which can also lead to problems with walking. Foot drop is when the individual has difficulty lifting the front part of the foot when walking (Brainandspinalcord, 2016). However, surgery, orthopedic devices, and therapy can help this problem. Typically, these patients get physical therapy which is a standard treatment.

Another type of spastic cerebral palsy is diplegia. This type of cerebral palsy tends to affect the legs more than arms (“Cerebral palsy: Hope through research,” 2016) Therefore, this patient may have difficulty walking. The gait may appear as crouched, toe walking, and flexed knees. However, this can be corrected with proper treatments. In most cases the patient with spastic diplegia has a normal IQ. However, may have other problems such as the turning in or out of one eye commonly called cross-eye or strabismus (“Cerebral Palsy: Hope through research,” 2016). This is due to weakness of the eye muscles. Furthermore, this patient may be nearsighted. Often, this too can be corrected with aids such as glasses. The patient may also use leg braces to help with their gait. In the infant, developmental milestones are often delayed. These include rolling over, sitting, or standing. Also, a scissor leg often occurs due to leg muscles being stiff and tight (“Spastic diplegia cerebral palsy,” 2014).

The last type of spastic cerebral palsy is quadriplegia. This is the most severe form of spastic cerebral palsy and is usually associated with moderate to severe intellectual disabilities (“Cerebral Palsy: Hope through research,” 2016). The cause is widespread brain damage or malformations of the brain. These children often have severe stiffness in their muscles but a floppy neck (“Types of cerebral palsy,” 2016). All limbs are affected as well as the body trunk. They are usually not able to walk. Speaking and being understood is difficult and seizures are often hard to control (“Types of cerebral palsy,” 2016).

Other forms of cerebral palsy include Anthenoid or Dyskinetic and Ataxic types. Anthenoid and Dyskinetic forms are more difficult to correct with surgery. Each is characterized by slow uncontrollable writhing or jerking movements of the hands, arms, feet, or legs. Hyperactivity in the muscles of the face and tongue may make the patient appear to be grimacing or cause drooling. The patient is usually not able to sit straight or walk. Comorbidities include hearing problems, breathing problems, speaking problems. Intellectual abilities are usually normal.

Ataxic cerebral palsy represents approximately 10% of all cases (Bochek, 2016). Again, surgery does not correct this type of cerebral palsy. Typically balance and depth perception are affected as well as coordination in the walk. These patients will typically have a wide base gait and have difficulty with writing or buttoning a shirt.

Dyskinetic cerebral palsy is characterized by involuntary muscle movements. The spasms that result in the unwanted movement are typically difficulty to control and painful for the patient (Dystonia Society, 2014). This type of cerebral palsy will often be seen in combination with other types of cerebral palsy. The patient with dyskinetic cerebral palsy presents with uncontrollable movements of the face, tongue, lips, jaw, throat, and even respiration (Dystonia Society, 2014). This can often lead to problems with eating, drinking and speech.

Additional impairments typically associated with cerebral palsy are intellectual dysfunction, delayed development, impaired vision, hearing loss, language disorders, incontinence, abnormal sensations and perceptions, muscle contractions, swallowing issues, emotional problems, and dental problems (Hegnar & Acello, 2014). Medical comorbidities can include seizures, hydrocephalus, GERD, pneumonia, dental problems, muscle spasms and urinary tract infections as well as constipation (Hegnar & Acello, 2014).

There are several legal acts that have been passed to help those with disabilities have access to education and medical care. The Individuals with Disability Education Act was passed in 1975 to make sure patients with disabilities have access to education (“Landmark legislation”, 2015). This involves an individualized education program or IEP to be developed in the school to meet the needs of the child. Furthermore, in 2008 the American Disabilities act took this one step further to protect those with disabilities in the workplace (“Landmark legislation”, 2015). Those with disabilities cannot be discriminated against in any public area including their job, school, or transportation. Additionally, in 2010 the Affordable Care Act excludes pre-existing conditions and prohibits discrimination due to health status (“Landmark legislation”, 2015). These acts have been instrumental in helping patients with disabilities attain a more productive life.

Healthcare workers play a valuable role in working with this population. Healthcare workers need to be aware and observe for developmental issues and medical issues as well as helping families to address complications.

Since this is a disorder found mostly in childhood, healthcare workers need to be aware of what is abnormal development. Observations of problems and the severity of motor abnormalities needs to be considered. Children will show delays in all milestones of motor movements. However, language and social achievements may be normal (Hockenberry & Wilson, 2014). Early signs may be that hand dominance does not develop until later preschool years. Crawling may also appear different and look like a bunny hop, or the child may crawl using one hand to propel themselves while dragging the opposite hand or leg (Hockenberry & Wilson, 2014). The child may also walk on their toes, appear uncoordinated, and have involuntary movements. Other physical signs may include poor head control after the age of three months, stiff legs and arms, sloppy or limp body posture, inability to sit up without support by eight months, seizures, sensory impairments, tongue thrusting that persist after the age of six months, extreme irritability, feeding difficulties, and little interest in their surroundings (Hockenberry & Wilson, 2014).

The goal is early recognition and to promote increase movement, language skills, and independence. Since the disorder is permanent but not progressive, physical therapy is very important. Parents are also essential in the care of the child. It is important to consider their goals and desires as well as their cooperation in all aspects of care. The child will need a multidisciplinary team to promote self-care and empowerment. Many children wear mobilizing orthotic devices that include braces, splints, castings, or wheelchairs and standing devices. They may also use special utensils for eating and writing (Hockenberry & Wilson, 2014). Often the patient will have had corrective surgery and will be on several medications to help control muscle spasms or seizures.

The assessment should include identification of poor muscle tone, eating issues, nutritional needs, difficulty swallowing, constipation, and incontinence (Hockenberry & Wilson, 2014). A child with spasticity cerebral palsy will expend a lot of energy and will require more intake for adequate nutrition. Be aware that nutritional needs may be a challenge due to difficulties chewing and swallowing (Nursing Help, 2012). However, some patients are inactive. For those patients, it is important to monitor growth to avoid overfeeding and obesity. A growth and weight chart are good ways to help monitor the child’s growth. Routine assessment of the skin is also important for those with limited movements as well as patients with assistive devices such as wheelchairs or braces (Nursing Help, 2012). Parents can assist in this assessment and may need advice on nutrition and medication education. Any new symptoms or if any current symptoms become worse, contact the nurse immediately.

Additional observations related to mobility and muscle tone include coordination, reflexes, posture, balance, fine and gross motor activities, and speech (Hockenberry & Wilson, 2014). Observe to see how the patient completes activities of daily living. For example, is the patient able to bathe or dress themselves. Do they need regular help eating, transferring, or walking? It is also important to observe the support network, housing situation, transportation, and education of the patient. The goal is to provide the parent and the child with healthcare needs that support the entire family. Managing and preventing complications, increasing mobility, maximizing communication and learning as well as encouraging social interaction will enhance quality of life and well-being of the patient (Hockenberry & Wilson, 2014).

Although there is typically a team of people to care for the patient with cerebral palsy, the certified nursing assistants can be helpful for the patient and the parents. First, it is important to look at the treatment plan for the patient to determine what interventions are required. Often the patient will have decreased muscle control and strength. Here, the goal should be to attain maximum physical ability. Take into consideration the patient age, developmental status, and milestone achievements. Activities may include fine and gross motor skills such as holding a pen or toy (Nursing Help, 2012). Positioning a toy to encourage reaching or rolling can also be beneficial. Be sure to allow time for activities to be completed. Range of motion may be ordered to promote tendon stretching or for patient who is inactive. The patient may wear braces. Be sure the patient and the parents understand how to work the device. For children, play activities can be useful to promote physical developments. Remember that activities may be performed at a slower pace the normal.

Nutrition may be altered due to difficulty chewing or swallowing. Monitor for increased metabolic needs of the patients as well. The CNA may be asked to monitor height and weight and to check hydration status. The family should be taught how to increase caloric intake as well as what foods can be given to the patient if they have trouble swallowing. If this is the case, the patient should sit upright for feedings and if they need to be fed place the food far back in the mouth, especially if tongue thrust is an issue (Nursing Help, 2012). The patient may also need soft or blended foods. Be sure to teach a family how to assess and avoid for aspiration by giving small bites and allowing extra time for meals. Any changes in nutritional status should be reported to the nurse.

Be sure to discuss with the family the impact that a child with cerebral palsy has on them. Allow the family to express and explore their own emotional needs. Help them explore community services, review achievements of the child, review medication administration and seizure management as needed. Also, helping a child and the family with social skills and locating community programs for the entire family.

The Certified Nursing Assistant is part of the healthcare team that develops and carries out interventions to help the child or adult with cerebral palsy achieve optimal daily living to improve the abilities of the individual. Although there is no cure for cerebral palsy, there are several treatments that, if part of an ongoing treatment plan, can help the patient and family. The CNA is in a unique position to help prevent and address problems or concerns that may arise due to comorbidities or inability to perform tasks. Being aware of symptoms and support services can also be a valuable asset to the family and help the patient achieve a higher quality of life.

Johnny is a 10-year-old who has been diagnosed with cerebral palsy. You have been assigned his case and are visiting for the first time. Johnny lives with his mother, father and older sister. The parents have some concerns about how Johnny can learn to interact with others. You observe that Johnny has leg braces and uses a walker but is for the most part mobile. He can communicate fairly well and is eating normal foods. His mother confides that he does have emotional outbursts at times but they are able to help him through the outbursts and settle down. Johnny’s sister is embarrassed to be seen with Johnny, and this concerns the parents. How do you proceed with this case?

First, you will check the treatment plan to see what home care Johnny is getting and what you are responsible for. You note that there are interventions noted for emotional outbursts and that the parents are very involved in his treatment planning. You do not, however, see anything about the sister or getting Johnny involved in activities. You can help the parents find organizations and activities in the community that Johnny can go to and associate with other boys his age. Talking to the sister may be an option to get a better understanding of her point of view. You can also talk to the nurse and see if there is another team member who may be able to help the sister understand and cope with her brother’s disability. Overall, you will need to do an assessment of Johnny’s conditions and observe for any increased problems or abnormalities not noted in the treatment plan. You will then discuss your findings with the nurse.

Emily is a 16-year-old who has been diagnosed with Cerebral Palsy. She recently had surgery for her foot drop and is now temporarily bedridden. She is very anxious and moving around in the bed. Her mother is concerned that Emily might hurt her foot so soon after surgery. As this is the mother’s main concern and you can see that Emily is very anxious, you decide to call the nurse. A new order is given for range of motion exercises while in bed. Part of the treatment plan is to teach the mother how to do the exercises with Emily as well. What other assessment do you need to complete on Emily?

Since Emily is bedridden, you need to check her skin for any irritation. This is particularly important as she is moving around in the bed. You can teach the mother to check her as well. The best way to do this may be during the range of motion exercises. Another area of assessment is nutritional status and bowel status. Constipation may be an issue if she is not getting enough to drink and is not as active as normal. Review diet and bowel habits with the mother. Report your findings to the nurse.

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