One of the most common causes of childhood disability, cerebral palsy (CP), is a group of neurological disorders that lead to motor impairment and limited functional capabilities.
Cerebral palsy is divided into several major motor syndromes that are differentiated according to the neurologic structures, pathophysiology, and etiology.
Spastic Hemiplegia:
- Decreased spontaneous movement on one side of the body, typically affecting the arm and hand
- May show hand preference at a very early age
- Walks on tiptoe due to tight heel tendon
- The affected upper extremity assumes a flexed posture during running
- Positive ankle clonus and Babinski sign
- Speech delayed
Spastic Diplegia:
- Manifests as bilateral spasticity of the legs
- Damage to the child’s immature white matter during gestation
- Prominent when the baby crawls; tends to drag the legs than assume a 4-limbed crawl
- Brisk reflexes, ankle clonus, and a bilateral Babinski sign
- Legs may “scissor” due to tight muscles
Spastic Quadriplegia:
- The most severe form of CP is due to marked motor disorders in all extremities.
- Associated with intellectual disability and seizures
- May experience swallowing difficulties
- Increased tone and spasticity in all extremities
- Rarely able to walk
- Brisk reflexes and plantar extensor responses
Athetoid:
- Less common
- Infants are hypotonic with poor head control but may develop increased tone with rigidity as they grow
- Hyperactivity of the face and tongue
- Absent or slurred speech
- Feeding may be difficult with prominent tongue thrust and drooling
Ataxic:
- Affects balance, depth perception, and coordination
- Unsteady, wide-based gait
- Difficulty with fine motor movement
Cerebral palsy is attributed to multifactorial nonprogressive disturbances in the fetus or infant’s brain, which may occur before, during, or after the baby’s birth.
Risk factors and causes of cerebral palsy include:
- Congenital brain malformations
- Chromosomal abnormalities
- Intrauterine infections
- Seizures during infancy
- Anoxic brain injury or trauma
- Multiple gestation birth
- Preeclampsia
- Placental pathologies
- Maternal substance abuse
- Rh incompatibility
- Prematurity and low birth weight
Cerebral palsy is confirmed through a series of patient histories and standardized developmental assessments, physical examination, and imaging modalities. MRI is the imaging choice for identifying the etiology and detecting neuroanatomy alterations, as it provides higher image resolution and sensitivity.
Nursing Process
Managing cerebral palsy requires an interdisciplinary approach. Early identification leads to prompt treatments that could optimize neuroplasticity, improve functionality, promote independence, and reduce the disease burden. Nursing interventions concentrate on physical and psychosocial assessments and resources that could help maximize the quality of life and prevent further disability.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for cerebral palsy, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for cerebral palsy.
Imbalanced Nutrition: Less Than Body Requirements
Difficulty swallowing, sucking, chewing, or eating due to muscle weakness or uncoordinated upper extremity movements may lead to inadequate nutrition to meet metabolic needs.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Difficulty in swallowing, chewing, or sucking
- Decreased spontaneous movement of upper extremities
- Inability to perform self-care (feeding)
- Food intake less than recommended daily allowances
As evidenced by:
- Body weight 20% or more below the ideal weight range
- Decreased muscle tone
- Inability to control the tongue
- Reduced subcutaneous fat or muscle mass
Expected outcomes:
- Patient will demonstrate gradual and safe weight gain toward their target weight.
- Patient will display safe chewing and swallowing without gagging or coughing.
Assessment:
1. Conduct nutritional assessments.
Establish baseline intake and nutritional deficiencies that will be the basis for creating a diet plan.
2. Assess the patient’s ability to feed themself.
Neuromuscular impairments caused by cerebral palsy that may affect the patient’s eating ability may require coordination with other healthcare professionals.
Interventions:
1. Facilitate strategies that promote the patient’s appetite.
Determining food preferences, eliminating offensive odors and sights, and providing a relaxing atmosphere help boost appetite, promoting more food intake.
2. Collaborate with a dietitian or nutritionist in creating a meal plan.
Consultation with a dietitian or nutritionist ensures an optimal nutritional intake.
3. Assist the patient in using utensils for feeding.
Patients with CP may have decreased spontaneous upper arm movement, making feeding difficult. An occupational therapist can recommend tools and utensils that allow the patient to feed themselves
4. Elevate the patient’s head when eating.
Some patients may have poor head control and difficulty swallowing. Keep the patient upright while eating to prevent aspiration pneumonia.
5. Consider a feeding tube.
A large number of children with CP require a feeding tube and enteral nutrition to meet their nutritional needs. Nurses can train parents to use a feeding pump and care for the child’s tube.
Impaired Physical Mobility
Restrictions in purposeful and independent movement of one or more extremities secondary to the motor disturbances brought on by cerebral palsy.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Decrease in muscle strength or control
- Neuromuscular impairment
- Alteration in cognitive functioning
- Spasticity
- Hyperactive reflexes
As evidenced by:
- Muscle weakness
- Alterations in gait
- Decrease in fine or gross motor skills
- Limited ROM
- Spastic limbs
- Inability to walk
- Paralysis of limbs
- Inability to control head movement
- Poor balance and coordination
- Use of assistive devices
Expected outcomes:
- Patient will maintain or increase muscle strength and function of the affected extremity.
- Patient will demonstrate independence in certain activities of daily living (ADLs).
Assessment:
1. Assess the degree of immobility, noting muscle strength and tone, joint mobility, balance, and endurance.
This helps in identifying strengths and deficits. The degree of functional ability varies with CP, as some patients can still ambulate with or without assistive devices. The degree of immobility will facilitate the planning of appropriate physical activities.
2. Note the emotional/behavioral responses of the patient and family to mobility issues.
Feelings of frustration and powerlessness brought by motor impairments hinder patient and family participation in care. CP is a permanent disorder requiring lifetime support that the family must be prepared for.
Interventions:
1. Perform passive or active ROM exercises.
Active ROM increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. Passive ROM improves joint mobility and circulation and decreases the likelihood of contractures.
2. Position in alignment to prevent complications.
Patients with severe subtypes of cerebral palsy need to be repositioned frequently in bed and chairs to prevent complications. Maintaining proper alignment prevents foot drops and contractures that may worsen the patient’s condition.
3. Teach how to ambulate with adaptive equipment.
Safe and effective use of ambulatory aid equipment such as braces, walkers, and wheelchairs will maximize physical mobility and prevent injury.
4. Collaborate with PT/OT.
Physical and occupational therapists are a significant part of the care team for a patient with CP. PT programs can improve muscle strength and balance, and OT can recommend ways to complete everyday activities.
5. Consider a baclofen pump.
An intrathecal baclofen pump implanted near the spine delivers a muscle relaxant to reduce muscle spasticity.
Impaired Verbal Communication
Patients with CP may experience difficulty in expressing thoughts and ideas to others due to speech and language abnormalities. Many patients with CP often have normal intelligence.
Nursing Diagnosis: Impaired Verbal Communication
Related to:
- Impaired motor function of muscles for speech
- Impaired comprehension or language
As evidenced by:
- Use of incomprehensible words or sounds to express wants/needs
- Difficulty expressing verbally
- Difficulty understanding and maintaining a communication pattern
Expected outcomes:
- Patient will demonstrate an increased ability to express themself.
- Patient will demonstrate effective alternative methods of communication.
Assessment:
1. Assess the ability to comprehend, speak, and write.
This will help identify the most efficient way to initiate communication with the patient.
2. Identify factors that promote communication.
The patient may not be able to form comprehensible words, but the healthcare team and family may learn what certain sounds or movements signal for that patient.
Interventions:
1. Establish therapeutic nurse-patient relationships through active listening.
Nurses should take time to learn their patient’s individual abilities through active listening, observation, and patience.
2. Make eye contact.
Eye contact shows that one is interested in what the patient would like to convey. This is necessary, especially for patients who also have hearing deficits.
3. Keep the communication slow and relaxed yet distinct and straightforward.
Speaking clearly assists in promoting comprehension and improved overall communication. Patients may respond ineffectively to shouting and high-pitched sounds because they amplify vowels and obscure consonant sounds.
4. Provide alternative methods of communication.
Nurses may use other creative measures such as alphabet boards, picture charts, lip reading, sign language, writing, etc. Alternative forms of communication ease anxiety and alienation and promote the patient’s sense of control and safety.
5. Refer to speech and language therapy.
A speech-language pathologist can help improve the child’s ability to speak and instruct on using communication devices.
References
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice. (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M. E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. (10th ed.). F.A. Davis.
- Hallman-Cooper JL, Rocha Cabrero F. Cerebral Palsy. [Updated 2022 Oct 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538147/
- Jameson, L.J., et al. (2018). Harrison’s principles of internal medicine. (20th ed.). McGraw Hill.
- Kliegman, R.M., Stanton, B.F., St. Geme III, J.W., et al. (2016). Nelson Textbook of Pediatrics. (20th edition). Elsevier.
