Hagerstown Community College

Nursing 229
Clinical Prep Card
Condition/Disease Cerebral Palsy
Description
An umbrella term for a group of nonprogressive but frequently changing motor impairment syndromes
secondary to lesions or anomalies of the brain arising in the early stages of its development. CP is a symptom
complex rather than a specific disease. For the vast majority of children born at term in whom CP later
develops, the disorder cannot reasonably be ascribed to birth injury or hypoxic-ischemic insults during
delivery. CP rarely occurs without associated defects such as mental retardation (60% of cases) or epilepsy
(50% of cases). CP is classified by the extremities involved and the type of neurological dysfunction present,
such as spastic (50%), hypotonic, dystonic, athetotic (20%), ataxic (10%), or a combination of these. Early
recognition and promotion of optimal development assist the child to realize his or her potential.
Pathophysiology
Risk factors have been divided into several groups: those factors occurring before pregnancy, such as an
unusually short interval (less than 3 months) or an unusually long interval since the previous pregnancy;
those factors occurring during pregnancy, including physical malformations, twin gestation, abnormal fetal
presentation, fetal growth retardation, brain asphyxia during labor and delivery, intracranial bleeding,
cerebral dysgenesis (malformation of brain cells and tracts and often resulting from genetic anomalies or
exposure to toxic substances), disorders of myelin; maternal or fetal infections, or maternal hypothyroidism;
and perinatal factors such as prematurity, premature separation of the placenta, or newborn encephalopathy.
Nonetheless among infants with one or more of these risk factors, 95% do not have CP.
Clinical Manifestations
Signs

Impaired Swallowing and or drooling

Impaired speech
Dental abnormalities
Vision deficits
Hearing deficits
Reading disabilities

Symptoms

History of gross motor developmental delay in the

first year of life

Abnormal muscle tone: The most frequently

observed symptom; the child may present as either

hypotonic or, more commonly, hypertonic, with
either decreased or increased resistance to passive
movements, respectively; children with cerebral
palsy may have an early period of hypotonia
followed by hypertonia. A combination of axial
hypotonia and peripheral hypertonia is indicative of
a central process.
Definite hand preference before age 1 year: A red
flag for possible hemiplegia
Asymmetrical crawling or failure to crawl
Growth disturbance: Especially failure to thrive
Increased reflexes: Indicating the presence of an
upper motor neuron lesion; this condition may also
present as the persistence of primitive reflexes
Underdevelopment or absence of postural or
protective reflexes

Diagnostic Tests
Laboratory studies
The diagnosis of cerebral palsy is generally made based on the clinical picture. There are no definitive
laboratory studies for diagnosing the condition, only studies, including the following, to rule out other
symptom causes:

 Thyroid function studies: Abnormal thyroid function may be related to abnormalities in muscle tone or
deep tendon reflexes or to movement disorders
Lactate and pyruvate levels: Abnormalities may indicate an abnormality of energy metabolism (ie,
mitochondrial cytopathy)
Ammonia levels: Elevated ammonia levels may indicate liver dysfunction or urea cycle defect
Organic and amino acids: Serum quantitative amino acid and urine quantitative organic acid values may
reveal inherited metabolic disorders
Chromosomal analysis: Chromosomal analysis, including karyotype analysis and specific DNA testing,
may be indicated to rule out a genetic syndrome, if dysmorphic features or abnormalities of various organ
systems are present
Cerebrospinal protein: levels may assist in determining asphyxia in the neonatal period; protein levels can
be elevated, as can the lactate-to-pyruvate ratio
Imaging studies
Cranial imaging studies to help evaluate brain damage and identify persons who are at risk for cerebral palsy
include the following:
Cranial ultrasonography: Can be performed in the early neonatal period to delineate clear-cut structural
abnormalities and show evidence of hemorrhage or hypoxic-ischemic injury
Computed tomography scanning of the brain: In infants, helps to identify congenital malformations,
intracranial hemorrhage, and periventricular leukomalacia or early craniosynostosis.
Magnetic resonance imaging of the brain: The diagnostic neuroimaging study of choice because this
modality defines cortical and white matter structures and abnormalities more clearly than does any other
method; MRI also allows for the determination of whether appropriate myelination is present for a given
age
Other
Additional studies in cerebral palsy can include the following:
Electroencephalography: Important in the diagnosis of seizure disorders
Electromyography and nerve conduction studies: Helpful when a muscle or nerve disorder is suspected
Collaborative Care
A specially trained physical therapist designs an individualized program of exercises and other treatment
modalities to meet the child's specific problems and needs and to stimulate the child to achieve functional
goals. A speech therapist is an important team member and initiates speech training early before the child
develops poor communication habits. Eye and ear specialists deal with visual and auditory deficits. Dental
care is esp. important and should start as soon as teeth erupt. Braces and other mobilizing devices help
prevent or reduce deformities, control alignment, and permit self-propulsion. An orthopedic surgeon
intervenes when spasticity causes progressive deformities. Nurses in pediatric facilities and community
settings are involved in all aspects of therapeutic management and provide support and encouragement. They
teach the child (as appropriate) and the parents about the desired and adverse effects of any medications used
in the therapeutic regimen.

POSSIBLE Nursing Diagnoses and Interventions

Diagnosis

Interventions

Impaired verbal communication

Determine clients own perception of communication

difficulties and potential solutions when possible.
EB:The Communication Confidence Rating Scale
for Aphasia (CCRSA) was found to be an effective
tool for assessment of the self-report of
communication confidence among clients with
aphasia

Impaired physical mobility

Screen for mobility skills in the following order: (1)

bed mobility; (2) supported and unsupported sitting;
(3) transition movements such as sit to stand, sitting
down, and transfers; and (4) standing and walking
activities. Use a tool such as the Assessment Criteria
and Care Plan for Safe Patient Handling and
Movement. CEB:Assess for quality of movement,
ability to walk and move, gait pattern, ADL function,
presence of spasticity, activity tolerance, and activity
orders

Psychosocial Implications
Compromised family coping: may be related to permanent nature of condition, situational crisis, emotional
conflicts/temporary family disorganization, and incomplete information/understanding of client's needs,
possibly evidenced by verbalized anxiety/guilt regarding client's disability, inadequate understanding and
knowledge base, and displaying protective behaviors disproportionate (too little/too much) to client's abilities
or need for autonomy.
Discharge Planning
Proper nutrition will help keep patient healthy. Specialists may also help patient with swallowing or
feeding problems so he can get the nutrients he needs.
Frequent checkups with patient's PHP or specialist will be needed to monitor patient's growth,
development, and general health. This will help find early signs or symptoms of CP. Patient will need
regular physical, hearing, and eye exams.
Support devices such as splints, braces, or a wheelchair may be needed to help patient move around.
Vaccinations may be needed to prevent the flu and pneumonia. These infections are more dangerous for a
child with CP. Ask patient's PHP or specialist for more information.
Teaching Needs: Acute illness and home care
The child's needs and potential determine his or her educational requirements, which range from attendance
at regular school to special classes or facilities designed to meet his or her needs. The teaching team develops
an individual educational prescription (IEP), which they communicate to parents and others involved in the
child's learning. Special Olympics and other community programs can enable the child to participate in
competitive sports, adding an extra dimension to physical activities. The child should also be encouraged to
participate in artistic programs, games, and other activities. Parents should be advised against overprotection
and helped to recognize the childs need to establish relationships with other children. A valuable intervention
on the part of health care professionals is providing the family with emotional support, helping them to cope
with the disorder and to connect with other families. Parent groups share concerns and problems and provide
practical information as well as comfort. United Cerebral Palsy Association Inc. (800-692-4453

[cerebralpalsy.org]) provides a variety of services for children with CP and their families. Local chapters can
be contacted through a local telephone directory or health department.
Prevention/Health Promotion
A wide variety of technical aids are available to help improve the child's function. They include
electromechanical toys, microcomputers, voice synthesizers, and other devices the child can control. Passive
range of motion, stretching, and elongation exercises are valuable at any age. Training in activities of daily
living and manual skills is based on the child's developmental level and functional abilities. Manual activities
are started early to improve the child's motor function and to provide sensory experiences and environmental
information. The child is encouraged to feed himself or herself, using specially designed utensils and placing
food well back in the mouth to aid swallowing. A high-calorie diet should be provided to meet the childs highenergy status. Thoroughly chewing food, drinking through a straw, and sucking on lollipops all help in
developing muscle control, and minimizing drooling. Washing and dressing independently are also
encouraged, with clothing modified to aid this independence rather than carrying out these tasks for the
child. Parents are taught to assist only when necessary and then in an unhurried manner because hurried
movements tend to increase muscle spasticity. Play is incorporated into the therapeutic program.