1. Cerebral Palsy Lewis, pp. 1716-1724

2. Etiology/Pathophysiology Non-progressive neuromuscular disorder Caused by perinatal trauma/hemorrhage or anoxia to areas of brain or prenatal brain abnormalities Characterized by early onset and impaired movement and posture. May be accompanied by developmental delays, and intellectual impairment (about 50% have some degree) Variety of manifestations in brain, but are not common to all cases—atrophy, lesions, vascular occlusions, infarctions, hemorrhages

3. Risk Factors LBW preterm birth Periventricular leukomalacia (studies have shown low levels of white matter in brain—MRI can show lesion) In utero exposure to maternal infection Severe newborn hypoglycemia Postnatal infections and trauma

4. Types (1717, Box 55-1) Spastic (most common)—hypertonia; poor posture, balance, coordination; impaired fine and gross motor skills Dyskinetic—involuntary, writhing and jerking movements; drooling; poor articulation Ataxic—wide-based gait; rapid, repetitive, poorly performed movements Mixed/dystonic—combination of spastic and dyskinetic

5. Early Motor Signs of CP Poor head control after age 3 mos Stiff or rigid limbs Arching back/pushing away Floppy tone Unable to sit without support at age 8 mos Clenched fists after age 3 mos Persistent tonic neck and Moro reflexes Hand preference in first 2 years

6. Early Behavioral Signs of CP Excessive irritability No smiling by age 3 mos Feeding difficulties Persistent tongue thrusting Frequent gagging or choking with feeds

7. Interventions for CP Goal is early recognition and promotion of optimum development through: Meeting needs for locomotion, communication, self- help skills Correct defects ASAP to gain optimal appearance and function Provide optimal educational and socialization experiences

8. Interventions Most children need wide variety of support services— PT, OT, speech, medical, dental Considerable help may be needed in ADLs and training for self-help. Ortho needs include orthotics, motor devices, adaptive devices, surgery to correct tendon deformities or control spasticity and contractures

9. Medications Muscle relaxers to decrease spasticity include po forms of Dantrium, Baclofen, and Valium, and Botox injections. A Baclofen pump infused intrathecally has been approved. Antiseizure meds for those who need them (Tegretol, Depakote) Ritalin for those who have ADHD Pain meds

10. Technology Technical devices to improve functioning and promote independence: Voice activated computer technology Toys controlled with head device when head and trunk are in alignment Computerized toys and games to improve hand-eye coordination

11. Educational and Social Needs Mainstreaming is encouraged. Many children have normal intelligence but are unable to demonstrate it on standardized tests. Vocational training for those who are unable to do formal education Encourage recreational activities and appropriate sports activities such as Special Olympics Refer family to United Cerebral Palsy organization (www.ucp.org)www.ucp.org

12. Nursing Responsibilities Encourage early intervention and multidisciplinary approach Encourage frequent rest periods Promote optimal nutrition (oral vs. gastrostomy, manual jaw control) Good oral hygiene Safety precautions if fall risk Immunizations Encourage normalization Support family Realize hospitalization may be a form of respite care