University of Saint Louis

Mabini Street, Tuguegarao City, Cagayan, Philippines, 3500

Tel. No. (078) 844-1872-73 local 204
SCHOOL OF HEALTH AND ALLIED SCIENCES

A CASE PRESENTATION
ON
CEREBRAL PALSY

Submitted by:
Babaran, Kamille Victoria T.
Bumatay, Jillian Ezabella V.
Jimenez, Princess Jade
Marzan, Brenelyn B.
Orita, Valerie A.
Paudan, Lyra Naveen A.
Peralta, Zhairhen Nicole
Saguilla, Hannah Faye R.
Uroa, Jean Antonette G.

Submitted to:
Mrs. Rosalie A. Turingan, MSN
Mrs. Rosario Caazares, MSN
Mrs. Rosemarie Tadena, MSN
GENERAL OBJECTIVE

The general objective of this case presentation is to have a comprehensive study and understanding
about Cerebral Palsy, to provide broad introduction about the condition and to provide better
perception.

SPECIFIC OBJECTIVES

At the end of the case presentation, we will be able to:

1. Define Cerebral Palsy, differentiate its classifications, enumerate and explain its clinical
manifestations, identify risk factors associated which lead to the causation of said condition as
well as possible effects. It is aimed to identify and explain appropriate diagnostic and laboratory
examinations, and possible nursing responsibilities which are deemed to be well suited for the
patients condition and treatments and management of the said condition.
2. Present national and international statistics of the prevalence of the condition and as possible,
interpret and analyze the data gathered to identify possible factors.
3. Elicit additional information using the patients past and present medical history and relate this
particular information to determine what other factors have contributed to the disease process
of the patient.
4. Identify, define and elaborate the holistic functioning of the patient with the use of the
P.E.A.R.S.O.N. and to know the condition of the patient in relation to his present illness.
5. Present the cephalocaudal assessment obtained from the patient.
6. Discuss the anatomy and physiology of the organs involved in the patients condition.
7. Trace the pathophysiology of the patients condition.
8. Identify, categorize and prioritize all problems occurring in the family and also to the patient.
9. Present specific, measurable, attainable, realistic, and time-bounded family nursing care plans
for the client.

INTRODUCTION
The brain controls all that we do. Different parts of the brain control the movement of every
muscle of the body. In cerebral palsy, there is damage to, or lack of development in, one of these areas
of the brain.

'Cerebral' refers to the brain and 'palsy' can mean weakness or paralysis or lack of muscle
control. Cerebral palsy isnt one condition. Rather, the term describes a wide range of disorders and
developmental disabilities that can arise from damage to a childs developing brain before, during or
shortly after birth.

The damage occurs in a region of the brain that controls muscle functions. Therefore, people
with cerebral palsy might have problems with: motor skills (control of muscle movement), muscle tone
(abnormally stiff or loose muscles), muscle weakness, reflexes, and balance.

Some people with cerebral palsy experience cognitive difficulties because the damage has
affected multiple areas of the brain. Muscle-tone and motor-skill impairments can also affect cognitive
development. If a child has trouble moving independently, it might be difficult to participate in some of
the typical childhood activities that foster learning.

The brain damage that causes cerebral palsy is permanent and non-progressive. In other words,
it cant be repaired, but it doesnt get worse. Abnormal tone or motor control can shorten muscles and
deform bones, however, affecting the normal growth process. People who have cerebral palsy might
find that resulting difficulties increase or evolve as they grow older. Such deterioration is more common
when people dont receive appropriate health care.

Cerebral palsy occurs in approximately 2 per 1,000 live births. It is a major cause of disability
among children.

In the United States, more people have cerebral palsy than any other developmental disability,
including Down syndrome & epilepsy. It is estimated that 764,000 children and adults in the U.S.
manifest one or more of the symptoms of cerebral palsy. According to the Centers for Disease Control
and Prevention (CDC), each year about 10,000 babies born in the United States will develop cerebral
palsy. 1,200 - 1,500 preschool age children are also recognized to have cerebral palsy each year. A 2009
CDC study found that the average prevalence of cerebral palsy in 2004 was 3.3 per 1,000. The
prevalence was significantly higher in boys than in girls overall (male/female ratio, 1.4:1).

In the Philippines, there are more patients with cerebral palsy than those with polio, spinal
lesions and other movement disorders combined which approximate about 1-2% of the total
population. Despite this, there is no government program that addresses this condition; both in
treatment and prevention. Philippine Cerebral Palsy [Rehabilitation Center], Inc. is the only non-stock;
non-profit foundation dedicated to the treatment and alleviation of cerebral palsy and related motor
disorders in the Philippines.

CAUSES OF CEREBRAL PALSY

Cerebral palsy results from two types of brain damage. Sometimes, the brain develops
improperly. More frequently, illness or injury damages a brain that was otherwise developing normally.

Both types of damage can occur in the uterus, during birth, or as late as one year into a childs
life. Sometimes, the symptoms associated with cerebral palsy are apparent at birth. Other times, a
diagnosis doesnt occur until a child is several months or years old. At times, doctors can trace brain
damage to a particular incident or a combination of factors. In other cases, no definitive cause is found.

RISK FACTORS

A. Prenatal factors (70-80% of causes, most common)

1. Advanced maternal age (>35 y/o)

2. Intrauterine infections

Fetoplacental and uterine infection or inflammation can cause initiation of preterm labor,
which can lead to CNS injury and cerebral palsy.

Chorioamnionitis is an infection of the chorion and amnion, the two membranes

surrounding the developing fetus. It is the most frequently associated maternal infection in
cerebral palsy.
TORCHS is an acronym for perinatal infections: toxoplasmosis, other infections (varicella
zoster, adenovirus, and enterovirus), rubella, cytomegalovirus, herpes simplex virus, syphilis.
TORCHS infections are associated with approximately 5% of all CP cases.
3. Exposure to certain medicines, such as thyroid hormones, estrogen, or methotrexate

4. Use of alcohol or illegal drugs

5. Premature birth and low birth weight

 About half of all children who have cerebral palsy are born prematurely. The risk of a baby
having cerebral palsy increases as the birth weight decreases.

A baby who is born prematurely usually has a low birth weight, less than 5.5 lb (2.5 kg). But
full-term babies can also have low birth weights. Multiple-birth babies are more likely than
single-birth babies to be born early or with a low birth weight.

Most children with cerebral palsy had a disruption in the normal development of parts of
their brain during fetal growth. Low-birth-weight, premature babies are more likely than full-
term, normal-weight babies to have had developmental problems during fetal growth that can
injure the brain.

Periventricular leukomalacia (PVL) is a condition of underdeveloped white matter in the

brain surrounding the ventricles. It is the leading cause of cerebral palsy in preterm infants.
Intraventricular hemorrhage (IVH) is predominantly associated with prematurity and is due
to fragility of developing blood vessels in the infants brain. IVH may cause PVL or ischemia
in other parts of the brain.

B. Perinatal factors (10% of causes)

In rare cases, some babies develop cerebral palsy as a result of complications during the mother's
pregnancy or at birth. Risk factors include:

1. Difficult or prolonged labor

2. Brain infection or physical trauma
3. A lack of oxygen
4. Placenta abruptio
5. Infections in the mother's uterus or vagina, such as strep infections

C. Postnatal factors
1. Head trauma
2. Infant illnesses Illnesses in a newborn baby that can greatly increase the risk of cerebral palsy
include:
Bacterial meningitis. This is a bacterial infection that causes inflammation in the
membranes that surround the brain and spinal cord.
Viral encephalitis. This viral infection causes inflammation in the membranes that surround
the brain and spinal cord.
Severe or untreated jaundice. Jaundice is a condition that appears as a yellowing of the
skin. Jaundice occurs when certain byproducts of "used" blood cells aren't filtered from the
bloodstream.

ABOUT MUSCLE TONE

Signals from the brain and spinal cord work together to produce appropriate muscle tone (the
amount of strength and flexibility a muscle has). Sometimes the brain signals muscles to be stiff; at
other times, it shuts off such signals, allowing muscles to become loose. When the signals work properly,
muscles have enough tone to maintain posture and enough flexibility to perform quick, smooth
movements.
When people have cerebral palsy, however, proper messages from the brain dont reach the
muscles. High muscle tone (spasticity or hypertonia) causes muscles that are overly tight or stiff. Low
muscle tone (hypotonia) results in abnormally loose muscles and floppy body movements. Some people
have mixed tone some parts of their bodies have high tone, and other parts have low tone or tone
that fluctuates.
Although one type of tone abnormality might be obvious during infancy, other tone problems
might appear as a childs nervous system develops. A change in muscle tone, however, doesnt mean
that a persons cerebral palsy is getting worse.

CLINICAL MANIFESTATIONS
EARLY SIGNS
1. Asymmetrical movements
2. Listlessness and irritability
3. Difficulty in feeding or swallowing or poor sucking with tongue thrust
4. Excessive, high-pitched, or feeble cry
5. Long, thin infants who are slow to gain weight
6. Poor head control

LATE SIGNS
1. Failure to follow normal pattern of motor development. Delayed gross motor development is a
universal manifestation of cerebral palsy
2. Persistence of infantile reflexes
3. Weakness
4. Preference for one hand and before the infant is age 12 to 15 months
5. Abnormal postures
6. Delayed or detective speech
7. Evidence of mental retardation

TYPES OF CEREBRAL PALSY

A. Classification by clinical type

Individuals with cerebral palsy manifest motor disabilities, which fall into three major groups. These are
as follows:

Spastic cerebral palsy (40%-50%, usually appears by age 6 months)

Injuries to the cerebral cortex can result in spastic cerebral palsy, which causes abnormally
stiff muscles. This condition the most common type of cerebral palsy can also cause bone
deformities and shortened muscles (contractures).
Dyskinetic cerebral palsy (20%-25%, accentuated by emotional stress)
This refers to the type of cerebral palsy with abnormal involuntary movements. It is divided
into two types of movement problems, called dystonia and athetosis.

a. Dystonia Injuries to the basal ganglia also can result in dystonia, which causes
fluctuating muscle tone. Although tone is sometimes low, it increases when a person
attempts to move or experiences heightened emotions.
b. Athetoid Injuries to the basal ganglia can result in athetoid cerebral palsy, which
causes involuntary muscle movements. The movements often interfere with speaking,
feeding, grasping, walking and other skills requiring coordination.
Ataxic cerebral palsy (1%-10%)
Injuries to the cerebellum can result in ataxic cerebral palsy, which causes poor
coordination. That, in turn, affects balance, posture and controlled movements. Ataxic cerebral
palsy can cause unsteadiness when walking and difficulties with motor tasks.
 Mixed
Injuries to multiple brain areas usually the cerebral cortex and basal ganglia can result
in more than one kind of abnormal muscle tone. For example, someone could have
spasticity and dystonia, or dystonia and rigidity.

B. Topographical Classification

Topographical classification describes body parts affected.

Diplegia (10%-20%) affects the legs (typically both) more than the arms. Its most common in
premature babies.
Hemiplegia (35%-40%) affects one side of the body. Its most common in babies who have
strokes or traumatic brain injuries.
Quadriplegia (15%-20%) affects all four limbs. Its most common in babies who experience an
interruption in oxygen supply.
Monoplegia (rare) affects one limb.
Triplegia (rare) affects three limbs.

C. Classification by the Degree of Severity

Even when doctors agree on the level of severity, the classification provides little specific
information. Still, this method is common and offers a simple method of communicating the scope of
impairment, which can be useful when accuracy is not necessary.

Mild Mild cerebral palsy means a child can move without assistance; his or her daily activities
are not limited.
Moderate Moderate cerebral palsy means a child will need braces, medications, and adaptive
technology to accomplish daily activities.
Severe Severe cerebral palsy means a child will require a wheelchair and will have significant
challenges in accomplishing daily activities.
No CP No CP means the child has cerebral palsy signs, but the impairment was acquired after
completion of brain development and is therefore classified under the incident that caused the
cerebral palsy, such as traumatic brain injury or encephalopathy.

EFFECTS OF CEREBRAL PALSY

People with cerebral palsy typically experience a combination of effects, partly because the direct
results of their brain damage often lead to additional, correlated difficulties.

A. Primary Effects

Primary effects stem directly from damage to the central nervous system, in a region of the brain
that controls muscle functions and coordinates movement. Resulting problems include:

Abnormal muscle tone

Poor motor control
Abnormal reflexes
Balance and movement problems
Muscle weakness

Almost all children with cerebral palsy experience delays in reaching motor milestones such as
sitting, standing and walking. People with cerebral palsy tend to use more energy and tire more easily
than other people during daily activities.

B. Secondary Effects
 Although the damage that causes cerebral palsy occurs in the brain, a child with resulting motor-
control and muscle-tone problems might experience the following secondary effects.

Inadequate Muscle Growth

Muscles grow only when theyre stretched. People with cerebral palsy sometimes lack the
balance, control, strength and flexibility needed for the kinds of activities such as running and
playing that would typically stretch their muscles. Instead, their muscles tighten and contract
abnormally, impairing their physical abilities and sometimes causing pain.
Malformed Bones and Joints
The shape a bone takes depends upon forces from other nearby bones, muscles, joints, tendons
and other tissues. If those forces are abnormal, a bone might become distorted or misaligned.
People who have spasticity might develop hip dislocations or deformities of the feet, hands and
arms. Muscle imbalances can lead to scoliosis (an abnormal curvature of the spine).

Although secondary effects develop as children grow, medical treatment particularly when it
begins early in a childs life often helps reduce the severity of cerebral palsys secondary effects.

C. Accompanying Effects

People with cerebral palsy sometimes face additional physical and cognitive difficulties. Damage
that extends to multiple areas of the brain might impair several kinds of functions. Meanwhile,
abnormal muscle tone and poor motor control can pose obstacles to learning and development.

Effects that can accompany cerebral palsy include the following.

Cognitive Impairments
Roughly one-quarter of people with cerebral palsy experience some degree of learning
difficulties. The more severe the brain damage, the greater the risk of cognitive impairments.
Problems might include difficulty with executive functions the skills needed to solve
problems, make decisions, pursue goals and exercise self-control.

Among people who have cerebral palsy, those with spastic quadriplegia have the highest
likelihood about a 50-percent chance of mental retardation. Its also possible, however, for
cerebral palsy to affect a persons entire body, yet have no impact on intelligence.

When assessing the cognitive abilities of someone with cerebral palsy, its important to involve a
psychologist, neuropsychologist or developmental pediatrician experienced in testing people
who have disabilities.

Attention-Span Problems
Attention-deficit hyperactivity disorder (ADHD) or attention-deficit disorder (ADD) affects about
20 percent of people with cerebral palsy. Children who have ADHD or ADD are often impulsive,
easily distracted, restless and overly talkative. They tend to have trouble following directions,
taking turns and completing tasks such as schoolwork that require sustained concentration
and mental effort.

Children with ADHD or ADD might benefit from consultations with a neurodevelopmental
pediatrician and a psychologist. In some instances, a physician will prescribe medication.

Vision Problems
Brain damage or muscle imbalances in the eyes can cause abnormal vision. Many people with
cerebral palsy experience difficulties related to eyesight. Those problems include:
a. Astigmatism
b. Blurry vision
 c. Cortical visual impairments (the eye is normal, but the brain cant properly interpret
what is seen)
d. Lazy eye
e. Nearsightedness or farsightedness
f. Optic nerve problems
g. Problems with depth perception
h. Problems with visual perception (the ability to recall and discern meaning from what is
seen, which contributes to memory and problem solving skills)
i. Retina disorders
j. Smaller-than-usual field of vision
k. Strabismus (eyes turn in or drift to one side)
l. Trouble with visual motor control (the ability to use visual information to guide
intentional movements, such as drawing, building models and putting together puzzles)

Addressing sight abnormalities at an early age might help protect a childs vision

Hearing Loss
Nerve damage sometimes causes hearing loss in people with cerebral palsy. Children who
experience chronic ear infections might also have trouble hearing. Early identification and
treatment of hearing impairments are important if children are to develop normal speech
patterns.

Speech and Language Difficulties

Abnormal muscle tone and poor motor control in the mouth, tongue and face can interfere with
speaking skills. Language-processing problems make communication and self-expression
difficult. Such troubles can lead to learning difficulties. Speech and language therapy, and
augmentative communication devices, help some people achieve their communication and
language goals.
Feeding Difficulties, Malnutrition and Low Bone Density
Cerebral palsys effects on muscles and motor skills can interfere with proper nutritional intake,
weight gain and other aspects of health. For example, difficulties with chewing and swallowing,
or heightened sensitivity in the mouth can make eating difficult. Abnormal patterns of
movement can burn inordinate amounts of energy and calories. And some people with cerebral
palsy follow diets that restrict dairy products, putting them at risk of calcium, phosphorus and
vitamin D deficiencies. Such deficiencies can lower bone density.
Breathing and Sleeping Difficulties
When abnormal muscle tone affects the chest muscles, deep breathing can be difficult. When it
affects the mouth and throat muscles, clearing the airway can be difficult. As a result, people
might aspirate food and saliva into the lungs. Breathing problems can also interrupt sleep,
causing fatigue. Sleep problems affect many children who have cerebral palsy.
Sensory Problems
Some people with cerebral palsy have unusual levels of sensitivity either heightened or
reduced to such things as touch, smell and sounds. Their tolerance of sensory input might
therefore be low.
Seizures and Epilepsy
Children with spastic hemiplegia and spastic quadriplegia are more likely than other people to
experience seizures. Recurring seizures can lead to a diagnosis of epilepsy.
LABORATORY AND DIAGNOSTIC TESTS

A complete history, physical examination, and ancillary investigations are the primary modality for
establishing a diagnosis of cerebral palsy. Common supplementary laboratory and diagnostic studies
ordered for the diagnosis and assessment of cerebral palsy include:

1. Cranial ultrasound/ultrasonography uses sound waves to capture an image of the brain. The
cranial ultrasound is painless and the least intrusive of the possible techniques, but does not
produce the same quality of results as an MRI or a CT scan. Still, results can show abnormalities,
cysts, and structures in the brain.

The cranial ultrasound can only be used on an infant before the cranial bones are fully formed or
after a fully formed skull is surgically opened, as the sound waves cannot pass through bones. The
cranial ultrasound is deemed valuable on infants from birth to age 18 months.

2. MRI (magnetic resonance imaging) uses a combination of magnetic fields and radio waves to
capture an image of the brain or spine. It is the preferred neuroimaging method and achieves the
clearest results. The child needs to remain still for the length of the exam, which lasts around 30 to
45 minutes. It is also a very loud process which, although completely painless, can be extremely
uncomfortable for children. Sedation may be necessary if this is difficult for the child. Two types of
MRIs may be valuable in diagnosing cerebral palsy:

MRI of the brain is thought to define brain structure and abnormality more accurately than CT
Scans or ultrasound.
MRI of the spinal cord is useful in detecting abnormalities of the spinal cord for children with leg
spasticity, bowel complications, and improper bladder functioning. The condition may be
related to cerebral palsy.

3. CT scan (computer tomography scan) combines X-rays taken from numerous angles to provide
cross-sectional views of a childs brain. The results are better than cranial ultrasounds, but not as
conclusive as MRIs. The test can take 30 minutes or more. Sedation may be necessary for children
who find it difficult to remain still.
4. Electroencephalography (EEG) is not used to detect cerebral palsy, but instead is used to diagnose
seizure disorders. Epilepsy is a condition commonly associated cerebral palsy. An EEG is ordered
when doctors find evidence of seizures. With an EEG, electrodes are attached to a childs scalp to
detect brain activity. The procedure is painless.

5. Electromyography (EMG) is used to detect nerve impulses relating to muscle activity. Nerves fire
by sending electric impulses along their length. Before a muscle can flex, nerves need to stimulate
the contraction. An EMG detects the nerve impulses sent to the muscles. Like an EEG special
electrodes are placed on the skin. EMGs are painless.

NURSING RESPONSIBILITIES

1. Cranial ultrasound
Prior to examination:

Angle the cot/incubator to make room for you and your machine after checking with the infants
nurse.
Dim the overhead lights and close blinds.
Clean probes.
Ensure correct hand washing technique is carried out.
Get comfortable by adjusting both the height and angle of the cot/incubator.
 Ask a nurse to help in positioning the infants head if needed and ask a parent or nurse to
support the head, if needed.
Use warmed Gel for the examination. Keep infant warm. A water-based gel is applied to the
infant's head, over the anterior fontanelle, to aid conduction of ultrasound waves

2. MRI (magnetic resonance imaging)

Prior to sedation:

SAFETY IN THE PRESENCE OF A MAGNETIC FIELD

A formal metal check form for the baby should be completed by an informed and MR-aware
member of staff.
At the same time earrings and hair ornaments as well as clothes with metal buttons and
religious artifacts should be removed. Baby-grows and clothes with metal poppers are not
suitable attire for an MR scan. A hospital flannelette nightie with tie or velcro fastenings is ideal,
leaving the feet free for attaching pulse oximeter probes and the chest accessible for ECG leads.

It is also essential that the person accompanying the baby throughout the procedure completes
and signs a metal check form.

Sedation:

Oral chloral hydrate is given slowly from a syringe into the side of the mouth with the infant
semi-upright in the mothers arms. However, it tastes awful and some infants will spit it out.
With patience and care it is usually possible to ensure that most of the dose is swallowed.
Infants with muscle disorders or generalized hypotonia are given a smaller dose of sedation,
calculated on an individual basis.

3. CT SCAN
The child should wear comfortable, loose-fitting clothing to the exam. He or she may be given a
gown to wear during the procedure.

Metal objects including jewelry, eyeglasses, hearing aids, non-permanent retainers and hairpins
may affect the CT images and may have to be removed prior to the child's exam.

The child may be asked not to eat or drink anything for several hours beforehand, especially if
a sedative or anesthesia will be used in the exam. With sedation or anesthesia, the child
probably will not be allowed to eat for several hours prior to the exam.

Obtain information about any medications the child is taking and if he/she has any allergies,
especially to intravenous (IV) or oral contrast materials (also known as dye), iodine, or seafood.

Obtain information of any recent illnesses or other medical conditions your child may have, and
if there is a history of heart disease, asthma, diabetes, kidney disease or thyroid problems. Any
of these conditions may influence the decision on whether contrast material will be given to the
child for the CT examination.

4. EEG

For the test, the patient lies on a bed, padded table, or comfortable chair and is asked to relax
and remain still during the EEG testing period. An EEG usually takes no more than one hour.
During the test procedure, the patient may be asked to breathe slowly or quickly; visual stimuli
such as flashing lights or a patterned board may be used to stimulate certain types of brain
activity.
5. EMG

Explain the procedure to the patient.

Instruct the patient to avoid using any creams or lotions on the day of the test.
Body temperature can affect the results of this test. It is important to tell the patient that if it is
extremely cold outside, he or she should wait in a warm room for a while before the test is
performed.
Prepare the patient for the discomfort of needle insertion. Inform the patient that he or she will
experience a sensation similar to that of an intramuscular injection as the needle is inserted into
the muscle.
Notify the client that the muscles examined may ache for a short time after the procedure.

TREATMENT

Even though Cerebral Palsy can't be cured, a variety of treatments can help patients to make the most
of their abilities and physical strength, prevent complications, and improve their quality of life.

Physical therapy, which can help your child become as mobile as possible. It is the rehabilitation
of physical impairments by training and strengthening a patients large muscles. Those in the
arms, legs, and abdomen. The goal of physical therapy is to maximize functional control of the
body, or increase gross motor function.
Upper limb splints are sometimes made by an occupational therapist to maintain range of
movement, facilitate better grasp and improve overall function of the arm and hand. These
splints, usually of plastic material, are individually made for each child.
Orthoses (sometimes known as braces) are used by many children for the lower limbs at some
stage in their development. These are custom made and individually fitted for each child from a
combination of materials including high temperature plastics with velcro closures.
Oral medications for spasticity include Diazepam, Dantrolene and Baclofen. These medications
are often not effective or may cause too many unwanted effects. Hence they are prescribed
relatively infrequently.
a. Diazepam is a good medication for spasticity, but may cause sedation. However it is useful
following surgery, particularly orthopedic procedures.
b. Dantrolene may be helpful, but can rarely cause liver problems. It may also cause
drowsiness, dizziness and diarrhea.
c. Baclofen is said to be more useful in spasticity due to spinal lesions than in spasticity due to
cerebral lesions. However, it is often used in children with severe spasticity. Side effects are
uncommon but may include nausea. It is reported to aggravate seizures though this is a rare
problem.
Selective dorsal rhizotomy is a major operation on the spine occasionally used to reduce
spasticity in the lower limbs. It is used mainly in young children aged between three to seven
years, with spastic diplegia. Following the procedure a very extensive rehabilitation period is
required.
Orthopedic surgery. Surgery is mainly undertaken on the lower limb, but occasionally in the
upper limb. Some children require surgery for scoliosis.
 Plastic surgery. Tendon transfers and releases can occasionally improve appearance or function
in the upper limb.
Occupational therapy helps teens and adults adapt to their limitations and live as independently
as possible. It ensures a child achieves the highest level of functional performance within their
home, school, public and work environments. Occupational therapy employs adaptive processes
to teach a child to perform tasks required in the normal course of a day.
Speech therapy helps control the mouth muscles. This therapy can be of great help to children
with speech or eating problems. Speech therapy often starts before the child begins school and
continues throughout the school years.
Both massage therapy and yoga are designed to help relax tense muscles, strengthen muscles,
and keep joints flexible. (Improve flexibility and breathing, decrease stress, and maintain
health.) .
Behavioral therapy may help some school-age children with CP learn better ways to
communicate with others.

PATIENTS PROFILE
Patients Initial: D.A
Home Address: Zone 1, Magalalag West, Enrile, Cagayan
Age: 5 years old
Date of Birth: January 24, 2011
Place of Birth: Magalalag West, Enrile, Cagayan
Nationality: Filipino
Religion: Roman Catholic
Gender: Female
Civil Status: Child
Educational Attainment: None
Mothers Initial: M.A
Occupation: Housewife
Fathers Initial: J.A
Occupation: Farmer
Source of Information: Family
PEARSON
Psychosocial

Patient D.A is the eldest in the family. She has a younger sibling aged 3 and her mother is
currently pregnant with an AOG of 21 2/7 weeks. She is 5 years old and still cannot talk
appropriately to her age. When she was an infant, she fell many times from the bed. She also
accidentally fell from the hammock while her mother was fixing it and hit her head hard on the
ground.

When we visited her she was just staring at us without speaking and uttered words that cannot
be understood. She began speaking at aged 1 but easily forgot the words she learned. She can only
say nana (lola), dede (milk), lalla (duyan). She smiled when we said that she was cute and seemed to
like the complement a lot.

She still hasnt experience going to school because of her condition. She doesnt have a lot of
friends and just plays at their house with her sister and cousin.

When she cries, her mother would play ringtones from the cellphone and she would stop crying.
Her mother stated, kapag pinapatunog ko yung cellphone ko, sumasayaw siya at linalagay niya sa
tenga niya yung cellphone parang nakikipag usap. Her lola would also sing lullabies to calm her
down. According to her mother, para niya kaming linoloko. She further stated, kapag nakahiga
siya sa duyan, nagtutulog-tulogan siya. Kapag sinilip ko siya nakapikit pero kapag umalis ako dilat
ang kanyang mga mata.

She is also easily irritated. She refuses to be assessed whenever we hold her. She also has short
attention span. She does not have direct eye contact when you are trying to catch her attention.

She always fights with her younger sibling. Her sister treats her as if she is a toy. She would pull
her arms and legs and her mother would scold her sister. They should always be given equal
treatment because they always fight when the other is given more especially when it comes to toys
and food.

Elimination

When we asked about the elimination pattern of the patient her mother stated, every other
day siya tumatae. Hahawakan niya yung dalawang paa niya tsaka niya ito itataas, as stated by her
mother. This is their only way to determine that she has already defecated.

She urinates in her underwear many times in a day because she drinks a lot of milk. She doesnt
use a diaper because her mother states that it easily gets full and costs a lot. When we asked about
the characteristics of her urine and stool her mother said that her urine is yellow in color and her
stool is soft, brown and odorous. Mabaho kasi every other day lang siya tumatae, she also added.

Activity and Rest

Her arms are strong and can resist very well with force but her legs are flaccid. She can only
grasp things for a short period of time and eventually let go. When we gave her food her mother
stated, hindi niya kayang hawakan yung pagkain. Saglit lang tapus bibitawan rin niya agad. She
also puts things in her mouth. She put the penlight in her mouth when we gave it to her. Kapag
binibigyan namin siya ng lapis, nabibitawan niya at yung papel sinusubo niya, as stated by her
mother.

She always bites her fingers as a way to gratify herself. Her mother stated, palagi niyang
nilalagay mga daliri niya sa bunganga niya (thumbsucking) tapus kinakagat niya kaya nasusugatan.
She always lifts her legs then suddenly releases it and hits the surface with force. At times she would
grind her teeth and closes her fist as if she is angry. She always keeps her mouth open and would
play with her tongue. Her tongue appears to be scaly because she always tends to bite her tongue.
 She cannot walk and is always dependent on her mother or her lola. When lied down, she tries
to get up but fails to do so.

She bathes and changes clothes everyday still with the help of her mother until now. But
sometimes she does not take a bath when the weather is cold and when she has asthma. When her
mother tries to brush her teeth, she would bite the toothbrush. When manual cleaning is used she
would bite her mothers finger. In order to brush her teeth, her mother would hold her arms and
legs forcefully and clean her teeth with a clean towel.

Naglalaro siya pag nasa mood at humihinto pag napagalitan her mother stated. She cries
when she is already sleepy and becomes hysterical. Natutulog siya kahit anong oras sa gabi, minsan
alas-dose. Ala-una gising pa siya. Hindi pare-pareho pagtulog niya, as verbalized by her mother. She
also added, paminsan minsan lang siya natutulog sa tanghali.

Sensory

She responds well to stimuli. When we hold her, she resists with force. She sometimes looks at
you when you catch her attention. She also responds well when we interact with her. She giggles
when we play with her and try to make her laugh.

Oxygenation

According to her mother, meron siyang asthma hanggang ngayon. She used to manage with
nebulizer from the health center before. She now manages by boiling oregano and giving it to D.A.
She also gives her a lot of water.

Her respiratory rate was 24 cpm upon assessment. Her cough was very course. There was
presence of flem but she doesnt know how to spit it out.

Nutrition

Her mother stated that patient D.A is fond of eating rice. Malakas siyang kumain ng kanin.
Hindi niya gaano gusto mga chichirya at softdrinks. Natrauma siya sa asin kaya ayaw niyang
nilalagyan ng asin ang pagkain niya kasi ang akala niya gamot ito, her mother stated. She is unable
to chew her food and swallows immediately that is why her mother only gives her soft foods. But
when her mother gives her biscuits like rebisco and skyflakes, she is able to chew.

She was completely immunized and is not taking any vitamins. Her height is 1.15 m and weighs
14 kg. She has a BMI of 11 kg/m2 which is considered underweight.

NURSING HEALTH HISTORY

OB History
According to the patients mother, she had her menarche at 10 years old. Her menstruation last
for approximately 3 to 4 days. She regularly menstruates every month and doesnt experience
dysmenorrhea. She had her coitarche when she was 14 years old. Her OB score is G3P2 (T2P0A0L2). As
of now, she has 2 children with ages of 5 and 3 and is pregnant with an AOG of 21 2/7 weeks. She had
her first delivery when she was 23 years old with patient D.A and got pregnant with her youngest
daughter when she was 25 years old. All of her pregnancies were delivered normally in their house and
in Lanna, Enrile by a hilot and they are all full term. According to the patients mother, she has not
gone prenatal check-up in all of her pregnancies every month. She didnt experience any chronic
illnesses during her pregnancies.
 Family history
A. Family Structure, Characteristics and Dynamics

Patient D.A., five years old, is currently living with her parents (where her mother is 21
2/7 weeks pregnant), grandmother (of father side) and younger sister (3 years old) at Magalalag
West, Enrile. Patient D.A is the eldest among the two daughters. Her mother is a plain housewife
and her father works as a farmer. The father makes most of the decisions and is the bread
winner of the family. They communicate and interact well and freely with each other.
Her grandmother takes care of the children when their mother and father is not around.
Patient D.A cannot decide for herself due to her condition. She is always supported by her family
and she is totally dependent on them.

B. Socio-economic and Cultural Characteristics

Her father can only provide what is enough for their basic needs every day. The
grandmother and the mother of D.A have conflicts often times because of financial burden.

Their family is Roman Catholic and they believe in the goodness of God. Patient D.A
cannot participate in community activities due to her condition and she is not even aware of
what is happening in the community.

C. Home and Environment

Patient D.As house type is bunggalo and has a cemented wall. Their house is divided into
three parts: the living room (cemented flooring), the bedroom (bamboo flooring) and kitchen
(cemented flooring). The living room consists of a television and a resting chair. Their bedroom
is elevated and has stairs leading to the room. The stairs is made of bamboo and is about three
meters in height and one and a half meters in length.

Outside the house is the extension of their kitchen and dining area. At the back of the house
is their bathing area and piggery. Their toilet is twenty meters away from their house. Their
garden is in the front of their house where they get vegetables to eat. Her family can contribute
in the development of the community by cleaning their house and maintaining the cleanliness of
the surrounding.

D. Health Status of each family member

E. Values, Habits, Practice on Health Promotion, Maintenance and Disease Prevention.

The family exercises unity and togetherness in problems they encounter. Despite of patient
D.As condition, they remained positive and they remain helping each other by coping each
others weaknesses. According to the family, they did not complete their immunization. They
cannot specify what type of immunization they have because they cannot remember it. They
cannot consult a physician due to financial constraints. During B.P taking, we realized that the
father is hypertensive due to inadequate sleep and rest. According to them, the father does not
consult health care providers for his B.P monitoring.

FIRST LEVEL ASSESSMENT

I. Presence of health threat conditions that are conducive to disease, accident or failure to
realize own health potential

A. Family History of hereditary conditions

According to Patient D.As mother, there are no known hereditary conditions in
the family starting from their grandparents.
B. Threat of cross infection from the communicable disease care
They have knowledge on how to prevent acquiring communicable disease
present on their community.
C. Family size beyond what family sources can adequately provide.
They are five who live together in the house. The father is the bread winner and
if his earning cannot provide them, they get sources from their vegetable
garden in front of the house.
D. Accident Hazards
Accident hazards include not wearing slippers (for patient D.A), resting chair
that is not well fixed and the stair in the sleeping area can be a cause of accident
when misbalanced in climbing.
E. Faulty/ unhealthful nutritional eating habits
They rarely eat pork. The mother of patient D.A lets her eat junk food often
times.
F. Stress Provoking Factors
Resources for the provision of their daily needs.
G. Poor Environmental Sanitation
Presence of breeding and resting sites of insects, mosquitoes and other vectors.
H. Unsanitary food handling and Preparation
They do not practice handwashing before cooking and preparing food.
I. Unhealthful lifestyle and Personal Practices
SELF MEDICATION: They do not consult a physician
POOR PERSONAL HYGIENE: Patient D.A is fun of thumb sucking with unclean
hands.
J. Inherent Personal Characteristics
Upon observation, they are industrious and perseverant in every task they have.
K. Health History which may Precipitate Health Deficit
There are no health history upon observation.
L. Inappropriate Role Assumption

Upon observation, there are no inappropriate role assumption in the family.

 M. Lack Immunization / inadequate Immunization Status
They do not complete immunization and cannot remember the specific vaccine.
N. Family Disunity
Patient D.Aa mother and grandmother has conflict sometimes because of
financial burdens.

II. Presence of health deficits failure in health maintenance

Cough of Patient D.A due to lack of personal hygiene.
Hypertension of the father due to not consulting to a health care provider for
B.P monitoring.
III. Presence of foreseeable crisis situations
Patient D.A may be bulied when she grows up due to her condition.
When the mother will give birth, there will be another burden on priorities and
responsibilities for the family on financial status.

SECOND LEVEL ASSESSMENT

I. Inability to recognize presence of a problem due to:
Economic Cost: the father as the bread winner cannot afford to
provide beyond their everyday basic needs.
II. Inability to make decisions with respect to taking appropriate health
action due to:
Fear of consequence of action especially on the economic
consequences and burden.
Inaccessibility of appropriate resources of care due to financial
constraints.
Low salience of the problem.
III. Inability to provide adequate nursing care to the sick, disabled, dependent
or vulnerable member of the family due to:
Inadequate knowledge of the nature and the extent of nursing care
needed: They do not yet consulted a physician.
Inadequate family resources: They do not have money for
consultation, medicine and transportation.
IV. Inability to provide a home environment which is conducive to health
maintenance and personal development due to:
Inadequate family resources: financial constraints
V. Failure to utilize community health resources for health dare due to:
Lack of inadequate family resources: Cost of medicines prescribed.