Sara Hollingworth February 24, 1998 Nursing 230 and 232
An Adult with Spastic Cerebral Palsy and Clinical Depression
Table of Contents
PATHOPHYSIOLOGY OF CEREBRAL PALSY AND
CAUSATIVE FACTORS
CLINICAL DEPRESSION PATHOPHYSIOLOGY
POSSIBLE PHYSICAL AND PSYCHOLOGICAL CAUSE
TREATMENT OF CLINICAL DEPRESSION
Muscle tightness or spasm, involuntary movements; disturbance in gait and mobility; abnormal sensation and perception; impairment of sight, hearing or speech; seizures and mental retardation are all symptoms that may be present with a diagnosis of Cerebral Palsy (CP). These symptoms can lead to feelings of dependence, despair and inadequacy. (Doman, p.43) Imagine also having an additional diagnosis of clinical depression. A client feels despair for no apparent reason and for great lengths of time and is unable to pull themselves up out of a dismal mood and proceed with life. (Depression FAQ, p. 1) There are specific nursing actions that can be implemented to address both the physical and the psychological symptoms of CP and clinical depression.
PATHOPHYSIOLOGY
OF CEREBRAL PALSY AND CAUSATIVE FACTORS
Cerebral palsy (CP) may be present from birth or early childhood and occurs
in 1.9 to 2.3 of a thousand live births. (Wong p. 1162) (Dzienkowski, Smith,
Dillow, Yucha, p.45 ) .
CP results in a broad range of static, nonprogressive motor disabilities attributable to a nonprogressive abnormality of the immature brain (Dzienkowski, Smith, Dillow, Yucha, p.45 ). Damage may occur before, during, or shortly after birth. Damage may be caused by lack of oxygen during the prenatal period, trauma at birth and shortly after, or infections during the postnatal period. Motor involvement is always present, but additional neuralgic, sensory and mental difficulties can occur as well.( King, Cheatham, p.57)
In a large definitive study on CP in the United States, done by National Collaboration Perinatal Project, it was discovered that perinatal factors such as congenital malformation, maternal mental retardation, low birth weight (less than 2500 grams) and breech birth are the strongest predictors of CP. The risk of CP is increased in normal birth weight infants who experienced severe perinatal asphyxia. (Dzienkowski, et al, p.45) " Asphyxia alone accounted for only 10% of the 38,000 cases of CP studied (Dzienkowski, et al,p.45,)." The presence of these factors does not always result in CP, and in many cases there may be no cause found (Dzienkowski, et al, p.45).
Functional deficits in CP depend on the nature and severity of the injury and can range from slight coordination difficulties to complete quadriplegia with sensorimotor and cognitive involvement. Usually the CNS structures (cerebral cortex, thalamus, basal ganglia, brain stem, cerebellum, and spinal cord with ascending and descending sensorimotor pathways) coordinate voluntary and involuntary motor performance, posture, and tone via an intricate communication network. (Dzienkowski, et at, p.46)
Many classification systems have been developed to organize and categorize the many distinctive features and complexities of CP. The Swedish classification system organizes the complex syndrome of CP into four primary, yet broad categories, based on disturbances in postural tone and reciprocal innervation. These are spastic, dyskintec, ataxic, and mixed. Spastic will be discussed in this paper since it is the most commonly occurring. (50-60%). (Dzienkowski, et al p.51, ) Spastic CP can be further categorized into three distinct subtypes, spastic quadriplegia (significant upper extremity involvement) , spastic diplegia (pronounced motor deficits to trunk and lower extremities), and spastic herniplegia (involvement is limited to limbs on one side of the body.) (Dzienkowski, et al p.52, )
The term spasticity refers to the function
of individual muscles in the adult body. (Doman, p.43) It is most frequently
associated with injury to the cerebral cortex or pyramidal tract. (Dzienkowski,
et al p.52) When an adult tries to move the muscle of the involved limb, it
responds with a strong contraction or tightening. If a limb remains in a state
of extreme tightening of the flexor muscle, causing a stretching of the extensor
for an extended period of time a condition develops which is known as a "contracture".
The general presentation includes: hpypertonia of a persistent, predictable
nature; clasp-knife like resistance of the extremity to flexion or extension;
clonic rigidity of extremities with fixation in typical patterns, cocontraction
of involved parts, especially proximal joints, such as shoulder and hip, exaggerated
deep tendon reflexes, persistent primitive reflexes, and persistent primitive
and inability to free self from reflex position without assistance.
Some associated behavioral characteristic are:
Associated disorders and complications that often occur are nystagmus, strabismus (lack, of convergence of the eyes) seizures (activity associated with abnormal electrical activity in their brains can also be exhibited) and gastrointestinal complications are not uncommon (Doman, p.45). Intellectual impairment such as mental retardation is common, occurring in 50%-75% of cases, ranging from mild to severe. (Doman p.45)
TREATMENT
Care, not cure, is the main focus in the management and treatment of an adult
with CP. Management and a multidisciplinary approach assist the client in achieving
the three major goals of therapy:
The main pharmacologic interventions are aimed at alleviating seizures, spasms, and gastrointestinal disturbances. To control spasms, bezodiazepines and skeletal muscle relaxants such as dantolene sodium and baclofen, may be used. Even though these medications offer the benefit of decreasing spasticity, they do not improve muscle coordination. To alleviate constipation the clients diet should be high in fiber. Stool softener and laxatives my be used as needed. (p. 52,Dzienkowski, et al)
Surgical interventions are aimed at preventing or correcting structural changes in the limbs and trunk, that are disabling and interfere with activities of daily living. Occupational therapy, physical therapy and speech therapy will also be involved in care. (Dzienkowski, et al p.54-58)
CLINICAL DEPRESSION
PATHOPHYSIOLOGY
Clinical depression is thought to result from an alteration in the brain chemistry.
The brain is functioning normally but there is too much or too little of certain
neurochernicals in the brain. This reaction occurs normally during stress but
in clinical depression does not go away once the stimulus is removed, indeed,
an initial stimulus may not be found at all. Approximately 15% of all depression
cases are diagnosed as clinical depression. (Depression FAQ, p.2-3)
POSSIBLE PHYSICAL
AND PSYCHOLOGICAL CAUSE
Depression may be the result of chronic illness; hormonal changes, that occur
in puberty or menopause; or inherited tendency. There may be an event that psychologically
triggers the initial depression or it may be the result of a spontaneous aberration
in brain chemistry with no specific cause identified. (Depression FAQ, p. 1)
It is associated with one or more of the following risk factors:
TREATMENT
It is unimportant whether the depression was triggered by a psychological or
physical factor. It quickly becomes a set of physical and psychological problems
which feed on each other and grow. This is why the best course of action is
often both drug therapy and psychological therapy
Cognitive therapy for managing depressing has been the focus on numerous articles. Behavioral therapy, psychotherapy, and pharmacotherapy have all been reported as effective treatment methods. (Maynard, p. 10) Cognitive therapy depends upon groups to address helplessness and dependency Behavioral therapy focuses on behaviors which need to be changed.( Fortinash & HolodayWoffet,p.90)
Pharmacologic therapy has become safer with the development of drugs such as tricyclics and SSRI's which have reduced toxicity and yet are highly effective. The drugs are relatively inexpensive and are now targeted directly at the specific chemicals in the brain believed to cause the depressed moods. Without any sort of treatment the depression can go on for weeks, months, or even years. Two out of three depressed clients will respond to any given anti depressant. Clients who do not respond to the first drug , have a very good chance of responding to another. (Depression FAQ, p. 10)
NURSING APPLICATION
The onset of any form of disability creates a disruption in self-concept and
body image for an individual. Also, the degree of disfunction is associated
with the individual's perceptions and personal meaning of the handicapping,
disabling condition. As a nurse, knowing about the needs of a client with both
clinical depression and spastic CP, will enable the individualization of his
care. (Lantican, Birdwell, Harrell p.74)
A nurse who is working with CP clients needs to know the basic steps in detecting depression so the client can get treatment. Several steps have been recommended for this evaluation. Maintain a high index of suspicion for client who has risk factors. Use the clinical interview or written questionnaire such as the Beck depression Inventory, the Zung Self -Rating Depression Scale, and the Center for Epiderniologic Depression Scale. These questionnaires are helpful in finding patients with depressive symptoms but they are not diagnostic instruments. Many clients with mild depressive episodes will be identified with these questionnaires. If a patient scores above the cut point on a questionnaire, the clinical interview should be used to elicit the criterion symptoms of a major depressive episode. Because these self-report questionnaires are very sensitive to depressive symptoms, they can be used to exclude major depression in patients who score below the cut points.
A nurse may also elicit additional information by questioning family or caretaker ( with patient's consent). Identity other possible causes for mood disorders, such as medical illness, medications, or substance abuse. Once a client is identified as having clinical depression a plan will be devised to address both physical difficulties of CP and the mental difficulties of depression. (Coulehan, p. 82)
The long term goal of the plan is to alleviate the depression so that the client can function limited only by his physical abilities. Some of the following activities may be performed by nurses to make steps toward this goal. Practice active listening. Through conversation patients will provide clues to what triggered the onset of clinical depression. By treating the patient as a valued individual, self esteem will be enhanced. The patient should feel supportive encouragement to discuss his/her feelings. (Davidhizar, p20)
If the patient is having problems sharing it may be easier for the patient to write them down or draw a picture. With CP this may not be possible so the client can describe a picture to the nurse which the nurse can draw. (Gorman, Sultan Raines, p 118) .
Some adjustments need to be made for a CP patient. Allow extra time due to possible speaking difficulties. Communication boards and computers are commonly used but are time consuming. Always speak directly to the client. The nurse should be at the client's eye level to show that the client and the nurse are on equal ground. (Davidhizar, p20)
Do not assume that the person has mental retardation or hearing deficit . This can be very insulting to a client and may result in a decrease in trust in the nurse client relationship.
If a client has a computer or communication board say the word or letter aloud, so that your level of understanding is clear. A clear understanding between the nurse and client is effective therapeutic communication. Nurses have a tendency to want to anticipate the client's sentences before the client has a chance to finish his thought. It is important to let the client finish in order to achieve clear communication and establish a sense of independence. A situation can arise in which a word or sentence is hard to understand. Asking the client to suggest a word of similar meaning rather than making suggestions or guessing promotes independence. Self esteem is fostered by the nurse's demonstration that what the client says is important. A relaxed environment can improve communication between client and nurse. Two relaxed people can listen more effectively than one who is trying very hard. If tension is present it can have an effect on motor control and communication is less achievable. (King, Cheatham, p.56)
Other things that need to be considered for positive and effective interaction, include arranging the room for wheelchair accessibility, if one is used, and providing special seating, if hearing or vision is a problem. Special learning tools that use all senses such as large printed materials, videos, audio tapes, & models may be useful. (King et al, p.57)
To promote a positive self image RN's should be alert to positive actions that the patient is taking and should be quick with praise and use positive reinforcement. Encourage the patient to voice his/her disagreement or the belief that his rights are being violated. This gives the client a voice to be heard which promotes independence. (Davidhizar, p2l) Give small tasks that can be easily met and point out any specific improvement (Vries, p.2). Clients who are depressed do not often notice an improvement because they are so focused on the negative. A progress chart to record concrete accomplishments , such as number of times they say something positive about themselves or number of times they have interacted with other people, will document to the client the progress that is being made and encourage the client to persevere. (Gorman, Sultan, Raines, p. 118)
Promote feelings of being useful and needed. The physical disability of CP causes a client to experience a certain degree of helplessness and dependency. Use what ever opportunities arise to promote feelings of competency and independence, and to reinforce of these feelings. Clients should be encouraged to be partners in the plan of care and to assume responsibility for carrying out certain tasks of therapy. (Davidhizar, p. 21) Encourage patients to be more independent in their communities rather than in custodial institutions or in other dependent arrangements, consistent with culturally defined roles for their stage in life. Promote skills and habits that reduce the experience of incapacity, enhance the ability to meet increasing challenges in function, and thus increase the chances for autonomy. (McCuaig, Frank, p. 224)
Bring rhythm into the day including a balance of activities and resting periods. Rest period renew strength for activities. The activities distract from the depression and also force the client to be involve with others. Since separating ones self from others is a characteristic of depression , it may be difficult to convince the patient of the value of group activities. Suggest activities that the patient has associated with pleasure in the past and emphasize that feeling better is not immediate, but follows with perseverance in a routine of normal activity. (Vries, p. 1)
Groups are structured so that relationships among members are formed for learning and examining attitudes, values and beliefs. These groups address the issues of learned helplessness and dependency and allow discussion of issues, such as anger and dependency on others. They provide positive identification with other patients with Cerebral palsy or depression and increase realistic self- assessment and feelings of empowerment. (Maynard, p. 12) Objectives of the group should follow and include the following:
It is important for a nurse to assess personal feelings when working with a patient who is both depressed and has CP. If the client is among the 50% who have mental retardation a nurse must remember that clients with mental retardation should be treated with a nonjudgmental attitude as people deserving rights and responsibilities as other human beings. A patient's despair and unhappiness can be very painful to be around and could lead to the nurse avoiding the patient. A nurse may reject the client due to the perception of the clients dependency, or may become over involved because of the patient's needs, and inadvertently create more dependency. A nurse may create unrealistic expectations for a patients recovery and feel inadequate when unable to make a quick impact on a patient's depression. (Gorman, et al p. 118)
REFERRALS
For CP there are many team members that work together, using special therapies
to give the patient more independence and keep the body healthy. For treating
abnormalities of tone and posture associated with CP, both the occupational
therapist and physical therapist are involved. The occupational therapist targets
oral motor function, visual problems and ADL's while the physical therapist
is involved in the development of posture and ambulation. The physical therapist
also assists clients to use adaptive tools, and seating devices. (Dzienkowsiki,
et al, p. 57)
The speech therapist focuses on interventions on speech and language skills to enhance communication and correct deficits. These professionals also help in teaching clients other modes of communication. By exploring the best position, seating and food texture that facilitate a good appetite the speech therapist also plays a key role in the feeding program (Dzienkowsiki, et al, p. 58)
Psychotherapy is also an option for the client, which helps sort through the depression . There is evidence that with therapy the depression will be less likely to recur once treatment is finished, since the clients learns how to cope with or avoid factors contributing to reoccurrence. It is the nurses role to guide the client and family through the many options that are available to reach optimum potential.
Support groups such as Depressed Anonymous and Emotions Anonymous are also very valuable. There are also support groups through the United Cerebral Palsy Associations which are good resources for individuals. Groups are a very effective support tool to clients. The involvement In a group gives the client something proactive to do while waiting to determine the usefulness of the drug. When sharing with a client about a support group it is important to let the client know, it is their personal choice whether or not to disclose the diagnosis with anyone other than the doctor or therapist. This may make a client more willing to go to support groups. (Dzienkowsiki, et al, p. 58)
CONCLUSION
This paper has presented information on how a nurse could adapt the care of
an adult with CP and clinical depression. It stressed the importance of considering
the possibility or even the likelihood of the presence of depression in clients
with CP. Helpful tips for proper etiquette when communicating and interacting
with these individuals were given. The role that promoting independence and
usefulness plays in developing a positive self image was discussed. Effective
care management and treatment methods, all working together toward the goals
of alleviating the depression and enhancing motor function, increases the number
of success stories in these clients.
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