Transcript Lecture 6 - Porterville College Home

Lecture 6
Developmental Disabilities P020A
Course Objective #36
• Describe the cause and symptoms in
the child suffering from the following
types of malnutrition:
– Kwashiorkor
– Marasmus
Malnutrition
• Body does not get
enough nutrients.
Causes of Malnutrition
• Inadequate diet
• Problems with digestion
or absorption
• Medical conditions
Malnutrition
Kwashiorkor
Marasmus
Rickets
Pellegra
-these are the most severe forms of
malnutrition
Kwashiorkor
• Not enough
protein in the
diet.
Kwashiorkor
Occurrence
World -Wide
U.S.A.
• Famine
• Limited food
supply
• Low levels of
education
• Weaning
Kwashiorkor
• When kwashiorkor does occur in
the United States, it is usually a
sign of …
• child abuse and severe neglect
Kwashiorkor
Severe
• infections
• Irritability
• Hepatomegaly  Ascites
• Lethargy
• Dermatitis
• Edema
Mild
•
•
•
•
•
•
△ skin pigment
h muscle mass
Diarrhea
i grow
Fatigue
Hair △
Kwashiorkor
Dx test
•
•
•
•
•
•
BUN
CBC
Creatinine clearance
Serum creatinine
Serum potassium
Total protein
Kwashiorkor
Treatment
h Calories & protein
• 1st
– Calories
– Slowly
• 2nd
– Protein
– Lactose free
Kwashiorkor
Prognosis
• “Children who have had this
condition will never reach their full
potential for height and growth”
• May be permanent
– Mental & physical problems
Kwashiorkor
Prevention
• Diet
– Carbohydrates
– Fat
• 10% total cal.
– Protein
• 12% total cal.
Marasmus
• Overall calorie
deficiency
Marasmus
S&S
• Tissue wasting
• Stunted growth
Marasmus
Treatment
• Slowly h calories
What is the difference?
Kwashiorkor
Maramus
•i
• i protein and
calories
protein
Ricketts
• Deficiency of
Vitamin D
Ricketts
S&S
• Bone
deformities
Ricketts
Treatment
• Vitamin D
• Sunlight
Pellagra
• i Niacin
–(B complex
vitamin)
Pellagra
S&S
• Scaly dermatitis
• Inflamed
mucosa
• Mental
disturbances
Pellagra
• + Niacin into diet
Course Objective #37
• Differentiate between the following
forms of cerebral palsy:
– Spastic
– Dyskinetic
– Ataxic
– Mixed
Cerebral Palsy
• Disorder of movement, balance and
posture
• Results from a non-progressive lesion
in the
– Cerebellum
Cerebral Palsy (CP)
• Motor problems
• May also have…
–cognitive impairments,
–seizures
–sensory loss
Cerebral Palsy (CP)
• h in neonatal care 
• h survival of very low birth
weight babies
–> risk of CP
Cerebral Palsy (CP)
- ~ ½ of all CP is found in birth weights
less than 5 ½ lbs.
Cerebral Palsy (CP)
- most often attributed to
perinatal injury
- Prenatally
- Postnatally
Causes of CP:
Prenatal:
-infections
-exposure to teratogens
-maternal-fetal blood incompatibilities
-faulty implantation of ovum
Causes of CP:
Perinatal:
-asphyxia*
-intra-cranial bleeding
Causes of CP:
Postnatal:
-infection
-brain abscess
-head trauma
-kernicterus
Types of CP
Classified by variations in motor symptoms
Spastic*
Dyskinetic
Ataxic
Atonic
Mixed
Spastic CP
• -#1
• lesion located in pyramidal tract
• “spasticity”
•
movement is slow, effortful, restricted
•
occasionally jerky and explosive
Spastic CP
Further sub-typed by limbs affected:
-all four limbs = quadriplegia
-two like limbs, mostly legs = diplegia
-three limbs = triplegia
-legs only = paraplegia
-limbs on one side only = hemiplegia
-one limb = monoplegia
Spastic CP
classified by severity
• Mild: May lack only fine motor movements,
have awkward gait, arms out for balance
• Moderate: problems with fine and gross
motor and speech
• Severe: unable to walk, use hands, or speak
Extrapyramidal CP
-AKA Dyskinetic CP
- Refers to one of the two nerve tracts in
the brain that control movement
- Impairment in muscle tone and a variety
of abnormal motor patterns and postures
Extrapyramidal CP
--movements are uncontrolled and
without purpose
-movements disappear with sleep and
increase with stress
Extrapyramidal CP
Types of movement:
• Athetosis*
– slow, wormlike, writhing.
– If movements are jerky
• choreic & choreoathetoid
Extrapyramidal CP Subtypes
• Rigidity
–Movement is impeded
–Resistance
Extrapyramidal CP Subtypes
• Tremor
–Rhythmic & pendulum-like
Ataxic CP
• 7% of all CP
• disorder of balance / incoordination
• lesion is in the cerebellum
Ataxic CP
-gait is unsteady
-wide-based gait
-
Ataxic CP
-hand movements awkward with
tendency to under or over reach
-difficulty with repetitive finger
movements or rapid turning
Atonic (Hypotonic) CP
-Usually hypotonic at birth and persists beyond
2-3 yrs.
-usually develops incoordination, ataxia,
difficulty with rapid movements
-cognitive impairment can be severe
-can also develop into athetoid form by age 3
Mixed Form CP
-combination of movement disorders
-most common mix is spasticity and
athetosis
-less common is ataxia and athetosis
CP Associated Disorders
1) Speech Impairment
may be the most disabling aspect of the disorder
~ 2/3 of people with CP are speech impaired
CP Associated Disorders
2) Intellectual Impairment
-assessment of intelligence is difficult due
to impairment in movement
-ataxia & athetoid types less affected
-spastic type more affected
-mixed type greatest affected
CP Associated Disorders
3) Perceptual Disorders
• visual, visual-motor, tactile, auditory
• ADD / ADHD
CP Associated Disorders
4) Health Problems
• seizures
• orthopedic deformities
• UTI
• Respiratory difficulties
• Eye abnormalities
• hearing loss
Treatment of CP
1) Physical Therapy-starting early
-prevents additional muscle tone problems
Treatment of CP
2) Surgery
-lengthen or release muscles and
tendons
-correct bone deformities
-Botox injections with muscle building
exercises
Treatment of CP
3) Medications
-not usually effective
Treatment of CP
4) Assistive Devices
-for communication and movement
Treatment of CP
5) Supported Employment & Living
-sheltered workshops, independent living
facilities
-in adults: 1/3-1/2 will achieve
independence
Course Objective #38
• Explain the prevalence of seizure
disorders in the DD population.
What do these people have in
common?
Alexander the Great
Danny Glover
Aristotle
Agatha Christie
Julius Caesar
Margaux Hemingway
Charles Dickens
Richard Burton
Napoleon
Truman Capote
St. Paul the Apostle
Socrates
Vincent Van Gogh
Epilepsy
- “epilepsy” from the Greek word meaning
“condition of being overcome, seized or
attacked”
- not a disease;
Epilepsy
-it IS a condition
-characterized by sudden, brief seizures
whose nature and intensity vary from
person to person
What is a seizure?
It may appear as:
a brief stare
an unusual movement of the body
a change in awareness
a convulsion
How long do seizures last?
What is a seizure?
It may last:
a few seconds
a few minutes
continuously (status epilepticus)
What is a seizure?
-not all seizures indicate epilepsy!
-a single seizure is NOT epilepsy!
What causes a seizure?
•
•
•
•
high fever
TBI
i oxygen,
Hypoglycemia
What is a seizure?
-the type depends on which part of the brain is
affected by the abnormal electrical impulse
-divided into two major types: generalized
seizures and partial seizures
What is a seizure?
-many different types of seizures
-people may experience one type or more than
one type of seizure
Seizures
• Definition
– Excessive discharge cerebral neurons
Seizures
–Partial
–Seizure that begins in one part
of the brain
Seizures
– Partial
– Seizure that begins in one part of the brain
• Simple
– Repetitive purposeless behavior
– Dreamlike state
– No loss of consciousness
– Duration: < 1 minute
– I.e. talking unintelligibly, dizziness, hand shake,
picking at clothes, chewing, smacking lips, spitting,
fondling self
Seizures
• Classification
– Partial
• Simple
• Complex
– Repetitive purposeless behavior
– Loss of consciousness
– Lasts 2-15 minute
– Not aware of behavior
Seizures
• Classification
– Generalized
– Seizure that involves electrical discharges in the
whole brain
• Absence Seizure
– Occurs must often in children
– Period of staring
– Duration: several seconds
• Tonic-Clonic Seizure
Absence Seizure
•
•
•
•
•
•
< 10 sec
‘staring’
-usually begin between 4-14 yrs. age
-70% stop by age 18 yrs.
-may also have eye blinking, eyes roll-up
-no warning, no awareness of seizure, alert
immediately after
Atypical Absence Seizure
-usually last 5-30 seconds; usually more than 10 with
gradual beginning and end
-stare, somewhat responsive, eye blinking, jerking of
lips
-usually begin before 6 yrs.; continue into adulthood
-most have < IQ and other types of seizures
Seizures
• Classification
– Generalized
• Tonic-Clonic Seizure
–(grand mal seizure)
–Tonic – rigidity
–Clonic – contraction and relaxation of all
muscles  jerky, rhythmic
Seizures
• Possible Etiology
– Underlying cause is electrical disturbance 
emitting of abnormal, recurring, uncontrolled
electric discharge
•
•
•
•
•
•
Idiopathic origin
Head injury
Hypoglycemia
Brain tumor
Infection
Anoxia
Seizures
• Clinical manifestations
– Prodromal phase
• Vague emotion
• Min – hrs before seizure
Seizures
• Clinical manifestations
– Prodromal phase
– Aura
• Brief sensory experience
• Precedes seizure by a few seconds
• Usually the same aura each time
Seizures
• Clinical manifestations
–Prodromal phase
–Aura
–Loss of consciousness
• May or may not occur
–Seizure activity
Seizures
• Seizure activity
– Tonic Phase
• Duration: 30-60 sec
• Rigidity  fall
• Pupils fixed & dilated
• Hands and jaws clenched
• Stop breathing
– Clonic phase
Seizures
• Seizure activity
– Clonic phase
• Contraction & relaxation of all muscles, jerky rhythmic
fashion
• Incontinent
• Frothing at the mouth
• Dyspnea
• Epileptic cry
• Tongue chew
• Lasts 1-2 minutes  subsides
Seizures
• Characteristics
– Post-seizure / postictal
• Recover period
• Deep sleep
• Confused
Seizures
• Medical management
– Anticonculsants
• Caramazepine / Tegretol
– S/E
» Blood dyscrasias
» Hepatitis
• Clonazepam / Klonopin
– S/E
» Hepatotoxicity
» Behavioral changes
Seizures
– Anticonculsants
• Phenytoin / Dilantin
– S/E
» Gum hyperplasia
» Nystagmus
» Blood dyscrasias
» PG  cleft palate
Seizures
– Anticonculsants
• Valproate / Depakene
– S/E
» Hepatotoxicity
» Blood dyscrasias
• Diazepam / Valium
• Phenobarbital / Luminal
– S/E
» Rash
» h pain
Seizures
• Nrs Management w/ anticonvulsants
– Do not stop abruptly  seizures
– Monitor levels
– Take regularly
– Inform of all meds
– Alcohol only in moderation
Seizures
• Before Seizure
– At risk for injury
• Padded side rails
• Suction machine in room
• Loose clothing
• Know aura
Seizures
• Fear r/t possibility of a seizure
– Take meds routinely
– ID triggers
• Stress
• New environment
• Menstruation
• Fever
• Sleep deprivation
• Alcohol
What photic stimulation can
trigger a seizure?
• Give 3 examples!
Seizures
• Fear
– Avoid photic stim
• Bight flickering lights
• TV
• Wear dark glasses
– Regular routine
– Wear ID band
Seizures
• Ineffective coping
– Embarrassed
– Feel rejected, avoided, discriminated
– Frequently lonely  psych problems
– Driving restrictions
Seizures
• Knowledge deficit
–
–
–
–
–
Take meds daily
records of meds & seizures
Drug levels routine
Avoid activities requiring alertness after meds
Showers or bath?
• Shower!
– Exercise
– Sleep
Seizures
During a seizure
• Safety
–
–
–
–
–
Ease to floor
Protect the head
Turn to side
Loosen clothing
In bed?
• Remove pillow
• Side rails up
– Do not
• pry open mouth
• Insert anything in mouth
• restrain
– Stay with pt
• Support patient
– Privacy
Seizures
• Observe & document
–
–
–
–
–
–
–
–
Circumstance (before)
Aura?
1st
Movement
Area
Pupils
Automatisms
Incontinent
–
–
–
–
–
Duration
Unconsciousness
Weakness
Dysphasia
Post seizure behavior
Seizures
• Recovery position
• After a seizure
– Document
– At risk for
• Hypoxia
• Vomiting
• Aspiration
Seizures
• Post Seizure Nursing care
–
–
–
–
Side lying
Bed low
Padded side rails
i stimulation
• Dim lights
• Noise i
–
–
–
–
VS
Check mouth
Clean pt
Allow to “sleep it off”
Status Epilepticus
• Defines
– Prolonged seizure activity
– Series of generalizes seizures
w/o full recovery btw attacks
–
Medical emergency
Status Epilepticus
• Affects
– Metabolic demand
– Respiration
– Anoxia
– Brain damage
Status Epilepticus
• Medical
Management
– Goal
• Stop seizure activity
• Airway
• Rx of choice
– Diazepam
• Valium
Status Epilepticus
• Dx
– Blood studies
• Electrolytes
• Glucose
• Phenytoin level
What is an AURA?
-some people experience an aura; a
sensation or warning before a seizure
starts
-varies from person to person
-may occur enough in advance that person
can protect self from injury
-seizure dogs help
What is an AURA?
-may manifest as a change in body temp,
tension/anxiety, musical sound, strange taste,
or odor
-precise description of aura helps diagnose the
region of brain involved
-not always followed by full scale seizure
-aura is a simple-partial seizure
Myoclonic Seizure
-brief, shock-like jerks of a muscle or muscle group
-last 1-2 seconds; just one, or many in a row
-usually both sides of body at once
-seen in several epilepsy syndromes
-many people have ‘normal’ myoclonus w/o having
epilepsy
Atonic Seizure
-AKA drop attacks or drop seizures
-usually last < 15 seconds
-sudden loss muscle strength
-eyelids may droop, head may nod, drop items,
falls to ground
-usually remains conscious
-often begins in childhood; continues into
adulthood
Tonic-Clonic Seizure
-when massive bursts of electrical
energy sweep through the whole
brain at once, causing loss of
consciousness, falls, convulsions,
massive muscles spasms
Tonic-Clonic Seizure
-AKA Grand Mal
-usually lasts 1-3 minutes
-sudden onset, some preceded by aura
-characteristics:
immediate loss of consciousness
two phases: Tonic and Clonic
Tonic-Clonic Seizure
Tonic Phase:
-sudden contraction of all muscle groups
-lasts 10-30 seconds, at times, loud cry
-if standing, forcibly fall
-pupils dilate, face is pale or flushed
-eye roll up to one side or to the back
-stops breathing!
Tonic-Clonic Seizure
Clonic Phase:
-spasmodic jerking of all muscles
-lasts 1-5 minutes or longer
-breathing resumes, but labored
-profuse sweating, salivation
-tongue may be bitten
-involuntary bowel/bladder
-gradually becomes less violent and finally ceases
Tonic-Clonic Seizure
-may have quick recovery to consciousness with
no effects, if episode is short
-often followed by stuperous state (postictal
phase) and sleep
-upon waking; headache, fatigue, restlessness,
agitation, sadness
Types of Seizures
Partial Seizures:
-simple partial
-complex partial
-secondarily generalized
Partial Seizures
Two forms: Simple Partial and Complex Partial
-difference is whether or not there is a change in level
of consciousness
Causes: head trauma, serious infections, tumors of any
kind, brain surgery, strokes, Alzheimer’s disease,
arteriosclerosis
Simple Partial
-usually last < 2 minutes
-do not lose consciousness
-remain awake and aware
-may talk normally
-can remember what happened
-can affect movement, emotions, sensation,
feelings in unusual and sometimes frightening
ways
Complex Partial Seizures
-usually lasts 30 seconds to 2 minutes
-affects larger area of the brain and affects
consciousness
-cannot interact normally during
-can’t remember what happened
-will be in dreamlike, trancelike state
-may talk, but unlikely to make sense
-often takes place in temporal lobes
-AKA “psychomotor epilepsy”
Secondarily Generalized Seizure
-starts as a partial seizure, then
spreads and becomes a generalized
seizure
Status Epilepticus
-condition in which there are continual
seizures or a tonic/clonic seizure is barely
finished before another begins and the
person does not regain consciousness
-can produce exhaustion, severe anoxia
leading to brain damage and cardiac
arrest, brain hemorrhage and DEATH
Status Epilepticus
-can quickly become a
LIFE-THREATENING situation!
-treated with IM or IV Diazepam and/or IV
Phenobarbital
Treatment of Seizures
1) Medications:
-single or combination of drugs
-drugs control seizures – no cure!
-partial seizures are more difficult to
control
-meds must be taken consistently
Treatment of Seizures
2) Surgery:
-when meds don’t work and seizures are
frequent and affect quality of life
-remove small portion of the brain
-or if coming from many sites on one side and
spreading, will cut connections between two
sides (corpus callosotomy)
Treatment of Seizures
3) Vagus Nerve Stimulation (VNS)
-electrical stimulation of the brain via the vagus nerve
in the neck
-a small battery is implanted in the chest wall and
programmed to deliver short bursts of energy to the
brain via the vagus nerve
-interrupts abnormal electrical impulses triggering
seizures
Treatment of Seizures
4) Ketogenic Diet:
-an option for children with hard to control
seizures
-high in fat, low in carbohydrates, no sugar,
restricted calories
-must be closely monitored by MD, RD, family
-being used more often when other methods
fail
Nursing Actions During
-never leave them alone
-if upright, lower to floor and side-lying safety
position to aid respirations
-clear area of hazards, loosen tight clothing
-do not restrain
-padded tongue blade, if possible
-padded bed rails, no pillows
-accurate observations and documentation
Nursing Observations
-aura-presence or absence; if present, ability of
patient to describe it
-cry-presence or absence
-onset-initial sounds, movements, body parts
involved; chewing and salivation; posture; sensory
changes
-tonic and clonic phases- movements, progression,
duration of each
-skin color, respirations, pupillary changes,
incontinence
Nursing Observations
-relaxation (sleep)-duration and behavior
-postictal phase-duration, general behavior, ability to
remember, orientation, headache, injuries present
-duration of seizure-from aura to relaxation
-level of consciousness-changes and duration
-presence of injury-to mouth, lips, tongue, soft tissue,
injury to extremities
Patient Education
-use of meds, including side effects, dose,
timing, reporting side effects to Dr.
-importance of avoiding alcohol and illegal
drugs
-safety measures top prevent injury during
seizures
-good oral hygiene if taking Phenytoin
-importance of adequate rest and diet
Patient Education
-importance of taking meds even if seizure free
-community resources available
-restrictions concerning driving
-importance of follow-up care
-need to avoid excessive stress
-importance of wearing medical alert ID
-importance of not over-protecting self