CHAPTER 4

NURSING PROCESS

4.1 Assessment
Assessment oI the child gives a baseline to appropriate treatment and management
aims and techniques. Re-assessment should be continuing part oI treatment,which allows Ior
improvement or deterioration to be noted, thus enabling treatment to be more eIIective.
1. The nurses must have knowledge oI normal development.
2. During physical examination, it is important to discriminate between delay in
motor development and abnormal motor patterns.
3. It is very essential Ior the nurses to explain, what he is going to do beIore
handling the child.
4. Assessment needs to be playIul, interesting and non-threatening.
5. Assess young child as much as possible on parent`s lap.
6. Observe child among Iamiliar toys as well as with selected toys to activate
interest as well as reveal dormant abilities.
7. Keep sessions within the bounds oI a child`s concentration.
8. Have an unhurried atmosphere.
9. Have easy, successIul actions oI a child interspersed with diIIicult tasks.

4.1.1 Subjective Examination
Subjective inIormation should be obtained Irom the parents especially mother or Irom
relatives and through case-sheet.
1. General details includes
a. Name
b. Age & Sex
c. Address
2. When did the mother Iirst noticed the dysIunctions
3. Siblings having same type oI symptoms
4. Prenatal History
a. Age oI mother
b. Consanguity marriage
c. Any drugs taken during pregnancy
d. Any trauma & stress
e. Any addiction smoking or alcoholism
I. History oI rubella or cytomegalovirus, toxoplasmosis inIection
g. History oI previous abortions, still born or death aIter birth
h. Multiple pregnancies (duration between pregnancies)
i. Status & cast oI the mother
5. Perinatal History
a. Place oI delivery
b. History preterm or Iull-term delivery
c. History oI asphyxia at birth
d. Type oI delivery- Iorceps delivery
e. Presentation oI child- breech presentation
I. Any history oI prolonged labour pain
g. Condition oI mother at the time delivery
6. Postnatal History
a. Delayed birth cry (when child cried)
b. Weight oI the child at birth Low Birth Weight (LBW)
c. History oI any trauma to brain during the Iirst 2 years oI liIe
d. History oI neonatal meningitis, jaundice, or hypoglycemia
e. Hydrocephalus or Microcephaly
I. Nutritional habits oI the child (malnutrition)
g. Feeding diIIiculties
7. Any medical or surgical treatment taken
8. Any physiotherapy treatment previously taken
a. What was the ability level oI child at that time?
b. What obstructs the child Irom progress?
c. What treatment was used?
d. Was the treatment eIIective or not?
9. Apgar Score Irom the case-sheet






4.1.2 Objective Examination
4.1.2.1On Observation
1. Behaviour oI the child
a. Whether child is alert, irritable or IearIul in the session or during
particular activities
b. Child becomes Iatigued easily or not during activity
c. Find out what motivates his action particular situation, person or
special plaything
2. Communication oI the child
a. How child communicates with the parents
b. Whether child initiates or responds with gestures, sounds, hand or
Iinger pointing, eye pointing or uses words and speech
3. Attention span
a. What catches child`s attention?
b. For how much time child`s attention is maintained on particular
thing
c. How does parent assist him to maintain attention?
d. What distracts the child?
4. Does child Iollows suggestions to move or promptings to act?
5. Position oI the child
a. Which position does the child preIer to be in?
b. Can child get into that position on his own or with help?
c. With assistance, child makes any eIIort to go in that position
d. Symmetry oI the child (actively or passively maintained)
e. II involuntary movements present, then in which positions these
movements are decreased or increased
6. Postural control & alignment
a. How much parental support is given
b. Postural stabilization and counterpoising in all postures
c. Proper & equal weight bearing
d. II the child`s center oI gravity appears to be unusually high,
resulting in Iloating legs and poor ability to raise head against
gravity
e. Fear oI Iall in child due to poor balance
7. Use oI limbs & hands
a. Limb patterns in changing or going into position as well as using
them in position
b. Attitudes oI limbs during playing in all positions
c. Whether one or both hands are used, type oI grasp and release
d. Accuracy oI reach and hand actions
e. Any involuntary movements, tremors or spasms, which interIere
with actions, are present
8. Sensory aspects
a. Observe child`s use oI vision, hearing, oI touch, smell and
temperature in relevant tasks
b. Does child enjoys particular sensations
c. Whether child enjoys being moved or having position changed
9. Form oI Locomotion
a. How child is carried
b. Any use oI wheelchair or walking aids
c. Which daily activities motivates child to roll, creep, crawl, bottom
shuIIle or walk
10.DeIormities
a. Observe any recurring position oI the whole child
b. Any part oI the body, which remains in particular position in all
postures & in the movements
c. The positional preIerences typically seen in spastic cerebral palsies
are Ior mid positions oI the body .
i. In the arm, this generally consists oI :
1. Shoulder protraction or retraction, adduction and
internal rotation
2. Elbow Ilexion
3. Forearm pronation
4. Wrist & Fingers Ilexion
ii. In the legs, it includes
1. Hip semi-Ilexion, internal rotation and adduction
2. Knee semi-Ilexion
3. Ankle plantar Ilexion
4. Foot pronation or supination
5. Toes Ilexion
d. Athetoid or dystonic posturing usually incorporates extremes oI
movement such as total Ilexion or extension
e. Windswept DeIormity oI hip One hip Ilexed, abducted and
externally rotated; other hip Ilexed, adducted and internally rotated
and in danger oI posterior dislocation

4.1.2.2 On Examination
1. Sensory Assessment
a. It is diIIicult to assess sensation in babies and young children with
severe multiple impairments.
b. II any hearing or visual or psychological abnormalities are present
then assessment done by specialist is required
2. Motor Assessment
a. Growth Parameters
i. Height
Until 24 to 36 months oI age, length in recumbency is
measured using an 31,39420907. AIter the age oI 2 years
standing height is recorded by a 89,/420907.
eight Centimeters Inches
At birth 50 20
At 1 year 75 30
2 to 12 years (Age in years 6) 77 (Age in years 2) 30

ii. Weight oI the child
eight Kilograms Pounds
At birth 3.25 7
3 to 12 months (Age in months 9) / 2 Age in months 11
1 to 6 years (Age in years 2) 8 (Age in years 5) 17
7 to 12 years |(Age in years 7) 5| / 2 (Age in years 7) 5

iii. Head circumIerence oI the child
The tape is used to measure the occipitoIrontal head
circumIerence Irom external occipital protuberance to the
glabella.
ead circumference Centimeters
At birth 35
3 months 40
1 year 45
2 years 48
12 years

b. Developmental Assessment
Age Developmental Milestones
4 to 6 weeks Social smile
3 months Head holding
6 months Sits with support
7 months Sits without support
5 to 6 months Reaches out Ior a bright object & gets it
6 to 7 months TransIers object Irom one hand to other
6 to 7 months Starts imitating cough
8 to 10 months Crawls
10 to 11 months Creeps
9 months Standing holding Iurniture
12 months Walks holding Iurniture
10 to 11 months Stands without support
13 months Walks without much oI a support
12 months Says one word with meaning
13 months Says three words with meaning

15 to 18 months Joints 2 or 3 words into sentence
13 months Feeds selI with spoon
15 to 18 months Climbs stair
15 to 18 months Takes shoes and socks oII
24 months Puts shoes and socks on
24 months Takes some clothes oII
3 to 4 years Dresses selI Iully
2 years Dry by day
3 years Dry by night
3 years Knows Iull name and sex
3 years Rides tricycle

c. Joint Range oI Motion (active & passive)
1. Active head and trunk Ilexion, extension, rotation observed
during head raise in prone, supine, sitting, standing
developmental channels
2. Active shoulder elevation, abduction, rotation, Ilexion and
extension movements are observed during the Iunctional
examination oI creeping, reaching and other arm movements
3. Active elbow Ilexion and extension observed during child`s
reach to parts oI body or toys
4. Active wrist and hand movements will be observed during
Iunction development
5. Active hip Ilexion and extension will be observed during all
Iunctions
6. Active knee Ilexion and extension seen with active hip
Ilexion extension
7. Foot movements are also check during Iunctional
development
d. Reactions, Responses and ReIlexes
1. Sucking ReIlex (3 months)
2. Rooting ReIlex (3 months)
3. Grasp ReIlex (3 months)
4. ReIlex Stepping (2 months)
5. Galant`s Trunk Incurvation (2 months)
6. Moro ReIlex (0-6 months)
7. Startle ReIlex (remains)
8. Landau ReIlex (3 months - 2 years)
9. Flexor Withdrawal (2 months)
10. Extensor Thrust (2 months)
11. Asymmetric Tonic Neck ReIlex (ATNR) (usually
pathological)
12. Symmetrical Tonic Neck ReIlex (STNR) (usually
pathological)
13. Tonic Labyrinthine Supine (pathological)
14. Tonic Labyrinthine Prone (3 months)
15. Neck Righting (5 months)
16. Positive Supporting (3 months)
17. Negative Supporting (3-5 months)
e. Protective ReIlexes
II reIlexes are persistent beyond the usual duration then they are
called positive signs. II reIlexes, which are supposed to be,
present during particular age but are absent are known as
negative signs.
I. Muscle tone
g. ReIlexes
1. SuperIicial ReIlexes
2. Deep Tendon ReIlexes
h. Limb Length Discrepancy
1. Apparent (umbilicus to lateral malleolus)
2. True (ASIS to medial malleolus)
i. Contractures
j. DeIormities
3. Gait (iI applicable)
4. TransIer activities (iI applicable)
5. Balance (iI applicable)
6. Assessment oI daily activities
a. Assessment oI Ieeding, dressing, washing, toileting, play and hand
Iunction
b. Ambulation (dependent or independent)
7. Cognitive Assessment (iI applicable)
a. Response to external environment & Behaviour
b. Sense oI colour, size, shape
c. Sense oI common dangers as Iire
d. Toilet training
e. Sense oI household articles

4.1.3 Physical Examination
Common challenges seen in Individuals with cerebral palsy

Parameter Challenges
Growth Underweight
Overweight
Short stature
Mobility Ambulatory
Nonambulatory
Power/manual wheelchair
Assistive devices
Dysphagia Oropharyngeal
Esophageal
Muscle tone Hypertonia
Hypotonia
Alternative/
Complementary
Medicine
Side eIIects
Drug-nutrient interactions
Feeding Oral
Enteral
Parenteral
GI Gastroesophageal reIlux
Dysmotility
Dumping syndrome
Malrotation
Diarrhea/constipation
Orthopaedic Contactures
Scoliosis
Dislocated hips
Osteopenia
Medications Drug-nutrient interactions
Side eIIects on muscle tone,
bowels, appetite
Pulmonary status EIIects on energy expenditure



4.2 Diagnose
1. Impaired Physical Mobility related to decreased muscle strength and control
2. Sensory/Perceptual Alteration: Visual or Auditory related to cerebral damage
3. Altered Nutrition: Less than Body Requirements related to diIIiculty in chewing and
swallowing and high metabolic needs
4. IneIIective Management oI Therapeutic Regimen: Family related to excessive
demands made on Iamily with child`s complex care needs
5. Diversional Activity DeIicit (Child) related to poor social skills

4.3 Intervension
1. Impaired Physical Mobility related to decreased muscle strength and control
oal Intervention Rationale Expected Outcome
NIC Priority
Intervention:
Exercise
Therapy, Joint
Mobility: Use oI
active and passive
body movement to
maintain joint
Ilexibility
NOC Suggested
Outcome: Joint
MovementActive:
Range oI
motion oI joints
with selI-limited
movement
The child will attain
maximum
physical abilities
possible.
PerIorm
development
assessment
and record age oI
achievement oI
milestones (e.g.,
reaching Ior
objects, sitting)




Delayed
development
milestones
are common with
cerebral palsy.
Once one milestone
is achieved,
interventions are
revised to assist in
the next skill
necessary

The child reaches
maximum physical
mobility and all
developmental
milestones.




Plan activities to use
gross and Iine
motor skills (e.g.,
holding pen or
eating utensils, toys
positioned to
encourage reaching
and rolling
over)

Allow time Ior the
child to
complete activities


PerIorm range-oI-
motion exercises
every 4 hours Ior the
child unable
to move body parts.
Position the
child to promote
tendon stretching
(e.g., Ioot plantar
Ilexion instead oI
dorsiIlexion, legs
extended instead
oI Ilexed at knees
and hips)
Many activities oI
daily living and
play activities
promote physical
development.





The child may
perIorm tasks more
slowly than most
children.

Promotes mobility
and increased
circulation, and
decreases the risk
oI contractures.














Arrange Ior and
encourage parents
to keep
appointments with a
rehabilitation
therapist.


Teach the Iamily to
maintain
appropriate brace
wear

A regular and
Irequently
reevaluated
rehabilitation
program
assists in promoting
development.

Adaptive devices
are oIten
necessary to
maximize physical
mobility.

2. Sensory/Perceptual Alteration: Visual or Auditory related to cerebral damage
oal Intervention Rationale Expected outcome
NIC Priority
Intervention:
Communication
Enhancement:
Visual DeIicit or
Auditory DeIicit:
Assistance with
accepting or learning
alternative methods
Ior living with
diminished vision or
hearing.
NOC Suggested
Outcome: Body
Image: Positive
perception oI own
appearance and body
Iunctioning
The child will
receive and
beneIit
Irom varied
Facilitate eye and
auditory
examinations by
specialist. Promote
Adaptive devices
oIten enhance
sensory input. These
devices need
The child receives
adequate
sensory/perceptual
input to maximize
Iorms oI sensory
and
perceptual input.
the use oI adaptive
devices (glasses,
contact lenses,
hearing aids), and
encourage
recommended return
visits to specialists.

Maximize the use oI
intact senses
(e.g., describe
verbally the
surroundings to a
child with poor
vision, allow
touching oI objects,
provide visual
materials to enhance
learning in the child
with impaired
hearing, use
computers to
promote
communication).
Irequent changes as
the child
grows.





Other senses can
compensate Ior
those that are
impaired.
developmental
outcome.

3. Altered Nutrition: Less than Body Requirements related to diIIiculty in chewing and
swallowing and high metabolic needs
oal Intervention Rasionale Expected Outcome
NIC Priority
Intervention: Weight
Gain Assistance:
Facilitation oI body
weight gain.
NOC Suggested
Outcome: Nutritional
Status: Extent to
which nutrients are
available to meet
metabolic needs.
The child will
receive nutrients
needed Ior
normal growth.
Monitor height and
weight and plot on a
growth grid. PerIorm
hydration status
assessment.

Teach the Iamily
techniques to
promote caloric and
nutrient
intake:
a. Position the child
upright Ior
Ieedings.
b. Place Ioods Iar
back in the
mouth to
overcome tongue
thrust.
c. Use soIt and
blended Ioods.
d. Allow extra time
and quietm
environment Ior
meals.

PerIorm Irequent
respiratory
assessment. Teach
the Iamily to
avoid aspiration
pneumonia. Teach
InsuIIicient intake
can lead to
impaired growth and
dehydration.


Special techniques
can Iacilitate
Iood intake.

















Aspiration
pneumonia is a risk
Ior
the child with poor
swallowing.
Special Ieeding
The child shows
normal growth
patterns Ior height,
weight, and other
physical parameters.
NOC
care oI gastrostomy
and tube
Ieeding technique as
appropriate.
techniques may be
needed.

4. IneIIective Management oI Therapeutic Regimen: Family related to excessive
demands made on Iamily with child`s complex care needs
oal Intervention Rationale Expected Outcome
NIC Priority
Intervention: Family
Process
Maintenance:
Minimization
oI Iamily process
disruption eIIects.
NOC Suggested
Outcome: Not yet
developed.
The Iamily will
adapt to growth
and
development
needs oI the child
with
cerebral palsy.
Allow opportunities
Ior parents to
verbalize the impact
oI cerebral
palsy on the Iamily.
Provide reIerral
to other parents and
support
groups.

Explore community
services Ior
rehabilitation, respite
care,
childcare, and other
needs and
reIer Iamily as
appropriate.
The Iamily needs an
opportunity to
explore the emotional
and social
impact oI the child`s
care to
integrate and grow
Irom the
experience.

Diverse services are
available and
will be needed due to
the multiple
impacts oI cerebral
palsy on the
child.

The Iamily continues
its development
and provides support
Ior all oI its
members.

During home and
oIIice visits
review the child`s
achievements
and praise the Iamily
Ior care
provided.

Teach the Iamilies
skills needed to
manage the child`s
care (e.g.,
medication
administration,
physical
rehabilitation, seizure
management).

Teach case
management
techniques.




Involve siblings in
the care Ior the
child with cerebral
palsy. Review Ior
parents the needs oI
all children in
the Iamily.

The child`s
achievements are
positive
reinIorcement oI the
Iamily`s eIIorts.



Complex skills must
be learned
beIore they can be
perIormed with
eIIiciency.





The child requires
care by many
specialists. Many
parents become
case managers to
coordinate care.

Siblings oI the child
with cerebral
palsy may Ieel leIt
out because oI
the care provided.
Special eIIorts
contribute to meeting
the
developmental needs
oI all Iamily
members.

5. Diversional Activity DeIicit (Child) related to poor social skills
oal Intervention Rationale Expected Outcome
NIC Priority
Intervention:
Recreation
Therapy: PurposeIul
use oI recreation
to promote relaxation
and
enhancement oI
social skills.
NOC Suggested
Outcome: Play
Participation: Use oI
activities as
needed Ior
enjoyment,
entertainment,
and development by
children.
The child will
engage in
adequate
diversional
activity to
maximize
growth and
development
ReIer the Iamily to
early childhood
stimulation
programs. Encourage
contact with other
children. When
hospitalized, place
the child in a
room with other
children when
possible.

Work with the local
school to
develop an
individualized
education plan that
The child needs a
variety oI
activities and contact
with other
children and adults to
maximize
development.





Public schools must
provide an
individualized
education plan.
Parents may need
The child engages in
activities that
maximize
development
allows the child
contact with other
children and a
variety oI activities.

Investigate
recreational
programs
Ior children with
disabilities and
share inIormation
with the parents.
assistance to
interact eIIectively
with the school
system.

Recreational
programs Ior children
with disabilities may
promote social
experiences and
physical activity.

REFERENCE :
1. http://www.scribd.com/doc/6130708/Cerebral-Palsy-Assessment accessed Friday,
November, 18 on 08.00 pm
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #92
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0|el|l|ar, Texas 3coll|sr R|le losp|la| lor Cr||drer,
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Caro| Rees Parr|sr, R0, V3, 3er|es Ed|lor
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES
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3. http://wps.prenhall.com/wps/media/objects/354/362846/Child20-
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