Cerebral Palsy and Osteotomy
Scenario
T.M. is a 3-year-old boy with cerebral palsy (CP) who has been admitted to
your unit. He is scheduled for surgery tomorrow morning for a femoral
osteotomy and tendon lengthening to stabilize hip joints and to help reduce
spasticity. You are orienting the parents to the unit and have a nursing
student assisting you.
1. After getting the family settled, you return to the nurses' station and the
nursing student asks you to explain what CP is and what might have
caused it in this patient. How would you answer the student's question?
CP is a nonprogressive group of chronic conditions that affect muscle
coordination and body movements. It is usually caused by damage to the
brain during the prenatal, perinatal, or postnatal period. Clinical signs
depend on the location of the neurologic lesion. From 70% to 80% of
prenatal cases have an unknown cause. Exposure to maternal or perinatal
infection is a risk factor, as is preterm birth. Meningitis, motor vehicle
accident, encephalitis, and shaken baby syndrome can also be risk factors.
2. The nursing student asks what the family might have noticed that would
indicate CP in T.M. when he was a baby. Which of these findings will you
include in your discussion with the student? Select all that apply, and
state your rationale.
a. Head lag at 5 months
b. Ability to sit unassisted at 7 months
c. Positive Moro (startle) reflex at 2 months
d. Leg scissoring
e. Right hand preference at 12 months
f. Use of pincer grasp at 9 months
g. Increased irritability
Answers: a, d, e, g
Common signs of CP are persistence of primitive reflexes; early preference
for one side (hand or gross motor such as crawling); rigidity in arms and
legs, which can be evidenced by unusual stiffness or “scissoring”; or floppy
muscle tone, which can be evidenced by persistent head lag and lack of
, neck control. Infants with CP may also be irritable, poor feeders who
struggle with coordinated suck and swallow, or excessive sleepers who
show little interest in their environment. Normal findings would include a
history of sitting at 7 months, a Moro reflex until 5-6 months, and use of
pincer grasp at 9 months.
You and the nursing student finish a health history with the family and
determine that T.M. has impaired vision corrected with glasses, a speech
impairment, and a seizure disorder and has had poor weight gain and
feeding issues since birth. He has a skin-level feeding device (Mic-Key
button) and receives supplemental tube feedings in addition to oral intake.
He is not able to ambulate without braces and wears ankle-foot orthotics.
He receives physical, occupational, and speech therapy on an outpatient
basis. T.M. is verbal and able to answer questions with simple phrases and
responds to commands. T.M. weighs 12 kg.
3. The admitting provider orders the following. Explain the rationale for
each order.
Chart View
Admission Orders
Baclofen (Lioresal) 5 mg every 8 hours PO
Diazepam (Valium) 2 mg twice a day PO
Lamotrigine (Lamictal) 60 mg twice a day PO
Diet as tolerated; NPO for solids and hold tube feedings at midnight; clear
fluids until 4 am
Place IV on admission and begin D5NS at 45 mL/hr
VS every 4 hours
Baclofen (Lioresal) 5 mg every 8 hours PO: Skeletal muscle relaxant.
Diazepam (Valium) 2 mg twice a day PO: Muscle relaxant for patients with
CP; also used at a higher dose for seizures.
Lamotrigine (Lamictal) 60 mg twice a day PO: Anticonvulsant for partial
seizures.
Diet as tolerated; NPO after midnight: Pediatric guidelines generally
indicate to stop solids 8 hours before surgery and may allow clear fluids
until 2 to 4 hours before surgery.
Scenario
T.M. is a 3-year-old boy with cerebral palsy (CP) who has been admitted to
your unit. He is scheduled for surgery tomorrow morning for a femoral
osteotomy and tendon lengthening to stabilize hip joints and to help reduce
spasticity. You are orienting the parents to the unit and have a nursing
student assisting you.
1. After getting the family settled, you return to the nurses' station and the
nursing student asks you to explain what CP is and what might have
caused it in this patient. How would you answer the student's question?
CP is a nonprogressive group of chronic conditions that affect muscle
coordination and body movements. It is usually caused by damage to the
brain during the prenatal, perinatal, or postnatal period. Clinical signs
depend on the location of the neurologic lesion. From 70% to 80% of
prenatal cases have an unknown cause. Exposure to maternal or perinatal
infection is a risk factor, as is preterm birth. Meningitis, motor vehicle
accident, encephalitis, and shaken baby syndrome can also be risk factors.
2. The nursing student asks what the family might have noticed that would
indicate CP in T.M. when he was a baby. Which of these findings will you
include in your discussion with the student? Select all that apply, and
state your rationale.
a. Head lag at 5 months
b. Ability to sit unassisted at 7 months
c. Positive Moro (startle) reflex at 2 months
d. Leg scissoring
e. Right hand preference at 12 months
f. Use of pincer grasp at 9 months
g. Increased irritability
Answers: a, d, e, g
Common signs of CP are persistence of primitive reflexes; early preference
for one side (hand or gross motor such as crawling); rigidity in arms and
legs, which can be evidenced by unusual stiffness or “scissoring”; or floppy
muscle tone, which can be evidenced by persistent head lag and lack of
, neck control. Infants with CP may also be irritable, poor feeders who
struggle with coordinated suck and swallow, or excessive sleepers who
show little interest in their environment. Normal findings would include a
history of sitting at 7 months, a Moro reflex until 5-6 months, and use of
pincer grasp at 9 months.
You and the nursing student finish a health history with the family and
determine that T.M. has impaired vision corrected with glasses, a speech
impairment, and a seizure disorder and has had poor weight gain and
feeding issues since birth. He has a skin-level feeding device (Mic-Key
button) and receives supplemental tube feedings in addition to oral intake.
He is not able to ambulate without braces and wears ankle-foot orthotics.
He receives physical, occupational, and speech therapy on an outpatient
basis. T.M. is verbal and able to answer questions with simple phrases and
responds to commands. T.M. weighs 12 kg.
3. The admitting provider orders the following. Explain the rationale for
each order.
Chart View
Admission Orders
Baclofen (Lioresal) 5 mg every 8 hours PO
Diazepam (Valium) 2 mg twice a day PO
Lamotrigine (Lamictal) 60 mg twice a day PO
Diet as tolerated; NPO for solids and hold tube feedings at midnight; clear
fluids until 4 am
Place IV on admission and begin D5NS at 45 mL/hr
VS every 4 hours
Baclofen (Lioresal) 5 mg every 8 hours PO: Skeletal muscle relaxant.
Diazepam (Valium) 2 mg twice a day PO: Muscle relaxant for patients with
CP; also used at a higher dose for seizures.
Lamotrigine (Lamictal) 60 mg twice a day PO: Anticonvulsant for partial
seizures.
Diet as tolerated; NPO after midnight: Pediatric guidelines generally
indicate to stop solids 8 hours before surgery and may allow clear fluids
until 2 to 4 hours before surgery.
