Left Sided Spastic Hemiplegia | Case Study

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11th Feb 2020 Nursing Case Study Reference this

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Intervention Analysis

Background

Jane Walters is a five year old girl and has a diagnosis of left sided spastic hemiplegia, a form of Cerebral Palsy. Jane has two older sisters who attend horse riding lessons at their local stables. Jane has recently expressed an interest in joining them to her parents. However her parents are worried that because of her diagnosis she will not be able to keep up with her siblings. Jane is very aware of her condition, and has recently lost confidence, asking her parents why she is different from other children her age.

Diagnosis – Cerebral Palsy (CP) refers to non-progressive conditions characterised by impaired voluntary movement or posture, and resulting from prenatal developmental malformations or postnatal CNS damage (Reed, 2013, pp. 38-47).

According to the National Institute of Neurological Disorders and Stroke (2008), it is highly likely that a child with CP will have other medical disorders such as; cognitive impairments, seizures, delayed growth and development. Spastic syndromes such as Jane’s occur in more than 70 percent of CP cases.

Spastic hemiplegia is a type of CP that typically affects the body down one side. The spasticity creates a state of resistance against any range of motion; this resistance ultimately increases with increasing speed of that movement (Reed, 2013, pp. 38-47). Children like Jane with spastic hemiplegia will generally walk later than other children and will tend to walk on their tiptoes because often they will suffer from high heel tendons. Often the arm and leg on the child’s affected side are shorter and thinner (National Institute of Neurological Disorders and Stroke 2008).

Impact of Right Hemisphere Brain Damage- Jane has left sided spastic hemiplegia, indicating that damage to the brain has occurred in the right hemisphere. The primary cause of CP is damage to white matter of the brain this is often caused by abnormal brain development. This can be caused by a bleed on the brain, or by a lack of oxygen to the brain, generally caused by a difficult birth (NINDS 2008).

It was important to consider additional complications related to right sided brain damage to ensure an awareness of Jane’s level of functional ability be it; physically, cognitively or behaviourally. Those that may relate to Jane’s case are listed below in table one.

Table one: How damage to the Right Hemisphere can affect function and the occupation of horse riding.

Attention Span

There may be difficulty concentrating on a task or focusing on what is said or seen (ASHA 2014). This can make riding difficult because focus must be given to the horse at all time.

Perception

Visual perception deficits can cause a person to have difficulty perceiving and processing any information received from the left visual field (ASHA 2014). For example, individuals with right hemisphere damage may have difficulty acknowledging the left side of their body making riding on the left reign increasingly difficult.

Reasoning and problem solving:

When presented with a challenge a person may have difficulty identifying that there is a problem and generating solutions (ASHA 2014). For example if a horse spooks Jane will need to be able to solve the problem that has arisen.

Memory:

There may be difficulty recalling previously learned information and learning and retaining new information, such as riding or tack instructions.

Jane’s diagnosis would mean that she would need input from a Multi-Disciplinary Team (MDT). Given her age this would come from a community paediatric teams (CPT). The team will work closely with the children’s’ team in social services and primary care. The team will provide a range of assessments and interventions to young people and their families. In Jane’s MDT team there will be a range of different members such as: Physiotherapists, Paediatricians, Occupational Therapists, Social Workers, Speech and Language Therapists and Educational Psychologists (NHS 2012). According to the Disability Act Jane is entitled to an independent assessment of her individual needs. The act is designed to promote the participation of people with disabilities in society by supporting the provision of disability specific services (NCSE 2011).

A standardised interview was used, this was to allow the OT staff to observe how Jane and her family interact with each other making it easier to; obtain information, identify strengths needs and goals as well as generate an intervention plan and enable goal scaling Due to Jane’s condition she would have already been known to social services and the MDT, as she had already received physiotherapy to aid with muscle stiffness and improve core strength.

Therefore upon the OT department accepting Jane’s referral, an initial assessment was carried out in her home environment with mother and father present (An and Palisano 2013). Collaboration between professional ataff and Jane’s family is a vital component in family-centred services, this is considered best practice in early intervention and paediatric rehabilitation (An and Palisano 2013). Collaboration between the two parties is essential for setting meaningful and achievable goals for a child. Planning and implementing interventions must be able to fit within the context of family life. (An and Palisano 2013)

The following strengths and weaknesses were identified during the initial assessment.

Table two: Jane’s strengths and limitations

Strengths

Limitations.

Jane has an awareness of her disability and it keen to engage in OT intervention

Jane feels her parents do not allow her to do as much as she would like to be able to do for fear of hurting herself or become too tired.

Jane is active and wants to be involved in sport especially riding

Despite Jane’s positive outlook, she is aware that she is different to her siblings and this does upset her, Jane has become self-conscious

Jane’s family are loving and supportive and want to be involved in her treatment/OT intervention.

Jane is worried that because of her condition she won’t be strong enough to engage in horse riding.

 

Due to her condition Jane tires easily and suffers from fatigue. This worries Jane’s mother

During the initial assessment Jane’s mother expressed concerns about her core strength and whether this would affect Jane’s ability to ride. In order to address these concerns a Sitting Assessment for Children with Neuromotor Dysfunction (SACND) assessment was completed this is a clinical instrument to assess static and dynamic postural control in sitting in children with neuromotor dysfunction’ (Reid 1995)

This standardised assessment was used to ascertain how Jane’s CP affects her ability to sit comfortably and concentrate. This skill will be essential if Jane wants to be able to sit upon a horse comfortably and be able to concentrate for the entire session. The SACND measures quality of independent sitting ability across four areas: proximal stability, postural tone, postural alignment, and balance (Knox 2002). The assessment revealed that Jane has weak upper trunk control and so will be issued a specially adapted chair which will enable her to sit more comfortably and for longer periods of time compared to standard chair.

After both assessments were completed an intervention plan was made with input from Jane, her family and the occupational therapist. Jane identified her long term goal of horse riding and to achieve this long term goal, four short term aims were set to serve as recovery milestones (Duncan 2011).

Table three: Jane’s long term aim and short term goals.

Occupational therapists are not required to use a specific functional outcome assessment tool in the selection of their assessments. When a professional is selecting an assessment, they must rely on their clinical and professional judgment (Asher 2007). Therapists need to reflect on what it is that they intend to achieve with the assessment, and if this is managed the assessment can be classed as a success. One way of evaluating an assessment is to look at the performance of patients on an individual assessment task (Steultjens 2005). And will be able to question how well did the assessment relate to the goal setting and objectives for the patient (Duncan 2011).

As part of the Model of Human Occupation horse riding will play a central part in Jane’s habituation. Not only will this establish a routine, it can be something that Jane can take pride in (Kielhofner and Forsyth 2011). Riding will help Jane build upon her self-confidence, having that natural trusting relationship with a horse that shows no judgment and does not understand that she is different (Horseback UK).

The major concern that Jane’s mother presents is the worry that she will not be able to keep up with the physical requirements of riding and that this will dishearten Jane’s enthusiasm. This concern will be tackled in goal number four. Once Jane and her family have a better understanding of hemiplegic cerebral palsy, the OT can begin discussing, through the use of pictures how this may affect her. If Jane has a basic understanding of her condition it will be easier for her to set more realistic goals with the OT as she will have a greater awareness of what she is able to do and may struggle with. This will reduced the likelihood becoming distressed when trying to achieve goals her agreed goals, this will hopefully reduce mum’s concerns about the intervention plan.

Jane feels her parents do not allow her to do as much as she would like to be able to do for fear of hurting herself or become too tired. The OT decided to make to make Jane aware of what fatigue is and may feel like. This would hopefully encourage Jane to let her mum or dad know when she is feeling tired. With this information Jane’s parents can keep a fatigue diary with Ellie.

This will provide the OT with some information regarding when Jane feels most tired and how this impacts on her occupations. This can then be discussed with Jane’s parents and the RDA and suitable arrangements can be made regarding fatigue management as to when would be the most appreciate time for Jane to have her riding lesson when she has the most energy.

Once a pattern of fatigue can be established the OT staff will develop strategies to manage Jane’s fatigue. For example Jane should engage in an activity that she finds relaxing such as reading, colouring or watching television. This can be done after more strenuous activity or in the morning if Jane is known to have a busy afternoon full of physical activities such as a riding lesson. If Jane is able to vary her day with relaxing and more strenuous activities, she will be able to conserve energy for the more strenuous activity of riding and therefore last the full hour lesson.

This form of intervention uses the Compensatory Approach. The principle behind this approach is adapting to and compensating for a dysfunction rather than just treating the cause of the problem. Which in this is Jane’s cerebral palsy and her left sided weakness – there is more of an emphasis on treating the symptoms (Feaver and Edmans 2006). Additionally, the Compensatory Approach may allow Jane to be able to regain a degree of her independence by compensating where the main cause cannot be treated. In Jane’s case this is managing and compensating on her weakness and fatigue, and therefore allowing her to conserve energy in order to complete a riding lesson (Addy 2006).

The social approach recognises Jane as a social being who is easily influenced by the people around her. Therefore by using Jane’s whole family in her therapy and fatigue management, the professionals are integrating Jane’s social environment into her therapy (Polglase and Treseder 2012).

Both interventions also reveal the perception of Jane by her social circle, thereby mitigating Jane’s fear about her social circle (Polglase and Treseder 2012). Jane has always said that Jane feels her parents do not allow her to do as much as she would like to be able to do for fear of hurting herself or become too tired. The treatment will require Jane to trust her parents and tell them when she is tired instead of retreating from her social circle (Martin 1998).

In order to determine if Jane’s intervention has been a success we first evaluate it. Evaluation a professionals practice is one of the most important elements in occupational therapy; without it, the value of their intervention diminishes (Lawcett 2007).

Evaluation is important as in theory it enables the OT and the client to see if intervention is affective. However it is vital that the client is willing to be part of the evaluation process, because if they are not this could present an incorrect evaluation of effectiveness of treatment (Lawcett 2007).

There are four main was a professional can evaluate their intervention process these are;

  1. Using up to date outcome measures.
  2. Using valid and reliable evidence based outcome measures.
  3. Evaluate from view point of the service user
  4. Evaluate throughout therapy process, at end of intervention

(Lawcett 2007).

The success of Jane’s intervention plans can be evaluated by the ‘Goal Attainment Scale’(GAS) (King’s College London [no date]).

The GAS is a measurement technique which consist of individualising a person’s outcome indicators (Turner-Stokes 2009). In order to evaluate the intervention the professional must first construct a list of thorough and complete outcome measures, which will then be given a numerical value to determine the success of the intervention (Kiresuk and Sherman 1968; Purkiss et al. 2013).

Jane’s goals were based on a realistic forecast of her progress (May-Benson 2012) Jane’s performance was scaled into five levels, these reflected her actual performance in comparison to her expected outcomes (Kiresuk et al. 1994).

Table four: Example of GAS goals used from Jane’s second RDA lesson.

Goal Attainment

Score

Energy conservation whilst riding.

Much better than expected

+2

Jane completed the full hours riding lesson with the RDA assistant and occupational therapist

Somewhat better than expected outcome

+1

Jane spends 45 minutes riding with the RDA assistant and occupational therapist

Expected outcome

0

Jane spends 30minutes riding with the RDA assistant and occupational therapist

Somewhat less than expected outcome

-1

Jane spends less than 20 minutes riding with the RDA assistant and occupational therapist

Much less than expected outcome

-2

Jane not able to attend the session due to fatigue

A score like this was recorded for each weekly session over the course of a month and a total was tallied at the end, scoring the intervention with a numerical value. The professional knew it would be vital to give Jane and her control in her treatment in order to motivate an improvement (Turner-Stokes 2009), hence it was decided that the GAS goals would be discussed at the end of the session, showing a level of improvement (King et al. 1999) instead of recording it as s pass, fail assessment (Turner-Stokes 2009).

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