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Impact of Cognitive or Sensory Impairment on the Child and Family Chapter 19 Mosby items and derived items © 2005, 2001 by Mosby Inc. Cognitive Impairment • Any type of mental difficulty or deficiency • AKA Mental retardation (MR) Mosby items and derived items © 2005, 2001 by Mosby Inc. Early Behavioral Signs of Cognitive Impairment • Non-response to contact, voice, movement • Irritability • Poor/slow feeding • Poor eye contact during feeding • Diminished spontaneous activity Mosby items and derived items © 2005, 2001 by Mosby Inc. Mental Retardation -American Academy of Mental Retardation • Sub-average intellectual function (IQ <75) • Onset before age 18 • Functional impairments Mosby items and derived items © 2005, 2001 by Mosby Inc. Functional Impairments (at least 2 of these 10) • Communication • Self care • Home living • Social skills • Community use • Functional academics • Leisure • Work • Health and safety • Self-direction Mosby items and derived items © 2005, 2001 by Mosby Inc. Causes of Mental Retardation • Intrauterine infection and intoxication • Trauma (prenatal, perinatal, postnatal) • Metabolic or endocrine disorders • Inadequate nutrition • Postnatal brain disease Mosby items and derived items © 2005, 2001 by Mosby Inc. Causes of Mental Retardation (cont’d) • Chromosomal anomalies • Prematurity, LBW, postmaturity • Environmental influences • Unknown prenatal influences • Psychiatric disorders with onset in childhood Mosby items and derived items © 2005, 2001 by Mosby Inc. Classification of MR (591) • Educable/mild—IQ 50-75—EMR— comprise 85% of MR • Trainable/moderate—IQ 35-55—TMR— 10 % • Severe—IQ 20-40 • Profound—IQ <20-25 Mosby items and derived items © 2005, 2001 by Mosby Inc. Primary Prevention of Mental Retardation • Rubella immunization • Genetic counseling • Use of folic acid supplements • Educate about fetal alcohol syndrome • Educate about lead exposure Mosby items and derived items © 2005, 2001 by Mosby Inc. Interventions to Assist MR • Task analysis • Provide assistive devices • Early intervention programs • Teach self-care • Promote good physical care and regular MD visits • Teach socially acceptable behavior • Teach about safety issues • Consider sexuality issues and contraception Mosby items and derived items © 2005, 2001 by Mosby Inc. “Syndrome” • A recognized pattern of malformations with a single, specific, anatomic, physiologic, or biochemical cause Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome (596) • “Syndrome”—a recognized pattern of malformations with a single, specific, anatomic, physiologic, or biochemical cause • AKA Trisomy 21 – Extra chromosome 21 in 95% – Translocation of chromosome 21 in 3-4% (not associated with parental age) – Mosaicism in 1%-2%--refers to cells with both normal and abnormal chromosomes Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome (cont’d) • Etiology unknown—likely multiple causality • Most common chromosomal abnormality – 1 in 800-1000 live births • Most common genetic cause of mental retardation Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome (cont’d) • Maternal age – Age 30: Incidence ~ 1 in 950 – Age 40: Incidence ~ 1 in 100 – In about 5% cases extra chromosome is from father – Most DS infants have moms <35 yrs old Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome— Manifestations (598) • Head small, round, with flat occiput • Face—flat, eyes slanted with inner folds and Brushfield’s spots, ears low set, nose flat, tongue protrudes • Musculoskeletal—hypotonia, hyperflexibility, short stature • Chest—pectus excavatum, neck short, abdomen protrudes • Genitalia—small penis, crytorchidism, skin—dry and mottling present • Hands show Simian crease, feet have plantar crease; both hands and feet are short & stubby Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome Congenital Anomalies • 40%-45% heart defects—most common are septal defects. Heart defects coupled with respiratory infection is leading cause of death in first year • Renal disease, Hirschsprung (congenital bowel obstruction), T.E. fistula • Altered immune function • Skeletal defects—atlantoaxial instability (neck pain, weakness, torticollis) Mosby items and derived items © 2005, 2001 by Mosby Inc. Down Syndrome IQ • Wide variation from severely retarded to low-average intelligence • Generally mild to moderate mental retardation Mosby items and derived items © 2005, 2001 by Mosby Inc. Nursing Interventions for DS • Teach swaddling • Re-feeding techniques, small freq feeds, watch for obesity and constipation • Use of bulb syringe for increased mucus, vaporizer, changing positions • Good skin care and sun protection • Support if surgery is indicated for any congenital anomalies • Genetic counseling—teach about low alpha fetoprotein Mosby items and derived items © 2005, 2001 by Mosby Inc. Hearing Impairment (602) • Ranges from mild to profound • Deaf: a person whose hearing disability precludes processing linguistic information with or without hearing aid • Hard of hearing: Generally able to hear with hearing aid Mosby items and derived items © 2005, 2001 by Mosby Inc. Etiology of Hearing Impairments • Anatomic malformation • LBW • Ototoxic drugs • Chronic ear infections • Perinatal asphyxia • Perinatal infections • Cerebral palsy Mosby items and derived items © 2005, 2001 by Mosby Inc. Pathology of Hearing Impairments • Conductive hearing loss—middle ear—most common usually from chronic serous otitis media • Sensorineural hearing loss—nerve deafness • Mixed conductive-sensorineural loss—may follow recurrent OM with complications • Central auditory imperception – Organic—inability to express or interpret sounds, inability to discriminate sounds – Functional—autism, hysteria, schizophrenia Mosby items and derived items © 2005, 2001 by Mosby Inc. Symptom Severity • Measured in decibels (dB) at 500, 1000, and 2000 levels (listening speech ranges) • Hearing threshold—measured by audiometer • Effect on speech Mosby items and derived items © 2005, 2001 by Mosby Inc. Therapeutic Management • Lipreading, sign language • Speech/language therapy • Telecommunications devices • Closed captioning • Hearing aid—for conductive loss • Cochlear implants—for sensorineural loss Mosby items and derived items © 2005, 2001 by Mosby Inc. Manifestations of Hearing Impairment in Infancy • Lack of startle reflex • Absence of babbling by age 7 months • General indifference to sound • Lack of response to spoken word Mosby items and derived items © 2005, 2001 by Mosby Inc. Childhood • Profound deafness likely to be diagnosed in infancy • Entry into school usually requires hearing test. If not, hearing is tested in school at early age • Concerns with speech development usually prompts officials and/or parents to seek help of professional Mosby items and derived items © 2005, 2001 by Mosby Inc. Care for Hearing Impaired Child During Hospitalization • Reassess understanding of instructions given • Supplement with visual and tactile media • Communication devices – Picture board – Common words and needs (food, water, toilet) Mosby items and derived items © 2005, 2001 by Mosby Inc. Prevention of Hearing Loss • Treatment and management of recurrent otitis media • Prenatal preventive measures • Avoid exposure to noise pollution Mosby items and derived items © 2005, 2001 by Mosby Inc. Visual Impairment • General term that refers to visual loss that cannot be corrected with regular prescription lenses Mosby items and derived items © 2005, 2001 by Mosby Inc. Visual Impairment • General term that refers to visual loss that cannot be corrected with regular prescription lenses • Partially sighted—AKA school vision – Acuity of 20/70-20/200 – Usually able to read type of print used in public school system • Legal blindness – Acuity of 20/200 or less – Legal as well as medical term to allow for special considerations Mosby items and derived items © 2005, 2001 by Mosby Inc. Etiology of Visual Impairments • Perinatal or postnatal infections – Gonorrhea, chlamydia, rubella, syphilis, toxoplasmosis • Retinopathy of prematurity • Perinatal or postnatal trauma • Other disorders—SCD, JRA, retinoblastoma • Unknown causes Mosby items and derived items © 2005, 2001 by Mosby Inc. Refractive Errors • Refraction: bending of light rays through the lens of the eye • Myopia (near-sighted)—most common • Hyperopia (far-sighted) Mosby items and derived items © 2005, 2001 by Mosby Inc. Other Visual Impairments • Astigmatism—uneven cornea • Amblyopia—blindness in one eye from lazy eye • Strabismus—crossed eyes or lazy eye • Cataracts • Glaucoma Mosby items and derived items © 2005, 2001 by Mosby Inc. Nursing Assessment • Infancy – Response to visual stimuli – Parental observations and concerns – Expect binocularity by age 6 months • Childhood – Visual acuity testing Mosby items and derived items © 2005, 2001 by Mosby Inc. Promoting Child’s Optimum Development • Play and socialization—should focus on fine and gross motor skills, and stimulation of other senses and promoting interactions outside of home to prevent development of “blindisms” • Development of independence—Braille tags, tapping, guides • Education—Braille, audio books and learning materials Mosby items and derived items © 2005, 2001 by Mosby Inc. Hospitalization of the Visually Impaired Child • Safe environment • Reassurance • Orient child to surroundings and do not change furniture. If something is moved, tell child • Encourage independence—tying rope from bed to bathroom, for instance, can help with mobility • Consistency of team members Mosby items and derived items © 2005, 2001 by Mosby Inc. Measures to Prevent Visual Impairment • Prenatal care/prevention of prematurity • Rubella immunizations for all children • Safety counseling for preventing eye injuries Mosby items and derived items © 2005, 2001 by Mosby Inc.