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Chapter 37 Impact of Cognitive and Sensory Impairment on the Child and Family All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. Cognitive Impairment “Cognitive impairment” (CI) is a general term that encompasses any type of mental difficulty or deficiency Used synonymously with “intellectual disability” Diagnosis Made after a period of suspicion by family or health professionals In some instances, made at birth All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 2 Intellectual Disability Intellectual functioning Functional strengths and weaknesses Subaverage intellectual function: IQ of 70-75 or below Impairment in 2 of 10 adaptive skills Younger than age 18 at the time of diagnoses All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 3 Functional Impairments (Adaptive Skill Areas) Communication Home living Community use Leisure Health and safety Self-care Social skills Academics Work Self-direction All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 4 Cognitive Impairment (CI): Classification Results of standardized tests are used in making a diagnosis of cognitive impairment Diagnosis of mildly impaired characterizes 85% of the population with CI Educable Diagnosis of moderately impaired characterizes 10% of the population with CI Trainable All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 5 Cognitive Impairment: Causes Intrauterine infection and intoxication Trauma (prenatal, perinatal, postnatal) Metabolic or endocrine disorders Inadequate nutrition Postnatal brain disease All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 6 Cognitive Impairment: Causes (Cont.) Unknown prenatal influences Chromosomal anomalies Prematurity, low birth weight, postmaturity Psychiatric disorders with onset in childhood Environmental influences All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 7 Nursing Care of Children with Impaired Cognitive Function Educate child and family Early intervention Teach child self-care skills Promote child’s optimal development Encourage play and exercise All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 8 Nursing Care of Children with Impaired Cognitive Function (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 9 Nursing Care of Children with Impaired Cognitive Function (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 10 Nursing Care of Children with Impaired Cognitive Function (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 11 Nursing Care of Children with Impaired Cognitive Function (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 12 Nursing Care of Children with Impaired Cognitive Function (Cont.) Provide means of communication Establish discipline Encourage socialization Provide information on sexuality Help families adjust to future care Care for the child during hospitalization All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 13 Nursing Care of Children with Impaired Cognitive Function (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 14 Measures to Prevent Cognitive Impairment Counseling and education regarding nutrition and tobacco use Awareness of danger of chemicals, including prenatal exposure to alcohol Rubella immunization Genetic counseling Folic acid supplementation All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 15 Down Syndrome Most common chromosome abnormality 1 per 691-1000 live births Causes unknown; probably multiple Occurs in populations of all races All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 16 Down Syndrome: Causes Nonfamilial trisomy 21 Extra chromosome 21 in 95% of cases Translocation of chromosomes 15 and either 21 or 22 in 3%-4% of cases Mosaicism, a mixture of abnormal and normal cells, in 1%-2% of cases Maternal age Age 35: risk is 1 per 350 births Age 40: risk is 1 per 100 births All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 17 Down Syndrome: Diagnostic Evaluation Clinical manifestations Square head with upward slant to eyes Flat nasal bridge, protruding tongue Hypotonia Chromosome analysis Physical problems Congenital heart disease Hypothyroidism Leukemia All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 18 Down Syndrome: Diagnostic Evaluation (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 19 Down Syndrome: Therapeutic Management Available therapies Surgery to correct congenital anomalies Evaluation of hearing and sight Periodic testing of thyroid function Supporting child’s family at time of diagnosis Prevention of physical problems Assist in prenatal diagnosis and genetic counseling All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 20 Fragile X Syndrome Second most common genetic cause of cognitive impairment after Down syndrome 1 per 3600 boys 1 per 4000-6000 girls Caused by abnormal gene on the lower end of the long arm of the X chromosome All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 21 Fragile X Syndrome: Clinical Manifestations Large head circumference Long face with a prominent jaw (prognathism) Large, protruding ears Large testes (postpubertal) Manifestations variable in female carriers of gene All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 22 Fragile X Syndrome: Classic Behavioral Features Mild to severe cognitive impairment Delayed speech and language Hyperactivity Hypersensitivity to taste, sounds, and touch Autistic-like behaviors Aggressive behaviors All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 23 Fragile X Syndrome: Therapeutic Management Tegretol/Prozac for behavioral control Stimulants for hyperactivity (similar to management of attention deficit/hyperactivity disorder) Referral to early intervention program Normal life span expected Genetic counseling All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 24 Hearing Impairment 1-6 per 1000 healthy full-term infants 2-4 per 100 premature infants Slight to moderately severe Residual hearing with the use of an aid Severe to profound hearing loss Cannot process linguistic information All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 25 Hearing Impairment: Causes Anatomic malformation Family history Low birth weight Ototoxic drugs, O2 administration Chronic ear infections Perinatal asphyxia Perinatal infections Cerebral palsy All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 26 Hearing Impairment: Pathology Conductive hearing loss: middle ear Sensorineural hearing loss: damage to inner ear or auditory nerve Mixed conductive-sensorineural loss: interference with transmission of sound Central auditory interception Organic Functional All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 27 Hearing Impairment: Symptom Severity Measured in decibels (db) Measured at varying frequencies Hearing threshold A unit of loudness Critical listening speech range Effect on speech All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 28 Hearing Impairment: Therapeutic Management Medical or surgical interventions Hearing aids Cochlear implants Multichanneled implants All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 29 Hearing Impairment: Therapeutic Management (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 30 Hearing Impairment: Manifestations in Infancy Lack of startle reflex Absence of reaction to auditory stimuli Absence of well-formed syllables by age 11 months General indifference to sound Lack of response to spoken word All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 31 Hearing Impairment: Manifestations in Childhood Profound deafness: likely to be diagnosed in infancy If not detected in infancy, identified upon entry into school Abnormalities in speech development Learning disabilities All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 32 Hearing Impairment: Promoting Communication Lip reading Cued speech Sign language Speech-language therapy Additional aids Socialization Support of child and family All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 33 Hearing Impairment: Care for Child During Hospitalization Reassess understanding of instructions given Supplement with visual and tactile media Provide communication devices Picture board with common words Assistance of child life specialist Additional aids All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 34 Hearing Impairment: Preventive Measures Treatment and management of recurrent otitis media Prenatal preventive measures Genetic testing Avoidance of ototoxic drugs Testing to rule out syphilis, rubella, or blood incompatibility Avoidance of exposure to noise pollution All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 35 Visual Impairment Common problem during childhood In the United States, prevalence of blindness or serious visual impairment is 30-64 per 100,000 5%-10% of all preschoolers Identified through vision screening programs All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 36 Visual Impairment: Classification Partially sighted (school vision) Acuity of 20/70 to 20/200 Education usually in public school system Legally blind Acuity of 20/200 or poorer Legal and medical term All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 37 Visual Impairment: Causes Prenatal or postnatal infections Retinopathy of prematurity Trauma Postnatal infections Other disorders Sickle cell disease Juvenile rheumatoid arthritis Tay-Sachs disease All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 38 Visual Impairment: Types Refraction Bending of light rays through the lens of the eye Myopia Hyperopia Strabismus (may or may not be refractive) Amblyopia All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 39 Visual Impairment: Trauma Common cause of blindness in children Injuries to eyeballs or adnexa Penetrating: sharp instruments, propulsive objects, blunt objects, motor vehicle accidents Nonpenetrating: lacerations, blows to the eyes or head, burns Treatment: aimed at preventing further damage All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 40 Visual Impairment: Infections Conjunctivitis Ophthalmic antibiotics Systemic antibiotics in some cases Caution with use of steroids: may exacerbate viral infections Infection control concerns All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 41 Visual Impairment: Care Management Nursing assessment Identify children who by virtue of their history are at risk Observe for behaviors that indicate a vision loss Screen all children for visual acuity Nursing alert Suspect visual impairment in a child of any age whose pupils do not react to light All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 42 Visual Impairment Care Management (Cont.) Promote parent-child attachment Promote child’s optimal development Development and independence Play and socialization Education Braille Audio books and learning materials All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 43 Visual Impairment: Hospitalization of Affected Child Provide a safe environment Provide reassurance during all treatments Orient child to surroundings Encourage independence Treatment team members should be consistent All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 44 Visual Impairment: Preventive Measures Prenatal care/prevention of prematurity Rubella immunizations for all children Safety counseling for preventing eye injuries Periodic screening of all children All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 45 Hearing-Visual Impairment Profound effects on development Motor milestones usually achieved Other development often delayed “Finger spelling” Developing future goals for the child All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 46 Retinoblastoma Most common congenital malignant intraocular tumor in children 11 cases per million annually Affects primarily children younger than 5 years Caused by genetic mutation or is inherited All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 47 Retinoblastoma (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 48 Retinoblastoma (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 49 Autism Spectrum Disorders (ASDs) Complex neurodevelopmental disorder accompanied by intellectual and social alterations Verbal effects, repetitive and restrictive behavior patterns 1 per 100-150 children Four times as common in boys All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 50 ASDs: Causes Genetic disorder of prenatal and postnatal brain development Immune and environmental factors that may interact with genetic susceptibility Relatively high risk of recurrence of ASDs in families with one affected child All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 51 ASDs: Clinical Manifestations and Diagnostic Evaluation Peculiar and bizarre characteristics primarily in specific areas: Socialization Communication Behavior Difficulty with eye and body contact Language delay Diagnosis often delayed until age 2-3 years All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 52 ASDs: Care Management Severely disabling condition No cure for autism Some improvement with language skills Numerous therapies used Recognize early Attempt behavior modification Provide a structured routine Decrease unacceptable behavior All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 53 ASDs: Family Support Autism often becomes a family disease Frequently parents express guilt and shame Stress importance of family counseling Autism Society of America is good source of information Clients should be managed at home or in longterm placement facility All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 54 Question The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. What should the nurse consider when dealing with this issue? A. Sterilization is recommended for any adolescent with cognitive impairment. B. Sexual drive and interest are limited in individuals with cognitive impairment. C. Individuals with cognitive impairment need a welldefined, concrete code of sexual conduct. D. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 55
