cerebral palsy - Nursing Case Study

Pathophysiology

• Primary Mechanism: Brain Damage - Cerebral palsy results from a non-progressive injury to the developing brain, occurring either during pregnancy, at birth, or shortly after birth. This damage affects the brain's ability to control movement and posture, leading to motor impairment.

• Secondary Mechanism: Disrupted Communication - Damaged neurons in the brain cannot effectively transmit signals to muscles. This leads to the characteristic symptoms of cerebral palsy, including spasticity, muscle weakness, and coordination problems.

• Key Complication: Contractures - Over time, the imbalance between muscle groups can lead to joint contractures, where a joint becomes permanently fixed in a bent or straightened position, further limiting mobility and increasing discomfort.

Patient Profile

Demographics:

34-year-old female, works as a freelance graphic designer

History:

• Diagnosed with cerebral palsy at age 2, history of recurrent lung infections

• Current medications include Baclofen for muscle spasticity and Keppra for seizure control

• Allergies to Penicillin and Sulfa drugs

Current Presentation:

• Chief complaint of increased difficulty in breathing and persistent productive cough

• Key symptoms include fatigue, fever, and increased muscle weakness

• Vital signs show a temperature of 100.6 F, heart rate of 98 bpm, blood pressure of 130/85 mmHg, respiratory rate of 22 breaths per minute, and oxygen saturation level of 92% on room air.

Section 1

Change in Patient Status:

Over the next few hours, the patient's condition progressively worsens. Her respiratory rate escalates to 28 breaths per minute, and her oxygen saturation drops to 88% while on room air. The patient appears increasingly fatigued and reports feeling more short of breath. Auscultation of the lungs reveals decreased breath sounds in the lower lobes with fine crackles. The patient continues to have a productive cough, and the sputum has become copious and purulent. The patient's temperature spikes to 101.8 F, and her heart rate is now 110 bpm.

This change in status suggests that the patient's lung infection is worsening, potentially leading to a pneumonia. The increased work of breathing and hypoxia are causing her to fatigue, which is likely exacerbating her muscle weakness. Given this patient's history of recurrent lung infections and current symptoms, it is crucial to expedite further diagnostic testing to confirm the suspected diagnosis and to determine an appropriate treatment plan. The worsening status of this patient requires critical clinical reasoning to manage her complex health situation and prevent further complications.

Section 2

New Diagnostic Results:

The patient's blood work reveals a high white blood cell count at 15,000 cells/mm3, indicating a systemic response to infection. Blood gas analysis shows a partial pressure of oxygen (PaO2) at 70 mmHg and a partial pressure of carbon dioxide (PaCO2) of 45 mmHg, suggesting the presence of hypoxemia and hypercapnia respectively. The chest X-ray report comes back and reveals diffuse infiltrates in the lower lobes of both lungs, confirming the suspicion of pneumonia. The sputum culture is sent to the lab for further analysis to identify the causative organism of the infection.

The diagnosis of pneumonia in this patient, who is already suffering from cerebral palsy, adds another layer of complexity to the case. The pneumonia is likely causing the increased fatigue and shortness of breath, as her lungs struggle to provide oxygen to her body. The elevated carbon dioxide levels indicate that the patient is not able to exhale effectively due to weakened lung muscles, which may be exacerbated by her cerebral palsy. The causative organism of the pneumonia is still unknown, which leaves the treatment plan uncertain. It's crucial to start broad-spectrum antibiotics promptly while awaiting the sputum culture results. The patient's worsening condition requires careful monitoring and frequent reassessments to address any further changes in her status promptly.

Section 3

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorates. Her respiratory rate increases to 30 breaths per minute, her heart rate spikes to 120 beats per minute, and her oxygen saturation drops to 88%, despite receiving supplemental oxygen at 2L via a nasal cannula. On auscultation, her breath sounds are diminished in the lower lobes, and crackles are heard. Her level of consciousness decreases, and she becomes less responsive to verbal stimuli.

The patient's increased respiratory rate and heart rate, along with the decreased oxygen saturation, indicate that she is in respiratory distress, likely caused by the progression of the pneumonia. Her decreased level of consciousness may be due to hypoxia or carbon dioxide retention, or possibly a combination of both. These changes in her condition necessitate immediate intervention and re-evaluation of her treatment plan. The healthcare team needs to consider escalating her oxygen therapy, possibly to non-invasive ventilation, and prepare for the possibility of intubation and mechanical ventilation if her condition continues to worsen. The sputum culture results are urgently needed to guide the antibiotic therapy.

Section 4

New Diagnostic Results:

The results of the sputum culture reveal a heavy growth of Streptococcus pneumoniae, which is resistant to the current antibiotic treatment. Concurrently, her arterial blood gas results are alarming: she has a pH of 7.28, indicating acidosis, a PaO2 of 58 mmHg, indicating hypoxia, and a PaCO2 of 52 mmHg, representing hypercapnia. Her lactate level is also elevated at 3.5 mmol/L, indicating tissue hypoperfusion.

These results confirm the clinical suspicion that the patient's condition is deteriorating due to the progression of her pneumonia. The antibiotic resistance of the identified pathogen necessitates a change in the antibiotic regimen. The elevated PaCO2 level suggests the patient might be retaining CO2, which could be contributing to her decreased level of consciousness. The elevated lactate level indicates that her tissues are not getting enough oxygen, which is consistent with the clinical picture of her respiratory distress. The healthcare team needs to quickly decide on a new treatment plan, considering the new diagnostic results and the patient's deteriorating condition. The potential need for escalating oxygen therapy or even intubation becomes more pressing.

Section 5

Change in Patient Status:

As the day progressed, the patient's condition continued to decline. Her respiratory rate increased to 36 breaths per minute, and her SpO2 levels dropped further to 88%, even with a high-flow nasal cannula delivering 15L of oxygen. Additionally, she became increasingly lethargic, arousable only by strong verbal stimuli. The patient also developed a new cough, productive of greenish sputum. Her heart rate was 130 beats per minute and blood pressure was low at 90/55 mmHg.

These clinical findings suggest that the patient's pneumonia is worsening and causing her to go into respiratory failure, and that she might be developing septic shock from the resistant bacterial infection. The healthcare team must urgently reevaluate the treatment plan to prevent further deterioration of her condition. This could include starting her on broad-spectrum antibiotics, considering intubation and mechanical ventilation, and starting vasopressors to support her blood pressure. The team must also be prepared to manage potential complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).