The Child with Cognitive Impairment Lecture Flashcards
Overview of Cognitive Impairment (CI)
Definition: Cognitive Impairment is a general term that encompasses any type of intellectual disability. It is commonly referred to by the abbreviation CI.
AAIDD Criteria for Diagnosis: According to the American Association on Intellectual and Developmental Disabilities (AAIDD), a child must meet specific criteria to be diagnosed with CI:
Intelligence: Must manifest sub-average intelligence, defined as an IQ below the range of .
Functional Impairment: Must demonstrate functional impairment in at least of the following domains:
Self-direction.
Health and Safety.
Functional academics.
Leisure.
Work.
Communication.
Self-care.
Home living.
Social skills.
Use of community resources.
Severity Spectrum: Impairment levels ranges from mild to severe.
The Nursing Role in Caring for Children with CI
Primary Goal: The central objective is to promote optimum social, physical, cognitive, and adaptive development as individuals within the context of their family and community.
Identifying Children with CI: Nurses must be vigilant for early signs suggestive of cognitive impairment, including:
Dysmorphic features (physical abnormalities).
Irritability or non-responsiveness to contact.
Abnormal eye contact during feeding.
Gross motor delay.
Decreased alertness to voice or movement.
Language difficulties or delays.
Feeding difficulties.
Educational and Legal Support: Developing and implementing individualized plans in collaboration with the school system involves several legal frameworks:
ADA: Americans with Disabilities Act.
IDEA: Individuals with Disabilities Education Act.
IEP: Individualized Education Plan.
IFSP: Individualized Family Services Plan.
Education of the Handicapped Act Amendments of 1986.
Education of Child and Family: Nurses must account for specific learning challenges such as:
Difficulty discriminating between or more stimuli.
Short-term memory deficits.
Motivation issues.
Utilizing technology and early intervention programs.
Promoting Optimum Development: Focusing on specific areas of life:
Communication.
Discipline.
Socialization.
Sexuality.
Play and Exercise.
Promoting Independent Self-Help Skills: Encouraging autonomy in daily living activities:
Feeding.
Toileting.
Dressing.
Grooming.
Genetic Disorders: Down Syndrome (Trisomy 21)
Genetic Cause: Presence of a copy of the chromosome.
Inheritance Pattern: This is typically not passed on as an affected gene from parents. However, the mechanism of translocation can recur, resulting in a risk of having another child with Trisomy .
Frequency: Occurs in approximately live births.
Risk Factors: Advanced maternal age (specifically mothers over the age of ).
Clinical Manifestations:
Inner epicanthal folds.
Depressed nasal bridge and small nose.
Decreased muscle tone (hypotonia).
Excess or loose skin on the back of the neck.
Wide space between the big toe and the toe.
High arched palate.
Large, protruding tongue.
Atlantoaxial instability.
Transverse palmar creases (Simian crease).
Oblique palpebral fissures (upward slant to eyes).
Separated sagittal suture in newborns.
Other Outstanding Features:
Lower intelligence.
Social development delay.
Cognitive anomalies.
Sensory problems.
Growth Patterns: Height and weight are generally reduced; however, weight is often high for their height, leading to obesity.
Sexual Development: Often delayed.
Associated Illnesses and Comorbidities:
Congenital Heart Defects.
Respiratory Tract Infections (Upper Respiratory Infections).
Leukemia (specifically Acute Megakaryoblastic Leukemia).
Hypothyroidism.
Acute Otitis Media (ear infections).
Feeding difficulties, constipation, and obesity.
Nursing Care for Down Syndrome:
Provide family support.
Assist the family in preventing physical problems.
Promote the child’s developmental progress.
Assist with genetic counseling.
Autism Spectrum Disorder (ASD)
Nature of the Disorder: A complex developmental disorder characterized by core deficits in social interactions, communication, and behavior.
Prevalence: live births (based on data), an increase from in the preceding years.
Risk Factors: Risk is higher in males.
Causes: The exact cause is unknown. It is NOT related to vaccines, socioeconomic level, race, or parenting style. While it runs in families, the genetic link is usually another disorder associated with ASD.
Social Interaction Deficits:
Abnormal eye contact (often the earliest sign).
Failure to smile.
Failure to orient to their name.
Lack of imitation.
Lack of interactive play.
Lack of gesture use (pointing or waving).
Communication Deficits:
Absent to delayed speech.
Atypical language: humming, grunting for extended periods, laughing inappropriately, or using echolalia (repeating words/phrases).
Behavioral Impairments:
Repetitive, impulsive, restrictive, and obsessive behaviors.
Stereotypical movements: Rocking, flapping hands, head nodding, spinning, or twirling.
Difficulty with change (requires structured routine).
Self-injurious behaviors (e.g., biting).
Associated Illnesses: GI problems, Epilepsy, Feeding issues, disrupted sleep, ADHD, Anxiety, Depression, OCD, Schizophrenia, and Bipolar Disorder.
Nursing Care Management for ASD:
Structure: A structured routine is key.
Therapy Goals: Provide positive reinforcement, increase social awareness, teach verbal communication, and decrease unacceptable behaviors.
Communication Strategies:
Show skills on a trusted object or person first.
Use simple nonverbal communication (like pointing).
Use few words and very concrete wording.
Avoid figures of speech (e.g., Avoid saying "You're red as a tomato" because the child may take it literally and deny being a vegetable).
Ask parents how the child communicates best.
Observe nonverbal behaviors and use alternative means (pictures, music, electronics, comfort objects).
Environment: Dim lighting and minimize the number of people in the room.
Attention Deficit/Hyperactivity Disorder (ADHD)
Definition: Developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity appearing in children aged years.
Epidemiology: More common in boys than girls.
Etiological Theories: Theorized to be caused by decreased levels of dopamine, norepinephrine, or epinephrine.
Diagnostic Criteria:
Behavior must be present in at least different settings.
Behaviors must be present before the age of years.
Types: Inattentive type and Hyperactive type.
Associated Problems: Academic difficulties, social difficulties, and higher risk for conduct disorders, oppositional defiant disorders, depression, anxiety, learning disabilities, and speech/language delays.
Treatment Modalities:
First Line (Ages 4-5): Behavior therapy and psychotherapy are the primary treatments. Medication is not advised as first-line therapy for this age group.
Pharmacologic Therapy:
Psychostimulants: Methylphenidate (Ritalin, Concerta, Methylin) and Dextroamphetamine (Dexedrine).
Others: Tricyclic antidepressants (Imipramine) and Clonidine.
Medication Side Effects:
Weight loss, decreased appetite, and potential impact on growth velocity.
Abdominal pain, headaches, and sleeplessness.
Nursing Management for Medications:
Usually taken BID (at breakfast and noon).
Give immediate-release formulations on an empty stomach.
Avoid caffeine (as it can decrease medication effectiveness).
Adjust insulin dosing for children with diabetes if necessary.
"Drug holidays" are NOT recommended.
Frequent evaluation of effectiveness is required.
Monitor for headaches as they may indicate increased blood pressure.
General Nursing Care:
Focus on the child's strengths, not weaknesses.
Environmental manipulation: consistency, organizational charts, and decreasing distractions during periods of concentration.
Coordinate school modifications.
Questions & Discussion
Q: What is a primary goal in caring for a child with cognitive impairment?
A: Promoting optimum development.
Q: What intervention is most appropriate to facilitate social development of a child with a cognitive impairment?
A: Provide peer experiences, such as infant stimulation and preschool programs.
Q: The nurse is assessing a child with Down syndrome. Which are possible comorbidities directly associated with Down syndrome?
A: Congenital heart defects, Respiratory tract infections, and Acute megakaryoblastic leukemia.
Q: The diagnostic criteria for autism include delayed or abnormal functioning in which area with onset before age 3 years?
A: Ability to maintain eye contact (associated with social interaction deficits).
Q: You are caring for a child with ASD who is completely nonverbal. What is the best way to communicate with him?
A: Observe his nonverbal behaviors, and respond using alternative means of communication such as pictures, music, electronics, & comfort objects.
Q: What intervention should be included in the nursing care of a child with ASD?
A: Communicate with the child at his or her developmental level.
Q: Which physician order would a nurse caring for a 12-year old patient with nonverbal ASD question?
A: Non-sedated MRI (due to the difficulty of remaining still and the potential for sensory/anxiety issues in a nonverbal child with ASD).
Q: When teaching a parent about methylphenidate for ADHD, what should be included?
A: Call the office if the child has headaches as the medication can increase blood pressure. (Note: Meds should not be given at bedtime due to sleeplessness side effects).