The purpose of this paper is to understand the concepts of a child with cognitive impairment ( which is used synonymously with mental retardation). The student nurse will interact with a child with mental retardation (MR) at a developmental center and watch how the nursing process is used in the care of child. Also to understand the concept of an “Individualized Education Plan” (IEP).Before this can be done, there must be an understanding of what the functional and educational categories of MR are, and what factors brought about the use of the IEP.
MR is defined in children as three components that assess intellectual functioning, functional strengths and weaknesses, and age at time of diagnosis. Intellectual functioning is measured by the intelligence quotient (IQ), which is found to be 70-75 or below. Deficits in functional behaviors are defined by strength and weaknesses in 10 different adaptive skill areas: communication, self care, home living, social skills leisure, health and safety, self direction, functional academics, functional use and work. Finally MR must be diagnosed by 18 years of age (Wong, Hockenberry-Eaton, 2005).
Mild retardation (50-55 to 70 IQ) in the preschool child is not noticed as often by the casual observer, but is slower to walk, feed self, and talk. The school age child can acquire practical skills, reading and arithmetic to a 3rd-6th grade level. As adults they can achieve social and vocational skills, may need occasional guidance and support when under social and economic stress.
Moderate retardation (35-40 to 50 -55) in the preschool child has more noticeable motor delays especially in speech. The school age child can learn simple communication, elementary, health and safety habits and simple manual skills. This child has a mental age of 3 to 7. The adult can perform simple tasks, participate in simple recreation, and is usually incapable of self maintenance.
Severe retardation (23-25 to 35-40 IQ) in the preschool child has marked delay in motore development, little or no communication skills and may respond to training in elemtary self care. The school age child usually walks barring specific disability, has some understanding of speech and achieves a mental age of a toddler. The adult can conform to dialy routines and repetitive activities, needs continuous direction and supervision.
Profound retardation (below 20-25 IQ) in the preschool child has gross retardation, minimum capacity for functioning in sensorimotor areas and needs total care. The school age child has delays in all area of development, shows basic emotional responses, may respond to skillful training in use of legs, hands, and jaw. This child achieves a mental age of a young infant. The adult may walk, needs complete custodial care and has primitive speech (Wong, Hockenberry-Eaton, 2001).
The change and increasing opportunities for children with MR have come about within the last 30 years. Many states now offer Early Intervention Programs (EIP) in the school system. The EIP accommodates special needs for children with MR from birth to three years of age; it also offers special classes to children between ages 3-5 years who have special needs (Donovan, Noreen, nurse at Wing Lake, 2004). These changes and opportunities have resulted because of the public law 94-142 (The Education for all Handicapped Children Act of 1975). This act was passed to provide free appropriate public education for all handicapped children from 3-21 years of age and to provide for supportive services that ensure the benefit of special education (Wong, Hockenberry-Eaton, 2001). This act also provides safeguards for parents of handicapped children when special education decisions are made by the schools. These safeguards ensure the rights of handicapped children are protected (Mitchell, Espin, 1990).
Later the amendment to the Education of Handicapped Act of 1986 was passed to allow comprehensive community services to infants and toddlers with disabilities and their families. This law requires a timely comprehensive multidisciplinary evaluation including assessment activities related to the child and the child’s family (Fewell, 1991). In 1990 another amendment was passed (The Individual with Disabilities Educational Act). This act encouraged states to provide educational opportunities for all children with disabilities from birth to 21 years of age. All these changes led to changes in trends which include; family centered care (the family is the constant in the child’s life), normalization (child and family live their life as normal as possible), mainstreaming (to integrate children with special needs into regular classrooms) (Wong,Hockenberry-Eaton, 2001).
Personal attitudes, beliefs and feelings regarding children with MR can affect care provided to the child. It was once believed that children with MR were better off in institutions ti be forgotten about. They were treated as outcasts, seen as different and many people were afraid of children with MR. This affected the care given. Now they receive the services, assessment and treatments that lead to better education (Wong, Hockenberry-Eaton, 2001)
There are many that make up the multidisciplinary team responsible for people with MR. This team consists of a physical therapist, occupational therapist, social worker, the educational teacher, the family and the nurse. This team working together provides the student with their own “Individualized Education Plan”. There are yearly team meetings that allow this team to share information insights, perspectives and concerns about the student. Nurses in these programs develop care plans, pass medication, and make sure the overall wellbeing of the child is being met (Donovan, nurse at Wing Lake, 2004). Also the nurse is involved in programs in which ways to prevent MR are discussed. There are social and environmental factors that are preventable which can cause MR. These factors are poor nutrition, cigarette smoking, chemical abuse, poor parental care, and lead poising. Major interventions regarding educating the mother of he dangers of alcohol use. Other important preventions that play a role are genetic counseling and prenatal screening, especially regarding Downs Syndrome or Fragile X syndrome. The use of folic acid supplements during pregnancy to decrease neaural tube defects, optimal medical care of high risk newborns, and rubella immunizations. Newborn screening for treatable inborn errors of metabolism such as congenital hypothyroidism, phenyketonuria, galactosemia, and early appropriate therapies and rehabilitation services for children with developmental disability can help in prevention (Wong, Hockenberry-Eaton, 2001).
The students at Wing Lake Developmental Center attend for educational programs. The program at this center is set up to teach many skills of daily living and self care as possible. Each child has their own Individual Education Plan specifically written to meet that child’s needs. The educational team evaluates the student’s abilities in areas of fine motor, gross motor, socialization and self care skills. Evaluations are done on the student’s birthday each year and then a complete evaluation is done every 3 years. Wing Lake provides these education programs for severe mental impairments (SCI) and severe multiple impairments (SXI) for students from birth to 25 years of age.
In order to provide better outcome and enhance IEP ( individualized education plan), the nurse is required to use strategies adapted to the needs of the individual and family, as evidence by: nurse has to be sensitive to cultural nuances of role, touch, and space. Consider child’s safety, security, family preference, privacy, and equipment on which child is dependent. Have available a supply of toys that are colorful, nonbreakable, easily cleaned, and that have no removable parts. Be direct, confident, and positive in approach. Establish and maintain trust. Explain clearly and simply what will be done. Keep child in position of comfort. Use smooth, efficient movement. Incorporate play and games. Proceed in an orderly, unrushed manner. CC is a nineteen-year old student in an adult SXI program at Wing Lake Developmental Center. She is at the developmental age of 6 month. CC was born May 11th 1986. Her medical diagnosis is Rett Syndrom and seizure disorder. Her weight at present time 149.4 lb and height 5 ft 51/2in. Her present medication is Depakene liquid 4 tsp (250 mg /5ml) bid and Keppra 250mg ½ tablet daily every pm. By approximately age 3 years, CC loss of her previously acquired skills. Purposeful use of the hand has been lost as well as mosts spoken language, such as previously learned words or word combinations. Cass (2003) states that “the regression is characterized by deterioration in babble or speech and functional hand use , social withdrawal, unexplained screaming , and sleep disturbance” (p.325). CC has a history of fractures and sprains to both upper and lower extremities including: fracture to right foot 10/91, fractured left ankle 12/91 and fractured left hip 6/95. She is monitored closely both at home and school to avoid any injury to her extremities. CC lives at home with her mom and dad. On May 28th student is alert, eyes open spontaneously, oriented-incomprehensible sounds, using vocalizations, facial expressions, recognizes her name, familiar people and familiar objects in her immediate environment (spoon, plate, straw).Compliance with assistance with command to move body part (rolling on the changing table). Develop autistic-like behaviors. Eye contact and attention span very limited. Psychosocial Development 🙁 Trust versus Mistrust) stage.
Development of sense of trust with primary caretaker. Socialization behavior : Prefers caretaker figures to other adults. Freezes” in presence of strangers (time for diaper change).Hearing and vision are functional. No wearing glasses or using hearing aid. Continue informal hearing and vision screening outlined by the Oakland County Health Department. Mouth condition is good. Mucous membrane pink and moist. CC eats a regular school lunch and is able to chew, tolerate different texture of food. Language development: Makes vowel-like sounds. Smiles in response to adult speech. At this time speech therapy is discontinued because of the decline in verbal participation. Gross Motor Development: can sit for long periods with firm support. Rolls from back to side and from side to back with assistance. Fine Motor Development: CC requires assistance with scooping her food but is able to bring the spoon to her mouth independently. CC is also able to drink independently with a straw. CC participates in grooming activities such as face and hand washing. CC required assistance for all ADL. CC makes purposeful attempts to grab objects and able to hold objects in both hands (spoon).Conscious control of the hands and fingers is gradually replaced by uncontrolled, stereotypic movements. No ability to consciously coordinate purposeful movements (apraxia). CC is receiving physical therapy with emphasis upon activities to maintain ROM and gross motor skills. CC sits up in a “Gillette seating chair” especially made for her. It has special chest, arm and leg straps which holds her in. She has minimal participation with activities. CC enjoys music and being read to most of the day. CC respirations and heart rate are within normal limits, and there are no coughs, Wheezes or abnormal breathing sounds heard with interaction. CC skin is white/pink in appearance and is warm to the touch. CC continues to experience ongoing swelling in both feet with the left foot more swollen than the right. Left foot is very dry with black color scab area 0.5 cm in diameter noted. Her primary care doctor is aware of these problems. No itching in, inflammation, tearing, bleeding is noted. CC is incontinent to bowel and bladder. CC is wearing briefs. No abdominal distention, ascites, herniation, lesion is noted. Urine is light amber color .No odor noted.
At risk for injury R/T uncontrolled movements during seizure (Ackley, 2005). NOC: The student will remain free from any injury from seizure activity throughout the day. The teacher and facility will identify symptoms that indicate risk for injury from seizure every day. NIC: Seizure Precaution and Management: 1. The teacher will remove potentially harmful objects from the environment during the day.2. The facility will have oxygen and suctioning equipment in the room during the day.3. The teacher will stay with child during seizure reorient when awake, and allow to rest or sleep after seizure. 4.The teacher will maintain sidelying position with chair padded and provide gentle support to head and arms if harm might result during seizure.5. The teacher will assess skin for color (pallor, flushed or cyanosis), respiratory rate, depth, and for sign of distress.( Provides information about possible obstruction or aspiration of secretion if seizures are prolonged and affect ventilation.) The nurse will administer and evaluate anticonvulsant medication. Diastat rectal gel 10 mg is to be administered prn for seizure activity lasting fifteen minutes or longer. The student was strapped in her chair with proper padding when the tray was not in place,all sharp objects were locked away in closet, and there was always room between each student so the teacher can stay close to the child all the time.
At risk for injury R/T cognitive and sensory disability (Ackley, 2005).NOC: The student will remain free from any injury throughout the day. The teacher will use adequate lighting throughout the day. The teacher and facility will identify symptoms that indicate risks for injury every day. The teacher and faculty will use healthcare services congruent with the needs of the student every day (use of the nurse). NIC: Environmental Management: safety: 1. Identify needs of student, based on level of physical and cognitive function and history of behavior (motor skills, communication, ADL’s, sensory or hearing level).2. Identify safety hazards in the environment (all chemicals locked in closet, clutter removed and put away, sharp objects locked away, distance between each student).3. Use protective devices (straps to keep student secured in chair, trays to help secure student in chair, proper padding in the chair. The student was strapped in her chair when the tray was not in place all chemicals and sharp objects were locked away in closets, and there was always room between each student so no one got hit another students swinging arm.
At risk for impaired skin integrity R/T mechanical forces(shearing forces, pressure, restraint), decreased physical mobility (Ackley,2005). NOC: Risk Detection: The teaching faculty and nurse will recognize symptoms that indicate risks (restraints, pressure, moist skin from secretions, red areas that are not blanchable). The teaching faculty and nurse will perform examination of skin every 2 hours. The teaching faculty and nurse will use health care services congruent with needs every day .NIC: Skin Surveillance: 1. Observe extremities for color, warmth, swelling, pulses, texture, edema, and ulcerations every day and every 2 hours.2. Monitor skin for areas of redness and breakdown every day and every 2 hours. 3. Monitor for sources of pressure and friction every day. 4. Monitor skin for excessive dryness or moistness every day. 5. Instruct family member, caregiver about signs of skin breakdown ( non blanchable redness, infection to a site, open areas to skin, swelling, drainage from an inflamed area). The restraints were removed during the day and legs were rubbed. Proper repositioning was not always done, because the student had to remain in her chair all day. During diaper changes skin was examined quickly.
Impaired social interaction R/T communication barriers, AEB: inability to speak more than one word (Ackley, 2005). NOC: Social Involvement: The student will interact with neighbors every day using non verbal interaction. The student will interact with family members every day using nonverbal interaction. The student will participate in organized activities every day. NIC: Socialization Enhancement: 1. Help student to increase awareness in communicating with others.2.Encourage social activiyies.3. Encourage involvement in new activities.4.Give positive feedback. The student sometimes demonstrates socialization: she would participate in all group activities with help.
Self-care deficit R/T impaired ability to perform ADL, AEB: immobility, no functional hand use (Ackley, 2005). NOC: Self -Care: The student will maximize self-care capability with use of aids. NIC: Self care Assistance: 1. Balance activities with rest as needed every day.2. Place needed articles within reach during activities 3. Provide assistive aids or devices to perform ADL , allow choices when possible. ( washing hands in the basin, hold the colm, special spoon). The student sometimes demonstrates self care: she would participate in self feeding activities: scooping her food , bringing the spoon to her mouth independently.
The experience for the student nurse at Wing Lake was interesting. Although it was challenging and heartening, the student nurse received a better understanding of children with cognitive impairment. This experience will help during the care of children by being able to see the differences that each child has and the student nurse will feel more comfortable when the care for a cognitively impaired patient arrives.
Reference
Ackley, E., Ludwig., (2005). Nursing Diagnosis Handbook (6th ed.) St. Louis: C.V. Mosby
Cass, H., Reilly, S., Owen, L., Wisbeach, A., (2003). Finding from a multidisciplinary clinical case series of females with Rett syndrome. Developmental Medicine and Child Neurology 45,( 5), 325.
Mount, R. (2003). Features of Autism in Rett Rett Syndrome and Severe Mental Retardation. Journal of Autism and Developmental Disorders, 33, (4), 435-441.
Wong, D., Hockenberry-Eaton, M., (2005) Essentials of Pediatric Nursing. (6th ed.) St Louis.
C.V. Mosby.
