Transcript class 12 chapter 13

Chapter 13
Neurologic and Sensory Disorders
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The Nervous System
• Grows rapidly before birth and during the first year
• Central nervous system (CNS)
– Cerebrum, cerebellum, brainstem, spinal cord
– Myelinization is cephalocaudal and proximodistal
– Primary focus of Chapter 13
• Peripheral nervous system (PNS)
– Cranial and spinal nerves
• Autonomic nervous system (ANS)
– Sympathetic/parasympathetic systems
• Choroid plexus: primary site of CSF formation
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Increased Intracranial Pressure
• Caused by volume increase of brain, CSF, or
blood which exceeds cranial capacity
• Signs and symptoms
– Cushing triad
• Increase in systolic blood pressure, widening pulse
pressure, decrease in pulse, altered respiratory pattern
– Possible temperature elevation from
inflammation, systemic infection, damage to
hypothalamus
– More pronounced as consciousness deteriorates
– As ICP increases, cerebral perfusion decreases
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Intracranial Hemorrhage
• Description
– Broken blood vessels within the skull cause
bleeding in the brain; from trauma or anoxia
– Complete recovery is likely if symptoms are mild
– Death results if there is a massive hemorrhage
• Diagnosis
– History of delivery, CT, MRI, increased CSF
pressure, symptoms and course of the disease
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Intracranial Hemorrhage
• Signs and symptoms
– Inability to move normally, lethargy, poor
sucking reflex, irregular respirations,
cyanosis, twitching, forceful vomiting, highpitched shrill cry, convulsions
– Opisthotonic posture
– Tense, pressurized fontanel
– Pupil of one eye sometimes smaller than the
other
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Intracranial Hemorrhage
• Treatment and nursing care
– Newborn placed in an isolette
• Allows temperature control, ease in administering
oxygen, continuous observation
– Head is elevated
– Doctor may prescribe medication to control
bleeding and convulsions
– Nurse observes for signs of increased ICP and
convulsions
• Nurse’s observation of convulsion aids the physician in
determining the exact location of bleeding
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Head Injuries
• Description
– Falls, motor vehicle injuries, shaken baby
syndrome, bicycle injuries, etc.
– Infants and toddlers have soft skulls to absorb
impact
– By 2 years of age, both fontanels have
completely closed; impact absorption decreases
• Complications
– Hemorrhage, infections, cerebral edema (swelling
of the brain), and compression of the brainstem
– Increased ICP
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Head Injuries
• Treatment and nursing care
– ABCs (airway, breathing, circulation), assess for
spinal cord injury, document baseline vital signs
– Level of consciousness (LOC)
– Record type and amount of any drainage from
ears/nose
– Fluids are carefully monitored to control cerebral
edema
– Feeding difficulties should be noted as the child’s
diet is increased
– Patients should be observed for signs of shock
– Watch for decerebrate/decorticate posturing
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Hydrocephalus
• Description
– Increased CSF in the ventricles of the brain
• Causes increased head size, pressure changes in
the brain
– May occur along with a meningomyelocele or
as a sequela of infections, including
encephalitis, meningitis, or TORCH
• Toxoplasmosis, other, rubella, cytomegalovirus,
herpes simplex
– Can also be caused by perinatal hemorrhage
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Hydrocephalus
• Signs and symptoms
– Depend on site of obstruction and the child’s age
– Impairment of CSF absorption within subarachnoid
space (communicating)
– Obstruction of CSF flow within ventricles
(noncommunicating)
– Increase in head size
– Bulging anterior fontanel
– Separation of cranial sutures
– Shiny scalp, dilated veins
– Eyes may appear deviated downward
• “Setting sun” sign
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Hydrocephalus
• Diagnosis and treatment
– Head circumference is measured daily
– Echoencephalography, CT, MRI locate
enlarged ventricles and level of obstruction
– Ventriculoperitoneal (VP) shunt or
ventriculoatrial (VA) shunt
– Prognosis has improved with modern drugs
and surgical techniques
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Shunts have a one way valve to
prevent back pressure causing fluids
to enter the brain.
Shunts have a filter also.
Shunt malfunctions are frequently
caused by filter becoming plugged
with protein. A surgical revision then
needs to be done as quickly as
possible to prevent increased
pressure from forming.
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Hydrocephalus
• Nursing care
– The position of the infant must be changed
frequently to prevent hypostatic pneumonia and
pressure sores
– In addition to routine postoperative care and
observations, the nurse observes the patient for
signs of increased intracranial pressure (ICP) and
for infection at the operative site or along the
shunt line
– If the fontanels are sunken, the infant should be
kept flat
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Myelodysplasia and Spina Bifida
• Both categorized as neural tube defects (NTD)
• Myelodysplasia
– CNS disorders characterized by abnormal
development of the spinal cord and associated neural
tube structures
• Spina bifida (divided spine)
– Congenital embryonic NTD; imperfect closure of
spinal vertebrae
– Cause unknown; multifactorial
– Development of a cystic mass in the midline of the
spine
• Meningocele (only meninges in sac)
• Meningomyelocele (meninges and spinal cord/ nerves in sac)
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Myelodysplasia and Spina Bifida
• Treatment
– Spina bifida: surgical closure to prevent
meningeal infection
• Observe for hydrocephalus, place shunt if
necessary
• Prognosis depends on lesion location, involvement
of spinal cord, presence of other anomalies
• Habilitation
• Vesicostomy may be necessary (surgical opening
of bladder to external skin surface)
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Myelodysplasia and Spina Bifida
• Nursing care
– Objectives of extensive nursing care
• *Preventing infection of or injury to the sac
• *Correct positioning to prevent pressure on the sac and
deformities from developing
• *Good skin care, particularly if incontinent of urine and feces
• Adequate nutrition
• Tender, loving care
• Accurate observations and charting
• Education of the parents
• Continued medical supervision
• Habilitation
• (* are pre-operative but may continue post-operatively)
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Bacterial Meningitis
• Description
– Inflammation of the meninges
– Infective organisms invade via teeth, sinuses,
tonsils, lungs, directly through the ear (otitis
media), from neurological procedures, or from
a fracture of the skull
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Bacterial Meningitis
• Signs and symptoms
– Onset generally follows two courses
• Typically URI or gastrointestinal problem followed by
irritability and lethargy
• Sudden rapid onset: shock, purpura, changes in level of
consciousness, disseminated intravascular coagulation
– Other nonspecific reactions: headache, drowsiness,
delirium, irritability, restlessness, fever, vomiting, and
stiffness of the neck and spine
• Petechiae: Small hemorrhages beneath the skin
• May have high-pitched cry, bulging tense fontanel
– Convulsions are common
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Bacterial Meningitis
• Treatment
– Spinal tap at first indication of meningitis
– Isolation is used until the patient has received
at least 24 hours of antibiotic therapy
– Antibiotics are given in combination and are
adjusted on the basis of culture and sensitivity
reporting
– Dilantin may also be necessary if the child is
having seizures
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Bacterial Meningitis
• Nursing care
– Frequent monitoring of the patient’s vital signs is
necessary
– Fever may be controlled with the use of antipyretics,
sponge baths, and a hypothermia blanket
– The patient’s intake and output are carefully observed
and recorded
– Syndrome of inappropriate antidiruetic hormone
(SIADH)
• Determined by weight, serum electrolytes, serum and urine
osmolarities
• Treated by fluid restriction
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Encephalitis
• Description
– An inflammation of the brain parenchyma
• Typically more severe than bacterial meningitis
– Can be caused by arboviruses, enteroviruses,
and herpes virus types 1 and 2
– Can be aftermath of upper respiratory tract
infections, measles, an untoward reaction to
vaccinations, lead poisoning
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Encephalitis
• Signs and symptoms
– Headache followed by drowsiness, may
proceed to coma
– Convulsions occur, particularly in infants
– Fever, cramps, abdominal pain, vomiting, stiff
neck, delirium, muscle twitching, and
abnormal eye movements are other
manifestations of the disease
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Encephalitis
• Treatment and nursing care
– Corticosteroids/immune globulin
– Acyclovir for herpes virus encephalitis
– Parenteral antibiotics until bacterial cause is ruled
out
– Sedatives, IV fluids, seizure control, monitoring
for increased intracranial pressure
– Antipyretics as ordered, seizure precautions
instituted
– Oxygen as needed, mouth and nose kept free of
mucus
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Question 12.2
Which is typically more severe?
A. Encephalitis
B. Bacterial meningitis
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Seizure Disorders
• Febrile seizures
– Occur in association with a rapid increase of
temperature
– Are a common pediatric neurological disorder and
are generally transient in nature
– They usually occur between the ages of 6 months
and 5 years and are common in toddlerhood
– Generally, the parents are educated on fever
management and seizure precautions, although
fever management (such as administering
acetaminophen) does not typically reduce the risk
for a seizure
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Seizure Disorders
• Epilepsy
– Recurrent paroxysmal attacks of
unconsciousness or impaired consciousness
• May be followed by alternating contraction and
relaxation of the muscles or disturbed feelings/behavior
– Disorder of the CNS in which the neurons or
nerve cells discharge in an abnormal way
– Idiopathic epilepsy: unknown cause
– Symptomatic epilepsy: cerebral abnormality is
found
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Epilepsy
• Signs and symptoms
– Vary according to seizure type
• Convulsive seizures
– Tonic phase, clonic phase, postictal state
– Abrupt onset preceded by aura; dizziness, visual
images, nausea, headache, or abdominal discomfort
– Status epilepticus: series of convulsions, typically caused
by withdrawal of anticonvulsants
• Nonconvulsive seizures
– Could be lapse in consciousness, loss of muscle tone,
distorted sensations, automatisms
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Epilepsy
• Treatment and nursing care
– First aid for a convulsive seizure includes protecting the
child from harm, loosening clothing around the neck,
turning on the side to maintain an airway, reassuring the
child when consciousness returns
– Seizure precautions in the hospital setting include padding
side rails and having oropharyngeal suction, oxygen, and
an oral airway at the bedside
– Anticonvulsants
– A ketogenic diet* is sometimes prescribed for children
who do not respond well to anticonvulsant therapy
– Surgery is considered with intractable seizures not
responding to medication
* see ‘1st do no harm’ with Susan Sarandon
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Meds used to suppress seizures; not abortive meds
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Reye’s Syndrome
• Description
– A pediatric disease characterized by a nonspecific
encephalopathy with fatty degeneration of the viscera
and altered ammonia metabolism
– Triggered by a virus, particularly influenza or varicella
– Patients noted to have taken aspirin before symptoms
• Signs and symptoms
–
–
–
–
Typically recovering from URI or chickenpox
Recuperation interrupted by general malaise
Sudden onset of persistent vomiting and lethargy
Diagnosis based on history, symptoms, laboratory
data
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Reye’s Syndrome
• Treatment and nursing care
– Admission to ICU
– Medications include osmotic diruetics,
sedatives, barbiturates
– Fluid management in conjunction with
treatment of increased intracranial pressure
(ICP) is crucial
– Nursing care similar to increased ICP with
greater awareness of respiratory status
– Most survivors recover completely
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Near-Drowning
• Signs and symptoms
– Prognosis affected by length of submersion,
physiologic response, exposure to hypothermia
– Hypoxia is the primary problem (Hypoxic ischemic
encephalopathy)
– Pulmonary edema (osmotic fluid shift), pneumonia
• Treatment and nursing care
–
–
–
–
On-site CPR
Immediate transportation to a trauma facility
Intensive pulmonary care
Risk of cerebral edema and anoxia
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Overview of Cognitive and Behavioral
Disorders
• Developmental disability: any
mentally/physically disabling condition that
begins in childhood and is expected to continue
throughout life
• Intellectual disability (mental retardation):
significantly below-average score on a test of
mental ability, limited function in daily life
• American Association on Intellectual and
Developmental Disabilities (AAIDD)
– Emphasizes both intelligence functioning and
adaptive behavior as criteria for disability
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Overview of Cognitive and Behavioral
Disorders
• Signs and symptoms
–
–
–
–
–
–
–
–
–
–
Failure to suck
Feeding difficulties
Spasticity
Convulsions
Listlessness, irritability
Floppy, hypotonic
muscles
Decreased alertness
Unresponsive to eye
contact
Unusual clumsiness
Jaundice
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–
–
–
–
Unusual-looking stools
Unusual odor to urine
Enlarged tongue
Asian appearance in
white infants
– Stubby fingers or toes
– Failure to achieve
developmental
milestones (smiling,
rolling over, sitting, etc.)
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Overview of Cognitive and Behavioral
Disorders
• Treatment and nursing care
– Be mindful that pace of development is slower
– Learn by habit formation; routine, repetition, relaxation
– Any progress that has been made at home should not be
allowed to slip during hospitalization
– Like other children, set firm, consistent limits on behavior
– Situations become more complicated as the child
develops physically but still requires constant supervision
– Nurses should familiarize families with community
resources; i.e., The Arc
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Attention Deficit/Hyperactivity Disorder
• Description
– Refers to specific patterns of behavior that include
inattention and impulsivity and might or might not
involve hyperactivity
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Attention Deficit/Hyperactivity Disorder
• Signs and symptoms
– DSM-IV-TR criteria identifies three major patterns
of ADHD
• Predominantly inattentive type
• Predominantly hyperactive-impulsive type
• Combined
– For ADHD diagnosis, symptoms must
•
•
•
•
Persist for at least 6 months
Appear before the age of 7 years
Be identified in more than one setting
Cause significant impairment in psychosocial or
educational adjustment and functioning
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Attention Deficit/Hyperactivity Disorder
• Signs and symptoms (continued)
– Inattentive to details, careless with schoolwork or
other activities
– Has difficulty organizing tasks
– Is unable to sustain attention for periods of time that
would be appropriate for age
– Does not listen, follow instructions, or complete tasks
– Avoids activities and games that require concentration
– Is easily distracted and fidgety; has difficulty
remaining seated and appears to have excessive
energy
– Is forgetful, loses things
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Attention Deficit/Hyperactivity Disorder
• Treatment and nursing care
– The specific medications used for the
treatment of behavior problems in ambulatory
patients are listed in Table 20-1
– Dietary modification (particularly eliminating
food additives, such as preservatives and
artificial flavors and colors) and the use of
megavitamins
– Behavior therapy
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Down Syndrome
• Signs and symptoms
– Close-set and upward-slanting eyes, small head,
round face, flat nose, mouth breathing, and a
protruding tongue that interferes with sucking
– The hands of the baby are short and thick, and
the little finger is curved
– Simian crease
– Undeveloped muscles (hypotonia) and loose
joints enable the child to assume unusual
positions
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Down Syndrome
• Nursing care
– Early infant stimulation enables children with
Down syndrome to reach milestones as
rapidly as possible
– The nurse should become familiar with
services located in and near the community
– Allowing parents to become involved in care
and planning for the infant from the start
facilitates bonding
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Autism
• A complex developmental disorder of the
brain, most likely caused by abnormalities
in brain structure or function
• Affects social interaction, language, and
communication, as well as behavior
• Typically appears in the first 3 years of life
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Autism
• Autistic children do not interact well with
others; they prefer to be alone
• They may play with toys in an unusual
manner and live in their “own little world”
• Often there is some degree of mental
retardation
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Deafness
• Description
– Hearing loss falls into two major categories
• Sensorineural hearing loss results from damage to
the structures of the inner ear or auditory nerve
• Conductive hearing loss occurs due to an
interruption in the transmission of sound waves
(from structural problems) from the external or
middle ear
– Some children have mixed hearing loss,
which combines conductive and sensorineural
causes
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Deafness
• Signs and symptoms : Infant does not….
– Startle with sudden loud sounds
– Turn his or her head toward a sound by 3 or 4
months
– Begin babbling by 6 months of age
– Respond by reacting to music around 8
months of age
– Attempt to speak syllables such as “da” by
around age 1 year
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Deafness
• Treatment and nursing care
– The auditory brainstem response (ABR) and
the otoacoustic emissions (OAE) provide
identification of infants with hearing losses
– Audiometry—the measurement of hearing
with an audiometer
– Tympanogram—measures the movement of
the eardrum in response to sound waves
– Nurses should stress the importance of
placing NO objects into the ear canal
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Deafness
• Treatment and nursing care (continued)
– Lip reading, sign language, writing, closed
captioning (on television), computers, visual
aids, music, and amplified sound are some
means of communication
– Flashing lights on the telephone and doorbell,
hearing aid dogs, and telecommunications
devices can facilitate communication
– Hearing aids and cochlear implants can boost
hearing
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Amblyopia
• Description
– A decrease in or loss of vision, usually in one eye
– The vision loss is not caused by structural eye damage but
results from the brain “turning off” confusing visual images
– (brain turned off eye input so eye ‘ambles around’ because
it is not used to see)
• Signs and symptoms
– An observant parent might notice that the child sits closer
to the television or appears to have difficulty seeing
• Treatment and nursing care
– Glasses for significant refractive errors (hyperopia,
myopia) and occlusion of the unaffected eye are used
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Strabismus
• Description
– Ocular misalignment; a condition in which the
child is not able to direct both eyes toward the
same object (muscles do not align eye to
focus on object)
– Most children with strabismus have esotropia,
or an inward deviation of one or both eyes;
some children have exotropia, which is
outward turning
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Strabismus
• Signs and symptoms
– Malalignment during the uncover/cover tests
• Uncover test: Eye is covered, child looks at a light
source; a quickly uncovered eye should not move
• Cover test: one eye is covered, movement of the other
is observed while looking at a distant object
• Treatment and nursing care
– Eye exercises and glasses
– Occlusion therapy
– Surgery is reserved for patients in whom
nonsurgical methods are likely to be unsuccessful
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