Transcript Neural Tube Disorders

Common Neurological Disorders in
Children

 Hydrocephalus
 Neural Tubes Defects
 Bacterial Meningitis
 Guillain-Barre Syndrome
 Reye’s Syndrome
 Seizures
Hydrocephalus

 “Water on the Brain”
 Imbalance between the production and absorption of
CSF.
 Often from congenital CNS malformations
 Results in rapid head enlargement in infants
Can lead to irreversible neurological
damage
Hydrocephalus
Symptoms in the infant

Early Signs
 Projectile vomiting not
associated with
feeding
 Scalp veins become
prominent
 Shrill, high pitched cry
 Increasing irritability
Late Signs
 Bulging anterior fontanel
 Head circumference that
increases at an abnormal
rate
 Enlargement of the
forehead
 Depressed eyes rotated
downward “sunset eyes”
(pupils sink downward)
Symptoms in the Child

 No enlargement of head (skull is closed)
 Begins with generalized neuro symptoms
 HA in morning
 Nausea
 Vomiting
 Followed by signs of increased ICP
Relief of hydrocephalus
Create a new
pathway to divert
excess CSF.
A catheter or shunt
is placed in the
ventricle and passes
the CSF to the
peritoneal cavity
Needs to be
replaced PRN
Post-op Nursing Care Shunt
Placement

Keep child flat unless ICP is present the bed
slightly elevated
Slowly increase HOB over few days
Support head when moving child
Pain management
Vital Signs
Post-op Nursing Care
Shunt Placement

 Observe for signs of increasing ICP – neurologic
assessment
 Observe for abdominal distention
 Strict I & O
 Antibiotics
 Meticulous skin care
 Support family
Discharge Management
Post Shunt Placement

 Teach parents to monitor for shunt complications:
 Headache, progressive or worsening
 Drowsiness or inappropriate sleepiness during the day,
irritability
 Nausea, vomiting
 Personality changes or changes in school performance
 Fever
 Redness or swelling along the shunt tract
Neural Tube Disorders

Defects of closure of neural tube during
fetal development
Congenital (present at birth)
Believed to be caused by genetic or
environmental factors, but exact etiology is
unknown
 Common in women with poor folic acid intake
before and during pregnancy
Neural Tube Disorders
Types:
 Spina Bifida

 Occulta
 Cystica
 Meningocele
 Myelomeningocele
Spina Bifida

Most common CNS defect
Caused by failure of neural tube to
close at some point along spinal column
Types:
 spina bifida occulta
 spina bifida cystica
Spina Bifida Occulta
Not visible
externally
Lamina fail to close
but spinal cord
does NOT herniate
or protrude
through the defect
No motor or
sensory defects
Spina Bifida Cystica
Meningocele
 External
sac that
contains meninges
and CSF
Protrudes through
defect in vertebral
column
Meningocele
Not associated with
neurologic deficit –
good prognosis
Hydrocephalus may
be an associated
finding, or
aggravated after
repair
Spina Bifida Cystica
 Myelomeningocele
 Same as above, but the
spinal cord and meninges
protrude through the
defect in the bony rings of
the spinal cord
 Contains nerves therefore
the infant will have motor
and sensory deficits below
the lesion
Myelomeningocele
Visible at birth, most
often in the
lumbaosacral area
Covered with a very
fragile thin
membrane/sac
which can tear easily,
allowing CSF to leak
out
Nursing Interventions

 Protect the sac from injury
 Keep free from infection
 Position: prone or side lying
 Cover sac with sterile, moist non-adherent dressing, sterile
technique imperative
 Parents need emotional support & education regarding
short and long term needs of infant
Nursing Interventions

Surgical repair usually within first 24
hours
observe for early signs of infection: elevated
temp, irritability, lethargy, nuchal rigidity
 observe for signs of increasing ICP (may
indicate hydrocephalus)
Habilitation

 Emphasizes constructive use of ‘normal’ parts of
body & minimizes the disabilities making the child
as self-helpful as is possible in the activities of daily
living
 Major problems: incontinence, constipation, obesity
or malnutrition
Meningitis

 Acute inflammation
of the cerebral
meninges as a
result of a bacterial
or viral infection
Bacterial Meningitis

 Haemophilus influenzae type b was the most
common cause of bacterial meningitis in children
prior to the use of the Hib conjugate vaccine
 Still may be caused by Strep pneumoniae in child <
24months as not fully vaccinated with PCV vaccine
 Meningococcal predominantly in unvaccinated
school-age children & adolescents
Symptoms
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Abrupt onset of fever
Chills
Increasing irritability
Headache
Nuchal Rigidity
Poor feeding
Weak Cry
Bulging fontanel
Opisthotonic position
Symtoms

Kerning’s Sign
Brudzinski’s Sign
Nursing Management

 Lumbar puncture
 Administer IV antibiotics
 Respiratory isolation
 Promote hydration- monitor I + O
 Frequently assess vital signs, LOC, neurologic
assessment to identify changes in the child’s
condition
 Measure head circumference frequently- risk for
hydrocephalus
 Prepare for seizures
Nursing Management

Promote comfort
• reduced stimulation (dim lights, quiet room)
Side-lying position
Identify parents’ concerns, provide support
Prevention is a major role for nurses
 Encourage parents to get their infants and
children fully immunized!
Complications

 Life Threatening Condition
 If Survival
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Hearing loss
Blindness
Paresis
Intellectual impairment
Guillain-Barre Syndrome

 Immune-mediated disease of motor weakness that is often
associated with viral or bacterial infection of respiratory or GI
tract or vaccine administration
 Adults have increased susceptibility, can affect children usually
ages 4-10
 Inflammation of nerve fibers, impairs nerve conduction though
demyleination
 Ascending paralysis from lower extremities
Initial Symptoms

Peripheral neuritis occurs several days after
primary infection
Muscle tenderness
Tendon reflexes decreased or absent
Paresthesia & cramps
Proximal symmetric muscle weakness
Urinary incontinence or retention
Decreased swallowing & respiratory effortsmay lead to respiratory failure
Treatment

 Wait for disease to stabilize
 Intravenous immune globulin IVIG
 Physical Therapy
 Rarely fatal, often residual paralysis
Nursing Care

 Monitoring respiratory status
 Managing autonomic nervous system dysfunction
 Preventing complications associated with immobility
 Providing emotional support
 Teaching the parents how to care for the child after
discharge
Reye’s Syndrome

 A life threatening acute encephalitis
 Occurs after viral infection if given aspirin
 Education efforts has helped to reduce
incidence (use Tylenol or Ibuprofen not ASA)
Reye’s Syndrome

 Begins with mild viral infection that worsens w/i 2448 hours
 Lethargy
 Vomiting
 Followed by
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Agitation
Anorexia
Combativeness
Confusion leading to stupor, coma, seizures, respiratory
arrest
Reye’s SyndromeNursing
Care

If Survival in PICU
Monitor:
 Neurological status
 Respiratory effort
 Hypoglycemia
 Cerebral edema
Seizures

 Involuntary contraction of muscle caused by
abnormal electrical brain impulses
 They are episodic and abrupt
 Often triggered by environmental of physiological
stimuli
 Exact location of the electrical foci and the number of
brain cells involved determines the nature of the
seizure (sterotypical)
 Some seizures in children are acute, not believed to
re-occur
 Re-ocurring seizures will be diagnosed as epilepsy
Seizures: 2 categories

Partial
 Simple
 Complex
 Only 1 area of brain
involved
 Symptoms are
associated with the area
affected
 No LOC or
consciousness is
impaired
Generalized

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Infantile spasms
Febrile
Absence
Tonic Clonic
 Entire brain
 Usually have loss of
consciousness
 May have aura
 Postical State
Seizure Terms

 Aura
 sensation experienced before the seizure activity
 it often manifests as the perception of a strange light,
an unpleasant smell or confusing thoughts or
experiences
 Postictal
 altered state of consciousness that a person enters after
the seizure, lasts between 5 and 30 minutes
 emergence from this period is often accompanied by
amnesia or other memory defects
Simple Partial Seizures
Complex Partial Seizures
Simple Partial Seizures

• Seizure is short, lasts < 30 seconds
• No loss of consciousness, aura, or postical state
Seizure Activity is either:
Abnormal motor activity
•
One extremity or part of extremity, uncontrolled movement
Abnormal sensory activity
 Numbness, tingling, paresthesia or pain starting in 1 area of
body, may spread to other parts of body
 May include abnormal auditory, olfactory and visual
sensations
Complex Partial
Seizures

 Seizure is longer, 30 seconds-5 minutes
 Consciousness is impaired immediately
 May have slight aura
Seizure Activity
 Sudden change in posture
 Abnormal motor activity, twitching, loss of tone, tingling or
numbness
 Automatisms-lip smacking, chewing, sucking
 Circumoral pallor
 Afterward: drowsiness
Infantile spasms
Absence
Tonic Clonic
Febrile
Infantile Spasms
 Age: 4 months to 2 years
 Occur in clusters 5-150/day, worse at night
 Altered consciousness
 Abrupt flexion/extension of neck, trunk, extremities
 Eye rolling
 May have permanent cognitive & developmental
delays

Absence Seizure
 Lasts 5-10 seconds, multiple
times a day 50-100 per

day
 Seizure is a brief loss of consciousness
 Appears to look like a staring spell
 Rhythmic blinking & twitching of mouth or arm
 Mistaken for daydreaming or behavior problems
 Interferes with learning
 1/3 of children will grow out of them by adolescence
Tonic Clonic
4 stages of Seizure

1. Prodromal:
Drowsiness, dizziness, malaise, lack of
coordination, “not himself”
2. Aura
May precede seizure, reflects portion of brain
where seizure originates
Tonic-clonic stage
3. Tonic-Clonic
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Tonic: 20 seconds, all muscles cx (rigid), child
falls to ground, LOC, respiratory muscles
affected, grunting, airway compromised
Clonic: 20-30 seconds, jerky muscle contract
& relax rapidly, froth or bloody sputum,
urinary or bowel incontinence
4. Postictal Appears to relax, semi-conscious,
sound sleep for hrs, no recollection of event
Acute Febrile Seizure

 Due to increased temperature
 > 102 F (but may occur as low as 100 F)
 Higher fever=higher risk
 Occur between 6 months and 5 years, with a peak
incidence between 18 and 24 months of age
 Tonic-clonic pattern
 Lasts 15-20 seconds
Epilepsy

 Chronic disorder with recurrent seizures in children
3 and older
 Symptoms depend on type of seizure
 No association with illness, injury
 Seizure may be triggered by something
Epilepsy Management

Anticonvulsants-monotherapy
is
desired
Dosage increased as child grows
Control the seizures or reduce
their frequency
Discover and correct the cause
when possible, know triggers
Help child live a normal life
Epilepsy Management

 Instruct parents on importance of giving meds to
achieve therapeutic drug levels
 Med can be withdrawn when child is seizure free for
2 yrs with normal EEG
 TAPER! Gradually decreased over 1-2 weeks
Triggers

 Changes in dark-light patterns
 Sudden loud noises, specific voices
 Sudden or startling movements
 Extreme changes in temperature
 Dehydration, fatigue
 Hyperventilation
 Hypoglycemia
 Caffeine, insufficient protein in diet
If A Patient is Admitted for
Seizure Activity or has PMH of

Seizures
 Ensure IV access and Patency
 Check MD orders for Seizure Medication
 Check that medication is on the Unit
 Check Suction at bedside, ambu bag, mask and 02
tubing, SaO2 is available and working!
 Are Side Rails Padded?
 ID band- correct? Indicate Seizure Risk?
 Know how to initiate emergency or rapid response
Nursing Management
during Seizures

1. Maintain Patent Airway
 Place nothing in the child’s mouth during a seizure
 Loose teeth may be knocked out and aspirated.
 Position side so secretions can drain
 Pulse oximetry reading (SpO2)
 Oxygen for < 95%- use mask
 Suction prn
Nursing Management
during Seizures

Ensure Safety
• If OOB gently assist to floor
• Bed in lowest position
• Stay near child
• Protect head from injury
Nursing Management
during Seizures

Administer Mediation
 Initial order is intravenous medications
 IV push slowly
 Benzodiazopene IV push slowly to avoid apnea
 Diazepam (Valium) or lorazepam (Ativan)
 Followed by anticonvulsant
Nursing Management
during Seizures

 Observe and Record
 Type of seizure activity
 Vital Signs
 Time seizure started and stopped
Dilantin
Toxicity: nystagmus, ataxia, decresed mental
capacity

Low levels: seizure activity
Side Effects gingival hyperplagia (discuss
oral hygiene), drowsiness, thrombpcytopenia,
leukopenia, increased liver enzymes
Nursing responsibility:
 Monitor CBC, LFT, therapeutic drug levels
A 10-year old is diagnosis is Guillain-Barre
Syndrome. It would be imperative for the
nurse to inform the physician after
observing which of the following?

1.
2.
3.
4.
Weak muscle tone in the feet
Weak muscle tone in the legs
Increasing hoarseness and cough
Tingling in the hands
A 4-year-old is being evaluated for hydrocephalus. The
nurse notes which of the following as an early sign
of hydrocephalus in a child?

1.
2.
3.
4.
Bulging fontanels
Rapid enlargement of the head
Shrill, high-pitched cry
Early morning headache
A child with a history of a seizure was admitted
2 hours ago. The history indicates fever,
chills, and vomiting for the past 3-4 hours.
In report the nurse is told that the child had
a positive Brudzinski’s sign. The nurse
infers this is most likely caused by:

1.
2.
3.
4.
Increased intracranial pressure
Meningeal irritation
Encephalitis
Intraventricular hemorrhage
A nurse is assessing a new admission. The 6-month-old
infant displays irritability, bulging fontanels, and
setting-sun eyes. The nurse would suspect:
1.
2.
3.
4.
Hydrocephelus
Hypertension
Skull fracture
Myelomeningocele

An 8-year-old client with a ventriculoperitoneal
shunt was admitted for shunt malfunction.
He presents with symptoms of increased
intracranial pressure. The mechanism of the
development of his symptoms is most
probably related to:

1.
2.
3.
4.
Increased flow of CSF
Increased reabsorption of CSF
Obstructed flow of CSF
Decreased production of CSF
 The nurse is taking a history of a child admitted for
EEG testing to determine seizure activity. The parent
reports that the child has “odd” behavior, including
periods of lip smacking, and muscle twitching. The
nurse suspects:
1. Simple Partial Seizures
2. Complex Partial Seizures
3. Absence Seizures
4. Tonic-Clonic Seizures
