Transcript Neurological system

Dr. Manal Al-kloub
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Neurological disorders results from: Congenital
anomalies, acquired dysfunction, infection, and
trauma
Major causes of neurological damage are
meningitis and head injuries.
Degeneration is permanent because, unlike
other tissues, neural tissue doesn’t have the
regeneration power.
Management mainly focuses on: help the child
accommodate with the mental and physical
dysfunction, making child comfortable, and
support the child’s growth by ensuring helpful
environment.
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Prevention is the highest priority to ensure
healthy nervous system
Nursing can help foster prevention by:
educate about the use of helmets, provide
best/safe care when dealing with head/neck
injuries, and apply infection control measures
to decrease spread of meningitis (hand
washing …etc).
Nurses should consider short term (stop
convulsions, regain consciousness, survive
meningitis ..etc) and long term outcomes
(ability to function, paralysis …etc).
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The brain is covered by three lyres (the
meninges: dura mater, archniod, & pia mater.
Cerebrospinal fluid circulation (6 hrs): produced
in pia mater- circulate within the ventricles of
the brain & around the brain & spinal cordthen reabsorbed by the archniod layer. CSF is 5
ml in a neonate and 150 ml in an adult
Brain size is 25% of adult size at birth, and 90%
of adult size at age 5.
By 12 years of age the sutures are completely
ossified & can not be separated.
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The pediatric skull is thinner, brain is softer
due to a higher water content and less
myelination, and the subarachnoid space is
wider. These allow increased movement of the
brain within the skull, which makes the child
more susceptible to brain injury, including
hemorrhage.
Diagnostic tests:
1)Lumber puncture: to obtain CSF for culture or analysis, Side lying
position for LP. Insertion of spinal needle into subarachnoid
space between the L4-L5 lumbar vertebrae.
1. obtain 3 tubes ( 2-3 ml each); for culture (Bacteriology),
sensitivity, glucose (biochemistry) and RBCs (hematology).
2. after 30 min order the child to drink fluid
3. Supine position after L.P (Lie flat for 1 hr after procedure)
4. Assess V/S (inc. B/P with dec. Resp. and heart rates indicates
increased IC compression), puncture site, headache & LOC
5. Post-LP headache: give analgesic
Contraindications: infection @ insertion site, or raised intracranial
pressure (ICP): may draw down the brain stem compromising
cardiac and respiratory centers.
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Topical anesthetic cream (AMLA) with S/C lignocaine is used.
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Give Sugar to infant <3 months decreases anxiety .
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Position: infant
seated upright
leaning forward;
older child on his
side with arched
back
Young children need
to be held in
position not to
move.
Explain procedure to
child
Strictly Sterile
technique
CSF analysis
Category
Normal range
Abnormal
Appearance
Clear, colorless
Turbid, cloudy : infection
Red: RBCs
Cell counts
0-8/ mm3
Increase WBC count means
infection or inflammation
protein
15-45 mg/100 ml
Elevated = viral meningitis
Glucose
60-80 % of serum
glucose level
Decreased = Bacterial
meningitis
Slight increase with viral
Albumin
/Globulin
8: 1
Increase = infection
Electroencephalogram (EEG)
◦ Records the electrical activity of the brain through
a series of electrodes on the scalp.
◦ Used to diagnose and evaluate seizures disorders,
identify tumors, brain abscesses or infections and
to confirm of brain death
X-ray. ( CT .skull x-ray , & MRI )
Ultrasound (Echoencephalography): to create
images of blood vessels, tissues, and organs.
Assess brain blood flow
Glasgow Coma Scale.
ICP: Children have a smaller intracranial space hence
easy to increase ICP if volume increased.
 Monitoring using a pressure monitor inserted through
the skull, usually lasts 24-72 hrs. ICP bolt is connected
to the computer, regular readings will be taken.
Changing position in bed, coughing or sneezing,
vomiting or crying increases ICP.
Increased ICP: A sign and not a disorder
Early signs: headache, visual disturbances, nausea &
vomiting, dizziness or vertigo, infants have bulging or
firm fontanel and rapidly increasing HC
Late signs: Decrease in level of consciousness,
bradycardia, irregular respiration, and fixed dilated
pupils.
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Increased ICP occur because of: inc. CSF
volume, Blood in CSF, Cerebral edema &
tumors.
Assessment:
 History, seizure, LOC, daily tasks ,headache
 Past medical history
 Infection during pregnancy
 increased H.C greater than normal
 Bulging fontanel, close late
 High temperature & B/P, dec. Pulse & Resp.
 Projectile vomiting /Poor feeding
 Spasticity of muscle/Hypotonia
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Physical Examination Considerations
◦ Level of Consciousness (LOC): confusion,
delirium, obtunded, stupor, and coma.
◦ Motor Function: gross and fine
◦ Pupilary Function / Eye Movements
◦ Vital Signs: Respiratory Patterns
Pulse rate decreases as ICP increases
Respiratory rate is initially slow as ICP rises
then rate becomes rapid and noisy leading to
apnea
Blood pressure rises slowly / late sign is
widening pulse pressure (Systolic-diastolic)
Doll’s eye reflex (turn head of child rapidly to
the right he will normally turn his eyes to the
left): Absent if increased ICP.
-Orientation ,performance , mood ,and behavior
-Child awareness
@ 4 years know the first and last name
@ 5 years child know address
@ 8 years child complete orientation of days
Nervous system function:
1 .Cerebellar function (balance, coordination &
walking )
2 .Motor function ( muscle size ,strength, tone,
movement , & range of motion )
3. Sensory function (with closed eyes can
distinguish pain ,hot ,cold)
4. Reflex testing- (See Newborn Reflexes)
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Monitoring can be done through insertion of
catheter into different sites in the head (e.g.
intra-ventricular, subarachnoid space, intraparenchymal) connected to an oscilloscope
screen.
ICP= 1-10mmHg, >15mmHg is abnormal
ICP rises and falls normally with the influx of
blood into the head
Monitoring ICP help determine when the child
needs O2 (detect ischemia), and withdraw CSF
samples.
A child who has been diagnosed with a
condition that directly affects the
neurological system is of greater concern to
parents. They will be distressed and
frightened of their child’s prognosis(guidance
and support throughout hospitalization is
important).
* Decorticate and decerebrate postures
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Accumulation of excess cerebrospinal fluid in
the ventricles of the fetal brain which result
from impaired circulation and re-absorption
of CSF. (Normal CSF production is 20 ml/h).
TYPES OF HYDROCEPHALUS:
1- OBSTRUCTIVE OR NON-COMMUNICATING
(OBSTRUCTION WITHIN THE VENTRICULAR SYSTEM)
2- NON OBSTRUCTIVE OR COMMUNICATING
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(MALFUNCTION OF ARACHNOID VILLI
 S/S: Bulging anterior fontanels; Eyes deviated
downward “Setting” Sun sign, irritable, poor feed,
vomiting, lethargy, headache
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Primary causes:
1- Congenital 1%
2- Acquired: Lesion,
tumors, infection,
intracranial bleed,
myelomeningocele
(spina bifida)
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SIGNS:
◦ ANTERIOR FONTANEL WIDE OPEN AND BULGING,
INCREASED HEAD CIRCUMFERENCE.
◦ DILATED SCALP VEINS
◦ SETTING SUN SIGN
◦ PROMINENT OCCIPUT (DANDY-WALKER)
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Clinical Therapy: Increased ICP makes head
enlargement which makes brain damages
(death if remains untreated).
Medications: ACETAZOLAMIDE, FUROSEMIDE
Surgical: V-P shunt
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V-P shunt: This is a device which drains the
extra fluid in the brain into the peritoneal
cavity where the fluid can be absorbed
◦ Early detection, Surgery is performed to shunt excess
fluid to minimize brain damage
◦ Promote family support
◦ Shunt placement requires threading of drainage
catheter into peritoneum through abdominal incision.
Aim: Placement of shunt to drain CSF from the
ventricles to another part of the body.
Dx: Risk for infection R/T presence of mechanical
drainage system (shunt).
Nursing care:
 frequent neurologic assessments (mental, cognitive,
motor and sensory functioning) and monitoring for
infection, IV prophylactic antibiotics. [S/S: fever,
lethargy, irritability, redness along shunt device
system, abdominal discomfort, or apnea].
 monitor for fluid leak from the incision
 patient will complain of postural headaches while
sitting up, but that resolves when lying down.
 should be encouraged to lead as normal a life as
possible
 feeding through a naso-gastric tube until bowel
sounds return, then fluids can gradually be
introduced. Should be held when fed.
 Observe for increased ICP S/S.
Neural tube abnormalities
 Examples: Anencephaly and spina bifida
 Genetic and environmental factors involve in
their etiology (Folic acid deficiency)
 Risk is increased when a previous child has
been affected
 Affects more girls than boys
 A surviving affected girl who become pregnant
has a 1 in 30 chance of bearing a child with
NTD
 Diagnosis: Alpha-fetoprotein screening,
termination of the affected fetuses reduce the
incidence
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is a fatal birth defect that happens when
there is absence of cerebral hemispheres. As
a result, part of the skull and brain are
missing. Babies with anencephaly die before
or shortly after birth.
Spina Bifida: Failure of osseous spine to close. Vertebral
column fails to close during intrauterine development.
Two types:
1) Spina bifida occulta: Not visible externally.
2) Spina bifida cystica: Visible defect with a Sac-like
protrusion; Two types:
a) Meningocele: Sac contains meningies and spinal fluid
but no neural elements (with no neurologic defects).
No paralysis because spinal cord is not involved.
b) Myelomeningocele: Clinically is called “spina bifida”.
Sac contains meningies, spinal fluid, and nerves.
Extent of paralysis depends on the location of the
defect. If below 2nd lumber Flaccid paralysis of lower
extremities and Sensory deficit occur.
With small sacral lesion no loss of mobility, but urinary
and fecal incontinence results because the nerve supply
to the bladder and sphincters mechanisms is impaired.
Medical Management
 Same day surgery: correct defect, minimize
complications, and prevent infection. Early closure (1272hrs) after birth prevent stretching of other nerve roots.
 In myelomeningocele, closure of the back is
recommended
 Folic acid supplements 4mg PO with future pregnancies
DX: Potential for complications (injury,
infection, bleeding, trauma, impared skin
integrity) R/t fragile spinal lesion
Interventions:
 Prevent injury, infection, or rupture of the sac
(it can lead to death)
 Apply sterile moist dressing on sac until
surgery to maintain moisture
 Position on back to prevent pressure
 Encourage parents to become involved with
infant care
Inflammation of meningies causes engorged cerebral
vessels causes cerebral edema, increased ICP, and
neurological deterioration
Meningitis: Highly incident in children <24 month, and
common in winter. Meningitis can kill in less than 24
hours or lead to permanent disabilities such as brain
damage
Assessment (S/S):
1.
Irritable (seizure) with high
temperature/chills/headache
2.
Nuchal (back of the neck)/spinal rigidity (Positive
Brudzinskis & Kernig's signs)
3.
Bulging Fontanels/poor feeding/projectile vomiting
4.
High-pitched cry or lethargy
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Kernig Sign: Raise
child’s leg with knees
flexed, then extend
leg at the knee. If
child becomes
resistance or in pain:
+ve sign.
Brudzinski Sign: Flex
the head while Child
in a supine position. If
involuntary flexion of
knees occur it is +ve
Brudzinski sign
Causes:
A-BACTERIAL
1. Neisseria
2. Meningococci
(Highly contagious)
3. Pneumococci (rare)
3. Group-B-beta
Streptococcus
4. Hemophilus
influenza (Most
common)
B-VIRAL
* Complications:
1. Deafness
2. Blindnesss
3. Facial paralysis
4. Hydrocephulus
5. Petechial rash in
meningococcal
infection
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Isolation precautions/quiet environment
Antibiotics agents (cephalosporins)
Dexamethasone (Steroid: anti-inflammatory)
Hydration/IV fluids
Antiepileptic drugs (phenobarbital, valproic
acid, carbamazepine [tegretol]).
Safety environment
Observation of vital signs, neurologic signs,
urinary output
Vaccines against the most common form of
meningitis are available.
CP is a group of disorders affecting body movement,
balance, and posture. It is abnormal development or
damage in one or more parts of the brain that control
movement. However, the exact cause is unknown.
Factors/Groups at risk:
A. Prenatal:
1. LBW (low birth weight)
2. birth injury
3. intrauterine anorexia
4. placenta disorder
5. drug administration or nutrition disorder during
pregnancy .
B. Perinatal: breech presentation
C. Postnatal: Infection
Types of C.P:
1. Spastic type (pyramidal): Increased muscle
tone (hypertonic muscle, abnormal reflex, Arch
their back, and scisors gait )-70-80% of cases.
2. Dyskinetic (extra-pyramidal):
a- Athetoid type (abnormal involuntary
uncontrolled and slow movements, make every
thing slow, difficult swallow and diet )
b- Ataxic type (wide based gait - fine
coordination motion disorder- failed to
perform finger-to-noise: affects balance and
coordination, difficulty with quick movements)
3. Mixed type (combination of spasticity &
athetosis)
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Infants with cerebral palsy are usually
slow to reach developmental
milestones such as rolling over, sitting,
crawling, and walking.
Problems often linked to cerebral palsy:
Mental retardation, seizures, learning
disabilities, incontinence problems,
skeletal deformities, eating difficulties,
and hearing and vision problems
Assessment :cognitive disorder, recurrent
seizures, sensory and motor disorders
* Management:
1. Medication to decreased spasticity
(Dantrolene; a muscle relaxant)
2. Physical therapy/Passive & active muscle
exercises
3. Self-care daily (dressing, bathing, toileting,
& feeding)
4. Speech therapy
Seizures: are periods of abnormal electrical discharges
in the brain that causes involuntary movements as
well as, behavioral & sensory alteration
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B)
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Acute/Non-recurring (provoked by stimuli)
(i) with fever: febrile convulsion, infections e.g.
meningitis, encephalitis. (MMR vaccine).
(ii) without fever: poisoning including medicinal
overdose, metabolic disturbance e.g. hypoglycaemia,
hypocalcaemia and electrolyte imbalance, head
injury, brain tumour, emotional stress, anxiety.
Chronic/Recurring :
(i) without fever: epilepsy (a chronic disorder
characterized by recurrent, unprovoked (idiopathic)
seizures secondary to CNS disorder).
Status Epilepticus: More than thirty minutes of
continuous seizure activity, or recurrent seizures
without intercurrent recovery of consciousness
Partial or focal seizures: electrical activity in one
hemisphere or area of the cerebral cortex.
results in localized symptoms.
 Generalized/Tonic-clonic: result from a diffuse
electrical activity that begin in the hemispheres
& spread throughout the cortex into the
brainstem. Hence the movements & spasm are
bilateral & symmetric.
* Seizures increase in the metabolic rate, leading
to cyanosis, paleness & hypoglycemia (length of
the seizure is vital)
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Stages of seizures:
1-the Aura: an olfactory or visual
sensory sensation as an early warning
sign of seizure.
2-tonic phase: muscles are contracted
while patient is unconscious.
3-clonic phase: involves periods of
contractions & relaxations.
4-the postictal period: after the seizure
where the patient's LOC is decreased.
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Treat underlying cause
 Antiepileptic medication
(Phenytoin or Carbamazepine tablets)
-Check blood medication level
-The doses need to be increased as child
grows
-CBC, LFT, KFT are monitored frequently
-If child on anticonvulsants for 2 years &
with no risk factor gradual decrease of dose
until discontinue is allowed
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Safety measures during an attack:
-ease child to the floor immediately
-place child on side
-suctioning
-V/S
Other measures:
1. Side rails raised & padded (precaution)
2. Monitor for electrolytes, glucose, blood
gases, & abnormal blood pressure.
3. Family support & teaching
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It is the most common seizure disorder
during childhood. Usually generalized
seizures occur in children with high grade
fever >39C but without evidence of
intracranial infection. It involves tonic-clonic
movements and lasts a few seconds to 15min. Simple febrile seizures are the most
common form.
Age dependent and are rare before 9 months
and after 5 yrs of age.
A strong family history of febrile convulsions.
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No anticonvulsant therapy is administered.
A careful search for the cause of the fever.
Use of antipyretics.
If severe, control seizure with IV or rectal
diazepam (anti anxiety, CNS depressant)
Reassurance of the parents.
If febrile seizure lasts more than 5 minutes,
parents should seek medical help immediately
Ineffective breathing patterns.
 Ineffective airway clearness.
Intervention: Maintain airway patency by
positioning child on the side to drain
secretions, O2 therapy
 Risk for trauma
Interventions: Ensure safety and protect from
injury by padding side rails, stay with
patient until seizure stops
 Anxiety ; ensure parents and teach them
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A disease of protein metabolism inherited as an
autosomal – recessive trait, characterized by the
inability to metabolize the essential amino acid
phenylalanine
The hepatic enzyme which controls the conversion
of phenylalanine to tyrosine is absent in PKU
patients
the accumulation of phenylalanine in the blood
hence urinary excretion of phenyl acids termed
“phenylketonuria”
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Accumulation of phenylalanine affect
the normal development of the brain
and CNS, and mental retardation
occurs.
Clinical manifestations: Failure to
thrive, frequent vominting, irritability,
anxiety reactions, screaming episodes,
disorientation, Failure to respond to
strong stimuli, and convulsion
Dx: diagnosing then treating the disorder
is vital to prevent mental retardation. Serum
phenylalanine levels greater than 4 mg/dl is
abnormal (after birth a heel stick is
conducted).
Treatment:
 Dietary consultation: Decrease phenylalanine in diet.
Foods high in phenylalanine : Meat and Dairy products,
Sweeteners (equal, Nutra sweet)
Foods low in phenylalanine : Vegetables, Fruits,
cereals, breads, starche
Natural food proteins contain about 15% phenylalanine
(use specially prepared milk substitutes).
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Family need to monitor phenylalanine levels
frequently
◦ Once weekly during 1st year
◦ Twice monthly from 1 – 12 years
◦ Monthly after 12 years
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Parents support (emotional + education: diet and
heel stick)
Thanks for your attention 