Transcript Neurological Disorders in the Pediatric Patient

Neurological Disorders
in the Pediatric Patient
Presented by Marlene Meador RN, MSN
Neurological System of
Children

Top Heavy
 Cranial bones- thin, not well developed
 Brain highly vascular with small
subarachnoid space
 Excessive spinal mobility
 Wedge-shaped cartilaginous vertebral
bodies
Etiology and Pathophysiology
Altered Mental Status
Mnemonic = Mitten
Metabolic
Infections
Toxins
Trauma
Endocrine
Neurological/Neoplasm
Neurological Assessment

Vital Signs
 Eyes
 Behavior
 Respiratory Status
 Motor Function
 Skin
 Children’s Coma Scale
Assessment:
Infant

Irritability and restlessness
 Full to bulging fontanelles
 Increase in FOC
 Poor feeding, poor sucking, projectile
vomiting
 Distension of superficial scalp veins
 Nuchal rigidity and seizures (late signs)
Assessment:
Child early signs
Irritability, lethargy
 Sudden change in mood
 Headache
 Vomiting
 Ataxia
 Nuchal rigidity
 Deterioration of cognitive ability
Assessment Child:
Late signs

Changes in Vital signs
 Seizures
 Photophobia
 Positive Kernig’s sign
 Positive Brudzinski’s sign
 Opisthostonos
Therapeutic Intervention
Nursing care
Medications
 Corticosteroid (decadron)
 Osmotic
diuretic (Manitol)
Nursing Care

Minimize activity
 Monitor IV rate
 Place in semi-fowlers
 Monitor VS, Neuro VS, and behavior
 Treat for pain
 Organize care
 Educate parents
Critical Thinking
What would you expect as a first sign of
IICP in an infant?
What would you expect as an initial sign
of IICP in a 10 year old child?
Meningitis
Bacterial Meningitis
Vs.
Viral Meningitis
Bacterial Meningitis
Potentially Fatal
Viral Meningitis
Same signs and symptoms, may be
milder and self-limiting. Usually
lasts a few days
Assessment
Infants & Young Children
 Fever not always present
 Lethargy
 Alterations in sleep and feeding
habits
 Nuchal rigidity (late sign)
Assessment:
Childhood & Adolescence
 Hyperthermia
 S&S
of IICP
Complications of Meningitis

IADH
 Intravascular coagulation with
thrombocytopenia
 CSF obstruction
 Nerve Damage
Diagnostic Tests:


Lumbar Puncture
Serum Glucose Level

Blood Cultures
Therapeutic Interventions
Mediation Therapy
Antibiotics
Ampicillin
Claforan
Rocephin
Nursing Care

Assess
 Antibiotic therapy
 Monitor lab values
 Strict I&O
 Isolation
 Monitor FOC
Nursing Care cont...

CSF culture
 Temperature control
 Seizure activity
 Environment
 Planning
 Education
Hydrocephalus
Hydro= Water
Cephaly= of the head/brain
Etiology and Pathophysiology:

Congenital anomalies


Trauma
Unknown causes
Types of Hydrocephalus

Non-communicating or Obstructive

Communicating
Clinical Manifestations

1.
2.
3.
4.
5.
Infants- prior to fusion of cranial sutures
FOC
Changes in assessment of skull
Forehead
Eyes
Behavior changes
Clinical Manifestations

After closure of cranial sutures:
1.
Eyes
S & S of IICP
2.
Diagnostic Tests

LP
 MRI/ CT scan
 Skull X-ray
 FOC
 Transillumination
Interventions:
Surgical

Shunting to bypass the point of obstruction
by shunting the fluid to another point of
absorption
Complications of Shunts

Infections

Blocked shunts

Seizures
Nursing Interventions








Monitor VS and neurological status
Assess functioning of the shunt
Assess operative site
Assess for infection
Positioning of the patient
Activity of patient
Promote nutrition
Education
Critical Thinking

What is the most important assessment data
on a child who has just had a shunt
placement for hydrocephalus?

What is the most important teaching for the
parents or caregivers?
Spina Bifida
Most common defect of the CNS
Occurs when there is a failure of the osseous
spine to close around the spinal column.
Clinical Manifestations:

Visualization of the defect
 Motor sensory, reflex and sphincter
abnormalities
 Flaccid paralysis of legs- absent sensation
and reflexes, or spasticity
 Malformation
 Abnormalities in bladder and bowel
function
Diagnostic Tests:
Prenatal detection

Ultrasound
 Alpha-fetoprotein
Following Birth:

NB assessment
 X-ray of spine
 X-ray of skull
Surgical Intervention

Immediate surgical closure

Prior to closure keep sac moist & sterile

Maintain NB in prone position with legs in
abduction
Nursing Interventions:
Pre-OP:
 Place in prone position
 Sterile moist dressing with normal saline or
antibiotic solution
 Maintain proper abduction of legs and alignment
of hips
 Meticulous skin care
 Protect from feces or urine
 Keep in isolette
Post-Op Nursing Interventions

Assess surgical site
 Monitor VS and neuro VS
 Institute latex precautions
 Encourage contact with parents/care givers
 Positioning
 Skin Care
Nursing Interventions cont...

Antibiotic therapy
 Prevent UTI
 Education
 Emphasize
the normal, positive
abilities of the child
Critical Thinking

Would you expect a 5-year-old with
meningomyelocele to have bladder/bowel
sphincter control?

Which type of neural tube defect is most
likely to have no outward signs or
symptoms?
Cerebral Palsy (CP)

Static Encephalopathy- spastic CP most
common type (80%)
– Nonspecific term give to disorders
characterized by impaired movement and
posture
– Non-progressive
– Abnormal muscle tone and coordination
Assessment

Jittery (easily startled)
 Weak cry (difficult to comfort)
 Experience difficulty with eating (muscle
control of tongue and swallow reflex)
 Uncoordinated or involuntary movements
(twitching and spasticity)
Assessment cont...

Alterations in muscle tone
– Abnormal resistance
– Keeps legs extended or crossed
– Rigid and unbending

Abnormal posture
– Scissoring and extension (legs feet in plantar
flexion)
– Persistent fetal position (>5 months)
Diagnostic Tests:

EEG, CT, or MRI
 Electrolyte levels and metabolic workup
 Neurologic examination
 Developmental assessment
Complications

Increased incidence of respiratory infection

Muscle contractures

Skin breakdown

Injury
Goals & Interventions:
Early detection
Mental Retardation
“Significant sub average, general intellectual
functioning existing concurrently with
deficits in adaptive behavior and manifested
during the developmental period”.
American Association of Mental Deficiency
Down Syndrome
Trisomy 21- the most common
chromosomal abnormality resulting in mild
to profound mental retardation
Assessment

See syllabus
 Primary concern with cardiac and GI
anomalies

What are the most obvious indications of
Down’s Syndrome in a newborn?
Goals and Interventions

Primary focus on the parents and care givers
to provide support and achieve a realistic
view of the child’s capabilities
 Support siblings
 Refer to family counseling services
 Support parents in feelings of guilt and
chronic sorrow
Hyperfunction/Hypofunction

Pediatric Seizures
– Febrile seizures- occur as a result of rapidly
increasing core temperature (101.8 F– 38.8C)
– General seizures- occur as a result of insult of
the nervous system
Clinical Manifestations

Tonic-clonic- absence seizures, minor
motor-atonic

Partial seizures- partial simple or partial
complex
Diagnostic Tests:

EEG
 CT, MRI
 Lumbar puncture
 CBC
 Metabolic screen for glucose, phosphorus
and lead levels
Jitteriness –vs- Seizure
 Jittery
– Responsive
 Seizure
– Not responsive to
stimuli
– Gaze Okay
– Abnormal gaze
Goals:
Primary focus to identify the cause and
eliminate the seizure with minimum side
effects using the least amount of medication
while maintaining a normal lifestyle for the
child.
Interventions

Febrile seizures

Seizure precautions

During seizure activity

Education
Autism

Most severe pervasive developmental
disorder of childhood. Moderate to severely
incapacitating with lifelong developmental
disabilities

Etiology/Pathophysiology
– Cause unknown
– Possible genetic or prenatal hypoxic event
Clinical Manifestations of Autism






Developmental disturbances of verbal and social
language skills
Abnormal response to sensation/stimuli (difficulty
distinguishing self from environment)
Repetition of self-stimuli
May have savant capabilities
Does not show pain with injuries
Dependent on severity of condition
Diagnosis

Extensive and thorough interview of family
regarding behaviors
 Behaviors classically begin before age 3

Direct observation of child
Nursing Care of Hospitalized
Child with Autism
Attempt to maintain child’s daily routines
from home- very ritualistic
 Work closely with family to decrease
anxiety
 Provide for the child’s safety-particularly if
ritual self stimulation is potentially harmful
(head banging, biting)

Shaken Baby Syndrome

Intracranial & retinal bleeding

Physical abuse causing a whip-lash induced
trauma to the child’s brain
Nursing Interventions

Assessment- observe for S&S of:
– Hemorrhage to sclera
– Apnea
– Seizures
– Respiratory irregularities
– Increased intracranial pressure (ICP)
– Drowsiness or lethargy
Long Term Prognosis

Complete recovery is rare
 Mental retardation
 Cerebral Palsy
 Death
Legal Implications
Nurses must report suspected child abuse to Child
Protective Services (CPS).
It is not your obligation to prove the abuse you must
report any suspicion. CPS will document and
follow through on the case
*remember…the abuser may not be the person you
suspect, and disclosure to the wrong individual
may endanger the child.
Please contact me with any further questions.
Marlene >^,,^<
[email protected]