Transcript Care of the Pediatric Patient with Cognition or Perception Problems

CARE OF THE PEDIATRIC
PATIENT WITH COGNITION OR
PERCEPTION PROBLEMS
Elizabeth Allen RN, MSN
LEARNING OBJECTIVES
Describe the neurologic anatomic and physiologic
differences between infants and children and
adults
 Identify aspects of the pediatric neurologic
assessment including Glasgow Coma Scale and
signs of meningitis
 Identify and create a treatment plan for pediatric
neurologic infectious diseases
 Compare pediatric traumatic brain injuries for
different age groups
 Describe pediatric pain management

ANATOMIC DIFFERENCES

Brain & spinal cord



Cranial Nerves



Head to toe
Cranial bones


Present, must mature
Myelination


Intact from birth
Reflexes


Large head
Brain growth
Not complete
Head vs. chest size
Blood brain barrier
NEUROLOGICAL DEVELOPMENT
Neurological system of the infant is incompletely
developed.
 First year the neurons become myelinated.
 Myelinization occurs in a cephalocaudal and
proximodistal manner.

NEUROLOGIC ASSESSMENT
Cerebellar
Noting
Functioning
milestones
Fine and gross motor skill

Behavioral
assessment
Waking activity
Responses to environment
Social interaction

Cranial
nerves
Motor system
Head control
Reflexes
Primitive reflexes
Stepping
Tonic-Neck
Moro/Startle
Sucking

NEUROLOGIC ASSESSMENT
Brudzinski’s sign
 Kernig’s sign
 Nuchal rigidity - neck
 Photophobia
 ICP
 LOC
 Glasgow Coma Scale

Glasgow Coma
Scale
Including Pediatric
Assessment
INCREASED INTRACRANIAL PRESSURE


Increased ICP creates
decreased CPP
(Cerebral Perfusion
Pressure)
Causes





Head injury
Bleeding
Space occupying lesion
Infection
Hydrocephalus

Infant Signs & Symptoms
Fontanels (bulging)
 Sutures (widened)
 Scalp veins (dilated)
 Sunset eyes


Older child Signs &
Symptoms





Normal ICP < 20 mmHg


Headache
Nausea, vomiting
Decreased LOC, irritability
Pupil changes
Sunset eyes
Posturing
Cushing’s Triad (Late sign)
AMBLYOPIA
Amblyopia: Reduced
vision in 1 or both
eyes
 From visual
deprivation of eye
 Most often from
strabismus
 Visual assessment
and correction by age
6 years

Strabismus
NEUROLOGIC INFECTIOUS DISEASES
Bacterial Meningitis

Infant Signs &
Symptoms
Poor
feeding/suck
Vomiting
High-pitched cry
Bulging fontanel
Fever or hypothermia
Poor muscle tone
Bacterial Meningitis

Child & Adolescent Signs
& Symptoms
Abrupt onset
Fever & chills
HA
Nuchal rigidity
Vomiting
Irritability
Seizures
Photophobia/alterations
in sensorium
BACTERIAL MENINGITIS
 Nursing
Interventions
Droplet Isolation!
 Maintain patent airway, ventilation support prn
 Post-LP care
 Assessment


Increased ICP
Nutrition
 Pain control
 Monitor IV antibiotic therapy
 Monitor for complications- seizures, immobility

VIRAL MENINGITIS (ASEPTIC MENINGITIS)

Infant and Toddler
Signs & Symptoms
Irritability
Lethargy
Vomiting
Change in appetite

Children & Adolescent
Signs & Symptoms
Preceded by nonspecific
febrile illness
HA
Malaise
Muscle aches
N&V
Photophobia
Nuchal/spinal rigidity
VIRAL MENINGITIS
 Treated
symptomatically
 Hospitalized?
 Decease stimulation
 Hydration
 Comfort measures
NEUROLOGIC INFECTIOUS DISEASES
 Reye
Syndrome
Usually develops after mild viral illness
 Strongly associated with Aspirin (salicylates) use
in viral infections
 Acute encephalopathy and fatty infiltration of the
liver and other organs
 Poor liver function
 Hypoglycemia
 Prolonged Prothrombin time
 Developmental and neurologic deficits may occur

REYE SYNDROME
 Stages
Progress with decreasing LOC
1.
Vomiting and drowsiness, listlessness
2.
Personality changes: irritable, aggressive
3.
Disorientation: confusion, irrational, combative
4.
Delirium, seizures, coma, loss of deep tendon
reflexes, respiratory arrest
 Symptoms of Reye Syndrome in infants do not
follow a typical pattern
 Symptoms appear most commonly after a viral
illness

(National Reye Syndrome Foundation, 2013)
REYE SYNDROME
 Signs
& Symptoms
Abrupt change in LOC
 Vomiting
 Liver enzymes, ammonia levels elevated
 Blood sugars low
 PT prolonged
 Bilirubin remains normal
 Liver biopsy shows small fat deposits

REYE SYNDROME
 Nursing
Interventions
Monitor
ICP
Fluid restrictions
Neurological
assessments
Monitor lab values
Ammonia
Glucose
Blood gases

Provide
emotional
support
Medications
Vitamin
K
Phenytoin
Corticosteroids
Family
education
ACCIDENTS & HEAD INJURIES
Shaken baby syndrome
 Head trauma

Falls
 Child abuse
 MVA


Near-Drowning
SHAKEN BABY SYNDROME
Pathophysiology – central nervous system injury
from repeated coup and contra-coup injury
 Symptoms
 blindness or eye damage





delay in normal development
seizures
damage to the spinal cord



Retinal hemorrhage
paralysis
brain damage
death
SHAKEN BABY SYNDROME
Maintain cardiopulmonary function
 Prevent complications- Secondary Brain Injury
 Promote recovery


Maximize developmental function
Provide emotional support
 Role of Social Work
 Discharge planning and home care teaching
 Resources

HEAD INJURY
Mild to Severe
 Highest rate of death in adolescents 15-19 years,
then <5 years
 Side effects of trauma = cerebral edema &
increased ICP
 Major cause falls
 Child abuse, shaken baby syndrome <1yr.
 Other causes




MVA
Bicycle, skateboard, snowboard, skiing
Alcohol or drug-related MVAs, sports injuries in
teens
HEAD INJURY
Primary Brain Injury
Develop
at time
of trauma
Direct blow
Inc. ICP
Apnea
Loss of
consciousness
Secondary Brain Injury
Results
as
response to injury
Few hours to
weeks post injury
Inc. ICP can
result in
irreversible brain
damage by
decreased CPP
(cerebral perfusion
pressure)
HEAD INJURY
 Nursing
Interventions
Assessment
 Seizure precautions
 Decrease environment stimulus
 Coordinate rehabilitation
 Coordinate resource services
 Administer meds as ordered



Corticosteroids
Seizure medications
Fosphenytoin
 Phenobarbital


Child and Family Education
OTHER HEAD INJURIES
Skull fractures
 Contusion
 Concussion


http://www.cdc.gov/headsup/basics/index.html
Subdural hematoma
 Epidural hematoma

SEIZURE DISORDER
Most are idiopathic
 Genetic factors- associated with syndromes
 Head injury
 Stroke/cerebrovascular disorders
 Metabolic disturbances






Electrolyte
Hypoglycemia
Renal failure
Hepatic failure
Hypoxia
SEIZURE DISORDER
Chronic disorder characterized by recurrent
seizures, result of underlying brain abnormality
 Intractable seizures
 Can suffer from poor self-esteem, academic
failure, poor social relationships
 Anti-epileptic Drugs
 For some surgery may be an option to control
seizures
 Prolonged, uncontrolled seizures often result in
developmental delays, neurological damage

SEIZURE DISORDER
Priority Nursing
Diagnoses
Risk for aspiration
 Risk for injury r/t type
of seizure and possible
loss of consciousness
 Altered family
processes r/t having
child with chronic
illness

Nursing Interventions




Keep calm
A = Airway
Safety
Seizure Medications
Benzodiazepine (lorazepam,
intranasal midazolam)
 Phenobarbital
 Tegretol




Assessment
Provide emotional support
for patient/family
Resource information and
F/U
CONGENITAL NEUROLOGIC PROBLEMS

Neural tube defects
Spina bifida occulta
 Meningocele
 Myelomeningocele

Hydrocephalus
 Cerebral Palsy

SPINA BIFIDA
Congenital neural tube defect affects head and
spinal column
 Approximately 1500 births in US per year
 Higher the defect the greater the neurologic
dysfunction
 Cause unknown (possibly chemicals, medications,
maternal low folic acid levels, genetic)

SPINA BIFIDA
Pre Op Nursing Care
Sac care
 Position
 Assess motor function
 Assess bowel and
bladder function
 Nutrition/Hydration

Post Op Nursing Care
Monitor VS
 Assess

Infection
 CSF Leak
 ICP

Positions
 Pain management
 Education

SPINA BIFIDA
 Associated



Musculoskeletal

Talipes (clubfoot), dislocated hip, scoliosis, kyphosis

neurogenic bladder, hydronephrosis, renal damage, UTI,
incontinence
Genitourinary
Gastrointestinal



Hydrocephalus
cognitive deficit, visual perceptual problems, sensory
dysfunction, paralysis, muscle weakness, feeding
difficulties, swallowing problems, sleep apnea
Integumentary


constipation, impaction, incontinence
Neurologic



Problems
Skin breakdown related to immobility, incontinence
Psychosocial
Latex sensitivity/ allergy
SPINA BIFIDA
 Nursing
Interventions
Assistance with bowel and bladder function
 Promote Mobility
 Maintain skin integrity


Positioning & turning
Provide emotional support
 Resources
 Child and Family Education

HYDROCEPHALUS
Imbalance between production and absorption of
CSF
 Most common congenital defect (50%)
 Etiology

Congenital
 Acquired from meningitis, trauma, hemorrhage in
premature infant
 Idiopathic (50%)


If untreated can cause permanent brain damage
related to increased ICP
HYDROCEPHALUS
Ventriculoperitoneal
Shunt
HYDROCEPHALUS
Signs & Symptoms

All Children




Vomiting
Lethargy
Cheyne-Stokes
respiratory pattern
Infant






Inc. head circumference
Split cranial sutures
High-pitched cry
Bulging fontanels
Irritability when awake
Seizures
Signs & Symptoms

Toddlers & Older
Children








Setting-sun eyes
Seizures
Irritability
Papilledema
Decreased LOC
Inc. B/P
HA
Difficulty with balance
& coordination
HYDROCEPHALUS
Priority Nursing
Diagnoses
Altered tissue
perfusion (cerebral)
 High risk for infection
 Risk for impaired skin
integrity r/t large size
of head and inability
to move

Nursing Care


Ventriculoperitoneal
Shunt
Provide post-op care

Assess






Infection
ICP
HOB?
Antibiotic therapy
Provide emotional
support
Child and Family
Education
CEREBRAL PALSY
Non-progressive motor and posture dysfunction
secondary to anoxic damage to motor centers in
fetal or infant brain( up to 2 yrs.)
 70% prenatal (fetal), 20% perinatal, 10% <2 years
 2- 2.5:1000
 Abnormal muscle tone and lack of coordination
 4 types: spastic, dyskinetic, ataxic & mixed
 Symptoms depend on area of brain involved

CEREBRAL PALSY

All infants that show developmental delays,
feeding difficulties, abnormal muscle tone should
be evaluated


Turn infant’s head to one side, persistent asymmetric
tonic neck reflex beyond 6 mo. Indicates pathologic
condition, if any primitive reflexes persist should
suspect CP
Other complications:

Intellectual disabilities, vision impairment, hearing
loss, delays in speech and language, seizures
CEREBRAL PALSY
Priority Nursing
Diagnoses






Impaired physical
mobility
Self-care deficit
Impaired verbal
communication
Altered nutrition: less
than body requirements
High risk for injury r/t
neuromuscular,
perceptual, or cognitive
impairments
Fatigue
Nursing Interventions








Provide adequate
nutrition
Maintain skin integrity
Promote physical
mobility
Developmental
progression
Safety
Emotional support
Team effort
Child and Family
Education
DEVELOPMENTAL DEFICITS
 Pervasive

Developmental Disorders
Autistic spectrum disorders
Asperger’s syndrome, Rett’s disorder, childhood
disintegrative disorder
 Approximately 1% of children, 1 in 100-150


Neurodevelopmental Disorder
Screening at well checks
 Early intervention

PERVASIVE DEVELOPMENTAL DISORDERS
 Priority
Nursing Diagnoses
Communication, verbal, impaired
 Social interaction, impaired
 Injury, risk for
 Caregiver role strain, risk for
 Coping, family, compromised

COGNITIVE DISORDERS
Learning
Disabilities

Alteration in information reception and processing

Not low IQ
Mental
Retardation
Intellectual functioning and adaptive behavior
 Congenital developmental disability



Low IQ
Trisomy 21 (Down Syndrome)
COGNITIVE DEFICITS
Expected Outcomes:
 Learning Disabilities



Will compensate through new strategies
Mental Retardation
Reach highest level of independence
 Encourage optimal family use of resources

COGNITIVE DEFICITS
Nursing Care:
 Language, Motor Delays = Risk for Learning
Disabilities



Refer for testing
Early Developmental Testing

Identify cognitive delays
Support Group Referral
 Help Families

Set goals: life and learning skills
 Promote self-esteem


Partner with Families

Plan health interventions together
PEDIATRIC PAIN MANAGEMENT
Non-pharmacological

Distraction

Play
Position
Heat/cold
Guided Imagery
Sucrose




Pharmacological

Non-narcotic
Acetaminophen
 Ibuprofen (>6 months)
 NO aspirin


Narcotic
Morphine
 Fentanyl
 Acetaminophen with
codeine
