Transcript The Child with a Sensory or Neurological Condition

Chapter 23
The Child with a Sensory or
Neurological Condition
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Lesson 23.1
Objectives
2. Discuss the prevention and treatment of ear
infections.
3. Outline the nursing approach to caring for the
hearing-impaired child.
4. Discuss the cause and treatment of
amblyopia.
5. Compare the treatment of paralytic and
nonparalytic strabismus.
6. Review the prevention of eyestrain in
children.
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2
Ears (p. 524)


Contains the receptors of the eighth cranial
(acoustic) nerve
Two main functions



Hearing
Balance
Three divisions



External
Middle
Internal
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Ears (cont.) (p. 524)

Newborn





Tympanic membrane almost horizontal
More vascular
Inconsistent light reflex
Eustachian tube is shorter and straighter than in
adult
Eustachian tube functions



Ventilation
Protection
Drainage
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4
Question 1
Breastfed infants are less likely to get middleear infections than formula-fed infants.
1) True
2) False
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5
Ears (cont.) (p. 524)



Ear alignment is observed
Top of ear should cross imaginary line drawn
from outer canthus of eye to the occiput
Low-set ears may be associated with kidney
disorders
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6
Ears (cont.) (p. 524)


Before instilling ear drops in infants, gently
pull the pinna of the ear down and back
In children, gently pull the pinna of the ear up
and back to straighten the external auditory
canal
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7
Otitis Externa (p. 525)

An acute infection of the external canal



Signs



Often referred to as swimmer’s ear
Pain and tenderness on manipulating the pinna or
tragus
Tympanic membrane is normal
Rule out the presence of a foreign body, cellulitis,
diabetes mellitus, or herpes zoster
Treatment

Irrigation and topical antibiotics or antivirals
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8
Acute Otitis Media (p. 525)

Pathophysiology


Inflammation of the middle ear
Structures lined by mucous membranes



Mastoid sinuses
Middle ear
Eustachian tube
• Protects middle ear
• Provides drainage
• Equalizes air pressure

Infection of the throat can easily spread to the middle
ear and mastoid
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Otitis Media (OM) (p. 525)




Occurs most often after upper respiratory
infection
Caused by various microorganisms, such as
Streptococcal pneumoniae and Haemophilus
influenzae
Infants more prone because of ear anatomy
Infant’s humoral defense mechanisms are
immature
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Safety Nursing Tip for
OM (p. 525)

Signs and symptoms of ear infection can
include
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
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Rubbing or pulling at the ear
Rolling the head from side to side
Hearing loss
Loud speech
Inattentive behavior
Articulation problems
Speech development problems
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Otitis Media (OM) (cont.) (p. 525)

Manifestations




Tympanic membrane is reddened and bulging
Eardrum can rupture if an abscess forms
OM is considered chronic if the condition persists for
more than 3 months
Treatment



Broad-spectrum antibiotics
Eardrops—to instill, pull pinna down and back for infants; for
children, pull the pinna up and back
Surgical intervention when conventional methods are not
successful
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12
Nursing Tip (p. 526)


Instruct caregivers that the child’s condition
may improve dramatically after antibiotics are
taken for a few days
To prevent recurrence, caregivers must
continue to administer the medication until
the prescribed amount has been completed
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13
Hearing Impairment (p. 527)


Can affect speech, language, social and
emotional development, behavior, and
academic achievement
Two types: congenital deafness or acquired


Can acquire it from common colds, medications,
exposure to loud noise levels, certain infectious
diseases
Hearing loss can also be from cerumen (earwax)
accumulation or from a foreign body being
inserted in the ear canal
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Hearing Impairment
(cont.) (p. 527)

Hearing loss can result from




Defects in the transmission of sound to the middle
ear
Damage to the auditory nerve or ear structures
A mixed loss involving both a defect in nerve
pathways and interference with sound
transmission
Behavior problems may arise because these
children do not understand verbal directions
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Hearing Impairment
(cont.) (p. 527)

Diagnosis
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

Routine newborn hearing screens are performed
before discharge
Lack of a response by the infant to sounds or
music, or the lack of a startle reflex in infants
under 4 months of age are the first signs that a
hearing impairment may exist
Medical or surgical treatment


Hearing aids
Cochlear implants
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Hearing Impairment
(cont.) (p. 527)


Nursing care
Some means of communicating with the
hearing-impaired include


Lip reading, sign language, writing, visual aids
Body language communicates a lot
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Nursing Tip (p. 528)
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When addressing a hearing-impaired child,
the nurse should do the following
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



Be at eye level with the child
Be face-to-face with the child
Establish eye contact
Talk in short sentences
Avoid using exaggerated face or lip movements
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Barotrauma (p. 529)

An injury that occurs when the pressure in the
atmosphere between a closed space and the
surrounding area changes


Airplane descent
Underwater diving
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The Eyes (p. 529)
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Begin to develop in the 4-week-old embryo
Newborn sight is not mature
Shape of eye is less spherical in the newborn
Tears are not present until 1 to 3 months of
age
Depth perception does not begin to develop
until about 9 months of age
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Nursing Tip (p. 530)
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
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At birth, the quiet alert infant will respond to
visual stimuli by cessation of movement
Visual responsiveness to the mother during
feeding is noted
The infant’s ability to focus and follow objects
in the first months of life should be
documented
Coordination of eye movements should be
achieved by 3 to 6 months of age
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Visual Acuity Tests (p. 530)
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Ability of an infant to fixate and focus on an
object can be demonstrated by 6 weeks of
age
The object should not emit a sound
Testing should begin at 2 to 3 years of age
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Visual Acuity Tests
(cont.) (p. 530)
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Dyslexia (p. 530)



Reading disability
Involves a defect in the cortex of the brain
that processes graphic symbols
Treatment involves remedial instruction
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Amblyopia (p. 530)


Reduction or loss of vision that usually occurs
in children who strongly favor one eye
Treatment

Glasses, opaque contact lens, or patching the
good eye
• Forces the weaker eye to be used
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Strabismus (pp. 530-531)
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
Also known as cross-eye
Child is not able to direct both eyes in same
direction




Lack of coordination between the eye muscles
that direct movement of the eyes
When coordination does not occur, the brain will
disable one eye to provide a clear image
The disabled eye can develop permanent visual
impairment due to sensory deprivation
Several types: nonparalytic and paralytic
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Nursing Tip (p. 531)

Symptoms of strabismus include the following
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
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

Eye “squinting” or frowning to focus
Missing objects that are reached for
Covering one eye to see
Tilting the head to see
Dizziness and/or headache
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Strabismus Treatment (p. 531)

Nonparalytic



If found in infancy, parents are instructed to patch
the unaffected eye, as it may improve through use
Glasses and eye exercises usually correct the
problem
Surgery if none of the above work
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Eye Strain (p. 532)

Symptoms






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Inflammation
Aching or burning of the
eyes
Squinting
A short attention span
Frequent headaches
Difficulties with
schoolwork
Inability to see the board
at the front of the class

Nursing
Interventions





Observe
Teach
Prevent
Refer
Rehabilitate
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Conjunctivitis (p. 532)

Inflammation of the conjunctiva or mucous
membrane that lines the eyelids




Caused by a variety of bacterial and viral organisms or from
a blocked lacrimal duct
Acute form is commonly called pink eye
Common forms respond to warm compresses, topical
antibiotic eye drops, or eye ointments
Symptoms include




Itching
Tearing of one or both eyes
Edema of the eyelids and periorbital tissues
Child may appear distracted or irritable
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Question 2
Once started on pharmacological treatment for
bacterial conjunctivitis, the child can return to
school:
1)
2)
3)
4)
immediately.
in one week.
as soon as symptoms subside.
after 24 hours have passed.
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Hyphema (p. 532)




Presence of blood in the anterior chamber of
the eye
One of the most common ocular injuries
Appears as a bright-red or dark-red spot in
front of the lower portion of the iris
Treatment


Bedrest with HOB elevated 30 to 45 degrees
decreases intraocular pressure and intracranial
pressure if there is an associated head injury
Topical medications may also be prescribed
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Retinoblastoma (p. 532)


A malignant tumor of the retina
Manifestations



Yellowish white reflex is seen in the pupil because
of a tumor behind the lens
Called the cat’s eye reflex or leukokoria
May be accompanied by loss of vision,
strabismus, hyphema, and in advanced tumors,
pain
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Retinoblastoma (cont.) (p. 533)

Treatment




Laser photocoagulation
Chemotherapy
External beam irradiation
Usually removal of the affected eye if no possibility
exists to save the vision
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Lesson 23.2
Objectives
7. Discuss the functions of the 12 cranial
nerves and nursing interventions for
dysfunction.
8. Outline the prevention, treatment, and
nursing care for the child with Reye’s
syndrome.
9. Discuss the symptoms of meningitis in a
child.
10.Discuss the various types of seizures and
the nursing responsibilities.
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The Nervous System (p. 533)

The body’s communication center




Transmits messages to all parts of the body
Records experiences
Integrates certain stimuli
Most neurological disabilities in childhood
result from congenital malformation, brain
injury, or infection
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Safety Alert! (p. 533)

The sudden appearance of a fixed and
dilated pupil is a neurologic emergency.
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Causes of Altered Level of
Consciousness (ALOC) (p. 533)







A fall to 60 mm Hg, or below, of PaCO2
A rise above 45 mm Hg of PaCO2
Low blood pressure causing cerebral hypoxia
Fever (1° rise in fever increases oxygen need
by 10%)
Drugs (sedatives, antiepileptics)
Seizures (postictal state)
Increased ICP
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Neurological Clock (p. 534)
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Reye’s Syndrome (p. 533)



Acute noninflammatory encephalopathy and
hepatopathy that follows a viral infection in
children
May be a relationship between the use of
aspirin during a viral flu or illness
Some studies show that a genetic metabolic
defect triggers Reye’s syndrome when the
stress of a viral illness produces vomiting and
hypoglycemia
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Reye’s Syndrome (cont.) (p. 533)

Manifestations


Ammonia accumulates in the blood due to liver
involvement
In children, effortless vomiting and altered
behavior, or ALOC after a viral illness, are
characteristic of Reye’s syndrome
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Reye’s Syndrome (cont.) (p. 533)

Treatment


If early, can result in complete recovery
Goals are
•
•
•
•

Reducing ICP
Maintaining a patent airway
Cerebral oxygenation
Fluid and electrolyte balance
Observe for signs of bleeding due to liver
dysfunction
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Medication Safety Alert! (p. 533)


Discourage the use of aspirin and other
medications that contain salicylates in
children with flulike symptoms
Advise parents to read medication labels
carefully to determine their ingredients
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Sepsis (p. 535)



Systemic response to infection with bacteria;
also results from viral or fungal infections
Causes a systemic inflammatory response
syndrome (SIRS) due to the endotoxin of the
bacteria that causes tissue damage
Untreated can lead to septic shock,
multiorgan dysfunction syndrome (MODS),
and death
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Sepsis (cont.) (p. 535)

Manifestations include





Fever
Chills
Tachypnea
Tachycardia
Neurological signs, such as lethargy
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Meningitis (p. 536)




An inflammation of the meninges (the
covering of the brain and spinal cord)
Caused by bacterial, viral, or fungal (rare in
immune-competent person) infection,
Haemophilus influenzae most common
Invades the meninges indirectly by way of the
bloodstream (sepsis)
Bacterial meningitis often referred to as
purulent because of pus-forming that can
occur
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Meningitis (cont.) (p. 536)

Manifestations


If bacterial, symptoms are a result of intracranial
irritation from the purulent toxins released by the
bacteria
The presence of petechiae suggests
meningococcal infection
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Meningitis (cont.) (p. 536)

Symptoms











Severe headache
Drowsiness
Delirium
Irritability
Restlessness
Fever
Vomiting
Stiffness of the neck (nuchal rigidity)
High-pitched cry in infants
Seizures are common
Coma may occur
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Meningitis (cont.) (p. 536)


Diagnosis confirmed by examination of the CSF
Treatment


The child is placed in droplet isolation until 24 hours after the
appropriate antimicrobials have been initiated
Nursing care

Neurological checks as ordered by physician
• Report findings such as weakness of the limbs, speech
difficulties, mental confusion, and behavior problems


Maintaining an accurate recording of vital signs and
intake/output
Maintain a quiet environment to help decrease stimuli
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Encephalitis (p. 537)

Inflammation of the brain


Also known as encephalomyelitis when the spinal
cord is also infected
Symptoms result from the CNS’s response to
irritation




Headache followed by drowsiness
May proceed to coma
Convulsions are seen, especially in infants
Fever, cramps, abdominal pain, vomiting, nuchal
rigidity, delirium, muscle twitching, abnormal eye
movements
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Encephalitis (cont.) (p. 537)

Treatment






Supportive
Provide relief from specific symptoms
Sedatives and antipyretics may be ordered
Seizure precautions are taken
Provide for adequate fluid and nutrition
Supplemental oxygen may be needed
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Brain Tumors (p. 538)





Second most common type of neoplasm in children
Most occur in lower part of the brain and commonly in
school-age children
Signs and symptoms directly related to location and
size of tumor
Diagnosis is made by clinical presentation, laboratory
tests, head CT or MRI, EEG
Surgical intervention in some cases, chemotherapy
and/or radiation therapy in others
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Seizure Disorders (p. 539)



Most commonly observed neurological
dysfunction in children
Etiology varies
Sudden, intermittent episodes of ALOC that
last seconds to minutes and may include
involuntary tonic and clonic movements
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Question 3
If the nurse witnesses a child begin to seize, the
first action should be to:
1)
2)
3)
4)
note the start time.
assess vital signs.
ensure safety.
insert tongue blade.
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Causes of Seizures in
Children (p. 539)

Intracranial







Epilepsy
Congenital anomaly
Birth injury
Infection
Trauma
Degenerative disease
Vascular disorder
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Causes of Seizures in
Children (cont.)(p. 539)

Extracranial







Fever
Heart disease
Metabolic disorders
Hypocalcemia
Hypoglycemia
Dehydration and malnutrition
Toxic



Anesthetics
Drugs
Poisons
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Types of Seizures (p. 539)



Febrile
Epilepsy
Classified as

Generalized
• Tonic-clonic or grand mal
• Three distinct phases

Partial
• Account for 40%
• Consciousness may be intact or slightly impaired
• Can have simple or complex seizures
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Question 4
The higher the fever, the higher the risk of
febrile seizure.
1) True
2) False
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Patient Teaching (p. 539)

The following are common triggering factors
for seizures




Flashing of dark/light patterns
Startling movements
Overhydration
Photosensitivity
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Seizure Diagnosis and
Treatment (p. 541)


Determine type, site, or cause
Multiple diagnostic techniques can be used




CT/MRI, EEG
Laboratory tests to rule out poisoning or
electrolyte abnormalities
Drug of choice depends on the type of
seizure
Diet changes may be needed for patients
who do not respond well to anticonvulsants
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Seizures Treatment
(cont.) (p. 541)

A fundamental principle of comprehensive
seizure management is that the child must
become an active member of the health care
team
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Safety Alert (p. 542)

The nurse is responsible for maintaining
seizure precautions






Keep side rails up
Pad all sharp or hard objects around the bed
Make sure child wears a medical ID bracelet
Provide supervision during potentially hazardous
play, such as swimming
Avoid triggering factors
Teach the importance of compliance with the
medication regimen
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62
Lesson 23.3
Objectives
11.Formulate a nursing care plan for the child
with a decreased level of consciousness.
12.Describe four types of cerebral palsy and the
nursing goals involved in care.
13.Prepare a plan for success in the care of
intellectually or developmentally disabled
child.
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Other Conditions Causing Decreased
Level of Consciousness (p. 543)



Can be mistaken for seizures because of the
paroxysmal ALOC
These conditions do not respond to antiepileptic
medications
Conditions are






Benign paroxysmal vertigo
Night terrors
Breath-holding spells
Cough syncope
Prolonged QT syndrome
Rage attacks or episodic dyscontrol syndrome
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Cerebral Palsy (CP) (p. 543)


A group of motor disorders caused by
dysfunction of various motor centers in the
brain and often related to antenatal or
developmental factors
Can be precipitated by many factors, such as
birth injuries, congenital anomalies, neonatal
anoxia, prematurity, subdural hemorrhage,
and prenatal infection
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Cerebral Palsy (CP)
(cont.) (p. 543)

Manifestations




Vary with each child
May range from mild to severe
Intellectual and Developmental Disabilities
sometimes seen
Suspected during infancy if



There are feeding problems
Convulsions not associated with high fevers
Developmental milestones are not being achieved
at expected age level
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Types of CP (p. 544)
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Question 5
Complete the analogy. Ataxic : cerebral palsy
as __________ : seizure
1)
2)
3)
4)
absence
clonic
neurological
intracranial pressure
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Treatment of CP (p. 544)



Botulinum toxin has been used to manage
spasticity problems
Levodopa has helped to control some of the
athetoid problems
Specific treatment is highly individualized


Good skin care is essential
All precautions taken to prevent contractures
• Braces are often used to treat these
• Orthopedic surgery is sometimes indicated
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Treatment Protocol
for CP (p. 545)







Establish communication
Establish locomotion
Use and optimize existing motor functions
Provide intellectual stimulation
Promote socialization
Provide technology to encourage self-care
and promote growth and development
Provide multidisciplinary approach to care
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Cognitive Impairment (p. 546)

Elements involved in mental functioning



Level of consciousness
Thought processes
Expressive language
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Intellectual Impairment (p. 546)

The American Association on Intellectual and
Developmental Disabilities (AAIDD):



Mild or severe
IQ below 70
Numerous test to measure intelligence



Stanford-Binet
All tests have limitations
Accuracy depends on abilities of the person
interpreting the results
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Intellectual Impairment
(cont.) (p. 546)

Limitations in at least 2 of the following










Communication
Self-care
Home living
Social skills
Community use
Self-direction
Health and safety
Functional academics
Leisure
Work
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Some Causes of Intellectual
Impairment (p. 547)

Neonatal period







PKU
Hypothyroidism
Fetal alcohol syndrome
Down syndrome
Malformations of the brain
Maternal infections
Birth injuries or anoxia during or shortly after
delivery
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Some Causes of Intellectual
Impairment (cont.) (p. 547)


Heredity
During childhood





Meningitis
Lead poisoning
Neoplasms
Encephalitis
Living in a physically or emotionally deprived
environment
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Nursing Tip (p. 548)

Intellectually impaired children have the same
psychosocial needs as all other children but
cannot express or respond as other children
do
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The Importance of Success in the Approach
to the Intellectually Impaired Child (p. 548)


The nurse must assist the parents to
understand that providing experiences that
the child can be successful in, and
concentrating on his or her strengths rather
than on weaknesses, are the keys to dealing
with a child who is developmentally different
A child who experiences constant failure
becomes angry

The anger causes behavior difficulties that can
cloud the problem and therapy
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Management and Nursing
Goals (p. 548)

Individualized plan of care




Initial step is to present the findings to the family
Provide emotional support
The child’s competence and adaptive behaviors
should be discussed along with the deficiencies
If child is in the hospital, the nurse needs to
obtain



The child’s stage of maturation and ability
Self-help activities
Home routines
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Nursing Tip (p. 548)

Nursing responsibilities to disabled children






Emphasize the strengths present
Maintain communication with the family
Avoid labels; use simple terms
Contact the school nurse; plan for school needs
Provide daily experiences in which the child can
succeed
Refer to local, state, and national support groups
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Nursing Tip (p. 549)


Many intellectually and developmentally
disabled children have a normal facial
appearance
Many children with unusual faces are not
intellectually and developmentally disabled
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Lesson 23.4
Objectives
14. Describe signs of increased intracranial pressure in
a child.
15. Describe three types of posturing that may indicate
brain damage.
16. Describe the components of a “neurological check.”
17. Discuss neurological monitoring of infants and
children.
18. State a method of determining level of
consciousness in an infant.
19. Identify the priority goals in the care of a child who
experienced near-drowning.
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Head Injuries (p. 548)



Major cause of death in children older than 1
year of age
A concussion is a temporary disturbance of
the brain that is usually followed by a period
of unconsciousness
A child’s response to a head injury may differ
from that of an adult
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Safety Alert! (p. 549)

A concussion with resulting amnesia and
confusion can be more serious than the
presence of a fractured skull with no clinical
symptoms
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Complications of Head
Injuries (p.)

Hypoxia, increased ICP, cerebral edema, and
infection can occur within a few days of a
head injury

Hypoxia causes the brain to need increased
energy, which increases cerebral blood flow
• Increased blood flow causes cerebral edema
• If ICP rises too high, cerebral perfusion diminishes, brain
damage or death results
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Shaken Baby Syndrome (p. 550)



Infants who are roughly shaken can sustain retinal,
subarachnoid, and subdural hemorrhages in the
brain, as well as high-level cervical spine injuries
Can result in permanent brain injury or death
Symptoms can include:






Headache (manifested as fussiness in a toddler)
Drowsiness
Blurred vision
Vomiting
Dyspnea
In severe cases child may be completely
unconscious
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Posturing Seen in Brain
Injury (p. 550)
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Observe Child for Signs of Increased
ICP (p. 550)

Four components of a cranial or
neurological check
•
•
•
•
LOC
Pupil and eye movement
Vital signs
Motor activity
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Nursing Care of a Brain-Injured Child
(cont.) (p. 552)


Subtle clues to change can be missed unless
the nurse performs aggressive assessment in
looking for them
The lack of the child’s ability to communicate
and cooperate poses a challenge in the
neurological assessment of infants, but
knowledge of normal growth and
development aids the nurse in evaluating the
status of the patient
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Neurological Monitoring of Infants
and Children (p. 552)











Pain stimuli response
LOC
Arousal awareness
Cranial nerve response
Motor response
Posturing
Pupil response of the eyes
Bulging fontanels
Scalp vein distention
Ataxia; spasticity of lower extremities
Moro/tonic neck with withdrawal reflexes
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Near-Drowning (pp. 553-554)



Accidental or near-drowning is the fourth leading
cause of death in children under 19 years of age
Near-drowning is defined as survival beyond 24
hours after submersion
Priorities include immediate treatment of




Hypoxia
Aspiration
Hypothermia
CNS injury remains the major cause of death or longterm disability
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Near-Drowning (cont.)
(pp. 553-554)

Submersion for more than 10 minutes with
failure to regain consciousness at the scene
or within 24 hours is an ominous sign and
indicates severe neurological deficits if the
child survives
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