Neurological Disorders in the Pediatric Patient

Neurological Disorders in the Pediatric Patient

Why is the CNS function so important?

What does it do?

What happens with impairment?

What affects the degree of disability?

Changes to be noted in pediatric neurological disorders

Reflexes: may be hypo/hyperLOC: may have altered mental statusCranial nerves:

I, IIIII, IV, VIIII, VIIIV,VIIIX, X

Neuro assessment, cont.Vital signs:changes in BP, HREyes: changes in pupils,focus,gazeBehavior: subtleRespiratory status: assess 1st

Motor function: movement? Spontaneous?Skin: dry vs. diaphoretic

Neurological System of Children

Top HeavyCranial bones- thin, not well developedBrain highly vascular with small subarachnoid spaceExcessive spinal mobilityWedge-shaped cartilaginous vertebral bodies

Assessment findings in children with neurological dysfunction

Increased Intracranial Pressure (ICP)Reflects the pressure exerted by the blood, brain, CSF and any other space-occupying fluid or mass (tumors)Pressure sustained at 20mm Hg or higherChanges in pressure present with altered assessments other than normal

Altered Mental StatusMnemonic = Mitten

Metabolic

Infections

Toxins

Trauma

Endocrine

Neurological/Neoplasm

Assessment:Infant

Irritability and restlessnessFull to bulging fontanellesIncrease in FOCPoor feeding, poor sucking, projectile vomitingDistension of superficial scalp veinsNuchal rigidity and seizures (late signs)

Assessment:Child early signs-

Irritability, lethargySudden change in moodHeadache, poor feedingVomitingAtaxiaNuchal rigidityDeterioration of cognitive ability

Assessment Child:Late signs

Changes in Vital signsSeizuresPhotophobiaPositive Kernig’s signPositive Brudzinski’s signOpisthostonos

Therapeutic Intervention:Nursing care

MedicationsCorticosteroid

Decadron

Osmotic diureticMannitol

Nursing Care

Minimize activityMonitor IV ratePlace in semi-fowlersMonitor VS, Neuro VS, and behaviorTreat for painOrganize careEducate 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?

Hyperfunction/Hypofunction

Pediatric SeizuresEpilepsy vs. “seizure episode”

• Status epilepticus

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

Generalized: Tonic-clonic- loss of consciousness(formerly called grand mal) Absence seizures-may have minor motor-atonic (formerly called petit mal)Partial seizures- partial simple or partial complex (may be focal or r/t tumors)

Diagnostic Tests:

EEGCT, MRILumbar punctureCBCMetabolic screen for glucose, phosphorus and lead levels

Jitteriness –vs- Seizure

JitteryResponsive

Gaze Okay

SeizureNot responsive to stimuli

Abnormal gaze

Goals:

What is the primary nursing goal when caring for the individual experiencing a seizure?What preventive measures does the nurse provide?How does the nurse maintain the airway of an individual experiencing a seizure?What is the priority nursing intervention following a seizure?

Long term goal for children with seizure disorders

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

MeningitisBacterial

Potentially fatal; abx given prophylactically if bacterial suspected. May kill within 24 hrs

C/S take 72 hrs to process

Infants at greatest riskNuchal rigiditySevere headachesContagious

ViralSame s/s but milder

and shorter durationMay follow a viral

infectionMay be accompanied

by rashNuchal rigidityAtaxia Not contagious

Assessment and diagnostics: Bacterial Meningitis

Streptococcus pneumoniae most common pathogenDiagnostics: LP, CSF eval (↑ WBCs, gram stain +)Treatment: ABCDs, cerebral edema, seizure control, abx, steroidsPrevention: Vaccination (HiB, Pneumococcal vaccine)

Assessment and diagnostics: Viral Meningitis

May be preceded by viral infection, rashDiagnostics: LP, CSF eval (mildly ↑WBCs, negative gram stain)Treatment: self limiting; resolves in 7-14 days, monitored in hospital until ABCs are stableMedications: antivirals (Acyclovir)

Diagnostic Tests:

Lumbar Puncture

Serum Glucose Level

Blood Cultures

Nursing Care for diagnostics of possible meningitis

Lumbar puncture

ASO titer

CBC/electrolytes/serum glucose

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

Infants- prior to fusion of cranial sutures

1. FOC increased at birth2. Changes in assessment of skull3. Forehead 4. Eyes5. Behavior changes

After closure of cranial sutures:1. Eyes2. S & S of ICP

Diagnostic Tests

LPMRI/ CT scanSkull X-ray FOCTransillumination

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 statusAssess functioning of the shunt Assess operative siteAssess for infectionPositioning of the patientActivity of patient Promote nutritionEducation

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 CNSOccurs when there is a failure of the

osseous spine to close around the spinal column.

Types of spina bifida

Meningocele: sac filled with spinal fluid and meninges

Myelomeningocele: more severe, sac filled with spinal fluid, meminges, nerve roots and spinal cord.

Clinical Manifestations:

Visualization of the defectMotor sensory, reflex and sphincter abnormalitiesFlaccid paralysis of legs- absent sensation and reflexes, or spasticityMalformation Abnormalities in bladder and bowel function

Diagnostic Tests:

Prenatal detectionUltrasoundAlpha-fetoprotein

Following Birth:NB assessmentX-ray of spineX-ray of skull

Surgical Intervention

Immediate surgical closure

Prior to closure keep sac moist & sterile

Maintain NB in prone position with legs in abduction preoperatively

Nursing Interventions:

Pre-OP:Meticulous skin careProtect from feces or urineKeep in isolette

Post-Op Nursing Interventions

Assess surgical siteMonitor VS and neuro VSInstitute latex precautionsEncourage contact with parents/care giversPositioningSkin Care

Nursing Interventions cont...

Antibiotic therapy Prevent UTIEducation

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 postureNon-progressiveAbnormal 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 toneAbnormal resistanceKeeps legs extended or crossedRigid and unbending

Abnormal postureScissoring and extension (legs feet in plantar flexion)Persistent fetal position (>5 months)

Diagnostic Tests:

EEG, CT, or MRIElectrolyte levels and metabolic workupNeurologic examinationDevelopmental assessment

Complications

Increased incidence of respiratory infection

Muscle contractures

Skin breakdown

Injury

Goals & Interventions:

Early detection

Head Injuries

Concussions: Assessment and Nursing Care

Grades 1-3: higher the number, more severe the injuryInvolves transient impairment“Second impact syndrome:Assess and manage according to grade

Treatment is supportiveUsually observed in the EDIf unconscious > 5 minutes, may be admittedRemoval from sports ranges from 1 wk-entire season

Nurse as Provider: Care PlanBrian, 10 years old, sustained a head injury when he collided with a tree while riding his bicycle.He did not have on a helmet. He is now unconscious in the PICU and is receiving an intravenous drip of Mannitol, central venous pressure monitoring, EEG and ECG monitoring, is being mechanically ventilated, and has a urinary catheter. Brian's parents have just arrived on the unit. How can the nurse prepare the parents for Brian's appearance? What are Brian's immediate needs? Fill in the appropriate steps of the Care Plan below for Brian for the next 24 hours.

Assessment and DiagnosisPlanning and ImplementationEvaluation

CASE STUDY: The nurse is assigned to an 14-year-old female who is being observed after a head injury sustained while playing soccer. She lost consciousness for a few minutes when it happened.

What should the client and her parents be told about the recovery time after a concussion? What should the client and her parents be told about playing soccer again? What should the nurse tell the parents and the client about second impact syndrome? What can the family do to assess her symptoms at home and determine if she is ready to play competitive sports again?

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

Autism

Not clearly understoodCharacterized by impaired social, communicative, and behavioral developmentUsually noted in the first year of life

Nursing interventions/educationHome setting-reduce environmental stimuli

-communicate age appropriately;

use of touch and verbalization

-safety with toys and articles that could be harmful

-routines: ritualism with ADLs -long term care to include

therapists and support groups

Acute care setting -keep one constant

caregiver; room quiet as possible

-may become aggressive when touched by a stranger; refer to parents for communication techniques

-monitor for safety at all times: removing tubes, etc.

-encourage to include therapists and support groups in care

Down syndrome

Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation

Assessment

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 capabilitiesSupport siblingsRefer to family counseling servicesSupport parents in feelings of guilt and chronic sorrow