Alterations in Neurological Function in Pediatrics ch 29

1
Alterations in Neurological Function in
Pediatrics ch 29

• Christine Limann Dyer, RN, MSN, CPN

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Pediatric Differences

• -Head is larger in proportion to body
• -Insufficient musculoskeletal support in neck
• -Fontenelles not closed in young child

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A P Review

• Nervous system
• Central nervous system
• Brain and spinal cord
• Peripheral nervous system
• Sensory-somatic
• Autonomic

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Altered States of Consciousness

• Arousal or level of consciousness awareness of
  the environment
• Content of thought all cognitive functions that
  ensure awareness of affective states, self, and
  environment

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The Unconscious Child

• Unconsciousness is a state in which a childs
  cerebral function is depressed and ranges from
  stupor to coma

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Caring for the Unconscious Child

• Evaluating neurological status
• The pediatric Glascow Coma Scale
• Eye opening, verbal response, and motor response

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Caring for the Unconscious Child

• Monitor vital signs
• Manage the airway
• Manage bladder and bowel elimination
• Maintain hydration nutrition
• Provide proper hygiene
• Position and perform exercise

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Persistent Vegetative State

• A complete unawareness of the environment
  accompanied by sleepwake cycles.
• The diagnosis is established if it is present for
  1 month after acute or nontraumatic brain injury
  or has lasted for 1 month in children with
  degenerative or metabolic disorders or
  developmental malformations
• Family support is needed

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Increased Intracranial Pressure

• Intracranial pressure (ICP) is the pressure of
  the cerebral spinal fluid (CSF) in the
  subarachnoid space between the skull and the
  brain. A child can have increased ICP as a result
  of many internal or external factors.
• Signs and symptoms
• See Table 29-2

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Increased Intracranial Pressure

• Nursing care
• Close monitoring (neurologic status)
• Maintenance of a patent airway
• Monitor vital signs closely (hyperthermia)
• Administer IV fluids
• Monitor fluid balance (I O)
• Protect child from injury
• Administer antiseizure medications
• Provide emotional support
• Administer medications to decrease cerebral edema
  
• Analgesia and sedation
• A craniotomy is recommended when all other
  measures have been unsuccessful

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Cushings Triad
Increased Systolic
Decreased Diastolic
(Ball, Bindler, Cowen, 2010)
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Seizures

• Most common neurologic dysfunction in kids
• Caused by malfunctions of brains electrical
  system
• Infections or high fever
• Chemical imbalance of the body that causes loss
  of metabolism
• Congenital conditions or trauma
• Genetic factors and family history
• Brain tumors and neurological problems
• Habits of the mother like smoking, alcohol
  consumption, drugs and certain medications

(Hockenbery Wilson, 2010)
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Types of Seizures

• Absence (3-12 years old)5-10 sec. Lip smacking,
  staring, twitching, brief loss of consciousness
• Partial (focal) Less than 30 sec., one
  extremity
• Generalized (tonic-clonic or grand mal)
• Febrile Dependent
• Epilepsy Chronic disorder

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Febrile Seizures

• Usually higher than 38.9 C or 101F
• Usually short in duration. Instruct parents to
  call 911 if longer than 5 minutes
• Use antipyretics and cooling measures

(Mayoclinic.com, 2010)
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Nursing actions with patients with seizures

• Before
• Where there triggers such as change in
  temperature, light?
• During
• Maintain airway
• Role to side if possible
• Time changes started
• Part of the body involved and movement
• Incontinence
• After
• Do they remember what happened?

(Ball, Bindler, Cowen, 2010)
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Treatment for Seizures

• Common pharmacological choices
• Ativan -Lorazepan
• Diazepam Diastat (can be given rectally)
• Phenobarbital or Phenytoin
• Remind parents not to stop once the seizures are
  controlled until directed by a doctor.
• Other types of treatment
• Vagal Nerve stimulator
• Ketogenic Diet

(Ball, Bindler, Cowen, 2010)
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Seizure Disorders

• Signs and symptoms
• See Table 29-3
• Nursing care
• Complete a detailed history
• Ensure airway management
• Maintain anticonvulsant therapy
• Implement seizure precautions (padded side rails,
  oxygen, suction equipment, IV access, and
  anticonvulsant medications)
• Provide continuous cardiac, respiratory, and
  oxygen monitoring
• Instruct caregivers instructed in CPR
• Keep school nurses and teachers informed about
  the condition
• Encourage medical alert identification bracelet

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Inflammatory Neurological Conditions
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Intracranial Infections -Meningitis

• Bacterial Meningitis

• Viral Meningitis

• More Dangerous
• Group B Streptococcus and gram-negative enteric
  bacilli most likely cause in newborns
• Neisseria Meningitidis 2 mo-12 yr
• Can also cause meningococcemia
• H influenzae B and Strep Pneumoniae are now less
  common because of vaccination
• -Fever, vomiting, irritable, hemorrhagic rash,
  headache, nuchal rigidity, seizures, Kernig
  and/or Brudzinski sign
• Treatment Antibiotics

• Does not appear as ill as the child with
  bacterial meningitis
• Caused by enteroviruses, mumps, vericella
• Irritable, fever, lethargy, headache, may have
  stick neck or back pain
• Usually resolves in 3-10 days
• Treat with antibiotics until bacterial meningitis
  is ruled out

Both Diagnosed by Lumbar Puncture-LP
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Encephalitis

• Signs and symptoms
• Disorientation, confusion, headache, high fever,
  photophobia, lethargy, aphasia, hallucinations,
  seizures, nuchal rigidity, and coma

• Nursing care
• Viral is treated with antiviral medication
• Bacterial is treated with a narrow-spectrum
  antibiotic
• Other medications include antipyretics,
  anticonvulsants, analgesics, and
  anti-inflammatories
• Provide intravenous fluids and nutrition
• Implement seizure precautions
• Monitor fluid balance
• Do not suction or give percussion

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Brain Abscess

• Signs and symptoms
• Localized headache, fever, drowsiness, stupor,
  confusion, general or focal seizures, focal motor
  or sensory impairments, ataxia, nausea and
  vomiting, papilledema, and hemiparesis
• Nursing care
• Assess neurological status, assess response to
  treatment, administer medications, and provide
  supportive care
• Monitor serum labs
• Surgery required if no response to antimicrobial
  therapy (postoperative care) or does not meet
  criteria for medical therapy

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Reye Syndrome

• Associated with use of aspirin with viral illness
  such as chicken pox or influenza b
• May cause permanent tissue damage to brain and
  liver
• Signs and symptoms
• Lethargy, vomiting, drowsiness, liver dysfunction
• Nursing care
• Conduct neurological assessment
• Administer IV fluids
• Administer corticosteroids and/or diuretics
• Monitor oxygen saturation (supplemental oxygen)
• Insert arterial line (blood gases)
• Take seizure precautions
• Limit invasive procedures
• Provide emotional support

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Guillain-Barré Syndrome

• Signs and symptoms
• Three phases acute, second, recovery
• Nursing care
• Plasma exchange and IV immunoglobulin therapy
• Give corticosteroids
• Monitor progression
• Insert indwelling urinary catheter
• Assess pain level
• Prevent contractures and loss of function
  (passive ROM)
• Provide skin care
• Suggest age-appropriate activities

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Developmental Neurological Conditions
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Spina BifidaNeural tube defects (NTDs)

• Signs and symptoms
• Vary depending on the level of the lesion and
  defect
• Spina bifida occulta
• Meningocele
• Myelomeningocele
• Types
• Meningocele
• Myelomeningocele
• Spina bifida occulta

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Spina Bifida

• Nursing care
• Place newborn in prone position (prevent injury
  to sack)
• Provide postoperative care for laminectomy
  closure of defect
• Evaluate orthopedic function
• Prevent joint contractures
• Assess bladder and bowel function
• Provide skin care
• Assess neurological status
• Measure head circumference and assess fontanel
• Manage pain

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Spina Bifida

• Surgery to close the repair usually occurs within
  24-48 hours. Some cases can be repaired in
  utero.
• May need VP shunt.
• Ongoing therapy
• Mobility-Braces, wheelchair
• Neurogenic bowel and bladder

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Hydrocephalus Cerebrospinal fluid build up

• Communicating hydrocephalus no blockage.
  Either a problem with over production of CSF or
  problem with absorption
• Non-communicating- obstruction

Aqueduct of sylvius
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Hydrocephalus- clinical manifestations

• Newborns and infants
• Bulging fontanels
• Increased head circumference
• Sun set eyes
• Irritability
• High-pitched, catlike cry
• Visible scalp veins

• Children
• Headache
• Visual disturbance
• Nausea/vomiting
• Pupils sluggish
• Decrease in consciousness
• Seizures
• Cushings Triad
• Widening pulse pressure
• Bradycardia
• Irregular respirations

(Ball, Bindler, Cowen, 2010)
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Hydrocephalus Treatment

• Ventriculoperitoneal shunt (VP Shunt)

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Hydrocephalus

• Signs and symptoms
• Increased ICP
• Macewen sign
• Nursing care
• Understand shunt function and complications
• Obtain history and physical (life-threatening
  conditions)
• Discuss pharmacological measures or surgical
  procedure
• Perform nursing actions related to ICP
• Measure head circumference
• Give preoperative and postoperative antibiotics
• Assess neurological status
• Assess for shunt malfunction (eye assessment)
• Assess abdominal status (pain, bowel sounds, and
  circumference)
• Elevate HOB 30

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Cerebral Palsy
Abnormal muscle tone, lack of coordination,
spasticity. Symptoms very depending on age and
type of CNS injury.

• Nursing Role
• Provide adequate Nutrition Promote safety
  and physical mobility
• Maintain Skin Integrity Prevent Constipation

(Ball, Bindler, Cowen, 2010)
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Cerebral Palsy

• Signs and symptoms
• Vary individually depending on the area of the
  brain involved and the extent of damage
• Four categories
• Spastic
• Ataxic
• Athetoid or dyskinetic
• Mixed

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Cerebral Palsy

• Nursing care
• Use splints and braces
• Promote self-care
• Administer medications (reduce muscle spasms,
  spasticity, anxiety, and seizure)
• Surgery (selective dorsal rhizotomy)
• Address feeding problems
• Provide intellectual stimulation
• Ensure safe environment

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Neurological Injuries
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Drowning/Near-Drowning

• Drowning is the second leading cause of
  accidental death in children
• Death occurs from asphyxia while submerged
• Can occur with even small quantity of water (even
  as little as a pail of water)
• Near-drowning survived at least 24 hours after
  submersion

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Near Drowning (Submersion)

• Signs and symptoms
• Cerebral edema, alteration in LOC, respiratory
  distress, cardiovascular complications,
  hypovolema
• Nursing care
• Assess and maintain airway
• Provide life support measures
• Suction secretions
• Insert NG tube
• Administer oxygen
• Assess other injures (head or spinal trauma)

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Head Injuries

• -Major cause of childhood deaths
• -Who is more at risk?

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Head InjuryTraumatic Brain Injury (TBI)

• Signs and symptoms
• Obvious signs blood on the scalp, depression of
  the skull, and an obvious penetrating wound
• Other signs and symptoms loss of consciousness,
  alteration LOC, seizures and combativeness
• Nursing care
• Provide immediate care to prevent
  life-threatening complications
• Maintain airway patency and oxygen administration
• Insert IV and administer hypertonic fluid
• Assess neurological status
• Assess ICP

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Concussion
Signs and Symptoms -Headache -Slowness in
thinking, acting, speaking -Fatigue -Memory
problems -Loss of balance
(Ball, Bindler, Cowen, 2010)
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Cerebral Contusion

• Bruising of the brain secondary to blunt trauma.
  
• Can be either coup or countercoup injuries.
• May involve tearing of brain tissue and may lead
  to areas of necrosis or infarction.

(Ball, Bindler, Cowen, 2010)
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Head Trauma

• Subdural Hematoma

• Epidural Hematoma

• Between dura and skull
• Almost never occurs in children less than 4 y/o.
  Blunt trauma such as MVA, assault, baseball
  injury
• Delayed onset followed by rapid change in mental
  status
• Headache, Fixed dialated pupils, s/s increased
  ICP
• Prognosis good

• Between dura and cerebellum
• Result of head trauma such as falls, MVA, or
  shaken child syndrome
• Symptoms may appear after 24-72 hours
• Change in LOC, Headache, N/V, retinal hemorrhage,
  pupil on side of injury may be dilated
• Prognosis poor

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Shaken Baby

• Physical abuse
• Countercoup injury
• Subdural Hematoma
• Retinal Hemorrhage
• Seizure
• Check baby for fractures in the rest of their body

Countercoup injury
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Shaken Baby Syndrome

• Signs and symptoms
• Seizure activity, apnea, budging fontanels, coma,
  hemorrhage, bradycardia cardiovascular
  collapse
• Nursing care
• Provide respiratory and cardiovascular support
• Assess for ICP
• Insert NG tube
• Maintain seizure precautions
• Maintain adequate fluid and nutritional intake
• Assess and document visible injuries
• Discuss short- or long-term care
• Assess parental concerns

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Spinal Cord Injury

• Signs and symptoms
• Numbness, tingling, or loss of function
• Nursing care
• Maintain airway management and respiratory
  function
• Provide cardiovascular and circulatory support
• Give steroid therapy
• Monitor fluid intake and output
• Maintain gastrointestinal function
• Provide nutritional support
• Provide emotional and social support
• Be attuned to an adolescents unique needs
• Explain lifelong care and support, circulation
  support, disability identification, and exposure
  of known and unknown physical limitations

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Nontraumatic Neurological Conditions
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Headaches

• Types
• Primary headaches
• Secondary headaches
• Tension
• Migraine
• Cluster

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Headaches

• Signs and symptoms
• Primary (triggers i.e., stress)
• Secondary (organic disorder i.e., trauma)
• Subtypes (tension, migraine, cluster)
• Nursing care
• Provide pharmacologic and nonpharmacologic care
• Discuss prophylactic measures
• Give intramuscular or intranasal medications
• Promote rest and stress reduction strategies

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Sensory Conditions
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Eye Disorders

• Hyperopia (farsightedness)
• Myopia (nearsightedness)
• Correction
• Concave lenses or contact lenses
• Laser assisted surgery

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Astigmatism

• Irregular curvature or uneven contour of the eye
• Correction
• Corrective lenses
• Surgery
• Complaints of headache, blurry vision, or
  dizziness ophthalmologist referral

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Amblyopia lazy eye

• Signs and symptoms
• Strabismus or anisometropia are the most common
  causes
• Correction
• Occlusion therapy (patching of the normal eye) is
  done to restore strength and function of the
  lazy eye

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Strabismus

• Nonparallelism in the different fields of gaze
  causing visual lines to cross even when focused
  on the same object
• Correction
• Ocular patching of the stronger eye, glasses, and
  pharmacotherapy
• Early identification and recognition

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Color Blindness

• X-linked recessive inheritable color vision
  deficiency
• Color blindness is detected using colored charts
  called the Ishihara Test plates
• Child can learn to compensate with support from
  family members, teachers, and friends

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Nystagmus

• Rapid irregular involuntary eye movement caused
  by a disorder of the central nervous system
• Correction
• Extraocular surgery

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Cataracts

• Signs and symptoms
• Excessive tearing, extraocular movements,
  photophobia, lens appears cloudy, or there is a
  white or dulled red reflex
• Correction
• Prevent loss of visual acuity
• Laser procedure
• Postoperative (monitor nausea, emesis, pain,
  hemorrhage and signs of infection)
• Postoperative eye drops
• Follow-up care for visual acuity
• Educate family
• Early identification and recognition

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Glaucoma

• Increase in IOP leads to retinal and optic nerve
  damage
• Signs and symptoms
• Bupthalmos (enlarged eye globe), epiphora
  (excessive tearing), and photophobia (sensitivity
  to light)
• Correction
• Preoperative maintain quiet environment
• Antiglaucoma medications
• Analgesia and anxiety reduction strategies
• Pre- and postoperative care (teach parents)

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Retinoblastoma

• Signs and symptoms
• Absence or abnormality of the red reflex
• A whitish or yellow color of the pupil called
  leukocoria
• Correction
• Laser, radiation, cryotherapy, or enucleation

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Eye Injuries
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Foreign Bodies

• Penetration
• Immediate transport to ER for removal
• Corneal abrasion
• Treatment
• Topical antibiotic solutions or ointments,
  analgesics, eye patch

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Hyphema

• Hemorrhage into the anterior chamber of the eye
• Treatment
• Rest, possible evacuation
• Monitor increased intraocular pressure
• Promote decreased activity
• HOB 30
• Patch both eyes

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Chemical burns

• Usually occur as a result of an accident
• Treatment
• Rapid eye flushing for 15 to 30 minutes followed
  by pH analysis of the chemical agent
• Eye patching

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Hearing Loss
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Hearing Loss

• Causes
• 1/3 of all cases are due to genetic causes
• 1/3 of all cases are due to non-genetic
  influences
• 1/3 of all cases are due to unknown causes

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Hearing Loss

• Diagnostic testing
• Universal infant hearing screening before 1 month
  of age is recommended
• Treatment
• Based on underlying pathologic conditions,
  presence of organic diseases, the severity of
  hearing loss, the degree of frequency loss, and
  any CNS abnormalities
• Amplification aids (hearing aid)
• Nursing care
• Provide emotional, educational, and collaborative
  support for the child and family

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Language Disorders

• Communication
• A process of complex interaction involving the
  exchange of information, feelings, ideas, and
  interactions
• Receptive language
• Expressive language
• Nursing care
• Recognize speech and language developmental delays

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