Neurological Disorders in the Pediatric Patient Presented by Marlene Meador RN, MSN, CNE

Review of CNS of the Pediatric Patient Head to torso ratio Cranial bones- thin, pliable, suture lines not fused Brain vascularity and small subarachnoid space Excessive spinal mobility Wedge shaped cartilaginous vertebral bodies

Neurological Assessment: LOC & behavior Vital Signs and respiratory status Eyes Reflexes and motor function Cranial nerve function (p 842 table 33-4) page 1467 discuses Modified Glasgow Coma Scale for ages 3 and younger ( p 1469, table 52-1)

Increased Intracranial Pressure- IICP or ICP (p 1468, Box 52-1) Infants Irritability & restlessness Fontanelles / FOC Poor feeding/sucking Skull & scalp veins Nucal rigidity, seizures (late signs) Children Headache Vomiting Irritable, lethargic, mood swings Ataxia, spasticity Nucal rigidity Deterioration in cognitive ability Vital sign changes

Priority nursing diagnosis for a child with IICP? What assessment findings should the nurse monitor? What emergency equipment should the nurse have on hand at all times for a child with IICP?

Nursing interventions: What diagnostic procedures would the nurse anticipate for this child? What priority interventions must the nurse include with respect to these diagnostic procedures? What specific teaching is required? What additional lab/serum tests would you anticipate?

Medications used to treat IICP: Corticosteroids Anti-inflammatory Contraindications-acute infections Monitor I&O Protect from infection Add K+ foods Discontinue gradually Osmotic diuretic Reduce fluid Contraindications- intracranial bleeding Monitor I&O carefully Monitor electrolytes Teaching

Quick Review: Priority nursing interventions/ rationale What equipment is essential? Vital signs & neuro signs Additional assessment findings Activity level Hydration status Positioning Parent teaching

Pediatric Seizures

International Classification of Seizures ( p 1489 Box 52-5) Febrile- rapid temp rise above 39°C (102°F) Generalized- loss of consciousness, involves both cerebral hemispheres onset at any age Tonic/Clonic- impaired consciousness, abnormal motor activity, posturing, automatisms Absence- may confuse with daydreaming or inattentiveness

Diagnostic Tests: EEG CT, MRI Lumbar puncture CBC Metabolic screen for glucose, phosphorus and lead levels

Nursing Interventions: Assessment findings Priority interventions Prevention During seizure Following seizure p 1490 Nursing Care Plan

Medications used to control seizures in children Phenobarbital- CNS depressant- monitor: sedation, VS, serum levels, Teach- S&S of toxicity, no ETOH, adhere to regime Carbamazepine- sedative/anticonvulsant hold med if lab values = Teach- S&S of toxicity Phenytoin- anticonvulsant Safety measures- on-hand equipment Teach- oral care, sun exposure

Quick Review: What is most important nursing intervention when a child is experiencing a seizure? What is most important teaching regarding seizure medication?

Meningitis

Meningitis Bacterial Potentially fatal; abx given prophylactically if bacterial suspected. May kill within 24 hrs C/S take 72 hrs to process Infants at greatest risk Nuchal rigidity Severe headaches Contagious Viral Same s/s but milder and shorter duration May follow a viral infection May be accompanied by rash Nuchal rigidity Ataxia Not contagious

Meningitis: Why does bacterial meningitis present more of a risk than viral meningitis? (p. 1494) How do the manifestations of meningitis differ between infants and young children (p. 1494)

Meningitis: Infant Child/Adolescent Fever Headache Photophobia Nuchal rigidity Altered LOC Anorexia/ vomiting Diarrhea Drowsiness Fever (not always present) Poor feeding Vomiting Irritability Seizures High-pitched cry

Lumbar Puncture- nursing interventions What findings differentiate between bacterial and viral meningitis? What specific interventions does the nurse include for this procedure? Monitor VS & neuro VS LOC Teaching

Nursing Care & Medications for treatment of meningitis: Ceftriaxone Sodium (Rocephin®)- who must receive this medication? Cefatoxime Sodium (Claforan ®)- Dexamethasone- special nursing care Antipyretics

Clinical Judgment: What intervention must the nurse initiate to protect the patients and staff when a diagnosis of bacterial meningitis is suspected?

Cephaly= of the head/brain Hydrocephalus Hydro= Water Cephaly= of the head/brain

Hydrocephalus: What priority nursing assessment of a newborn monitors for this condition? What assessment findings occur in the older child? What diagnostic measures confirm this diagnosis?

Diagnostic of Hydrocephaly: LP-dangerous MRI; CT scan Skull X-ray Measure FOC Provide for safety, informed consent, support for child and family, accurate H&P (added 2010)

Correction of Hydrocephaly: Shunt placement- surgical procedure to place a tube that drains CSF into the atrioventricular or peritoneal cavity. Atrioventricular- drains into atrium (not used as frequently) Ventricular peritoneal- drains into the peritoneal cavity

Nursing Care: Pre Operatively: Post-op: Baseline VS, monitor for IICP, What teaching/interventions for parents? Post-op: Monitor shunt function (how?) Positioning and activity VS, neuro VS & I&O Teaching

Long Term Nursing Care for the child with hydrocephaly Home care needs S&S of IICP S&S of infection S&S of seizures Emergency numbers of Pediatrician & neurosurgeon Refer to home care, social services and support groups

Spina Bifida

Spina Bifida Most common defect of the CNS Occurs when there is a failure of the osseous spine to close around the spinal column.

Spina Bifida: (see p 1470) Spina bifida occult Meningocele What common nutritional supplement is encouraged for all women of childbearing age? Discuss the 3 types of neural tube defects: Spina bifida occult Meningocele Meningomyelocele

Spina Bifida

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

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 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

Priority nursing diagnosis and interventions: At risk for infection- Protect Position At risk for injury- 38

Cerebral Palsy

Nursing care of the child with Cerebral palsy: (p.1477) 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 posture 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 of CP Increased incidence of respiratory infection Muscle contractures Skin breakdown Injury

What is the priority nursing goal for a patient with cerebral palsy (CP)?

Head Injuries

Head injuries in the Pediatric Client Anatomy predisposes infant/young to injury Pathophysiology of “Shaken Baby Syndrome”

Nursing care of child experiencing a closed head injury: (p 1483) Assessment findings- Immediate nursing interventions- Legal implications Why is it not prudent for the nurse to discuss suspicions of abuse with the parents or primary caregiver?

Autism

Autism Not clearly understood Characterized by impaired social, communicative, and behavioral development Usually noted in the first year of life

Pervasive Developmental Disorders / Autism (p. 1549) Home Setting Reduce environmental stimuli Communicate via age-appropriate touch & verbalization Keep toys or other items out of reach if child uses them for harmful self-stimuli Ritualistic ADLs Encourage therapists & support groups Acute Care Setting Keep at least 1 constant caregiver. Encourage parents to stay with,keep room quiet & limit number of staff Anxiety/aggression when touched by strangers Constant monitoring by nurse or parents Allow to maintain rituals of ADLs Encourage therapists & support groups

Downs Syndrome

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

What are some of the identified causes of Down syndrome? Failure of chromosomes to separate Advanced maternal age No other socio-economic or geographic factors have been identified

Assessment Primary concern with cardiac and GI anomalies What are the most obvious indications of Down’s Syndrome in a newborn

How does the nurse promote health of the child with Down’s syndrome? Health Promotion How does the nurse promote health of the child with Down’s syndrome? 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

For questions or concerns Contact Marlene Meador RN, MSN, CNE Email: mmeador@austincc.edu