Care of Children Experiencing Alterations in Neurologic Function Marydelle Polk, Ph.D., ARNP-CS Florida Gulf Coast University

Objectives  Review and understand basic anatomy and physiology of the neurological system.  Review and use assessment skills to identify adaptive/non-adaptive behaviors that may be exhibited by the pediatric client.  Utilize lab/diagnostic data to enhance your nursing assessments.

Objectives…con’t.  Review the pathophysiological processes that occur with examples of neurologic deficits: * Cerebral Palsy * Epilepsy * Spina Bifida * Hydrocephalus

Objectives…con’t.  Identify common nursing diagnoses that can be drawn after an assessment of a pediatric client with alteration in neurologic function.  Identify and specifically describe nursing coventions for a pediatric client with alteration in neurologic function.  Describe means of evaluation of nursing coventions that correlate with medical orders and interventions for a pediatric client with alteration in neurologic function.

Article: McDonald, M.E. (1997). Use of the ketogenic diet in treating children with seizures. Pediatric Nursing, 23(5),

Hydrocephalus  A condition in which the normal circulation of the spinal fluid is interrupted, resulting in increased pressure on the brain, deformity, and progressive enlargement of the head.

Hydrocephalus  CSF formed in the chorcoid plexuses  to lateral ventricles  Foramen of Monro  3 rd ventricle  Aqueduct of Sylvius into 4 th ventricle  into the Cisterna Magna  to the cerebral and cerebellar subarachnoid spaces – and is absorbed.

Causes of Hydrocephalus  Impaired absorption of CSF via the SAS (communicating hydrocephalus)  Obstruction of CSF through the 3 rd and 4 th ventricles (noncommunicating hydrocephalus)

Remember…  Hydrocephalus is often a sequalae of other developmental defects – most common is Spina Bifida and/or myomeningocele

Clinical Manifestations  Head enlargement  Bulging fontanels w/o head enlargement  Dilated scalp veins  “Cracked-pot” percussion sound  Abnormal eye position (P  RLA)  Neurological changes

Diagnostic Tests  MRI  CT  EEG, echoencephalography,  Ventriculograms

Treatment Depends on the Cause of the Increased Pressure.  Removal of part of choroid plexus to  production of CSF.  Shunting of the fluid out of the brain to the heart or to the peritoneal cavity.

Surgical Management  Ventriculoperitoneal (VP) shunt  Ventriculoatrial (VA) shunt

Preoperative Care  Prevent pressure sores on head by changing child’s position, placing child’s head on sheepskin, or by holding the infant.  Provide good head support when the child is sitting in a Fowler’s position.

Preoperative Care  Promote optimal nutritional status.  Keep eyes free of irritation.

Major Complications  Malfunction -  ICP  Infection  Brain Abscess  Subdural hematoma

Nursing Diagnoses  Risk for head trauma r/t impaired cerebrospinal fluid absorption.  Risk for infection r/t presence of infective bacterial organisms

Nursing Coventions  Frequent occipitofrontal circumference (OFC)  Frequent LOC  Frequent fontanel checks  Close monitoring of VS, NVS, and feeding patterns  Keep flat after surgery unless  ICP  Monitor Intake and Output

Postoperative Nursing Care  Observe for shunt malfunction and valve patency: watch for progressive increase in head circumference and s/s of  ICP.  Observe for infection:  Position child flat on the un-operative side.

Postoperative Nursing Care  Prevent postoperative complications: turn q 3-4 hours, evaluate lung sounds, and assess for signs of infections.  Protect the operative site: avoid pressure on the site; ensure sterile dressing changes.

Spina Bifida  The failure of the posterior portion of the lamina of the bony spine to form, which causes an opening in the spinal column.

Actions are Dependent on Severity of Condition  Neurological Interventions  Urological Interventions  Orthopedic Interventions

Actions are Dependent on Severity of Condition  Neurological Interventions + Observe for s/s of hydrocephalus + Measure head circumference daily + Observe for s/s of  ICP

Actions are Dependent on Severity of Condition  Urological Interventions + If child is catheterized, use sterile technique + Keep a careful record of I/O + Observe for s/s of urinary tract infection

Actions are Dependent on Severity of Condition  Orthopedic Interventions + Provide opportunities for the child to exercise and develop unaffected areas. + Prevent contractures through proper positioning.

Epilepsy  A series of seizures that result from focal or diffuse discharges in the cortical neurons – symptoms of abnormal brain function

Epilepsy – Types  Partial Seizures + Simple Partial + Complex Partial  Generalized Seizures + Absence + Tonic-Clonic + Myoclonic

Epilepsy – Nursing Care  Prevent injury during a seizure  Observe and document seizure pattern  Administer and monitor medications  Administer post-seizure procedures

Epilepsy – Nursing Care  Prevent injury during a seizure.

Epilepsy – Nursing Care  Observe and document seizure pattern.

Epilepsy – Nursing Care  Administer and monitor medications.

Epilepsy – Nursing Care  Administer post-seizure procedures

Cerebral Palsy (CP)  A group of disorders used to describe a group of disorders characterized by motor and postural impairments – due to abnormal muscle tone. CP may also involve language, perceptual and intellectual deficits. It is the most common permanent physical disability of childhood, occurring in approximately 2/1000 live births.

Cerebral Palsy (CP)  Interventions – multi-faceted * Depends on the particular manifestations of the disease. * The child’s capacities.

Cerebral Palsy (CP)  Classification of CP * Spastic * Dyskinetic/athetoid * Ataxis * Mixed types

Cerebral Palsy (CP)  Major Focus of Interventions * Develop motor control * Develop communication skills * Provide adequate nutrition * Prevent orthopedic complications.