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

2. 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

3. 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)

4. 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

5. 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?

6. 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?

7. 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

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

9. Pediatric Seizures

10. 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

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

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

13. 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

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

15. Meningitis

16. 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

17. 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)

18. 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

19. 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

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

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

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

23. 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?

24. 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)

25. 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

27. 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

28. 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

29. Spina Bifida

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

31. 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

32. Spina Bifida

33. 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

34. Surgical Intervention
Immediate surgical closure
Prior to closure keep sac moist & sterile
Maintain NB in prone position with legs in abduction preoperatively

35. Nursing Interventions:
Pre-OP:
Meticulous skin care
Protect from feces or urine
Keep in isolette

36. Post-Op Nursing Interventions
Assess surgical site
Monitor VS and neuro VS
Institute latex precautions
Encourage contact with parents/care givers
Positioning
Skin Care

37. Nursing Interventions cont...
Antibiotic therapy
Prevent UTI
Education
Emphasize the normal, positive abilities of the child

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

39. Cerebral Palsy

40. 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

41. 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)

42. 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)

43. Diagnostic Tests: EEG, CT, or MRI
Electrolyte levels and metabolic workup
Neurologic examination
Developmental assessment

44. Complications of CP Increased incidence of respiratory infection
Muscle contractures
Skin breakdown
Injury

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

46. Head Injuries

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

48. 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?

49. Autism

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

51. 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

52. Downs Syndrome

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

54. 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

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

56. 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

57. For questions or concerns
Contact Marlene Meador RN, MSN, CNE