Neurological Disorders in the Pediatric Patient

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Pediatric Neurological Disorders
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Increased Intracranial Pressure
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Increased Intracranial Pressure (IICP)

• What is it?
• Increased ICP results from a disturbance in the
  auto-regulation of the pressure exerted by the
  blood, brain, cerebrospinal fluid, and other
  space-occupying fluid/mass within the central
  nervous system.
• Increased ICP is defined as pressure sustained at
  20 mm Hg or higher.
•  

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Increased Intracranial Pressure
What Causes it?

• Overproduction or malabsorption of CSF
• Space occupying lesion tumor, hematoma
• Head Trauma
• Infection

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Clinical Manifestations Infant

• Irritability and restlessness high-pitched cry
• Full to bulging fontanels Increase in FOC
• Poor feeding, poor sucking
• Prominence of frontal portion of the skull with
  distension of superficial scalp veins
• Nuchal rigidity
• Nonreactive unequal pupils
• Seizures (late sign)

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Clinical Manifestations Child

• Headache
• Visual disturbances - diplopia
• Nausea and Vomiting
• Dizziness or vertigo
• Irritability, lethargy, mood swings
• Ataxia, lower extremity spasticity
• Nuchal rigidity
• Deterioration in school performance, or cognitive
  ability

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Severe Manifestations of IICP

• Widened pulse pressure
• Bradycardia
• Irregular respirations
• Abnormal Posturing
• Decorticate
• (rigid flexion)
• Decerebrate
• (rigid extension)

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Diagnosis

• Blood studies
• CT or MRI
• EEG
• Lumbar puncture may or may not be done
• 
  Why?

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Therapeutic Intervention and Nursing care

• Medications
• Corticosteroid (Decadron)
• Osmotic diuretic (Mannitol)
• Sedation

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Nursing Care

• Try to keep coughing, sneezing, vomiting to a
  minimum
• When burping infant do not put pressure on the
  jugular vein
• Monitor IV rate administration
• Place child in semi-fowlers position
• Monitor VS, Neuro VS, behavior
• Assess for increases in ICP
• Assess IO, Maintain optimal hydration
• Decrease stimuli, decrease pain or crying with
  activities
• Organize care, Educate parents

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Ask Yourself

• What B/P would indicate a neurological problem?

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Review

• What emergency equipment should the nurse have on
  hand at all times for a child with IICP?

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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?

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Spina Bifida Meningocele Meningomyelocele
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Spina Bifida

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

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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.

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What nutritional supplement is encouraged for
women during childbearing age?

• Folic Acid
• Why?
• To prevent neural tube defects

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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

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Diagnostic Tests

• Prenatal detection
• Ultrasound
• Alpha-fetoprotein
• Following Birth
• NB assessment
• X-ray of spine
• X-ray of skull

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Goals of Care

• Prevention of Injury to the sac
• Spontaneous rupture
• Ulceration of sac
• Prevention of Infection

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Surgical Intervention

• Immediate surgical closure
• Prior to closure keep sac moist sterile
• Maintain NB in prone position with legs in
  abduction preoperatively

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Nursing Interventions

• Pre-OP
• Meticulous skin care
• Protect from feces or urine
• Keep in isolette

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Post-Op Nursing Interventions

• Assess surgical site
• Monitor VS and neuro VS
• Institute latex precautions
• Encourage contact with parents/care givers
• Positioning
• Skin Care

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Nursing Interventions cont...

• Antibiotic therapy
• Prevent UTI
• Education
• Emphasize the normal, positive abilities of the
  child

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Critical Thinking

• Would you expect a 5-year-old with repaired
  meningomyelocele to have bladder/bowel sphincter
  control?
• Which type of neural tube defect is most likely
  to have no outward signs or symptoms?

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Hydrocephalus
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Etiology and Pathophysiology

• Imbalance between the production and absorption
  of cerebral spinal fluid causing
• Accumulation of fluid in the ventricles

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Clinical Manifestations

• Infants
• Increase in FOC
• Frontal enlargement or bossing
• Head larger than face
• Translucent skin
• Wide palpable suture lines
• Bulging Fontanels
• Eyes -wide bridge between
• Behavior changes

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Clinical Manifestations

• Children
• Depressed eyes strabismus
• Setting Sun Eyes
• Pupils sluggish, with unequal response to light
• Headache with nausea and vomiting that may be
  projectile
• S S of IICP

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Diagnostic Tests

• MRI/ CT scan
• Skull X-ray
• FOC
• Transillumination
• lumbar puncture very dangerous and usually NOT
  done

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Goal of treatment

• Prevent further CSF accumulation
• Reduce disability and death
• Bypass the blockage and drain the fluid from
• the ventricles to an area where it may be
  reabsorbed into the circulation

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Interventions Surgical

• Ventricular endoscopy or laser
• Shunting to bypass the point of obstruction by
  shunting the fluid to another point of absorption
• Atrioventricular
• Ventricular peritoneal

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Complications of Shunts

• Infections
• Blocked shunts
• Seizures

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Nursing Interventions

• Monitor VS and neurological status
• Assess functioning of the shunt
• Assess operative site
• Assess for infection
• Positioning of the patient
• Activity of patient
• Promote nutrition
• Avoid constipation
• Education
• Wear helmet

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Critical Thinking

• What is the most important assessment data on a
  infant who has just had a shunt placement for
  hydrocephalus?
• What is the most important teaching for the
  parents or caregivers?

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Cerebral palsy
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Cerebral Palsy (CP)

• What is it?
• Non-progressive disorder of upper motor neuron
  impairment that results in impaired movement and
  posture
• Characterized by abnormal muscle tone and
  coordination

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Factors associated with Cerebral Palsy

• Preterm
• Birth asphyxia
• Low Apgar
• Poor feeder
• Weak cry as a newborn
• Shaken baby syndrome
• Intrauterine anoxia placental perfusion
  decreased

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Assessment

• Determining diagnosis or extent of involvement in
  an infant can be difficult may be recognizable
  only when child is older and attempts more
  complex motor skills, such as walking
• 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)
• Abnormal newborn reflexes prolonged

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Assessment

• Alterations in muscle tone
• Abnormal resistance
• Keeps legs extended or crossed
• Rigid and unbending
• Abnormal posture
• Do not crawl on knees, scoot on back
• When try to walk, walk with toes first as in
  plantar flexion
• Scissoring and extension (legs feet in plantar
  flexion)
• Persistent fetal position (gt5 months)

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Diagnostic Tests

• EEG, CT, or MRI
• Electrolyte levels and metabolic workup
• Neurologic examination
• Developmental assessment

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Nursing Care

• Prevent injury and provide safety

• Maintain Mobility and Prevent disuse
• Maintain nutrition
• Maximize Communication ability
• Maintain Growth and Development

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Complications

• Increased incidence of respiratory infection
• Muscle contractures
• Skin breakdown
• Injury

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Head Injuries
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Shaken Baby Syndrome

• The subdural vessels are torn as the brain moves
  within the skull, as the brain moves over the
  skull floor bruising occurs, and the brain stem
  my become herniated with direct trauma

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Shaken Baby Syndrome

• Maintain airway to prevent hypoxia and further
  brain damage
• Nurse must report to child protective service
• Nursing care of a child with a brain injury is
  similar to care of child with IIP

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Seizure Disorders
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Seizures

• What are they?
• Brief convulsive behavior caused by abnormal
  discharge of neurons.
• The result of these discharges is involuntary
  contraction of muscles
• When numerous nerve cells fire abnormally at the
  same time, a seizure may result.

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Clinical Manifestations of General Seizure/
Tonic - Clonic

• Onset is abrupt. Usually less than 5 minutes
  duration
• Tonic Phase
• - Usually lasts 10-20 seconds
• - Child loses consciousness
• - Jaw clenches shut, abdomen and chest become
  rigid and may emit a cry or grunt as air is
  forced through the taut diaphragm.
• - Pale
• - Eyes roll upward or deviate to one side.
• - Arms flexed legs, head, neck extended
• - increased salivation and loss of swallowing
  reflex

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Clinical Manifestations of General Seizure/
Tonic - Clonic

• Clonic Phase
• Violent jerky movements as the trunk and
  extremities undergo rhythmic contraction and
  relaxation
• Respirations are irregular and may have stridor
• May foam at the mouth
• Incontinent of urine and feces
• Afterwards
• Drowsy and sleep afterwards

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Jitteriness vs- Seizure

• Jittery
• Responsive
• Gaze Okay

• Seizure
• Not responsive to stimuli
• Abnormal gaze

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Diagnostic Tests

• EEG
• CT, MRI
• Lumbar puncture
• CBC
• Metabolic screen for glucose, phosphorus and lead
  levels

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Goal of Care Maintain Patent
Airway Ensure Safety Administer
medications Emotional support
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What Preventive Measures does the nurse Provide?

• Padded side rails, helmets to protect head
• O2 Setup and Suction equipment at bedside
• Rectal /tympanic temperatures
• Interventions during a seizure
• Remain Calm
• Clear environment and make safe
• Maintain airway
• Do not attempt to restrain
• Turn to side
• Stay at the bedside and call out/emergency button
  for a nurse to assist you immediately

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How does the nurse maintain the airway during a
seizure

• Roll to the side
• Loosen clothing around neck
• Do NOT place anything in the mouth during a
  seizure
• May give oxygen
• Do not put fingers in the patients mouth

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What is the priority intervention following a
seizure?

• Notify primary care provider
• Provide emotional support
• Reposition, provide for sleep and rest
• Reorient to what has happened
• Document

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Seizure Medications

• Phenobarbital
• Carbamazephine (Tegretol)
• Phenytoin (Dilantin)
• Diazepam (Valium) used mainly for status
  epilepticus
• Know nursing implications for each

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Meningitis
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Meningitis
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Bacterial Meningitis

• potentially Fatal
• Caused by
• Streptococcus
• Neisseria meningitides
• E coli
• What is it?
• Bacteria enters blood stream, CS fluid, and
  brain causing an inflammatory response. Body
  sends WBC and they accumulate over surface of
  brain causing purulent exudates

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Viral Meningitis

• Same signs and symptoms, may be milder and
  self-limiting. Usually lasts a few days

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Assessment

• Infants
• Fever (not always present)
• Lethargy
• Alterations in sleep and feeding habits
• Fussy and irritable
• Nuchal rigidity (late sign)
• Bulging fontanel
• High pitched cry

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Assessment

• Childhood Adolescence
• Hyperthermia
• SS of IICP
• Nausea and vomiting
• Headache
• Seizures
• Photophobia

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Signs of Meningeal Irritation

• Headache
• Photophobia
• Nuchal Rigidy
• Opisthotonic position
• Positive Kernigs sign
• Postive Brudzinskis sign

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Diagnostic Tests

• Lumbar Puncture
• Serum Glucose Level
• Blood Cultures

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Therapeutic Interventions Mediation Therapy

• Antibiotics
• Ampicillin
• Claforan
• Rocephin
• Dexamethasone
• Antipyretics

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Nursing Care

• Place on Respiratory Isolation until on
  antibiotics for 24 hours
• Assess vital signs and behavior
• Antibiotic therapy
• Monitor lab values
• Strict IO
• Monitor FOC
• Bedrest do not flex neck
• Comforting they are very irritable

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Downs Syndrome

• Trisomy 21- the most common chromosomal
  abnormality resulting in mild to profound
  intellectual Disability

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Down syndrome

• Clinical Manifestations
• Congenital anomalies cardiac and GI tract
• Flat facial features, nose broad and flat
• Low set ears
• Upward slanting eyes
• Prominent epicanthial folds
• Short hands with simian crease
• Hypotonia
• Neck short with extra fat pad
• Usually sterile

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Health Promotion

• How does the nurse promote health of the child
  with Downs syndrome?
• Initial assessment of newborn
• Parental perception (focus on the positive)
• Initiate long-term assistance
• Speech
• Occupational
• Nutritional
• Financial assistance