Neurological Disorders in the Pediatric Patient

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Neurological Disorders in the Pediatric Patient

• Presented by Marlene Meador RN, MSN

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Neurological System of Children

• Top Heavy
• Cranial bones- thin, not well developed
• Brain highly vascular with small subarachnoid
  space
• Excessive spinal mobility
• Wedge-shaped cartilaginous vertebral bodies

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Etiology and Pathophysiology
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Altered Mental StatusMnemonic Mitten

• Metabolic
• Infections
• Toxins
• Trauma
• Endocrine
• Neurological/Neoplasm

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Neurological Assessment

• Vital Signs
• Eyes
• Behavior
• Respiratory Status
• Motor Function
• Skin
• Childrens Coma Scale

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AssessmentInfant

• Irritability and restlessness
• Full to bulging fontanelles
• Increase in FOC
• Poor feeding, poor sucking, projectile vomiting
• Distension of superficial scalp veins
• Nuchal rigidity and seizures (late signs)

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AssessmentChild early signs-

• Irritability, lethargy
• Sudden change in mood
• Headache
• Vomiting
• Ataxia
• Nuchal rigidity
• Deterioration of cognitive ability

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Assessment ChildLate signs

• Changes in Vital signs
• Seizures
• Photophobia
• Positive Kernigs sign
• Positive Brudzinskis sign
• Opisthostonos

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Therapeutic Intervention Nursing care

• Medications
• Corticosteroid (decadron)
• Osmotic diuretic (Manitol)

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Nursing Care

• Minimize activity
• Monitor IV rate
• Place in semi-fowlers
• Monitor VS, Neuro VS, and behavior
• Treat for pain
• Organize care
• Educate parents

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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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Meningitis

• Bacterial Meningitis
• Vs.
• Viral Meningitis

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Bacterial Meningitis

• Potentially Fatal

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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 Young Children
• Fever not always present
• Lethargy
• Alterations in sleep and feeding habits
• Nuchal rigidity (late sign)

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Assessment

• Childhood Adolescence
• Hyperthermia
• SS of IICP

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Complications of Meningitis

• IADH
• Intravascular coagulation with thrombocytopenia
• CSF obstruction
• Nerve Damage

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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

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Nursing Care

• Assess
• Antibiotic therapy
• Monitor lab values
• Strict IO
• Isolation
• Monitor FOC

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Nursing Care cont...

• CSF culture
• Temperature control
• Seizure activity
• Environment
• Planning
• Education

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Hydrocephalus

• Hydro Water
• Cephaly of the head/brain

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Etiology and Pathophysiology

• Congenital anomalies
• Trauma
• Unknown causes

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Types of Hydrocephalus

• Non-communicating or Obstructive
• Communicating

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Clinical Manifestations

• Infants- prior to fusion of cranial sutures
• FOC
• Changes in assessment of skull
• Forehead
• Eyes
• Behavior changes

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Clinical Manifestations

• After closure of cranial sutures
• Eyes
• S S of IICP

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Diagnostic Tests

• LP
• MRI/ CT scan
• Skull X-ray
• FOC
• Transillumination

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Interventions Surgical

• Shunting to bypass the point of obstruction by
  shunting the fluid to another point of absorption

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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
• Education

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Critical Thinking

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

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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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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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Surgical Intervention

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

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Nursing Interventions

• Pre-OP
• Place in prone position
• Sterile moist dressing with normal saline or
  antibiotic solution
• Maintain proper abduction of legs and alignment
  of hips
• 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
  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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Cerebral Palsy (CP)

• 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

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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)

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Assessment cont...

• Alterations in muscle tone
• Abnormal resistance
• Keeps legs extended or crossed
• Rigid and unbending
• Abnormal posture
• 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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Complications

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

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Goals Interventions

• Early detection

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Mental Retardation

• Significant sub average, general intellectual
  functioning existing concurrently with deficits
  in adaptive behavior and manifested during the
  developmental period.
• American Association of Mental Deficiency

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Down Syndrome

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

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Assessment

• See syllabus
• Primary concern with cardiac and GI anomalies
• What are the most obvious indications of Downs
  Syndrome in a newborn?

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Goals and Interventions

• Primary focus on the parents and care givers to
  provide support and achieve a realistic view of
  the childs capabilities
• Support siblings
• Refer to family counseling services
• Support parents in feelings of guilt and chronic
  sorrow

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Hyperfunction/Hypofunction

• Pediatric Seizures
• Febrile seizures- occur as a result of rapidly
  increasing core temperature (101.8 F 38.8C)
• General seizures- occur as a result of insult of
  the nervous system

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Clinical Manifestations

• Tonic-clonic- absence seizures, minor
  motor-atonic
• Partial seizures- partial simple or partial
  complex

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Diagnostic Tests

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

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Jitteriness vs- Seizure

• Jittery
• Responsive
• Gaze Okay

• Seizure
• Not responsive to stimuli
• Abnormal gaze

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Goals

• Primary focus to identify the cause and
  eliminate the seizure with minimum side effects
  using the least amount of medication while
  maintaining a normal lifestyle for the child.

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Interventions

• Febrile seizures
• Seizure precautions
• During seizure activity
• Education

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Autism

• Most severe pervasive developmental disorder of
  childhood. Moderate to severely incapacitating
  with lifelong developmental disabilities
• Etiology/Pathophysiology
• Cause unknown
• Possible genetic or prenatal hypoxic event

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Clinical Manifestations of Autism

• Developmental disturbances of verbal and social
  language skills
• Abnormal response to sensation/stimuli
  (difficulty distinguishing self from environment)
• Repetition of self-stimuli
• May have savant capabilities
• Does not show pain with injuries
• Dependent on severity of condition

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Diagnosis

• Extensive and thorough interview of family
  regarding behaviors
• Behaviors classically begin before age 3
• Direct observation of child

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Nursing Care of Hospitalized Child with Autism

• Attempt to maintain childs daily routines from
  home- very ritualistic
• Work closely with family to decrease anxiety
• Provide for the childs safety-particularly if
  ritual self stimulation is potentially harmful
  (head banging, biting)

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Shaken Baby Syndrome

• Intracranial retinal bleeding
• Physical abuse causing a whip-lash induced trauma
  to the childs brain

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Nursing Interventions

• Assessment- observe for SS of
• Hemorrhage to sclera
• Apnea
• Seizures
• Respiratory irregularities
• Increased intracranial pressure (ICP)
• Drowsiness or lethargy

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Long Term Prognosis

• Complete recovery is rare
• Mental retardation
• Cerebral Palsy
• Death

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Legal Implications

• Nurses must report suspected child abuse to
  Child Protective Services (CPS).
• It is not your obligation to prove the abuse you
  must report any suspicion. CPS will document and
  follow through on the case
• rememberthe abuser may not be the person you
  suspect, and disclosure to the wrong individual
  may endanger the child.

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• Please contact me with any further questions.
• Marlene gt,,lt
• mmeador_at_austincc.edu