Neurological Stressors and Adaptation

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NeurologicalStressors and Adaptation
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Common Neurological Disorders in Children

• Neural Tubes Defects
• Hydrocephalus
• Bacterial Meningitis
• Guillain-Barre Syndrome
• Reyes Syndrome
• Seizures

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Neural Tube Disorders

• Defects of closure of neural tube during fetal
  development
• Congenital (present at birth)
• Believed to be caused by genetic or environmental
  factors, but exact etiology is unknown
• Common in women with poor folic acid intake
  before and during pregnancy

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Nursing Implications

• Advise all women to adhere to routine
  screening/diagnostic testing
• Advise all women capable of becoming pregnant to
  consume
• 0.4 mg of folic acid daily

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Neural Tube Disorders

• Types
• Spina Bifida
• Occulta
• Cystica
• Meningocele
• Myelomeningocele

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Spina Bifida

• Most common CNS defect
• Caused by failure of neural tube to close at some
  point along spinal column
• Types
• spina bifida occulta
• spina bifida cystica

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Spina Bifida Occulta

• Not visible externally
• Lamina fail to close but spinal cord does NOT
  herniate or protrude through the defect
• No motor or sensory defects

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Spina Bifida Cystica

• Meningocele
• External sac that contains meninges and CSF
• Protrudes through defect in vertebral column

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Meningocele

• Not associated with neurologic deficit good
  prognosis
• Hydrocephalus may be an associated finding, or
  aggravated after repair

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Spina Bifida Cystica

• Myelomeningocele
• Same as above, but the spinal cord and meninges
  protrude through the defect in the bony rings of
  the spinal cord
• Contains nerves therefore the infant will have
  motor and sensory deficits below the lesion

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Myelomeningocele

• Visible at birth, most often in the lumbaosacral
  area
• Covered with a very fragile thin membrane/sac
  which can tear easily, allowing CSF to leak out

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Nursing Interventions

• Protect the sac from injury
• Keep free from infection
• Position prone or side lying
• Cover sac with sterile, moist non-adherent
  dressing, sterile technique imperative
• Parents need emotional support education
  regarding short and long term needs of infant
• Surgical shunting may be necessary

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Nursing Interventions

• Surgical repair usually within first 24 hours
• 90 develop hydrocephalus
• MUST observe for early signs of infection
  elevated temp, irritability, lethargy, nuchal
  rigidity
• MUST observe for signs of increasing ICP (may
  indicate hydrocephalus)

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Habilitation

• Emphasizes constructive use of normal parts of
  body minimizes the disabilities making the
  child as self-helpful as is possible in the
  activities of daily living
• Major problems incontinence, constipation,
  obesity or malnutrition

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Hydrocephalus

• Ventricles of the brain are enlarged as a result
  of an imbalance between the production and
  absorption of CSF
• Often occurs in conjunction with myelomeningocele
  which blocks the flow of CSF
• Can lead to irreversible neurological damage

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INFANT Hydrocephalus Early signs symptoms

• Projectile vomiting not associated with feeding
• Scalp veins become prominent
• Shrill, high pitched cry
• Increasing irritability

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Infant Hydrocephalus Later signs symptoms

• Bulging anterior fontanel and a head
  circumference that increases at an abnormal rate
• Enlargement of the forehead
• Depressed eyes rotated downward sunset eyes
  (pupils sink downward)

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Hydrocephalus Signs symptoms in older Child

• No enlargement of head (skull is closed)
• Begins with generalized neuro symptoms
• Followed by signs of increased ICP

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Relief of hydrocephalus

• VP shunt placement to bypass the obstruction
• Needs replaced PRN

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Pre-op for Shunt Placement

• Observe for increasing ICP
• Daily head circumferences
• Maintaining adequate nutrition with flexible
  feeding schedule offering small feedings at
  shorter intervals
• Sedate child prn for procedures (MRI, CT)
• Support head when feeding or moving

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Post-op Nursing Care Shunt Placement

• Keep child flat unless ICP is present the bed
  slightly elevated
• Pain management
• Observe for signs of increasing ICP neurologic
  assessment
• Observe for abdominal distention
• Strict I O
• Antibiotics
• Meticulous skin care
• Support family

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Discharge Management Post Shunt Placement

• Treatment of shunt complications meningitis,
  septicemia, bacterial endocarditis, wound
  infection, shunt nephritis, ventriculitis
• Management of problems r/t psychomotor
  development
• Lifelong problem, parents need to know signs of
  shunt malformation

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Meningitis

• Acute inflammation of the cerebral meninges as a
  result of a bacterial or viral infection

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Bacterial Meningitis

• Follows 2-3 days of upper respiratory infection
  (seasonal)
• May be caused by Strep pneumoniae Neisseria
  meningitis in child lt 24months
• Meningococcal predominantly in school-age
  children adolescents (vaccine preventable)

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Bacterial MeningitisSigns Symptoms

• Abrupt onset of fever
• Chills
• Increasing irritability
• Headache
• Convulsions
• Blurred vision
• Cranial nerve paralysis

Opisthotonic position
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Classic Signs and Symptoms

• Nuchal rigidity
• () Kernigs sign
• ()Brudzinskis sign

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Signs Symptomsin Newborn

• Above slides signs plus
• poor suck
• weak cry
• lethargy
• can lead to sudden shock, seizures, apnea
• bulging fontanel

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Bacterial Meningitis

• Diagnosis
• lumbar puncture to analyze CSF
• increased WBCs and protein decreased glucose
  (bacteria feed on glucose)
• Treatment
• ABX x 10 days, IV or Intrathecal
• Respiratory isolation x 24 hours while on ABX
• Maintenance of optimum hydration
• Maintenance of ventilation
• Reduction of increased ICP
• Management of bacterial shock
• Control of seizures
• Prophylactic ABX for family members
• Monitor for increasing ICP (Dexamethosone,
  Mannitol)

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Sequelae

• Hearing loss
• Blindness
• Paresis
• Intellectual impairment

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Encephalitis

• Acute inflammation of the brain
• Symptoms do not include nuchal rigidity or
  positive kernig or brudzinski
• Symptoms depend on the causative organism

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Guillain-Barre Syndrome

• Immune-mediated disease of motor weakness that is
  often associated with viral or bacterial
  infection of respiratory or GI tract or vaccine
  administration
• Adults have increased susceptibility, can affect
  children usually ages 4-10
• Inflammation of nerve fibers, impairs nerve
  conduction
• Ascending paralysis from lower extremities

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Initial Symptoms

• Peripheral neuritis occurs several days after
  primary infection
• Muscle tenderness
• Tendon reflexes decreased or absent
• Paresthesia cramps
• Proximal symmetric muscle weakness
• Urinary incontinence or retention
• Decreased swallowing respiratory efforts-may
  lead to respiratory failure

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Nursing care

• Assess degree of paralysis
• Prevent complications (immobility)
• Watch for difficulty swallowing, respiratory
  involvement
• Wait for disease to stabilize no abx, may get
  IVIG otherwise tx is supportive
• (PT important for recovery)

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Reyes Syndrome

• A life threatening acute encephalitis w/ fatty
  infiltration of liver, heart, lungs, pancreas
  skeletal muscle
• Occurs after viral infection if txd w/ aspirin
• Education efforts has helped to reduce incidence
  (use tylenol not ASA)

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Reyes Syndrome

• Dx
• Based on symptoms labs
• Staged 1-5

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Reyes Syndrome

• Begins with mild viral infection that worsens w/I
  24-48 hours
• Lethargy
• Vomiting
• Followed by
• Agitation
• Anorexia
• Combativeness
• Confusion leading to stupor, coma, seizures,
  respiratory arrest

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Reyes SyndromeLabs

• Increased
• Liver enzymes
• Serum ammonia
• PT, PTT
• Bun
• Amylase
• WBCs

• Decreased
• Serum glucose

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Reyes SyndromeNursing Care

• Monitor
• Neurological status
• Respiratory effort
• Hypoglycemia
• Brain edema

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Seizures

• Involuntary contraction of muscle caused by
  abnormal electrical brain impulses
• They are episodic and abrupt
• Often triggered by environmental of physiological
  stimuli
• Exact location of the electrical foci and the
  number of brain cells involved determines the
  nature of the seizure (sterotypical)

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Types of Seizures

• Nonrecurrent Acute
• Febrile episodes
• Drugs
• Metabolic alterations

• Recurrent Chronic (Epilepsy)
• Idiopathic (primary) epilepsy
• Epilepsy secondary to trauma, hemorrhage,
  infections, congenital defects

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Type and Cause of Seizures is predicted by age

• Newborn
• Infant and Toddler
• Children age 3 and older

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Seizures 2 categories

• Partial
• Simple
• Complex
• Only 1 area of brain involved
• Symptoms are associated with the area affected
• No LOC or consciousness is impaired

• Generalized
• Newborn
• Infantile spasms
• Absence
• Tonic Clonic
• Entire brain
• Usually have loss of consciousness
• May have aura

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Simple Partial Seizures

• Age any
• No loss of consciousness, no aura
• Has either
• Abnormal motor activity
• One extremity, uncontrolled movement, may
  progress into generalized seizure
• Abnormal sensory activity
• Numbness, tingling, paresthesia or pain starting
  in 1 area of body, may spread to other parts of
  body
• May include abnormal auditory, olfactory and
  visual sensations
• TX Variety of anticonvulsants

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Complex Partial Seizures

• Age Children age 3 and older
• Consciousness is impaired
• Idiopathic
• CT, MRI, EEG are normal
• May have slight aura
• Sudden change in posture
• Automatisms
• Slump to ground, unconscious
• Circumoral pallor
• Afterward drowsiness, no postictal state
• Tx Tegretol, Dilantin

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Generalized SeizuresNewborn Period

• Age Newborn to age 3 months
• Sudden twitching of head, arms, eyes, slight
  cyanosis, respirations may be affected
• After seizure may be limp
• Causes
• Trauma at birth
• Metabolic disorder
• Infection
• Kernicterus
• TX Phenobarbital

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Generalized SeizuresInfantile Spasms

• Age 3 months to 2 years
• Altered consciousness
• Rapid movement of trunk followed by relaxation
• Child falls forward or to ground
• Occur singly or in clusters
• May have permanent cognitive developmental
  delays
• TX variety of anticonvulsants

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Generalized Seizures

• Acute Febrile seizure
• Age Any
• Due to increased temperature gt 102 F (but may
  occur as low as 100 F)
• Tonic-clonic pattern
• 15-20 seconds
• Tx
• Protect from harm
• R/O infection (meningitis)

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Generalized SeizuresAbsence Seizure

• Age 3 years
• Brief loss of consciousness
• Staring spell
• Rhythmic blinking twitching of mouth or arm
• mistaken for daydreaming or behavior problems
• Lasts 5-10 seconds, multiple times a day
• TX
• Depakene
• Encourage normal school activities
• 1/3 of children will grow out of them by
  adolescence

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Generalized SeizuresTonic Clonic

• Age any
• 4 stages
• 1. Prodromal
• Drowsiness, dizziness, malaise, lack of
  coordination, not himself
• 2. Aura
• May precede seizure, reflects portion of brain
  where seizure originates

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Tonic-clonic stage

• 3. Tonic-Clonic
• Tonic 20 seconds, all muscles cx (rigid), child
  falls to ground, LOC, respiratory muscles
  affected, grunting, airway compromised
• Clonic 20-30 seconds, jerky muscle contract
  relax rapidly, froth or bloody sputum
• 4. Postictal
• Appears to relax, semi-conscious, sound sleep for
  1-4h, no recollection of event
• Tx Dilantin, Depakene, Tegretol

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Chronic Seizures in children 3 and olderEpilepsy

• Chronic seizure disorder with recurrent seizures
• Symptoms depend on type of seizure
• No association with illness, injury
• seizure may be triggered by something

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Epilepsy Management

• Anti-seizure meds
• Dosage increased as child grows
• Control the seizures or reduce their frequency
• Discover and correct the cause when possible,
  know triggers
• Help child live a normal life

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Epilepsy Management

• Instruct parents on importance of giving meds to
  achieve therapeutic drug levels
• Med can be withdrawn when child is seizure free
  for 2 yrs with normal EEG
• TAPER! Gradually decreased over 1-2 weeks

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Triggers

• Changes in dark-light patterns
• Sudden loud noises, specific voices
• Sudden or startling movements
• Extreme changes in temperature
• Dehydration, fatigue
• Hyperventilation
• Hypoglycemia
• Caffeine, insufficient protein in diet

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Status Epilepticus

• Continuous seizure activity lasting gt 30 minutes
  or a series of seizures from which the child does
  not regain a premorbid level of consciousness
• Nursing Responsibilities
• A, B, Cs
• IV access
• Observe and record
• Protect
• Medications -IV benzodiazepine (Ativan, Valium),
  then seizure meds

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Dilantin (phenytoin)

• Toxicity nystagmus, ataxia, decresed mental
  capacity
• Low levels seizure activity
• S/E gingival hyperplagia (discuss oral hygiene),
  drowsiness, thrombpcytopenia, leukopenia,
  increased liver enzymes
• Nursing responsibility
• Monitor CBC, LFT, therapeutic drug levels

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• A 10-year old client presents with weakness in
  legs and history of the flu. The medical
  diagnosis is Guillain-Barre Syndrome. It would be
  imperative for the nurse to inform the physician
  after observing which of the following?
• Weak muscle tone in the feet
• Weak muscle tone in the legs
• Increasing hoarseness
• Tingling in the hands

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• A 4-year-old is being evaluated for
  hydrocephalus. The nurse notes which of the
  following as an early sign of hydrocephalus in a
  child?
• Bulging fontanels
• Rapid enlargement of the head
• Shrill, high-pitched cry
• Early morning headache

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• A child with a history of a seizure was admitted
  2 hours ago. The history indicates fever, child,
  and vomiting for the past 3-4 hours. In report
  the nurse is told that the child had a positive
  Brudzinskis sign. The nurse infers this is most
  likely caused by
• Increased intracranial pressure
• Meningeal irritation
• Encephalitis
• Intraventricular hemorrhage

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• A nurse is assessing a new admission. The
  6-month-old infant displays irritability, bulging
  fontanels, and setting-sun eyes. The nurse would
  suspect
• Increased intracranial pressure
• Hypertension
• Skull fracture
• Myelomeningocele

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• An 8-year-old client with a ventriculoperitoneal
  shunt was admitted for shunt malfunction. He
  presents with symptoms of increased intracranial
  pressure. The mechanism of the development of his
  symptoms is most probably related to
• Increased flow of CSF
• Increased reabsorption of CSF
• Obstructed flow of CSF
• Decreased production of CSF