Neurological

1. Neurological

2. Common Neurological Disorders in Children • Hydrocephalus • Neural Tubes Defects • Bacterial Meningitis • Guillain-Barre Syndrome • Reye’s Syndrome • Seizures

3. Structural Defects

4. Hydrocephalus • “Water on the Brain” • Imbalance between the production and absorption of CSF. • Often from congenital CNS malformations • Results in rapid head enlargement in infants • Can lead to irreversible neurological damage

5. INFANT HydrocephalusEarly Signs • Projectile vomiting not associated with feeding • Scalp veins become prominent • **Shrill, high pitched cry • **Increasing irritability

6. Infant HydrocephalusLater 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)

7. HydrocephalusSigns & symptoms in older Child • No enlargement of head (skull is closed) • Begins with generalized neuro symptoms • HA in morning • Nausea • Vomiting • Followed by signs of increased ICP

8. Relief of hydrocephalus • Create a new pathway to divert excess CSF. • A catheter or shunt is placed in the ventricle and passes the CSF to the peritoneal cavity • Needs to be replaced PRN

9. Post-op Nursing Care Shunt Placement • Keep child flat unless ICP is present the bed slightly elevated • Slowly increase HOB over few days • Support head when moving child • Pain management • Vital Signs

10. Post-op Nursing Care Shunt Placement • Observe for signs of increasing ICP – neurologic assessment • Observe for abdominal distention • Strict I & O • Antibiotics • Meticulous skin care • Support family

11. Discharge Management Post Shunt Placement • Teach parents to monitor for shunt complications: • Headache, progressive or worsening • Drowsiness or inappropriate sleepiness during the day, irritability • Nausea, vomiting • Personality changes or changes in school performance • Fever • Redness or swelling along the shunt tract

12. 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

13. 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

14. Neural Tube Disorders Types: • Spina Bifida • Occulta • Cystica • Meningocele • Myelomeningocele

15. 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

16. 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

17. Spina Bifida Cystica • Meningocele • External sac that contains meninges and CSF • Protrudes through defect in vertebral column

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

19. 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

20. 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

21. 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

22. Nursing Interventions • Surgical repair usually within first 24 hours • observe for early signs of infection: elevated temp, irritability, lethargy, nuchal rigidity • observe for signs of increasing ICP (may indicate hydrocephalus)

23. 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

24. Neurologic Infections

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

26. Bacterial Meningitis Follows 2-3 days of upper respiratory infection • Haemophilusinfluenzaetype b was the most common cause of bacterial meningitis in children prior to the use of the Hib conjugate vaccine • May be caused by Strep pneumoniae in child < 24months (not fully vaccinated yet) • Meningococcal predominantly in school-age children & adolescents (vaccine preventable)

27. Bacterial MeningitisSigns & Symptoms • Abrupt onset of fever • Chills • Increasing irritability • Headache • Convulsions • Blurred vision • Cranial nerve paralysis • Opisthotonic position

28. Classic Signs and Symptoms • Nuchal rigidity • (+) Kernig’s sign • (+)Brudzinski’s sign

29. Signs & Symptomsin Newborn Above slide’s signs plus: • poor suck • weak cry • lethargy • can lead to sudden shock, seizures, apnea • bulging fontanel

30. Bacterial Meningitis • Diagnosis: • lumbar puncture to analyze CSF • increased WBC’s 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

31. Complications • Life Threatening Condition • If Survival: • Hearing loss • Blindness • Paresis • Intellectual impairment

32. Nursing Management • Frequently assess vital signs, LOC, neurologic assessment to identify changes in the child’s condition. • Measure head circumference frequently- risk for hydrocephalus. • Monitor intake and output

33. Nursing Management • Promote comfort • reduced stimulation (dim lights, quiet room) • Side-lying position • Identify parents’ concerns, provide support • Prevention is a major role for nurses. • Encourage parents to get their infants and children fully immunized!

34. 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 though demyleination • Ascending paralysis from lower extremities

35. 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

36. Treatment • Wait for disease to stabilize • Intravenous immune globulinIVIG • Physical Therapy • Rarely fatal, often residual paralysis

37. Nursing Care • Monitoring respiratory status • Managing autonomic nervous system dysfunction • Preventing complications associated with immobility • Providing emotional support • tTeaching the parents how to • care for the child after discharge.

38. Reye’s Syndrome • A life threatening acute encephalitis • Occurs after viral infection if tx’d w/ aspirin • High Mortality Rate • Education efforts has helped to reduce incidence (use Tylenol or Ibuprofen not ASA)

39. Reye’s 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

40. Increased: Liver enzymes Serum ammonia PT, PTT WBC Decreased: Serum glucose Reye’s SyndromeLabs

41. Reye’s SyndromeNursing Care If Survival in PICU Monitor: • Neurological status • Respiratory effort • Hypoglycemia • Cerebral edema

42. Seizures

43. 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)

44. Nonrecurrent – Acute Febrile episodes Drugs Metabolic alterations Recurrent – Chronic (Epilepsy) Idiopathic (primary) epilepsy Epilepsy secondary to trauma, hemorrhage, infections, congenital defects Types of Seizures

45. Partial Simple Complex Only 1 area of brain involved Symptoms are associated with the area affected No LOC or consciousness is impaired Generalized Infantile spasms Febrile Absence Tonic Clonic Entire brain Usually have loss of consciousness May have aura Postical Seizures: 2 categories

46. Partial Seizures Simple Partial Seizures Complex Partial Seizures

47. Simple Partial Seizures • Seizure is short, lasts < 30 seconds • No loss of consciousness, aura, postical state Seizure Activity: Abnormal motor activity • One extremity or part of extremity, uncontrolled movement 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

48. Complex Partial Seizures • Seizure is longer, 30 seconds-5 minutes • Consciousness is impaired immediately • May have slight aura Seizure Activity: • Sudden change in posture • Abnormal motor activity, twitching, loss of tone, tingling or numbness • Automatisms-lip smacking, chewing, sucking • Circumoral pallor • Afterward: drowsiness

49. Generalized Seizures Infantile spasms Absence Tonic Clonic Febrile

50. Infantile Spasms Age: 4 months to 2 years • Occur in clusters 5-150/day, worse at night • Altered consciousness • Abrupt flexion/extension of neck, trunk, extremities • Eye rolling • May have permanent cognitive & developmental delays