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Neurological Stressors and Adaptation

Neurological Stressors and Adaptation. Common Neurological Disorders in Children. Neural Tubes Defects Hydrocephalus Bacterial Meningitis Guillain-Barre Syndrome Reye’s Syndrome Seizures. Neural Tube Disorders. Defects of closure of neural tube during fetal development

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Neurological Stressors and Adaptation

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  1. NeurologicalStressors and Adaptation

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

  3. 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

  4. 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

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

  6. 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

  7. 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

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

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

  10. 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

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. INFANT HydrocephalusEarly signs & symptoms • Projectile vomiting not associated with feeding • Scalp veins become prominent • **Shrill, high pitched cry • **Increasing irritability

  17. 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)

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

  19. Relief of hydrocephalus • VP shunt placement to bypass the obstruction • Needs replaced PRN

  20. 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

  21. 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

  22. 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

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

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

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

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

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

  28. 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 • Monitor for increasing ICP (Dexamethosone, Mannitol)

  29. Sequelae • Hearing loss • Blindness • Paresis • Intellectual impairment

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

  31. 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

  32. 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

  33. 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)

  34. Reye’s Syndrome • A life threatening acute encephalitis w/ fatty infiltration of liver, heart, lungs, pancreas & skeletal muscle • Occurs after viral infection if tx’d w/ aspirin • Education efforts has helped to reduce incidence (use tylenol not ASA)

  35. Reye’s Syndrome Dx: • Based on symptoms & labs • Staged 1-5

  36. 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

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

  38. Reye’s SyndromeNursing Care Monitor: • Neurological status • Respiratory effort • Hypoglycemia • Brain edema

  39. 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)

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

  41. Type and Cause of Seizures is predicted by age: • Newborn • Infant and Toddler • Children age 3 and older

  42. 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 Seizures: 2 categories

  43. 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

  44. 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

  45. 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

  46. Generalized Seizures“Infantile 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

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

  48. 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

  49. 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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