Neurological Disorders in the Pediatric Patient

1. Neurological Disorders in the Pediatric Patient

2. Why is the CNS function so important? • What does it do? • What happens with impairment? • What affects the degree of disability?

3. Changes to be noted in pediatric neurological disorders • Reflexes: may be hypo/hyper • LOC: may have altered mental status • Cranial nerves: • I, III • II, IV, VI • III, VIII • V,VII • IX, X

4. Vital signs:changes in BP, HR Eyes: changes in pupils,focus,gaze Behavior: subtle Respiratory status: assess 1st Motor function: movement? Spontaneous? Skin: dry vs. diaphoretic Neuro assessment, cont.

6. 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

7. Assessment findings in children with neurological dysfunction

8. Reflects the pressure exerted by the blood, brain, CSF and any other space-occupying fluid or mass (tumors) Pressure sustained at 20mm Hg or higher Changes in pressure present with altered assessments other than normal Increased Intracranial Pressure (ICP)

10. Altered Mental StatusMnemonic = Mitten Metabolic Infections Toxins Trauma Endocrine Neurological/Neoplasm

11. Assessment:Infant • 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)

12. Assessment:Child early signs- • Irritability, lethargy • Sudden change in mood • Headache, poor feeding • Vomiting • Ataxia • Nuchal rigidity • Deterioration of cognitive ability

13. Assessment Child:Late signs • Changes in Vital signs • Seizures • Photophobia • Positive Kernig’s sign • Positive Brudzinski’s sign • Opisthostonos

14. Therapeutic Intervention:Nursing care Medications • Corticosteroid • Decadron • Osmotic diuretic • Mannitol

15. Nursing Care • Minimize activity • Monitor IV rate • Place in semi-fowlers • Monitor VS, Neuro VS, andbehavior • Treat for pain • Organize care • Educate parents

16. 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?

17. Hyperfunction/Hypofunction • Pediatric Seizures • Epilepsy vs. “seizure episode” • Status epilepticus • 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

18. Clinical Manifestations • Generalized: Tonic-clonic- loss of consciousness(formerly called grand mal) • Absence seizures-may have minor motor-atonic (formerly called petit mal) • Partial seizures- partial simple or partial complex (may be focal or r/t tumors)

19. Diagnostic Tests: • EEG • CT, MRI • Lumbar puncture • CBC • Metabolic screen for glucose, phosphorus and lead levels

20. Jittery Responsive Gaze Okay Seizure Not responsive to stimuli Abnormal gaze Jitteriness –vs- Seizure

21. Goals: • What is the primary nursing goal when caring for the individual experiencing a seizure? • What preventive measures does the nurse provide? • How does the nurse maintain the airway of an individual experiencing a seizure? • What is the priority nursing intervention following a seizure?

22. Long term goal for children with seizure disorders 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

24. Bacterial Potentially fatal; abx given prophylactically if bacterial suspected. May kill within 24 hrs C/S take 72 hrs to process Infants at greatest risk Nuchal rigidity Severe headaches Contagious Viral Same s/s but milder and shorter duration May follow a viral infection May be accompanied by rash Nuchal rigidity Ataxia Not contagious Meningitis

25. Assessment and diagnostics: Bacterial Meningitis • Streptococcus pneumoniae most common pathogen • Diagnostics: LP, CSF eval (↑ WBCs, gram stain +) • Treatment: ABCDs, cerebral edema, seizure control, abx, steroids • Prevention: Vaccination (HiB, Pneumococcal vaccine)

26. Assessment and diagnostics: Viral Meningitis • May be preceded by viral infection, rash • Diagnostics: LP, CSF eval (mildly ↑WBCs, negative gram stain) • Treatment: self limiting; resolves in 7-14 days, monitored in hospital until ABCs are stable • Medications: antivirals (Acyclovir)

27. Diagnostic Tests: • Lumbar Puncture • Serum Glucose Level • Blood Cultures

28. Nursing Care for diagnostics of possible meningitis • Lumbar puncture • ASO titer • CBC/electrolytes/serum glucose

29. Hydrocephalus Hydro= Water Cephaly= of the head/brain

30. Etiology and Pathophysiology: • Congenital anomalies • Trauma • Unknown causes

31. Types of Hydrocephalus • Non-communicating or Obstructive • Communicating

32. Clinical Manifestations • Infants- prior to fusion of cranial sutures • FOC increased at birth • Changes in assessment of skull • Forehead • Eyes • Behavior changes • After closure of cranial sutures: 1. Eyes 2. S & S of ICP

33. Diagnostic Tests • LP • MRI/ CT scan • Skull X-ray • FOC • Transillumination

34. Interventions: Surgical • Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption

36. Complications of Shunts • Infections • Blocked shunts • Seizures

37. 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

38. 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?

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

40. 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.

42. 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

43. Diagnostic Tests: Prenatal detection • Ultrasound • Alpha-fetoprotein Following Birth: • NB assessment • X-ray of spine • X-ray of skull

44. Surgical Intervention • Immediate surgical closure • Prior to closure keep sac moist & sterile • Maintain NB in prone position with legs in abduction preoperatively

45. Nursing Interventions: Pre-OP: • Meticulous skin care • Protect from feces or urine • Keep in isolette

46. Post-Op Nursing Interventions • Assess surgical site • Monitor VS and neuro VS • Institute latex precautions • Encourage contact with parents/care givers • Positioning • Skin Care

47. Nursing Interventions cont... • Antibiotic therapy • Prevent UTI • Education • Emphasize the normal, positive abilities of the child

48. 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?

49. 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

50. 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)