Neurological Disorders in the Pediatric Patient

1. Neurological Disorders in the Pediatric Patient Presented by Marlene Meador RN, MSN, CNE

2. Review of CNS of the Pediatric Patient • Head to torso ratio • Cranial bones- thin, pliable, suture lines not fused • Brain vascularity and small subarachnoid space • Excessive spinal mobility • Wedge shaped cartilaginous vertebral bodies

3. Neurological Assessment: • LOC & behavior • Vital Signs and respiratory status • Eyes • Reflexes and motor function • Cranial nerve function (p 842 table 33-4) page 1467 discuses Modified Glasgow Coma Scale for ages 3 and younger ( p 1469, table 52-1)

4. Infants Irritability & restlessness Fontanelles / FOC Poor feeding/sucking Skull & scalp veins Nucal rigidity, seizures (late signs) Children Headache Vomiting Irritable, lethargic,mood swings Ataxia, spasticity Nucal rigidity Deterioration in cognitive ability Vital sign changes Increased Intracranial Pressure- IICP or ICP (p 1468, Box 52-1)

5. Priority nursing diagnosis for a child with IICP? • What assessment findings should the nurse monitor? • What emergency equipment should the nurse have on hand at all times for a child with IICP?

6. Nursing interventions: • What diagnostic procedures would the nurse anticipate for this child? • What priority interventions must the nurse include with respect to these diagnostic procedures? • What specific teaching is required? • What additional lab/serum tests would you anticipate?

7. Corticosteroids Anti-inflammatory Contraindications-acute infections Monitor I&O Protect from infection Add K+ foods Discontinue gradually Osmotic diuretic Reduce fluid Contraindications- intracranial bleeding Monitor I&O carefully Monitor electrolytes Teaching Medications used to treat IICP:

8. Quick Review: Priority nursing interventions/ rationale • What equipment is essential? • Vital signs & neuro signs • Additional assessment findings • Activity level • Hydration status • Positioning • Parent teaching

9. Pediatric Seizures

10. International Classification of Seizures ( p 1489 Box 52-5) • Febrile- rapid temp rise above 39°C (102°F) • Generalized- loss of consciousness, involves both cerebral hemispheres onset at any age • Tonic/Clonic- impaired consciousness, abnormal motor activity, posturing, automatisms • Absence- may confuse with daydreaming or inattentiveness

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

12. Nursing Interventions: • Assessment findings • Priority interventions • Prevention • During seizure • Following seizure p 1490 Nursing Care Plan

13. Medications used to control seizures in children • Phenobarbital- CNS depressant- monitor: sedation, VS, serum levels, • Teach- S&S of toxicity, no ETOH, adhere to regime • Carbamazepine- sedative/anticonvulsant • hold med if lab values = • Teach- S&S of toxicity • Phenytoin- anticonvulsant • Safety measures- on-hand equipment • Teach- oral care, sun exposure

14. Quick Review: • What is most important nursing intervention when a child is experiencing a seizure? • What is most important teaching regarding seizure medication?

15. Meningitis

16. 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

17. Meningitis: • Why does bacterial meningitis present more of a risk than viral meningitis? (p. 1494) • How do the manifestations of meningitis differ between infants and young children (p. 1494)

18. Meningitis: Infant Child/Adolescent Fever Headache Photophobia Nuchal rigidity Altered LOC Anorexia/ vomiting Diarrhea Drowsiness • Fever (not always present) • Poor feeding • Vomiting • Irritability • Seizures • High-pitched cry

19. Lumbar Puncture- nursing interventions • What findings differentiate between bacterial and viral meningitis? • What specific interventions does the nurse include for this procedure? • Monitor VS & neuro VS • LOC • Teaching

20. Nursing Care & Medications for treatment of meningitis: • Ceftriaxone Sodium (Rocephin®)- who must receive this medication? • Cefatoxime Sodium (Claforan ®)- • Dexamethasone- special nursing care • Antipyretics

21. Clinical Judgment: • What intervention must the nurse initiate to protect the patients and staff when a diagnosis of bacterial meningitis is suspected?

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

23. Hydrocephalus: • What priority nursing assessment of a newborn monitors for this condition? • What assessment findings occur in the older child? • What diagnostic measures confirm this diagnosis?

24. Diagnostic of Hydrocephaly: • LP-dangerous • MRI; CT scan • Skull X-ray • Measure FOC • Provide for safety, informed consent, support for child and family, accurate H&P (added 2010)

25. Correction of Hydrocephaly: • Shunt placement- surgical procedure to place a tube that drains CSF into the atrioventricular or peritoneal cavity. • Atrioventricular- drains into atrium (not used as frequently) • Ventricular peritoneal- drains into the peritoneal cavity

27. Nursing Care: • Pre Operatively: • Baseline VS, monitor for IICP, • What teaching/interventions for parents? • Post-op: • Monitor shunt function (how?) • Positioning and activity • VS, neuro VS & I&O • Teaching

28. Long Term Nursing Care for the child with hydrocephaly • Home care needs • S&S of IICP • S&S of infection • S&S of seizures • Emergency numbers of Pediatrician & neurosurgeon • Refer to home care, social services and support groups

29. Spina Bifida

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

31. Spina Bifida: (see p 1470) • What common nutritional supplement is encouraged for all women of childbearing age? • Discuss the 3 types of neural tube defects: • Spina bifida occult • Meningocele • Meningomyelocele

32. Spina Bifida

33. 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

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

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

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

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

38. Priority nursing diagnosis and interventions: At risk for infection- Protect Position At risk for injury- Protect Position

39. Cerebral Palsy

40. Nursing care of the child with Cerebral palsy: (p.1477) • 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

41. 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)

42. 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 (>5 months)

43. Diagnostic Tests: • EEG, CT, or MRI • Electrolyte levels and metabolic workup • Neurologic examination • Developmental assessment

44. Complications of CP • Increased incidence of respiratory infection • Muscle contractures • Skin breakdown • Injury

45. What is the priority nursing goal for a patient with cerebral palsy (CP)?

46. Head Injuries

47. Head injuries in the Pediatric Client • Anatomy predisposes infant/young to injury • Pathophysiology of “Shaken Baby Syndrome”

48. Nursing care of child experiencing a closed head injury: (p 1483) • Assessment findings- • Immediate nursing interventions- • Legal implications • Why is it not prudent for the nurse to discuss suspicions of abuse with the parents or primary caregiver?

49. Autism

50. Autism • Not clearly understood • Characterized by impaired social, communicative, and behavioral development • Usually noted in the first year of life