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

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neurological disorders in the pediatric patient

Neurological Disorders in the Pediatric Patient

Presented by

Marlene Meador RN, MSN, CNE

review of cns of the pediatric patient
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
neurological assessment
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)

increased intracranial pressure iicp or icp p 1468 box 52 1
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)
priority nursing diagnosis for a child with iicp
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?
nursing interventions
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?
medications used to treat iicp
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:
quick review priority nursing interventions rationale
Quick Review: Priority nursing interventions/ rationale
  • What equipment is essential?
  • Vital signs & neuro signs
  • Additional assessment findings
  • Activity level
  • Hydration status
  • Positioning
  • Parent teaching
international classification of seizures p 1489 box 52 5
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
diagnostic tests
Diagnostic Tests:
  • EEG
  • CT, MRI
  • Lumbar puncture
  • CBC
  • Metabolic screen for glucose, phosphorus and lead levels
nursing interventions12
Nursing Interventions:
  • Assessment findings
  • Priority interventions
    • Prevention
    • During seizure
    • Following seizure

p 1490 Nursing Care Plan

medications used to control seizures in children
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
quick review
Quick Review:
  • What is most important nursing intervention when a child is experiencing a seizure?
  • What is most important teaching regarding seizure medication?
meningitis16
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
meningitis17
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)
meningitis18
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
lumbar puncture nursing interventions
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
nursing care medications for treatment of meningitis
Nursing Care & Medications for treatment of meningitis:
  • Ceftriaxone Sodium (Rocephin®)- who must receive this medication?
  • Cefatoxime Sodium (Claforan ®)-
  • Dexamethasone- special nursing care
  • Antipyretics
clinical judgment
Clinical Judgment:
  • What intervention must the nurse initiate to protect the patients and staff when a diagnosis of bacterial meningitis is suspected?
hydrocephalus
Hydrocephalus

Hydro= Water

Cephaly= of the head/brain

hydrocephalus23
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?
diagnostic of hydrocephaly
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)

correction of hydrocephaly
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
nursing care
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
long term nursing care for the child with hydrocephaly
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
spina bifida30
Spina Bifida
  • Most common defect of the CNS
  • Occurs when there is a failure of the osseous spine to close around the spinal column.
spina bifida see p 1470
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
clinical manifestations
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
surgical intervention
Surgical Intervention
  • Immediate surgical closure
  • Prior to closure keep sac moist & sterile
  • Maintain NB in prone position with legs in abduction preoperatively
nursing interventions35
Nursing Interventions:

Pre-OP:

  • Meticulous skin care
  • Protect from feces or urine
  • Keep in isolette
post op nursing interventions
Post-Op Nursing Interventions
  • Assess surgical site
  • Monitor VS and neuro VS
  • Institute latex precautions
  • Encourage contact with parents/care givers
  • Positioning
  • Skin Care
nursing interventions cont
Nursing Interventions cont...
  • Antibiotic therapy
  • Prevent UTI
  • Education
  • Emphasize the normal, positive abilities of the child
priority nursing diagnosis and interventions
Priority nursing diagnosis and interventions:

At risk for infection-

Protect

Position

At risk for injury-

Protect

Position

nursing care of the child with cerebral palsy p 1477
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
assessment
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)
assessment cont
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)
diagnostic tests43
Diagnostic Tests:
  • EEG, CT, or MRI
  • Electrolyte levels and metabolic workup
  • Neurologic examination
  • Developmental assessment
complications of cp
Complications of CP
  • Increased incidence of respiratory infection
  • Muscle contractures
  • Skin breakdown
  • Injury
head injuries in the pediatric client
Head injuries in the Pediatric Client
  • Anatomy predisposes infant/young to injury
  • Pathophysiology of “Shaken Baby Syndrome”
nursing care of child experiencing a closed head injury p 1483
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?
autism50
Autism
  • Not clearly understood
  • Characterized by impaired social, communicative, and behavioral development
  • Usually noted in the first year of life
pervasive developmental disorders autism p 1549
Home Setting

Reduce environmental stimuli

Communicate via age-appropriate touch & verbalization

Keep toys or other items out of reach if child uses them for harmful self-stimuli

Ritualistic ADLs

Encourage therapists & support groups

Acute Care Setting

Keep at least 1 constant caregiver. Encourage parents to stay with,keep room quiet & limit number of staff

Anxiety/aggression when touched by strangers

Constant monitoring by nurse or parents

Allow to maintain rituals of ADLs

Encourage therapists & support groups

Pervasive Developmental Disorders / Autism (p. 1549)
down syndrome
Down syndrome
  • Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation
what are some of the identified causes of down syndrome
What are some of the identified causes of Down syndrome?
  • Failure of chromosomes to separate
  • Advanced maternal age
  • No other socio-economic or geographic factors have been identified
assessment55
Assessment
  • Primary concern with cardiac and GI anomalies
  • What are the most obvious indications of Down’s Syndrome in a newborn
health promotion
Health Promotion

How does the nurse promote health of the child with Down’s syndrome?

  • Primary focus on the parents and care givers to provide support and achieve a realistic view of the child’s capabilities
  • Support siblings
  • Refer to family counseling services
  • Support parents in feelings of guilt and chronic sorrow
for questions or concerns
For questions or concerns

Contact Marlene Meador RN, MSN, CNE

Email: mmeador@austincc.edu