Neurological Disorders in the Pediatric Patient

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

2. 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

3. Etiology and Pathophysiology

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

5. Neurological Assessment • Vital Signs • Eyes • Behavior • Respiratory Status • Motor Function • Skin • Children’s Coma Scale

6. 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)

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

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

9. Therapeutic Intervention Nursing care Medications • Corticosteroid (decadron) • Osmotic diuretic (Manitol)

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

11. 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?

12. Meningitis Bacterial Meningitis Vs. Viral Meningitis

13. Bacterial Meningitis Potentially Fatal

14. Viral Meningitis Same signs and symptoms, may be milder and self-limiting. Usually lasts a few days

15. Assessment Infants & Young Children • Fever not always present • Lethargy • Alterations in sleep and feeding habits • Nuchal rigidity (late sign)

16. Assessment: Childhood & Adolescence • Hyperthermia • S&S of IICP

17. Complications of Meningitis • IADH • Intravascular coagulation with thrombocytopenia • CSF obstruction • Nerve Damage

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

19. Therapeutic Interventions Mediation Therapy Antibiotics Ampicillin Claforan Rocephin

20. Nursing Care • Assess • Antibiotic therapy • Monitor lab values • Strict I&O • Isolation • Monitor FOC

21. Nursing Care cont... • CSF culture • Temperature control • Seizure activity • Environment • Planning • Education

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

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

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

25. Clinical Manifestations • Infants- prior to fusion of cranial sutures • FOC • Changes in assessment of skull • Forehead • Eyes • Behavior changes

26. Clinical Manifestations • After closure of cranial sutures: • Eyes • S & S of IICP

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

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

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

30. 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

31. 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?

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

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

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

36. Nursing Interventions: Pre-OP: • Place in prone position • Sterile moist dressing with normal saline or antibiotic solution • Maintain proper abduction of legs and alignment of hips • Meticulous skin care • Protect from feces or urine • Keep in isolette

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

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

39. 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?

40. 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

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 • Increased incidence of respiratory infection • Muscle contractures • Skin breakdown • Injury

45. Goals & Interventions: Early detection

46. Mental Retardation “Significant sub average, general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period”. American Association of Mental Deficiency

47. Down Syndrome Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation

48. Assessment • See syllabus • Primary concern with cardiac and GI anomalies • What are the most obvious indications of Down’s Syndrome in a newborn?

49. Goals and Interventions • 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

50. Hyperfunction/Hypofunction • Pediatric Seizures • 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