chapter 13 neurologic and sensory disorders copyright © 2012 by saunders, an imprint of elsevier,...

Chapter 13

Neurologic and Sensory Disorders

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

The Nervous System

• Grows rapidly before birth and during the first year• Central nervous system (CNS)

– Cerebrum, cerebellum, brainstem, spinal cord– Myelinization is cephalocaudal and proximodistal– Primary focus of Chapter 13

• Peripheral nervous system (PNS)– Cranial and spinal nerves

• Autonomic nervous system (ANS)– Sympathetic/parasympathetic systems

• Choroid plexus: primary site of CSF formation

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 13-2

Increased Intracranial Pressure

• Caused by volume increase of brain, CSF, or blood which exceeds cranial capacity

• Signs and symptoms– Cushing triad

• Increase in systolic blood pressure, widening pulse pressure, decrease in pulse, altered respiratory pattern

– Possible temperature elevation from inflammation, systemic infection, damage to hypothalamus

– More pronounced as consciousness deteriorates– As ICP increases, cerebral perfusion decreases


Intracranial Hemorrhage

• Description– Broken blood vessels within the skull cause

bleeding in the brain; from trauma or anoxia

– Complete recovery is likely if symptoms are mild

– Death results if there is a massive hemorrhage

• Diagnosis– History of delivery, CT, MRI, increased CSF

pressure, symptoms and course of the disease



• Signs and symptoms– Inability to move normally, lethargy, poor

sucking reflex, irregular respirations, cyanosis, twitching, forceful vomiting, high-pitched shrill cry, convulsions

– Opisthotonic posture– Tense, pressurized fontanel– Pupil of one eye sometimes smaller than the

other



• Treatment and nursing care– Newborn placed in an isolette

• Allows temperature control, ease in administering oxygen, continuous observation

– Head is elevated– Doctor may prescribe medication to control

bleeding and convulsions– Nurse observes for signs of increased ICP and

convulsions• Nurse’s observation of convulsion aids the physician in

determining the exact location of bleeding


Head Injuries

• Description– Falls, motor vehicle injuries, shaken baby

syndrome, bicycle injuries, etc.– Infants and toddlers have soft skulls to absorb

impact– By 2 years of age, both fontanels have

completely closed; impact absorption decreases• Complications

– Hemorrhage, infections, cerebral edema (swelling of the brain), and compression of the brainstem

– Increased ICP


Head Injuries

• Treatment and nursing care– ABCs (airway, breathing, circulation), assess for

spinal cord injury, document baseline vital signs– Level of consciousness (LOC)– Record type and amount of any drainage from

ears/nose– Fluids are carefully monitored to control cerebral

edema– Feeding difficulties should be noted as the child’s

diet is increased– Patients should be observed for signs of shock– Watch for decerebrate/decorticate posturing


Hydrocephalus

• Description– Increased CSF in the ventricles of the brain

• Causes increased head size, pressure changes in the brain

– May occur along with a meningomyelocele or as a sequela of infections, including encephalitis, meningitis, or TORCH

• Toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex

– Can also be caused by perinatal hemorrhage


Hydrocephalus

• Signs and symptoms– Depend on site of obstruction and the child’s age– Impairment of CSF absorption within subarachnoid

space (communicating)– Obstruction of CSF flow within ventricles

(noncommunicating)– Increase in head size– Bulging anterior fontanel– Separation of cranial sutures– Shiny scalp, dilated veins– Eyes may appear deviated downward

• “Setting sun” sign


Hydrocephalus

• Diagnosis and treatment– Head circumference is measured daily– Echoencephalography, CT, MRI locate

enlarged ventricles and level of obstruction– Ventriculoperitoneal (VP) shunt or

ventriculoatrial (VA) shunt– Prognosis has improved with modern drugs

and surgical techniques


Shunts have a one way valve to prevent back pressure causing fluidsto enter the brain.

Shunts have a filter also.

Shunt malfunctions are frequently caused by filter becoming plugged with protein. A surgical revision then needs to be done as quickly as possible to prevent increased pressure from forming.


Hydrocephalus

• Nursing care– The position of the infant must be changed

frequently to prevent hypostatic pneumonia and pressure sores

– In addition to routine postoperative care and observations, the nurse observes the patient for signs of increased intracranial pressure (ICP) and for infection at the operative site or along the shunt line

– If the fontanels are sunken, the infant should be kept flat


Myelodysplasia and Spina Bifida

• Both categorized as neural tube defects (NTD)• Myelodysplasia

– CNS disorders characterized by abnormal development of the spinal cord and associated neural tube structures

• Spina bifida (divided spine)– Congenital embryonic NTD; imperfect closure of spinal

vertebrae– Cause unknown; multifactorial– Development of a cystic mass in the midline of the

spine• Meningocele (only meninges in sac) • Meningomyelocele (meninges and spinal cord/ nerves in sac)



• Treatment– Spina bifida: surgical closure to prevent

meningeal infection• Observe for hydrocephalus, place shunt if

necessary• Prognosis depends on lesion location, involvement

of spinal cord, presence of other anomalies• Habilitation• Vesicostomy may be necessary (surgical opening

of bladder to external skin surface)



• Nursing care– Objectives of extensive nursing care

• *Preventing infection of or injury to the sac• *Correct positioning to prevent pressure on the sac and

deformities from developing• *Good skin care, particularly if incontinent of urine and feces• Adequate nutrition• Tender, loving care• Accurate observations and charting• Education of the parents• Continued medical supervision• Habilitation• (* are pre-operative but may continue post-operatively)


Bacterial Meningitis

• Description– Inflammation of the meninges– Infective organisms invade via teeth, sinuses,

tonsils, lungs, directly through the ear (otitis media), from neurological procedures, or from a fracture of the skull



• Signs and symptoms– Onset generally follows two courses

• Typically URI or gastrointestinal problem followed by irritability and lethargy

• Sudden rapid onset: shock, purpura, changes in level of consciousness, disseminated intravascular coagulation

– Other nonspecific reactions: headache, drowsiness, delirium, irritability, restlessness, fever, vomiting, and stiffness of the neck and spine

• Petechiae: Small hemorrhages beneath the skin• May have high-pitched cry, bulging tense fontanel

– Convulsions are common



• Treatment– Spinal tap at first indication of meningitis– Isolation is used until the patient has received

at least 24 hours of antibiotic therapy– Antibiotics are given in combination and are

adjusted on the basis of culture and sensitivity reporting

– Dilantin may also be necessary if the child is having seizures



• Nursing care– Frequent monitoring of the patient’s vital signs is

necessary – Fever may be controlled with the use of antipyretics,

sponge baths, and a hypothermia blanket– The patient’s intake and output are carefully observed

and recorded– Syndrome of inappropriate antidiruetic hormone

(SIADH)• Determined by weight, serum electrolytes, serum and urine

osmolarities• Treated by fluid restriction


Encephalitis

• Description– An inflammation of the brain parenchyma

• Typically more severe than bacterial meningitis

– Can be caused by arboviruses, enteroviruses, and herpes virus types 1 and 2

– Can be aftermath of upper respiratory tract infections, measles, an untoward reaction to vaccinations, lead poisoning


Encephalitis

• Signs and symptoms– Headache followed by drowsiness, may

proceed to coma– Convulsions occur, particularly in infants– Fever, cramps, abdominal pain, vomiting, stiff

neck, delirium, muscle twitching, and abnormal eye movements are other manifestations of the disease


Encephalitis

• Treatment and nursing care– Corticosteroids/immune globulin– Acyclovir for herpes virus encephalitis– Parenteral antibiotics until bacterial cause is ruled

out– Sedatives, IV fluids, seizure control, monitoring

for increased intracranial pressure– Antipyretics as ordered, seizure precautions

instituted– Oxygen as needed, mouth and nose kept free of

mucus


Question 12.2

Which is typically more severe?

A.Encephalitis

B.Bacterial meningitis


Seizure Disorders

• Febrile seizures– Occur in association with a rapid increase of

temperature– Are a common pediatric neurological disorder

and are generally transient in nature– They usually occur between the ages of 6 months

and 5 years and are common in toddlerhood– Generally, the parents are educated on fever

management and seizure precautions, although fever management (such as administering acetaminophen) does not typically reduce the risk for a seizure


Seizure Disorders

• Epilepsy– Recurrent paroxysmal attacks of

unconsciousness or impaired consciousness• May be followed by alternating contraction and

relaxation of the muscles or disturbed feelings/behavior

– Disorder of the CNS in which the neurons or nerve cells discharge in an abnormal way

– Idiopathic epilepsy: unknown cause

– Symptomatic epilepsy: cerebral abnormality is found


Epilepsy

• Signs and symptoms– Vary according to seizure type

• Convulsive seizures– Tonic phase, clonic phase, postictal state– Abrupt onset preceded by aura; dizziness, visual

images, nausea, headache, or abdominal discomfort– Status epilepticus: series of convulsions, typically caused

by withdrawal of anticonvulsants

• Nonconvulsive seizures– Could be lapse in consciousness, loss of muscle tone,

distorted sensations, automatisms


Epilepsy

• Treatment and nursing care– First aid for a convulsive seizure includes protecting the

child from harm, loosening clothing around the neck, turning on the side to maintain an airway, reassuring the child when consciousness returns

– Seizure precautions in the hospital setting include padding side rails and having oropharyngeal suction, oxygen, and an oral airway at the bedside

– Anticonvulsants– A ketogenic diet* is sometimes prescribed for children

who do not respond well to anticonvulsant therapy– Surgery is considered with intractable seizures not

responding to medication * see ‘1st do no harm’ with Susan Sarandon



Meds used to suppress seizures; not abortive meds

Reye’s Syndrome

• Description– A pediatric disease characterized by a nonspecific

encephalopathy with fatty degeneration of the viscera and altered ammonia metabolism

– Triggered by a virus, particularly influenza or varicella– Patients noted to have taken aspirin before symptoms

• Signs and symptoms– Typically recovering from URI or chickenpox– Recuperation interrupted by general malaise– Sudden onset of persistent vomiting and lethargy – Diagnosis based on history, symptoms, laboratory

data


Reye’s Syndrome

• Treatment and nursing care– Admission to ICU– Medications include osmotic diruetics,

sedatives, barbiturates– Fluid management in conjunction with

treatment of increased intracranial pressure (ICP) is crucial

– Nursing care similar to increased ICP with greater awareness of respiratory status

– Most survivors recover completely


Near-Drowning

• Signs and symptoms– Prognosis affected by length of submersion,

physiologic response, exposure to hypothermia– Hypoxia is the primary problem (Hypoxic ischemic

encephalopathy)– Pulmonary edema (osmotic fluid shift), pneumonia

• Treatment and nursing care– On-site CPR– Immediate transportation to a trauma facility– Intensive pulmonary care– Risk of cerebral edema and anoxia


Overview of Cognitive and Behavioral Disorders

• Developmental disability: any mentally/physically disabling condition that begins in childhood and is expected to continue throughout life

• Intellectual disability (mental retardation): significantly below-average score on a test of mental ability, limited function in daily life

• American Association on Intellectual and Developmental Disabilities (AAIDD)– Emphasizes both intelligence functioning and

adaptive behavior as criteria for disabilityCopyright © 2012 by Saunders, an imprint of Elsevier, Inc. 20-40


• Treatment and nursing care– Be mindful that pace of development is slower– Learn by habit formation; routine, repetition, relaxation– Any progress that has been made at home should not be

allowed to slip during hospitalization– Like other children, set firm, consistent limits on behavior– Situations become more complicated as the child

develops physically but still requires constant supervision– Nurses should familiarize families with community

resources; i.e., The Arc


Attention Deficit/Hyperactivity Disorder

• Description– Refers to specific patterns of behavior that include

inattention and impulsivity and might or might not involve hyperactivity



• Signs and symptoms– DSM-IV-TR criteria identifies three major patterns

of ADHD• Predominantly inattentive type• Predominantly hyperactive-impulsive type• Combined

– For ADHD diagnosis, symptoms must• Persist for at least 6 months• Appear before the age of 7 years• Be identified in more than one setting• Cause significant impairment in psychosocial or

educational adjustment and functioning



• Signs and symptoms (continued)– Inattentive to details, careless with schoolwork or

other activities– Has difficulty organizing tasks– Is unable to sustain attention for periods of time that

would be appropriate for age– Does not listen, follow instructions, or complete tasks– Avoids activities and games that require concentration– Is easily distracted and fidgety; has difficulty

remaining seated and appears to have excessive energy

– Is forgetful, loses things



• Treatment and nursing care– The specific medications used for the

treatment of behavior problems in ambulatory patients are listed in Table 20-1

– Dietary modification (particularly eliminating food additives, such as preservatives and artificial flavors and colors) and the use of megavitamins

– Behavior therapy


Down Syndrome

• Signs and symptoms– Close-set and upward-slanting eyes, small head,

round face, flat nose, mouth breathing, and a protruding tongue that interferes with sucking

– The hands of the baby are short and thick, and the little finger is curved

– Simian crease

– Undeveloped muscles (hypotonia) and loose joints enable the child to assume unusual positions


Down Syndrome

• Nursing care– Early infant stimulation enables children with

Down syndrome to reach milestones as rapidly as possible

– The nurse should become familiar with services located in and near the community

– Allowing parents to become involved in care and planning for the infant from the start facilitates bonding


Autism

• A complex developmental disorder of the brain, most likely caused by abnormalities in brain structure or function

• Affects social interaction, language, and communication, as well as behavior

• Typically appears in the first 3 years of life


Autism

• Autistic children do not interact well with others; they prefer to be alone

• They may play with toys in an unusual manner and live in their “own little world”

• Often there is some degree of mental retardation


Deafness

• Description– Hearing loss falls into two major categories

• Sensorineural hearing loss results from damage to the structures of the inner ear or auditory nerve

• Conductive hearing loss occurs due to an interruption in the transmission of sound waves (from structural problems) from the external or middle ear

– Some children have mixed hearing loss, which combines conductive and sensorineural causes


Deafness

• Signs and symptoms : Infant does not….– Startle with sudden loud sounds– Turn his or her head toward a sound by 3 or 4

months– Begin babbling by 6 months of age– Respond by reacting to music around 8

months of age– Attempt to speak syllables such as “da” by

around age 1 year


Deafness

• Treatment and nursing care– The auditory brainstem response (ABR) and

the otoacoustic emissions (OAE) provide identification of infants with hearing losses

– Audiometry—the measurement of hearing with an audiometer

– Tympanogram—measures the movement of the eardrum in response to sound waves

– Nurses should stress the importance of placing NO objects into the ear canal


Deafness

• Treatment and nursing care (continued)– Lip reading, sign language, writing, closed

captioning (on television), computers, visual aids, music, and amplified sound are some means of communication

– Flashing lights on the telephone and doorbell, hearing aid dogs, and telecommunications devices can facilitate communication

– Hearing aids and cochlear implants can boost hearing


Amblyopia

• Description– A decrease in or loss of vision, usually in one eye – The vision loss is not caused by structural eye damage but

results from the brain “turning off” confusing visual images– (brain turned off eye input so eye ‘ambles around’ because

it is not used to see)• Signs and symptoms

– An observant parent might notice that the child sits closer to the television or appears to have difficulty seeing

• Treatment and nursing care– Glasses for significant refractive errors (hyperopia,

myopia) and occlusion of the unaffected eye are used


Strabismus

• Description– Ocular misalignment; a condition in which the

child is not able to direct both eyes toward the same object (muscles do not align eye to focus on object)

– Most children with strabismus have esotropia, or an inward deviation of one or both eyes; some children have exotropia, which is outward turning


Strabismus

• Signs and symptoms– Malalignment during the uncover/cover tests

• Uncover test: Eye is covered, child looks at a light source; a quickly uncovered eye should not move

• Cover test: one eye is covered, movement of the other is observed while looking at a distant object

• Treatment and nursing care– Eye exercises and glasses– Occlusion therapy– Surgery is reserved for patients in whom

nonsurgical methods are likely to be unsuccessful


chapter 13 neurologic and sensory disorders copyright © 2012 by saunders, an imprint of elsevier,...

Documents

imprint of elsevier

sign copyright

disease copyright

increased pressure

perinatal hemorrhage

increased csf pressure

surgical techniques

signs of increased icp