HEAD INJURY

A. Descriptiona. Head injury is the pathological result of any

mechanical force to the skull, scalp, meninges, or brain

b. Manifestations depend on the type of injury and the subsequent amount of increased intracranial pressure (ICP).

B. Assessment (ICP)a. Early Signs

i. Headacheii. Visual Disturbance, diplopiaiii. Nausea and vomitingiv. Dizziness or vertigov. Slight change in vital signsvi. Change in papillary response and

equalityvii. Sunsetting eyesviii. Slight change in level of

consciousnessix. Infant: bulging fontanel; wide sutures,

increased head circumference; dilated scalp veins; high-pitched cry

b. Late Signsi. Significant decrease in level of

consciousnessii. Cushing’s triad : increased systolic

blood pressure and widened pulse pressure, bradycardia, and irregular respirations

iii. Decorticate posturing: adduction of the arms at the should, the arms being flexed on the chest with the wrists flexed and the hands fisted, and the lower extremities being extended and adducted; seen with severe dysfunction of the cerebral cortex.

iv. Decerebrate postuing: rigid extension and pronation of the arms and the legs; a sign of dysfunction at the level of the midbrain.

v. Fixed and dilated pupilsC. Interventions

a. Monitor the airwayb. Assess injuries; immobilize the neck if a cervical

injury is suspectedc. Monitor vital signs and neurological functiond. Monitor for decreased responsiveness to pain

( a significant sign of altered level of consciousness).

e. Initiate seizure precautions.f. Maintain a nothing-by-mouth status or provide

clear liquids if prescribed, until it is determined that vomiting will not occur.

g. Administer oxygen and intravenous fluids as prescribed.

h. Monitor intravenous fluids carefully to avoid aggravating any cerebral edema and to minimize the possibility of overhydration.

i. Elevate the head of the bed 15 to 30 degrees if not contraindicated.

j. Position the client so that the head is maintained midline to facilitate venous drainage and avoid jugular vein compression; turning side to side is contraindicated because of the risk of jugular vein compression.

k. Assess wound dressings for the presence of drainage and monitor for nose or ear drainage, which could indicate leakage off cerebrospinal fluid (CSF); drainage that is positive indicates leakage of CSF from a skull fracture.

l. Administer tepid sponge baths or place on a hypothermia blanket if hyperthermia occurs.

m. Suctioning through the nares is contraindicated because of the high risk of a secondary infection and the probability of the catheter entering the brain through a fracture.

n. Administer acetaminophen (Tylenol) for headache, anticonvulsants for seizures, antibiotics if a laceration is present, and tetanus toxoid as appropriate.

o. Sedating medications are withheld during the acute phase of the injury.

p. Monitor for signs of brainstem involvementi. Deep, rapid, or intermittent and

gasping respirationsii. Wide fluctuations or noticeable

slowing of the pulseiii. Widening pulse pressure or extreme

fluctuations in blood pressureq. Epidural hematoma: monitor for asymmetric

pupils (one dilated, unreactive pupil in a comatose child is a neurosurgical emergency that may require evacuation of the hematoma).

HYDROCEPHALUS

A. Descriptiona. Hydrocephalus is an imbalance of CSF

absorption or production caused by i. Malformationsii. Tumorsiii. Hemorrhageiv. Infections, orv. Trauma

b. Hydrocephalus results in head enlargement and increased ICP

B. Typesa. Communicating

i. Hydrocephalus occurs as a result of impaired absorption within the subarachnoid space

ii. Interference of the cerebrospinal fluid within the ventricular system does not occur.

b. Noncommunicatingi. Obstruction of cerebrospinal flow

within the ventricular system occurs

C. Assessmenta. Infant

i. Increased head circumference

ii. Thin, widely separated bones of the head that produce a cracked-pot sound (Macewen’s Sign) on percussion

iii. Anterior fontanel tense, bulging, and non-pulsating

iv. Dilated scalp veinsv. Frontal bossingvi. Sunsetting eyes

b. Childi. Behaviour changes such as

irritability and lethargyii. Headache on awakeningiii. Nausea and vomitingiv. Ataxiav. Nystagmus

c. Late signs: a high, shrill cry and seizure activities

D. Surgical Interventionsa. The goal of surgical treatment is to prevent

further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where it may be reabsorbed.

b. In a ventriculoperitoneal shunt, the CSF drains into the peritoneal cavity from the lateral ventricle.

c. In an atrioventricular shunt, CSF drains into the right atrium of the heart from the lateral ventricle, bypassing the obstruction (used in older children and in children with pathological conditions of the abdomen).

E. Interventions postoperativelya. Monitor vital signs and neurological signsb. Position client on the unoperated side to

prevent pressure on the shunt valve.c. Keep the child flat as prescribed to avoid

rapid reduction of intracranial fluidd. Observe for increased ICP; if increased

ICP occurs, elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt

e. Monitor for signs of infection and assess dressings for drainage.

f. Measure head circumference.g. Monitor intake and output.h. Provide comfort measures, administer

medications as prescribed, which may include diuretics, antibiotics, or anticonvulsants.

i. Instruct parents in how to recognize shunt infection or malfunction.

j. In a toddler, headache and lack of appetite are the earliest common signs of shunt malfunction.

SPINA BIFIDA

A. Descriptiona. Spina Bifida is a central nervous system

defect that occurs as result of neural tube

failure to close during embryonic development

b. Associated deficits include sensory motor disturbance, dislocated hips, clubfoot, and hydrocephalus

c. Defect closure usually is done during infancy

B. Typesa. Spina Bifida occulta

i. Posterior vertebral arches fail to close in the lumbosacral area

ii. Spinal cord remains intact and usually is not visible

iii. Meninges are not exposed on the skin surface

iv. Neurological deficits are not usually present.

b. Spina bifida cysticai. Protrusion of the spinal cord

and/or its meninges occurii. Defect results in incomplete

closure of the vertebral and neural tubes, resulting in a saclike protrusion in the lumbar or sacral area, with varying degrees of nervous tissue involvement

iii. Defect can include meningocele, myelomeningocele, lipmeningocele, and lipomeningomyelocele.

c. Meningocelei. Protrusion involves meninges

and a saclike cyst that contains CSF in the midline of the back, usually in the lumbosacral area

ii. Spinal cord is not involvediii. Neurological deficits are usually

not presentd. Myelomeningocele

i. Protrusion of meninges, CSF, nerve roots, and a portion of the spinal cord occurs.

ii. The sac (defect) is covered by a thin membrane that is prone to leakage or rupture.

iii. Neurological deficits are evident.C. Assessment

a. Depends on the spinal cord involvementb. Visible spinal defectc. Flaccid paralysis of the legsd. Altered bladder and bowel functione. Hip and joint deformities

D. Interventionsa. Evaluate the sac and measure the lesionb. Perform neurological assessmentc. Monitor for increased ICP; which might

indicate developing hydrocephalusd. Measure head circumference; assess the

anterior fontanel for fullnesse. Protect the sac; cover with a sterile, moist

(normal saline), nonadherent dressing to

maintain the moisture of the sac and contents, and change the dressing every 2 to 4 hours as prescribed.

f. Placed in a prone position to minimize tension on the sac and the risk of trauma; the head is turned to one side for feeding.

g. Change the dressing covering the sac whenever it becomes soiled because of the risk of infection; diapering may be contraindicated until the defect has been repaired.

h. Use aseptic technique to prevent infectioni. Assess the sac for redness, clear or

purulent drainage, abrasions, irritation, and signs of infection.

j. Early signs of infection include elevated temperature (axillary), irritability, lethargy, and nuchal rigidity.

k. Assess for physical impairments such as hip and joint deformities.

l. Prepare the child and family for surgerym. Administer antibiotics as prescribed to

prevent infectionn. Administer anticholinergics to improve

urinary continence and laxatives to achieve bowel continence in the child, and antispasmodics to control bladder spasms.

REYE’S SYNDROME

A. Descriptiona. Reye’s syndrome is acute encephalopathy

that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver.

b. The exact cause is not clearc. Administration of aspirin is not

recommended for children with varicella or influenza because of its association with Reye’s syndrome

d. Acetaminophen (Tylenol) is considered the medication of choice for pediatric clients.

e. The goal of treatment is to maintain effective cerebral perfusion and control increasing ICP.

B. Assessmenta. History of systematic viral illness 4 to 7

days before the onset of symptomsb. Malaisec. Nausea and vomitingd. Progressive neurological deterioration

C. Interventionsa. Assess neurological statusb. Monitor for altered level of consciousness

and signs of increased ICP.c. Monitor intake and outputd. Provide rest and decrease stimulation in

the environment.e. Monitor for signs of bleeding and signs of

impaired coagulation, such as a prolonged bleeding time.

f. Monitor liver function studies.

MENINGITIS

A. Descriptiona. Meningitis is an infectious process of the

central nervous system caused by bacteria and viruses that may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections.

b. Diagnosis is made by testing CSF obtained by lumbar puncture, which shows increase pressure, cloudy CSF, high protein, and low glucose.

c. Meningococcal meningitis occurs in epidemic form and is the only type readily transmitted by droplet infection from nasopharyngeal secretions.

d. Viral meningitis is associated with viruses such as mumps, paramyxovirus, herpesvirus, and enterovirus.

B. Assessmenta. Signs and symptoms vary, depending on

the type, the age of the child, and the duration of the preceding illness; there is no one classic sign of symptom.

b. Fever, chillsc. Vomiting, diarrhead. Poor feeding or anorexiae. Nuchal rigidityf. Poor or high-pitched cryg. Altered level of consciousness, such as

lethargy or irritabilityh. Bulging anterior fontanel in the infanti. Kernig’s sign and Brudzinski’s sign in

children and adolescents.j. Muscle or joint paink. Petechila or purpuric rashes

(meningococcal infection)C. Interventions

a. Provide isolation and maintain it for at least 24 hours after antibiotics are initiated

b. Administer antibiotics as prescribedc. Perform neurological and cardiovascular

assessmentd. Assess for personality changes and

irritabilitye. Monitor intake and outputf. Assess nutritional statusg. Determine close contacts of the child with

meningitis because the contacts will need prophylactic treatment.

SEIZURE DISORDERS

A. Descriptiona. Sudden, transient alterations in brain

function resulting from excessive levels of electrical activity in the brain

b. Classified as partial or generalized, or unclassified, depending on the area of the brain involved

B. Assessmenta. Obtain information from the parents about

the time of onset, precipitating events, and behaviour before and after the seizure.

b. Determine the child’s history related to seizures

C. Seizure Precautionsa. Raise the side rails when the child is

sleeping or restingb. Pad the side rails and other hard objectsc. Place a waterproof mattress or pad on the

bed or crib.d. Instruct the child to wear or carry medical

identificatione. Instruct the child in precautions to take

during potentially hazardous activitiesf. Instruct the child to swim with a companiong. Instruct the child to use a protective helmet

and padding during bicycle riding, skateboarding, inline skating.

h. Alert caregivers to the need for any special precautions

D. Interventionsa. Ensure airway patencyb. Time the seizure episodec. If the child is standing or sitting, ease the

child down the floor, placing the child in a side-lying position

d. Place a pillow or folded blanket under the child’s head; of no bedding is available, place your own hands under the child’s head or place the child’s head in your own lap.

e. Loosen restrictive clothing.f. Remove eyeglasses from the child if

present.g. Clear area of any hazards or hard objects.h. Allow seizure to proceed and end without

interference.i. If vomiting occurs, turn child to one side as

a unit.j. Do not restrain the child, place anything in

the child’s mouth, or give any food or liquids to the child.

k. Prepare to administer medications as prescribed.

l. Remain with the child until the child fully recovers.

m. Observe for incontinence, which may have occurred during the seizure

n. Document the occurrence.

CEREBRAL PALSY

A. Descriptiona. Cerebral palsy is a disorder characterized

by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system

b. The most common clnical type is spastic cerebral palsy, which represents an upper motor neuron type of muscle weakness.

B. Assessmenta. Extreme irritability and cryingb. Feeding difficultiesc. Stiff and rigid arms or legsd. Delayed gross developmente. Abnormal motor performancef. Alterations of muscle toneg. Abnormal posturing, such as opisthotonic

(exaggerated arching of the back)h. Persistence of primitive infantile reflexes

C. Interventionsa. The goal of management is early

recognition and interevention to maximize the child’s abilities

b. A multidisciplinary team approach is implemented to meet the many needs of the child

c. Therapeutic management includes physical therapy, occupational therapy, speech therapy, education, and recreation.

d. Assess the child’s developmental level and intelligence.

e. Encourage early intervention and participation in school programs.

f. Prepare for using mobilizing devices to help prevent or reduce deformities.

g. Encourage communication and interaction with the child on his or her developmental level rather than chronological age level

h. Provide a safe environment such as by removing sharp objects, using a protective helmet if the child falls frequently, and implementing seizure precautions if necessary

i. Provide safe, appropriate toys for age and developmental level

j. Position the child upright after mealsk. Administer medications as prescribed to

decrease spasticity.l. Surgical interventions are reserved for the

child who does not respond to more conservative measures or for the child whose spasticity causes progressive deformity.

MENTAL RETARDATION

A. Descriptiona. In mental retardation, the child manifests

subaverage intellectual functioning along with deficits in adaptive skills.

b. Down syndrome is a congenital condition that results in moderate to severe retardation and has been linked to an extra group G chromosome, chromosome 21 (trisomy 21)

B. Assessmenta. Deficits in cognitive skills and level of

adaptive functioningb. Delays in fine- and gross-motor skillsc. Speech delaysd. Decreased spontaneous activity

e. Nonresponsivemenssf. Irritabilityg. Poor eye contact during feeding

C. Interventionsa. Medical strategies are focused at correcting

structural deformities and treating associated behaviours

b. Implement community and educational services using a multidisciplinary approach

c. Promote care skills as much as possibled. Assist with communication and

socialization skillse. Facilitate appropriate playtimef. Initiate safety precautions as necessaryg. Assist the family with decisions regarding

careh. Provide information regarding support

services and community agencies

AUTISM

A. Descriptiona. Autism is a severe mental disorder

beginning in infancy or toddlerhoodb. The disorder is apparent to the parents

before the child is 3 years oldc. It is characterized by impairment in

reciprocal social interaction and in verbal and nonverbal communication

d. The cause is unknown and the prognosis may be poor

e. Diagnosis is established based on symptoms and through the use of specialized autism assessment tools

f. The disorder also is called infantile autism.B. Assessment

a. The child experiences a disturbance in the rate and appearance of physical, social, and language skills

b. The child experiences abnormal responses of body sensations

c. The child has abnormal ways of relating to persons, objects, and events; the child is self-absorbed and unable to relate to others.

d. The child has no delusions, hallucinations or incoherence, and the facies is intelligent and responsive.

e. The child may play happily alone for hours but have temper tantrums if interrupted.

f. Language disturbance often includes repetition of previously heard speech and reversal of the pronouns “I” and “you”.

g. If the child can talk, he or she uses speech not for communication but to repeat words or phrases meaninglessly

h. The child may develop an unusual attachement to a significant object and display frequent rocking, spinning twirling, or other bizarre behaviours.

C. Interventions

a. Determine the child’s routines, habits, and preferences and maintain consistency as much as possible

b. Determine the specific ways in which the child communicates

c. Facilitate communication through the use of picture boards

d. Evaluate the child for safetye. Implement safety precautions as necessary

for self-injurious behaviours such as head banging

f. Monitor for stress and anxietyg. Avoid placing demands on the childh. Initiate referrals to special programs as

requiredi. Provide support to parents

ATTENTION-DEFICIT HYPERACTIVITY DISORDER

A. Descriptiona. Attention-deficit hyperactivity disorder is a

developmental disorder characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity.

b. The disorder is one of the most common reasons for referral of children to mental health services.

c. Childhood problems include lowered intellectual development, some minor physical abnormalities, sleeping disturbances, behavioural or emotional disorders, and difficulty in social relationships.

d. Diagnosis is established based on self-reports, parent and teacher reports, and psychological assessments.

B. Assessmentsa. Fidgets with hands or feet or squirms in the

seatb. Easily distracted with external or internal

stimulic. Difficulty with following through on

instructions d. Poor attention spane. Shifting from one uncompleted activity to

anotherf. Talking excessivelyg. Interrupting or intruding on othersh. Engaging in physically dangerous activities

without considering the possible consequences

C. Interventionsa. Provide environmental and physical safety

measuresb. Enhance capabilities and self-esteemc. Encourage support groups for parentsd. Administer prescribed medications; some

commonly prescribed medications include methylphenidate hydrochloride (Ritalin), permoline (Cylert), and dextroampethamine sulphate (Dexedrine)

e. Instruct the child and parents regarding medication administration

f. Inform the child and parents that positive effects of the medication may be seen within 1 to 2 weeks if taken as prescribed.