neurological disorders in the pediatric patient
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Neurological Disorders in the Pediatric Patient. Why is the CNS function so important?. What does it do? What happens with impairment? What affects the degree of disability?. Changes to be noted in pediatric neurological disorders. Reflexes: may be hypo/hyper - PowerPoint PPT PresentationTRANSCRIPT
Neurological Disorders in the Pediatric Patient
Why is the CNS function so important?
What does it do?
What happens with impairment?
What affects the degree of disability?
Changes to be noted in pediatric neurological disorders
Reflexes: may be hypo/hyperLOC: may have altered mental statusCranial nerves:
I, IIIII, IV, VIIII, VIIIV,VIIIX, X
Neuro assessment, cont.Vital signs:changes in BP, HREyes: changes in pupils,focus,gazeBehavior: subtleRespiratory status: assess 1st
Motor function: movement? Spontaneous?Skin: dry vs. diaphoretic
Neurological System of Children
Top HeavyCranial bones- thin, not well developedBrain highly vascular with small subarachnoid spaceExcessive spinal mobilityWedge-shaped cartilaginous vertebral bodies
Assessment findings in children with neurological dysfunction
Increased Intracranial Pressure (ICP)Reflects the pressure exerted by the blood, brain, CSF and any other space-occupying fluid or mass (tumors)Pressure sustained at 20mm Hg or higherChanges in pressure present with altered assessments other than normal
Altered Mental StatusMnemonic = Mitten
Metabolic
Infections
Toxins
Trauma
Endocrine
Neurological/Neoplasm
Assessment:Infant
Irritability and restlessnessFull to bulging fontanellesIncrease in FOCPoor feeding, poor sucking, projectile vomitingDistension of superficial scalp veinsNuchal rigidity and seizures (late signs)
Assessment:Child early signs-
Irritability, lethargySudden change in moodHeadache, poor feedingVomitingAtaxiaNuchal rigidityDeterioration of cognitive ability
Assessment Child:Late signs
Changes in Vital signsSeizuresPhotophobiaPositive Kernig’s signPositive Brudzinski’s signOpisthostonos
Therapeutic Intervention:Nursing care
MedicationsCorticosteroid
Decadron
Osmotic diureticMannitol
Nursing Care
Minimize activityMonitor IV ratePlace in semi-fowlersMonitor VS, Neuro VS, and behaviorTreat for painOrganize careEducate parents
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?
Hyperfunction/Hypofunction
Pediatric SeizuresEpilepsy vs. “seizure episode”
• Status epilepticus
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
Clinical Manifestations
Generalized: Tonic-clonic- loss of consciousness(formerly called grand mal) Absence seizures-may have minor motor-atonic (formerly called petit mal)Partial seizures- partial simple or partial complex (may be focal or r/t tumors)
Diagnostic Tests:
EEGCT, MRILumbar punctureCBCMetabolic screen for glucose, phosphorus and lead levels
Jitteriness –vs- Seizure
JitteryResponsive
Gaze Okay
SeizureNot responsive to stimuli
Abnormal gaze
Goals:
What is the primary nursing goal when caring for the individual experiencing a seizure?What preventive measures does the nurse provide?How does the nurse maintain the airway of an individual experiencing a seizure?What is the priority nursing intervention following a seizure?
Long term goal for children with seizure disorders
Identify the cause and eliminate the seizure with minimum side effects using the least amount of medication while maintaining a normal lifestyle for the child
MeningitisBacterial
Potentially fatal; abx given prophylactically if bacterial suspected. May kill within 24 hrs
C/S take 72 hrs to process
Infants at greatest riskNuchal rigiditySevere headachesContagious
ViralSame s/s but milder
and shorter durationMay follow a viral
infectionMay be accompanied
by rashNuchal rigidityAtaxia Not contagious
Assessment and diagnostics: Bacterial Meningitis
Streptococcus pneumoniae most common pathogenDiagnostics: LP, CSF eval (↑ WBCs, gram stain +)Treatment: ABCDs, cerebral edema, seizure control, abx, steroidsPrevention: Vaccination (HiB, Pneumococcal vaccine)
Assessment and diagnostics: Viral Meningitis
May be preceded by viral infection, rashDiagnostics: LP, CSF eval (mildly ↑WBCs, negative gram stain)Treatment: self limiting; resolves in 7-14 days, monitored in hospital until ABCs are stableMedications: antivirals (Acyclovir)
Diagnostic Tests:
Lumbar Puncture
Serum Glucose Level
Blood Cultures
Nursing Care for diagnostics of possible meningitis
Lumbar puncture
ASO titer
CBC/electrolytes/serum glucose
Hydrocephalus
Hydro= Water
Cephaly= of the head/brain
Etiology and Pathophysiology:
Congenital anomalies
Trauma
Unknown causes
Types of Hydrocephalus
Non-communicating or Obstructive
Communicating
Clinical Manifestations
Infants- prior to fusion of cranial sutures
1. FOC increased at birth2. Changes in assessment of skull3. Forehead 4. Eyes5. Behavior changes
After closure of cranial sutures:1. Eyes2. S & S of ICP
Diagnostic Tests
LPMRI/ CT scanSkull X-ray FOCTransillumination
Interventions: Surgical
Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption
Complications of Shunts
Infections
Blocked shunts
Seizures
Nursing Interventions
Monitor VS and neurological statusAssess functioning of the shunt Assess operative siteAssess for infectionPositioning of the patientActivity of patient Promote nutritionEducation
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?
Spina Bifida
Most common defect of the CNSOccurs when there is a failure of the
osseous spine to close around the spinal column.
Types of spina bifida
Meningocele: sac filled with spinal fluid and meninges
Myelomeningocele: more severe, sac filled with spinal fluid, meminges, nerve roots and spinal cord.
Clinical Manifestations:
Visualization of the defectMotor sensory, reflex and sphincter abnormalitiesFlaccid paralysis of legs- absent sensation and reflexes, or spasticityMalformation Abnormalities in bladder and bowel function
Diagnostic Tests:
Prenatal detectionUltrasoundAlpha-fetoprotein
Following Birth:NB assessmentX-ray of spineX-ray of skull
Surgical Intervention
Immediate surgical closure
Prior to closure keep sac moist & sterile
Maintain NB in prone position with legs in abduction preoperatively
Nursing Interventions:
Pre-OP:Meticulous skin careProtect from feces or urineKeep in isolette
Post-Op Nursing Interventions
Assess surgical siteMonitor VS and neuro VSInstitute latex precautionsEncourage contact with parents/care giversPositioningSkin Care
Nursing Interventions cont...
Antibiotic therapy Prevent UTIEducation
Emphasize the normal, positive abilities of the child
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?
Cerebral Palsy (CP)
Static Encephalopathy- spastic CP most common type (80%)
Nonspecific term give to disorders characterized by impaired movement and postureNon-progressiveAbnormal muscle tone and coordination
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...
Alterations in muscle toneAbnormal resistanceKeeps legs extended or crossedRigid and unbending
Abnormal postureScissoring and extension (legs feet in plantar flexion)Persistent fetal position (>5 months)
Diagnostic Tests:
EEG, CT, or MRIElectrolyte levels and metabolic workupNeurologic examinationDevelopmental assessment
Complications
Increased incidence of respiratory infection
Muscle contractures
Skin breakdown
Injury
Goals & Interventions:
Early detection
Head Injuries
Concussions: Assessment and Nursing Care
Grades 1-3: higher the number, more severe the injuryInvolves transient impairment“Second impact syndrome:Assess and manage according to grade
Treatment is supportiveUsually observed in the EDIf unconscious > 5 minutes, may be admittedRemoval from sports ranges from 1 wk-entire season
Nurse as Provider: Care PlanBrian, 10 years old, sustained a head injury when he collided with a tree while riding his bicycle.He did not have on a helmet. He is now unconscious in the PICU and is receiving an intravenous drip of Mannitol, central venous pressure monitoring, EEG and ECG monitoring, is being mechanically ventilated, and has a urinary catheter. Brian's parents have just arrived on the unit. How can the nurse prepare the parents for Brian's appearance? What are Brian's immediate needs? Fill in the appropriate steps of the Care Plan below for Brian for the next 24 hours.
Assessment and DiagnosisPlanning and ImplementationEvaluation
CASE STUDY: The nurse is assigned to an 14-year-old female who is being observed after a head injury sustained while playing soccer. She lost consciousness for a few minutes when it happened.
What should the client and her parents be told about the recovery time after a concussion? What should the client and her parents be told about playing soccer again? What should the nurse tell the parents and the client about second impact syndrome? What can the family do to assess her symptoms at home and determine if she is ready to play competitive sports again?
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
Autism
Not clearly understoodCharacterized by impaired social, communicative, and behavioral developmentUsually noted in the first year of life
Nursing interventions/educationHome setting-reduce environmental stimuli
-communicate age appropriately;
use of touch and verbalization
-safety with toys and articles that could be harmful
-routines: ritualism with ADLs -long term care to include
therapists and support groups
Acute care setting -keep one constant
caregiver; room quiet as possible
-may become aggressive when touched by a stranger; refer to parents for communication techniques
-monitor for safety at all times: removing tubes, etc.
-encourage to include therapists and support groups in care
Down syndrome
Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation
Assessment
Primary concern with cardiac and GI anomalies
What are the most obvious indications of Down’s Syndrome in a newborn?
Goals and Interventions
Primary focus on the parents and care givers to provide support and achieve a realistic view of the child’s capabilitiesSupport siblingsRefer to family counseling servicesSupport parents in feelings of guilt and chronic sorrow