Seizure Disorders A convulsion or seizure involves involuntary

muscle contraction and relaxation. Seizures may be a symptom of a wide variety of disorders.

Its occur in approximately 10% of children. Most seizures are caused by disorders that originate outside of the brain such as a high fever, infection, head trauma, hypoxia, toxins, or cardiac arrhythmias.

• In infants and children, febrile seizures usually accompany such infections as otitis media, upper respiratory infections, and meningitis. Clinical manifestations include sudden occurrence, body stiffening, and loss of consciousness followed by quick, jerking movements of the arms, legs, and facial muscles. Febrile seizures usually occur early in the course of a high fever (≥ 39)

Epilepsy is considered present when two or more unprovoked seizures occur more than 24 hours apart.

• Status epilepticus: Continuous seizure or a series of seizures lasting for >30 minutes during which there is a loss of consciousness.

Diagnostic Tools• History and physical - emphasis on seizure event is

most valuable tool• Lab tests • Serum glucose, electrolytes, and calcium to rule out

metabolic causes• - complete blood cell count, metabolic panel• Brain imaging studies - Computed tomography scan,

magnetic resonance imaging • Electroencephalogram (EEG) to differentiate

between non epileptic and epileptic seizures.

Managing Seizure Disorders• Goals: - freedom from seizures and adverse events - avoid drug interactions - adherence to therapy - minimal interference with daily life• Seizures lasting less than 3 minutes are self-limiting. • Seizures lasting 3 to 10 minutes: administer sedative • Surgery might be necessary to remove portion of the

brain that is causing the seizure.

Nursing Intervention • Place patient in a side laying position to prevent aspiration. • Slightly elevate the head of bed to prevent aspiration. • Administer 100% oxygen using a face mask if the patient is

hypoxic. • Monitor for depressed respiratory rate because this might

indicate increase intracranial pressure. • Monitor level of consciousness, vital signs and pulse oximetry

continuously. • Pad the side rails of the bed to prevent injury. • Parents should also tell the school and caregivers about the

child’s seizures and explain that they should lay the child on his side, protect him from injuring himself during the seizure, and not place anything in the child’s mouth.

Intracranial Infection • It’s an inflammation of the area invaded. Depending on the

location of the infection, different names are given to the diseases as:

• 1. Myelitis: inflammation of the spinal cord.. • 2. Encephalitis: inflammation of the brain

tissue. • 3. Meningitis: Inflammation of the meninges,

the lining surrounding the brain a

Meningitis • Meningitis is a serious illness in children and can lead to brain

damage, nerve damage, deafness, stroke, and even death. • Causes: • Mainly occur secondary infection to upper respiratory

infections, sinus infections, or ear infections. Three main types of bacteria may cause meningitis.

• a. Haemophilus influenza B • b. Streptocccus pneumonia• c. Neisseria meningitis. • Pathophysiology • Bacterial meningitis causes inflammation, swelling, purulent

exudates, and tissue damage to the brain.

Clinical manifestation: • Poor sucking and feeding, weak cry, lethargy and vomiting. • Sudden onset of symptoms, preceding with respiratory illness

or sore throat • Presence of fever, chills, vomiting and headache due to

increased intracranial pressure. • Photophobia (sensitivity to light) due to irritation of the

cranial nerve • Marked irritability and frequent seizures due to irritation of

brain • Bulging fontanel in infants (late sign), muscle rigidity and pain

in older children. • Stiff neck, nuchal rigidity (pain when flexing chin toward

chest) due to meningeal irritation and irritation of the spinal nerves

• Brudzinski sign where the head is flexed while in the supine position. A positive sign is if the child experiences pain or if the child’s hips and knees are flexed.

• Kerning sign where the child lies flat with legs flexed at hips and knees. The child resists positioning and experiences pain indicating a positive Kerning sign.

• The infant with bacterial meningitis may rest in the opisthotonos position (head and neck are hyperextended to relieve discomfort).

• Rash, petechial, vesicular, or macular rash.

Abrupt eruption of a petechial or purplish rash can be indicative of meningo-coccemia (infection with N. meningitis). Immediate medical attention is warranted

Diagnosis:-

• Lumber puncture: to examine the CS F, the test shows:

• a. Increase in white blood cells • b. Glucose level decreased (bacteria feed on

glucose). • c. Protein level increased• d. CSF culture to identify the microorganism

Therapeutic Management• Bacterial meningitis is a medical emergency and

requires prompt hospitalization and treatment to avoid long-term neurologic damage and even death.

• 1. Isolation precautions • 2. Antimicrobial therapy:- proper antibiotics for at

least 10 days. • 3. Maintenance of optimal hydration • 4. Maintenance of ventilation. • 5. Control of seizures • 6. Reducing ICP • 7. Control of temperature

Nursing Consideration:- • administer the antibiotics as soon as possible as it is

ordered. • Infection control: • Meningitis is transmitted by direct contact with respiratory

droplets from the nose or throat. • Control measures should be initiated in environments

where risk exists. Disinfect toys and other shared objects to decrease transmission of the microorganisms to others.

• The Haemophilus influenza B vaccine is routine starting at 2 months of age

• The pneumococcal vaccine is also routine for all children starting at 2 months of age and should be considered for preschoolers who are at risk.

• Monitor intake and output to check fluid balance. • Keep room darkened, due to photophobia, and quiet • Monitor neurologic function every 2-4 hours, mental status,

level of consciousness, pupil reactions, speech, and facial movement symmetry, signs of increased IP

• Seizure precautions and keep suction and oxygen available at bedside.

• Elevate head of bed 30 degrees to decrease intracranial pressure.

• Administer cooling blanket if the patient’s temperature rises > 38.5°C. Avoid measures that cause shivering because it increases heat production.

• Assess the anterior fontanel in infant to determine if it is bulging due to increase intracranial pressure.

• Measure the patient’s head circumference per shift to detect increase intracranial pressure.

• Assess motor skills.

Hydrocephalus • Refer to accumulation of CSF in the ventricular cavity of

brain causing ventricles to dilate and increase intracranial pressure. Hydrocephalus may be congenital or acquired.

• Congenital hydrocephalus• Acquired hydrocephalus develops at the time of birth or

later. It can occur at any age and can result from injury (trauma) or disease neoplasms, or infections.

• Hydrocephalus may classified as obstructive or non-communicating vs. non obstructive or communicating.

• Obstructive or non-communicating hydrocephalus occurs when CSF is unable to pass between the ventricles and spinal cord. Non-obstructive or communicating hydrocephalus occurs when passage of CSF between the ventricles and spinal cord does not occur.

Pathophysiology

• CSF is formed primarily in the ventricular system by the choroid plexus and is absorbed primarily by the arachnoid villi. Hydrocephalus results when there is an obstruction in the ventricular system or malfunction of the arachnoid villi.

Clinical Manifestation

• Infancy:- • 1. Bulging fontanels, non-pulsatile, and head

enlargement. • 2. Scalp veins dilated because of fluid

accumulation. • 3. Skull bones become thin and separated

produce the (cracked pot) sign.

• Childhood • 1. Headache • 2. Vomiting 3. • Papilledema (swelling of optic nerve). • 4. Strabismus (crossed eyes) • 5. Ataxia (unsteadiness of posture) • 6. Irritability and lethargic • 7. Confused, incoherent.

Diagnosis

• 1. Head circumference. • 2. CT scan, MRI visualizes the ventricles to

determine if the ventricles are dilated, detect the obstruction site.

Therapeutic management

• Surgical treatment: - directed toward resection neoplasm, cyst or obstruction.

• Shunting:- provides primary drainage of CSF from the ventricles to either the peritoneum or the heart, ventriculoperitoneal shunt (VP) or ventriculoatrial shunt (VA) shunt.

• Complication: • Most common complication are: infection,

septicemia, endocarditis, ventriculitis malfunction, kinking, or separation shunt obstruction (tissue or exudate in the peritoneal end).

Nursing care for a patient with VP shunt

• Monitor vital signs and assessment of neurological status.

• Place cotton behind and over the ear under the head dressing to prevent pressure sores on the skin overlying valve.

• Assess for abdominal distention resulting from paralytic ileus due to the VP shunt.

• Observe for signs of complication: • Increased intracranial pressure.

Dehydration. Assess for infection and VP shut malfunction: Severe headaches, irritability and vomiting. Fluid around the VP shunt valve, purulent drainage

from the incision and fever. Lethargy. Explain the disorder and treatment to the family and

explain that VP shunt may have to be replaced periodically to accommodate the child’s growth.

Also explain how to identify infection or malfunctioning of the VP shunt.

Neural tube defects • The neural tube develops into the brain and the

spinal cord. A neural tube defect is the failure of the neural tube to close within 28 days after conception in an area of the neural tube or the entire length of the neural tube resulting in a neurologic disorder in the fetus.

• The cause of neural tube defects is unknown; however, there is a link between inadequate intake of folic acid prior to pregnancy and during the first trimester. Also its link to maternal exposure to teratogenic agent as radiation, malnutrition and infections at early of pregnancy

Neural tube defects • The most common neural tube

defects are: • 1. Anencephaly: No cerebral

hemispheres (only small vascular mass attached to the base of the skull).

• 2. Encephalocele: a rare disorder in which the bones of the skull do not close completely, creating a gap through which cerebral spinal fluid, brain tissue and the meninges protrude into a sac-like formation.

• Spina Bifida: Latin word means (divided spine)

• Malformation of the spine in which the posterior portion of the lamina of one or more vertebrae fails to fuse with or without defective development of the spinal cord (neural tube).

• Occur in any area, but most common in lumbar or lumbosacral region

• Types of Spina Bifida:-• 1. Spina bifida occulta is a failure of the vertebral arch to

close. There is a dimple on the back, which may have a tuft of hair in it and no protrusion of the spinal cord or meninges. Mostly not visible and no care is required.

• 2. A meningocele is a saclike protrusion along the vertebral column filled with cerebrospinal fluid and meninges. Surgery is required to repair the defect, but there are no long-term effects.

• 3. A myelomeningocele is a saclike protrusion along the vertebral column filled with spinal fluid, meninges, nerve roots, and spinal cord. Because of the nerve root and spinal cord involvement, there will be paralysis at some level after surgical repair. Therefore, the long-term complications of paralysis, orthopedic deformities, and bladder and bowel incontinence are needed. The newborn with myelomeningocele is at increased risk for meningitis, hypoxia, and hemorrhage

• Prenatal Detection: • Elevated alpha-fetoprotein, perform in 16 – 18 weeks of gestation by

amniocentesis.

• Nursing Management: • 1. Prevent local Infection: • Cleanse myelomeningocele carefully with sterile

saline. • Inspect myelomeningocele for changes in

appearance as abrasions, tears, signs of infection. • Position infant to prevent contamination from

urine and stool • Administer antibiotics as ordered • Administer similar care of operative site

postoperatively.

• 2. Prevent local trauma and skin break down: • Handle infant carefully and change position frequently • Place infant in prone position or side - lying position, if permitted • Apply protective devices • Modify routine nursing activities, for example, feeding, making bed,

comforting activities. • Place soft foam or fleece pad under infant. • Rub skin with lotion periodically to stimulate circulation

• 3. Prevent complication • Observe infant carefully: head circumference daily and fontanels for

bulging. • Note irritability, lethargy, difficulty in feeding, high - pitched cry • Observe for signs of meningeal irritation and inflammation, for example,

fever, nuchal rigidity, irritability (take vital signs every 2 to 4 hours as ordered).

• 4. Prevent urinary tract infection • Avoid contamination with stool • Empty bladder periodically (apply gentle, downward

pressure to bladder).

• 6. Prevent or minimize hip and lower extremity deformity • Carry out passive range of motion and exercises, with care

to avoid fracturing fragile bones. • Maintain hips in slight to moderate abduction to prevent

dislocation.