Alterations in Neurological, Mental Health and Cognition FunctionsNR 322 Pediatric NursingChamberlain College of NursingWeek 2

Altered States of ConsciousnessLevel of ConsciousnessIncreased Intracranial Pressure

Altered States of Consciousness Level of consciousnessMOST CRITICAL CLINICAL INDEX OF NERVOUS SYSTEM FUNCTIONReflects status of BRAIN Patterns of breathingReflects cerebral hemisphere/brain stem functionPupillary changes and eye movementReflects brain stem functionMotor responsesReflects level, side & severity of brain dysfunction

Nursing Assessment of Altered Levels of ConsciousnessLevels of consciousness (LOC)most important indicator of neurological dysfunctionConsciousnessreceptiveness to stimuliAlertnessarousal, ability to reactCognitive power ability to process data and respond

Neurological AssessmentAlertness arousal with touch, voice, pain?Cognition processes? Posture and Movement MAE? (moving all extremities) Purposeful?Muscle tone mild, even resistance?Homeostatic mechanisms Temp, HR, RR, BP, U/O, digestion (vomit?) Pain headache

Altered Levels of ConsciousnessStages of altered LOCConfusion inability to think rapidly, impaired judgment or decision makingDisorientation to time, place, and person; memory affectedLethargy limited spontaneous movement, sluggish speech. Will arouse with moderate stimuli but returns to sleep quickly

Altered Levels of ConsciousnessObtunded reduced arousal need loud voice or strong touch, falls asleep often, yes/no ?s OK; mentally dulled; out of it5) Stupor- deep sleep; unresponsive; arouses only to vigorous, repeated stimulation; withdraws or grabs in response to pain or stimulation. 6) Coma no motor or verbal response to even deep pain

Deterioration of LOC: A Sequential PatternAwake and alert - responds appropriatelySlight disorientation to time, place, or personRestless, fussy, or irritableDrowsy but responds to loud commands, painful stimuliNonpurposeful responsePosturingNo response

*Tool to Quantify LOC:Pediatric Glasgow Coma Scale

Three part assessmentEyesVerbal responseMotor responseScore of 15: unaltered LOCScore of 3: extremely decreased LOC (worst possible score on the scale)

*Early Signs of Increasing ICP Changes in LOC, irritability, restlessnessHeadache, dizzinessVomiting, possibly projectileBlurred vision, double vision (diplopia) HR, RR, BP or pulse pressurePupil reaction time ; unequalSunset eyesSeizure activity

Kyle & Carman, Pediatric Nursing Clinical guide, 2013

*Additional Manifestations of Increased ICP in InfantsIrritability, poor feedingHigh pitched cry, difficult to sootheFontaneles: tense, bulgingCranial sutures: separatedEyes: setting-sun signScalp veins: distended

*Late Signs of Increasing ICPDecreased LOCDecreased motor and sensory response to commandAlterations in pupil size and reactivity; papilledemaDecerebrate or decorticate posturingCheyne-Stokes respirationsIrregular respirationsBradycardia

*DecorticateDecerebratePOSTURING

*Types of ICP MonitorsIntraventricular catheterSubarachnoid screw or boltEpidural sensorAnterior fontanelle pressure monitor

*Nursing Care for Child with Increased ICPPatient positioningAvoid activities that may increase ICPEliminate/minimize noise or stimulationSuctioning issuesAvoid overhydration

Seizure DisordersGeneralized SeizuresPartial SeizuresFebrile SeizuresStatus Epilepticus

Epilepsy (Seizure disorder)Seizures are triggered recurrently from within the brainTwo or more unprovoked seizures occur> 24 hours apartCan be acquired or familial

Seizures: IncidenceMost common neurological dysfunction in children50% idiopathic 5% of children have at least one seizureOccurs with wide variety of CNS conditions45,000 children develop epilepsy every year, 30% by age 4 years old

Seizures: PathoCaused by disruption of electrical communication among the brains neuronsExcessive uncontrolled discharge of neurons of cerebral cortex that interferes with normal functionNeurons recruit other neurons to fire synchronously in adjacent and distant areasMay have aura or sensory experienceMay occur without any clinical symptoms

*Common Pediatric Seizure TriggersChanges in dark-light patterns (camera flashes, headlights, rotating fan blades, reflections off snow or water)Sudden loud noises Extreme temperature changesDehydrationFatigue

Clinical Manifestations: Depends on the TypeCommon Seizure TypesInfantile spasmsAbsence (formerly petit mal)Tonic-clonic (formerly grand mal)MyoclonicAtonicFebrileSimple partialComplex partialStatus epilepticus

General s & sChange in LOCInvoluntary movementsPosturingChanges in perceptionChanges in behaviorChanges in sensationMay be brief, self-limiting

Infantile SpasmsUncommon type of generalized seizureIncidence:Usually seen between 3-12 months old, peak incidence 4-8 months and usually stops by 2 years oldMajority have some brain disorder before seizures beginClinical Manifestations:Sudden jerk followed by stiffeningHead flexed, arms extended, legs drawn upCry may precede or followTherapeutic Management: Steroids, anticonvulsants

*Absence SeizuresSudden cessation of motor activity or speech with a blank facial expression or rhythmic twitching of the mouth or blinking of the eyelidsMinimal or no change in muscle toneAlmost always appear in childhood between ages 5-12 years oldSudden onset of up to 20+ events per dayNo warning/no aura/no postictalDuration < 30 secondsMay drop object, child rarely fallsNo incontinence

*Absence SeizuresOften unrecognized or mistaken for:Inattention/daydreamingADD/ADHDSchool issuesBehavioral management

Tonic-Clonic Seizures:Extremely common generalized seizureAssociated with an auraLoss of consciousness occursTonic-clonic movementsCyanosis may be noted d/t apneaSaliva may collect in mouthMay bite tongueLoss of bladder sphincter controlPostictal state

*Myoclonic SeizuresSudden, brief, massive contractions of muscle group (whole body or 1 part)May be single or repetitiveMay or may not lose consciousnessOften occur with falling asleepMay be nonspecific symptom in many CNS disordersMay be mistaken as exaggerated startle reflex

*Atonic SeizuresSudden momentary loss of muscle toneOnset usually age 2-5 years oldMay or may not have LOC changesSudden fall to ground, often on face Less severehead droops forward several times

*Febrile SeizuresTransient disorder of childhoodAffect approximately 3% of children; 10% once dx epilepsyUsually occur between ages 6 mos and 3 yrsRare after age 5 years oldTwo times more frequent in males95%-98% of children with febrile seizures will not have epilepsy or neurologic damage

*Febrile SeizuresCause? unknown: linked to immature CNSUsually with temps >102FSeizure occurs while temp is rapidly increasing, not afterSeizure usually over by arrival to ER (duration

Partial Seizures (focal)Limited functional area is involved Simple Partial:No loss of consciousnessNo aura,

*Status EpilepticusSeizure lasting >30 minutes or series of seizures without regaining consciousness between seizuresCan be life-threateningAge of child, cause of seizure, duration of status epilepticus influence prognosis

*DiagnosticsAscertain type of seizureHealth history, observation, risk factorsPhysical ExaminationLabs/diagnostic testsLabs: glucose, lytes, calciumLumbar punctureSkull xray, CT, MRIEEG, Video EEG

Therapeutic Management of SeizuresAnticonvulsants: Primary mode of tx

Intractable seizures:Surgery: if seizures uncontrolledVagal nerve stimulator (VNS)Ketogenic diet

TABLE 536 Anticonvulsants Used to Treat Seizure Disorders

Obtain seizure historyProvide a thorough and accurate description of the event.Protect child from injury during seizuresAdminister appropriate medications and treatmentsLots of education of family members & caregiversNursing Care Management for All Seizure Disorders

Nursing Care: Seizure PrecautionsPad side rails and other hard objects.Raise side rails on the bed at all times when child is in the bed.Keep oxygen and suction at the bedside.Provide supervision, especially during bathing, ambulation, or other potentially hazardous activities.Encourage the use of a protective helmet during activities.Make sure child wears a medic alert bracelet.

Nursing Care:During the seizureRemain calmStay with the child until fully consciousProtect from injury & remove hazardsNote time of onset, duration, details of seizureBe ready with oxygen and suction Move to flat surface, away from dangerTurn child to side, let saliva drain outSupport childs head to prevent head bangDO NOT restrain childDO NOT use tongue blades or insert any object into the mouth (including fingers)Loosen tight clothing & jewelry from around neckTreat all injuries from fallDocument all details of the seizure

Interventions for Status EpilepticusBasic life support: ABCsAdminister anticonvulsants: crucialEnsure safetyEstablish intravenous accessMonitor vital signs and neurologic statusBlood glucose, electrolytes, blood gases monitoredIf hypoglycemic, administer glucose

*Febrile Seizures ManagementAvoid tepid bathsusually ineffectiveVigorous use of antipyreticsProtect child from injury during seizureCall 911 if seizure >5 minutes durationRectal diazepam

Infectious DiseasesBacterial MeningitisViral MeningitisEncephalitisReye Syndrome

MeningitisAcute inflammation of the meninges surrounding the brain and spinal cord caused by a bacteria or a virusWhos at Risk? Children who are ill with an upper respiratory infection such as sinus infections or ear infectionsChildren with head trauma/ post-lumbar puncture/neurosurgical intervention/Congenital structural abnormalities/ Foreign objects Age factor (infants, adolescents, young adults 15 -24 years old)

Bacterial Meningitis:Clinical ManifestationsFever, chills, malaise, lethargyRestless, lethargic, irritable, difficult to consoleChanges in feeding pattern, vomiting, diarrheaHeadache, anterior fontanel bulging or flatNuchal rigidity (stiff neck), photophobiaPositive Brudzinskis sign- flexion of neck causes neck pain and hips/knees flexPositive Kernigs sign flex hip and knee, then extend leg and note hamstring pain!!Seizures , Rash (Alert!! Meningococcal rash)SIADH fluid overload or DI - dehydration

Bacterial Meningitis:DiagnosticsLP is definitive diagnostic test.Cerebrospinal fluid (CSF):Increased WBCsIncreased ProteinDecreased GlucoseCBC:Increased WBCsBlood cultures:Done to rule out sepsis. Positive in cases of septicemia

Isolation: Droplet precautionsAntimicrobial therapy Started immediately after CSF & blood cultures have been obtained.Corticosteroids Hydration and nutritionVentilationReduce ICPObserve for/treat septic shock Control seizuresManage and reduce fever*Bacterial Meningitis:Therapeutic Management

Viral (Aseptic) MeningitisInflammatory response of meningesMost common cause: EnterovirusChild not as ill-appearing as child with bacterial meningitis

Viral Meningitis: Clinical ManifestationsIrritable or lethargic - general malaiseFeverHeadachePhotophobiaUpper respiratory symptomsPositive Kernig and Brudzinski signs - indicate meningeal irritationSeizures are rare

Viral Meningitis: Therapeutic ManagementLabs and cultures (blood, urine, cerebrospinal fluid)Intravenous antibiotics until cultures are negative - treat as bacterial meningitis until proven otherwiseTreatment of symptoms is supportiveSymptoms usually resolve in 3 to 10 daysNeurologic deficits are uncommon

EncephalitisAcute inflammation of brain & sometimes the meninges caused by infectionHighest incidence if < 1 year oldIf survive, often have significant neurological sequelaeEtiologiesMost common: Herpes viruses Enterovirus, Epstein-Barr virusMeasles and varicella Fungi, parasites

Encephalitis:Clinical ManifestationsGeneral SymptomsMalaiseFeverHeadache/dizzinessStiff neckNausea/vomitingAtaxiaSpeech difficultiesSevere SymptomsHigh feverDisorientation/ stupor/comaSeizuresSpasticityOcular palsiesParalysis

Encephalitis: Therapeutic & Nursing ManagementPharmacologicalAntibiotics if bacterialAcyclovir if herpes virusIVIG, corticosteroids, immune system modulators if postinfectious encephalitisNursing Care focus: SupportiveMonitoring cardiopulmonary statusPreventing complications resulting from immobilityReorienting the child when LOC improvesTeach family about childs condition

Reye SyndromeAcute metabolic, non-inflammatory encephalopathy of childhood with organ involvementDisrupts the process of changing ammonia to urea hyperammonemiaFatty degeneration of the liver, kidneys, brain and myocardiumWhos at Risk?Associated with viral illnessesStrongly associated with the use of salicylates (aspirin) to treat symptoms of varicella or influenza infection

Reye SyndromeClinical PresentationEncephalopathyIncreased ICPMetabolic dysfunctionHepatic dysfunctionRenal damageFatty infiltration of the viscera

Assessment FindingsHypoxiaSeizuresHypoglycemiaCoagulopathiesElectrolyte ImbalancesHyperthermia

Reye Syndrome: Clinical ManifestationsStage 1:Vomiting,lethargyStage 2Combative or stuporHyperactive reflexesStage 3:ComaDecorticatedStage 4:ComaDecerebratedStage 5Coma with SeizuresLoss of DTRs

Reye SyndromeTherapeutic Management:CorticosteroidsBarbiturates Mannitol or hypertonic salineAnticonvulsantsVitamin K liver coagulopathy

Reye Syndrome:Nursing Care ManagementPriority: Monitor for changes in neurological status, report immediatelyAssess for GI bleeding, pancreatitis, liver failureProvide IV hydration with glucoseProvide seizure precautionsMonitor respiratory statusElevate HOB 30-45 degreesKeep child calm and a quiet environmentEducate parents on need for long-term F/U

HeadachesBenignStructural

Headaches- StatsUp to 75% of children experience headache by age 15 years old.

Migraines occur in 1% of children by age 7 years and 5% by age 15 years.

Approx. 20% of children in U.S. have chronic headaches.

Headaches: EtiologiesBENIGNMigraine: VascularTension: Muscular contractionInflammatory: Sinusitis or dental abscess

STRUCTURALTumorsHemorrhageIncreased ICP

MEDICATION OVERUSE(Rebound)AcetaminophenNSAIDsDecongestantsErgotomines

Headaches:TriggersMIGRAINESStressFood containing nitrates, MSG, caffeine, tyramine, salt, yeast extracts, aspartame (Equal)MensesOral contraceptivesFatigueHungerTENSIONStress associated with schoolInsecurityConflict in the familyInadequate sleep

Structural DefectsHydrocephalusNeural Tube Defects: Spina Bifida

Hydrocephalus Increase in the amount of cerebrospinal fluid in the ventricles and subarachnoid spaces. Results from an imbalanced production or absorption of CSF. CSF accumulates within the ventricular system and causes the ventricles to enlarge and increases in ICP to occur.50% is idiopathicCommon disorders associated with hydrocephalus:Neural tube defectsintraventricular hemorrhage IVH (prematurity)MeningitisIntrauterine viral infectionsLesions or malformations of the brainInjury

Hydrocephalus:Pathophysiology & EtiologyNon-communicating: Most common type in childrenObstruction in ventricles blocks outflow of CSF to subarachnoid spaceCSF accumulates Communicating: Poor absorption of CSF Often due to scars, IVH, or congenital malformations of subarachnoid space

*Hydrocephalus(Note to instructor: Image available in Electronic Image Collection)

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Hydrocephalus:Clinical ManifestationsIn all ages, signs & symptoms of IICPPositive Macewens signInfants Rapid increase in head circumference, split sutures, bulging fontanelOlder children HEADACHE! Difficulty with balance and coordination, loss of development,Changes in personality

Hydrocephalus:Diagnostics & Therapeutic ManagementDiagnostics: Skull xray, CT & MRI of headTherapeutic Management:Most cases are treated with surgical placement of an extracranial shunt (Most often a ventriculoperitoneal (VP) shunt)Shunt revision surgery as child grows

Ventriculoperitoneal (VP) Shunt

*VP Shunt ComplicationsInfectionVS, tempPoor fdgNauses/VomitingMalaiseHeadacheRedness along the tractMalfunctionVomitingDrowsinessHeadache

Hydrocephalus

Nursing Management:Keep head flat and midline (venous drainage)Dont let baby lay on side of surgeryEducate s/sx of infection (fever, redness) and IICP (seizure, lethargy, vomiting)Monitor for complications

Neural Tube DefectsCongenital malformations that produce skull and spinal column defects (failure to close) usually at L5 or S1 level. Cause? Folic Acid! Chemicals, genetics, Moms DM, Moms meds: Valproic acid & Accutane (check AFP) Types:Anencephaly: No brain above the brainstemEncephalocele: Protrusion of meningeal tissue or brain through a defect in the skullMeningocele: Protrusion of a meningeal sac filled with CSF through a vertebral defectMyelomeningocele: Protrusion of meningeal sac that contains CSF, a portion of the spinal cord and nerves through a vertebral defect

Spina Bifida Occulta: Clinical ManifestationsDepression or dimple or tuft of hair over spinal defect; possible sacral lipomaMay see port wine nevi or soft fatty deposits at defectTethered cordAbnormal adhesion to body or fixed structurePuts traction on the cordAltered gaitBowel/bladder problemsFoot deformities

Spina Bifida Cystica: Myelomeningocele and Meningocele

*MyelomeningoceleNeural tube fails to closeMay be anywhere along the spinal columnLumbar and lumbosacral areas most commonMay be diagnosed prenatally or at birthSac contains meninges, spinal fluid, and nervesVarying and serious degrees of neurologic deficitClinically myelomeningocele term is used interchangeably with phrase spina bifida

*Spinal defects

Myelo/ Meningocele: Clinical ManifestationsSac like structure noted over spineOften ulcerations or cyanotic areaClub footKnee contracturesHydrocephalus seizureCurvature of the spineNeurologic dysfunction below defectBowel/bladder incontinence

*Intact sacRuptured sac

Myelomeningocele: Therapeutic ManagementSurgical closure as soon as possible after birth (within 48 hours)Goal: Prevent infection and minimize further loss of function In utero fetal surgery to repair defectLife-long multidisciplinary approachNeurologist, neurosurgeon, urologist, orthopedics, physical therapy, rehabilitation, intense nursing care

Cover sac with sterile dressing (warm saline). Avoid pressure on the sac.Monitor for CSF leakagePlace infant in prone position with knees slightly flexedKeep lesion free of feces/urineKeep in an isolette or warmerMonitor for signs of infectionFeed with head turned to one sideAvoid latex productsMyelomeningocele: Pre-op Nursing Care

Myelomeningocele: Post-op Nursing CareMonitor for wound healingMonitor for signs of infectionMonitor for signs of hydrocephalus, increased ICPPlace in prone or side-lying positionMeasure head circumference dailyAssess intake and outputKeep diaper away from incision siteAvoid latex products

Mylemeningocele: Nursing Management PrioritiesPrevent trauma and infection before and after surgical repair of the defectPromote urinary and bowel eliminationNeurogenic bladder is commonMay need catheterization or surgeryPromote adequate nutritionPrevent latex allergic reactionMaintain skin integrityEducate the child and family

Cerebral PalsySpasticDyskineticAtaxicMixed

Cerebral Palsy

Non-progressive, permanent, early onset motor disorder of CNS resulting in alteration in movement and posture. Results in activity limitations.

Etiology:Intrauterine hypoxia/asphyxiaIntrapartum asphyxiaPreterm birth of LBWMaternal infections rubellaMaternal drug useForceps, vacuum, trauma in birth processKernicterusProlonged labor

CP: Clinical ManifestationsClassifications:Spastic persistent primitive reflexes esp. Babinski Hypertonicity- contractures scissor gait= MOST COMMON CLINICAL TYPEDyskinetic Athetoid chorea- involuntary, wormlike movements of trunk, face and tongue Dystonic drooling and imperfect speech + slow twisting movement of trunkAtaxic wide based gait, non spastic, cannot reach for things or hold onto objects, disturbed coordination, rapid repetitive movementsMixed combination of spastic and athetosis

*Possible Motor Signs of CPPoor head control after age 3 mosStiff or rigid limbsArching back/pushing awayFloppy toneUnable to sit without support at age 8 mos Clenched fists after age 3 mos

Cerebral Palsy:Therapeutic ManagementOVERALL FOCUS:Assist the child to gain optimal development and function within the limits of the disease

TREATMENT IS:SymptomaticPreventativeSupportive

Cerebral Palsy: Therapeutic ManagementPHARMACOLOGIC MANAGEMENT:Treat Spasticity:Baclofen (Lioresal) poDantrolene sodium poDiazepam poBotulinum toxin injectionsContinuous infusion of intrathecal baclofen via implanted pump SURGICAL MANAGEMENTTHERAPEUTIC MODALITIES:Physical, Speech, Occupational Therapy

Cerebral Palsy:Nursing ManagementProvide nursing care related to therapeutic management modalitiesPromote adequate nutritionMaintain skin integrityPromote physical mobilityPromote safetyPromote growth and developmentFoster parental knowledgeProvide emotional support

Acceptance

Developmental and Behavioral DisordersAutistic Spectrum DisordersAttention Deficit/hyperactivity Disorder

Autistic Disorder(Autism)A developmental disorder characterized by severely abnormal development of social interaction and of verbal and nonverbal communication skills which usually appears in the first 3 years of life

Incidence:Autism makes up 50% of the Autism Spectrum Disorders2-15 times more common in males than females 1985: 0.4/1000 and in 2006: 6.6/1000Affects 12-16% of children

Autism: Etiology & PathophysiologyExact cause unknown although biologically-based.Possible Causes:Biochemical imbalances Brain abnormalitiesGenetic disorder of pre/postnatal developmentImmune responses to a virusToxic chemicalsNo demonstrated relationship to immunizations

Autism:Warning SignsDoes not babble by 12 mosNot pointing or using gestures by 12 monthsNo single words by 16 mosDoes not use 2-word phrases by 24 monthsLosing language or social skills at any age

Autism: Clinical ManifestationsInability to respond to change routine!Echolalia repeating rhythm, rhyme, songsRepetitive movements such as hand flapping or spinningStereotypy rigid, obsessive behaviorInability to maintain eye contact, relate, refuses comfortingIndifference to touch or affectionFascinated by spinning, light, sparkle, music Self-injurious behaviors such as head banging, hand bitingWont explore objects but will line them up, ritualsRestricted eating/touching certain colors, foodsWide range of intellect SavantMay appear deaf May make inappropriate noises

Autism: Therapeutic ManagementGoal: For child to reach optimal functioning within the limitations of the disorderIndividualized plans of careBehavioral and communication therapies importantHighly structured educational environmentsStimulants for hyperactivityAntipsychotic medications for children with repetitive and aggressive behaviors

Autism:Nursing ManagementMaintain home routines as much as possibleSet firm limits on behaviorsProvide safe environmentStabilize environmental stimuliSpeak in short, direct sentences to childProvide anticipatory guidanceAssess parents need for respite care

ADD/ADHDAttention Deficit Hyperactivity Disorder is a variation in CNS processing characterized by developmentally inappropriate behaviors involving inattention, impulsivity and hyperactivity

Incidence:Males 4 x more than Females 25% - 1st degree relative

ADHD: PathophysiologyExact cause unidentifiedPossible deficit in dopamine and norepinephrineBrain maturation delay, as much as 3 years, on imaging studiesCortex especially affected

ADHD: Risk FactorsSeizures and head traumaHigh levels of lead or mercury exposurePrenatal exposure to cigarette smoke or alcohol Prematurity, low birth weightGenetic? Specific mechanism not yet known. Genetic predispositionDaily TV exposure from 1-3 years old associated with attentional symptoms at age 7

ADD - Difficulty concentrating; cannot organize; loses things, forgets, failure to listen when spoken to directly, forgets to finish activity, feels different from others, isolatedADHD: Frustration, labile moods, emotional outbursts, peer rejection, poor school performance, low self-esteem, poor meta-cognitive abilities such as poor organization and poor time managementADD/ADHD: Clinical Manifestations

Administer stimulant medicationsMinimize environmental distractionsImplement behavioral management plansProvide emotional supportPromote self-esteemNursing Management: ADD/ADHD

Cognitive DisordersDown SyndromeFragile XFetal Alcohol Syndrome

Cognitive ImpairmentIntelligence significantly below average, existing with limitations in adaptive skillsWhos at Risk? Prenatal Down Syndrome, fetal alcohol syndrome, infectionsPostnatal factors brain trauma, metabolismManagement:Stimulation and activitiesPositive self-esteem: ability not disability! Head start < 3 y/o premie assessmentsDisabilities Act (education for all, IEP)

Severity ScaleMild IQ 50-70 (normal > 90) Mental age 8-12 yrs, reads, writes, basic math, vocationalModerate - IQ 35-50 Mental age 3-7 yrs, trainable, sheltered workSevere - IQ 20-35 Mental age 0-2 yrs, total careProfound -

Mild to severeIQ is not as important as functional assessmentMotor movementLanguageAdaptive behaviorAchieve developmental milestones slowlyIntellectual Disability: General Concepts

Early detection and screeningDevelopmental milestonesDenver II developmental screening testProvide emotional support and informationLoss of perfect childSupport groupsHonest informationMaintain safe environmentPhysical safetySafety with strangersNursing Management of Intellectual Disability

Promote adaptive functioningAllow home routine during hospitalizationSelf-care routinesMedication schedulesMedication administration techniquesInterventions (suctioning, feeding, etc) Nursing Management of Intellectual Disability

Down SyndromeTrisomy 21, characterized by intellectual disabilities in varying degrees and multiple associated defects Life expectancy to ~60 y/oWhos at Risk? 1:733 babies Increasing with maternal ageBut 80% born to < 35 y/o

Down Syndrome:Clinical Manifestations

HypotoniaSimian crease on palmSmall statureEpicanthal eye foldsSmall, low set earsFlat noseShort, thick neckProtruding tongueCognitive impairment- continuumCommon Co-existing Conditions:Congenital heart diseaseRespiratory infections d/t constant stuffy nose and mouth breathing Leukemia, Hearing loss, Thyroid disease, Strabismus

Genetic anomaly on X chromosomeProtein necessary for normal brain development is missingClinical manifestationsLong face with prominent jaw and large earsStrabismusAggressive behaviorsIntellectual DisabilityFragile X Syndrome

Caused by effect of alcohol on developing fetusClinical manifestationsFailure to thriveFlat midface with low nasal bridgePoor coordinationPoor impulse controlLow normal IQ to Intellectual DisabilityFetal Alcohol Syndrome

********Normal ICP is 5-15MAP-ICP=CPPCPP should be between 70-100*Open fontanel---increased FOC,

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********************high-fat, adequate-protein, low-carbohydrate ********

Neonates do not have stiff neck---Young childrenno stiff neck.brudzinski and kernig not helpful---cranky kidsAdolescents present like adults******* ********************Baclofen---skeletal muscle relaxant

*High calorie diet***************