Nervous System Anatomy and Development

Development of the Nervous System

• The nervous system beings to form early in embryonic development
• The fetus responds to stimuli later in intrauterine development
• The nervous system continues to develop after birth

Central Nervous System (CNS)

• The CNS consists of the brain and the spinal cord
• The brain consists of the cerebrum, which controls consciousness
• The cerebrum is divided into two hemispheres with the frontal, temporal, parietal, and occipital lobes
• Diencephalon includes the thalamus and hypothalamus
• The cerebellum is also part of the CNS
• The brainstem is also part of the CNS

Peripheral Nervous System (PNS)

• There are 12 pairs of cranial nerves
• There are 31 pairs of spinal nerves

Cranial Nerves

• I: Olfactory
• II: Optic
• III: Oculomotor
• IV: Trochlear
• V: Trigeminal
• VI: Abducens
• VII: Facial
• IX: Glossopharyngeal
• X: Vagus
• XI: Spinal accessory
• XII: Hypoglossal

Autonomic Nervous System (ANS)

• Controls involuntary body functions

Sympathetic Nervous System (SNS)

• The SNS controls emergency responses to stimuli
• The SNS relates to "fight or flight"

Parasympathetic Nervous System

• Influences muscle tone
• Relaxes sphincter muscles
• Controls "rest and digest"

Autonomic Innervation of Selected Body Structures

• Eye pupil (iris): Sympathetic dilation, parasympathetic constriction
• Heart: Sympathetic increased rate and force, parasympathetic decreased rate
• Lung bronchioles: Sympathetic dilation, parasympathetic constriction
• Gut wall: Sympathetic decreased motility, parasympathetic increased motility
• Gut sphincter: Sympathetic constriction, parasympathetic relax
• Bladder detrusor: Sympathetic relax, parasympathetic contraction
• Bladder-urethra smooth sphincter: Sympathetic constrict, parasympathetic relax
• Penis: Sympathetic ejaculation, parasympathetic erection
• Gallbladder bile and duct: Sympathetic relax, parasympathetic contract
• Salivary glands: Sympathetic concentrated viscous salvia, parasympathetic abundant watery saliva
• Nasal & lacrimal glands: Sympathetic vasoconstriction, parasympathetic abundant secretion

Anatomy of the Brain

• The brain has three protective membranes: dura mater, arachnoid membrane, and pia mater
• Cerebral spinal fluid (CSF) forms in the brain's lateral ventricles

Intracranial Pressure Balance

• Is maintained by production/absorption of CSF within the brain
• Is maintained by blood vessel dilation/constriction within the brain
• Is maintained by the production/circulation of hormones that increase or decrease urine production

Myelination

• The formation of a protective coating around nerve fibers needs to happen throughout the brain
• Myelination is important for motor control and coordination and cognitive maturity

Pediatric Neurological Assessment

• Includes a detailed health history, physical examination, and lab studies
• Reflexes must be assessed: Moro's, sucking, fencing/tonic, plantar, palmer, babinski's, rooting, stepping, crawling, and step
• Diagnostic tests are important

Levels of Consciousness

• Full (consciousness): Normal consciousness; alert, oriented, communicating
• Confused: Reduced awareness of being; bewildered and unable to think clearly
• Disoriented: Not oriented to person, place, or time with a deepened state of confusion
• Lethargic: Being sluggish, perhaps apathetic, and unable to stay aroused
• Obtunded: Loss of sensitivity to one's surroundings
• Coma: Deep unconsciousness

The Senses

• Auditory
• Olfactory
• Tactile
• Visual
• Gustatory
• Proprioception - sense of space

Congenital Neurological Disorders

• Cerebral Palsy
• Anencephaly
• Microcephaly
• Encephalocele
• Spina Bifida
• Type 1 Meningocele
• Type 2 Meningocele

Cerebral Palsy (CP)

• CP can occur during fetal development or during the the birthing process
• CP is caused by anoxia before, during, and after the birth process up to the second year of life

Cerebral Palsy Types

• Ataxic
• Spastic
• Hypotonia
• Dyskinetic
• Mixed

Evaluating Cerebral Palsy

• Tight muscles that possibly do not stretch
• "Scissors" movements of arms and legs
• Joint contractures in which the joints do not open and do not have full range of motion (ROM)
• Paralysis or muscle weakness
• Tremors
• Floppy extremities or overextension of joint areas
• Pain

Cerebral Palsy Nursing Interventions/Considerations

• No treatment or cure
• Provide support
• Symptom management
• Interventions to promote mobility and socialization
• Reduce injuries
• Reduce complications associated with CP
• Teach family how to maintain clear airway
• ROM exercises
• Ensure safety

Neural Tube Defects

• Anencephaly
• Microcephaly
• Encephalocele
• Spina Bifida
• Type 1: Myelomeningocele
• Type 2: Meningocele

Anencephaly

• The child is born with the absence of both hemispheres and the presence of brainstem and cerebellum only

Microcephaly

• The child is born with an abnormally small head and brain
• Exposure to the Zika virus is associated with congenital zika syndrome
• Microcephaly can lead to small brain that the skull collapses

Encephalocele

• The child is born with an abnormal sac of fluid that causes the brain and meninges to herniate/protrude through an abnormal defect in the skull
• Brain tissue may be found within the sac

Spina Bifida

• Myelomeningocele occurs when a child is born with a portion of the vertebral column not closed leading to a protruding sac filled with CSF, meninges, and a portion of the spinal cord; 80% are located in the lumbosacral areas
• Meningocele occurs when the child is born with a defect in a bony spinal column causing an abnormal protrusion of a CSF-filled sac

Evaluating Neural Tube Defects

• Early fetal assessment
• Ultrasounds during pregnancy
• Measure head circumference
• Assess for neurological deficiencies
• Assess bowel and bladder function

Neural Tube Defect Interventions

• Handle abnormal sac with care
• Look for leaks, rupture, and infection in the CNS
• Keep sac moist with NS-soaked gauze
• Educate family

Neural Tube Defect Post-Op Care

• Fluid balance
• ROM
• Support lower extremities
• Intermittent catheterization

Neural Tube Defect Nursing Considerations

• Latex allergy
• Educate on motor limitations
• Educate on folic acid

Neurological Injuries

• Drowning and Near Drowning
• Intraventricular Hemorrhage (IVH)
• Lead Poisoning
• Meningitis
• Reye's Syndrome
• Spinal Cord Injury (SCI)
• Traumatic Brain Injury (IBJ)

Drowning and Near Drowning

• Peak periods occur in toddlers and later adolescence
• Evaluate airway, ventilation, ability/quality of respirations, HR, BP, ABGs, and LOC
• Interventions include: CPR, ventilators, oxygen support, IV fluids, remove wet clothes, warm environment, and warm blankets
• Nursing considerations include: supporting the team and family, contacting social worker, and spiritual support

Intraventricular Hemorrhage (IVH)

• Rupture of the vascular network within the germinal matrix leading to a brain bleed
• Evaluation: Premature <32 Weeks, cases develop within 4 days, CT, MRI, Labs, H&H, ICP, Fontanels
• Interventions: Reduce stimuli, minimal handling, transfusion therapy, and ventriculostomy
• Nursing considerations: Keep head midline, support head, 2-person turn, avoid discomfort, and minimize crying

Lead Poisoning

• Irreversibly impairs brain functioning and can lead to encephalopathy
• Exposure can occur through: Contaminated soil, contaminated parent clothing, lead-based paints, imported candy, jewelry, pottery, contaminated household dust, lead pipes, imported canned foods, and brass fixtures
• Evaluation: lab tests at ages 1 & 2, environment assessment, monitor for pica behavior, assess teething behaviors
• Interventions/Considerations: Check lead levels, identify source, treat in hospital, monitor for behavior change

Signs and Symptoms of Lead Poisoning

• Metallic taste in the mouth
• Gastrointestinal (GI) upset including abdominal cramping
• Decreased UOP
• Alteration in thinking
• A "personality change"
• Black or blue discoloration along the gums
• Parents may describe child as having paresthesias or abnormal sensations
• Treat with chelation therapy at lead levels of 45 mcg/dL

Meningitis

• Inflammation of the membranes of the brain or spinal cord
• Often infectious (bacterial, viral, or chemical agents)
• If bacterial/viral, spread through droplets
• Meningitis can occur at all ages, but is most common in infants and toddlers
• Meningococcal meningitis is bacterial and the most dangerous, 90% mortality rate ,can cause sudden infection resulting in DIC, massive hemorrhages, and cause purple rash or petechial rash

Meningitis Signs and Symptoms

• Poor feeding habits
• Fever
• An irritable child is inconsolable when held, or has a high-pitched cry
• Lethargy
• Bulging fontanels
• Opisthotonos positioning
• Kernig's sign
• Brudzinski's sign

Meningitis Interventions and Nursing Considerations

• Interventions: Labs, blood cultures, spinal tap, antibiotics, corticosteroids and anticonvulsants
• Nursing considerations: Patent IV, IV antibiotics, Monitor ICP, and measure head circumference

Reye Syndrome

• Non-specific, non-inflammatory
• Encephalopathy involving the liver, spleen, kidney, pancreas, and lymph
• Strongly associated with salicylates- aspirin (ASA)

Evaluating Reye Syndrome

• Frequent vomiting and diarrhea (early stage)
• Rapid breathing (early stage in infancy)
• Encephalopathy (later stage)
• Increased ICP (later stage)
• Metabolic dysfunction (later stage)
• Hepatic dysfunction (later stage)
• Renal damage (later stage)
• Fatty infiltration of the viscera (later stage)
• Confusion, irrational behavior, and loss of consciousness (later stage)

Reye Syndrome Interventions

• Monitoring carefully for progression through the stages of REYE SYNDROME
• Implementing seizure precautions
• Keeping the child free of discomfort and help avoid crying
• Monitoring for changes in neuro status and reporting any changes
• Monitoring respiratory status and reporting any signs of dyspnea
• Providing a quiet environment
• Assessing for sx of GI bleeding, pancreatitis, or liver failure
• Checking Glasgow Coma Scale score
• Wound care after liver biopsy
• Providing hydration with a source of glucose (IV fluids)
• Assessing for increasing ICP
• Reinforcing patient/family teaching session about follow-up

Reye Syndrome Nursing Considerations

• Symptoms of Hypoxia
• Presence of Seizures
• Hypoglycemia
• Electrolyte Imbalances
• Hyperthermia
• Coagulopathies

Spinal Cord Injury (SCI)

• Complete SCI: complete loss of sensorimotor and reflex activity below the site of injury
• Incomplete SCI: preservation of some motor/ sensory function below site of injury
• Sacral Sparing SCI: motor/sensory in the anal mucocutaneous border exists

Nursing Considerations for Spinal Cord Injury (SCI)

• Evaluation: neuro exam followed by CT/MRI
• Intervention: straight backboard with neutral head/neck alignment and a cervical collar
• Nursing Considerations: elimination needs and catheterization

Traumatic Brain Injury (TBI)

• Primary injury develops at the time of trauma when brain tissue suffers initial damage
• Secondary injury develops as the body responds to the injury

Protecting the Head from Injury

• Neonate: support the head by one's hand or should lay on one's arm, carefully handle head during dressing, maintain head and neck alignment while sleeping or being held, and never shake the newborn
• Infant: Use car seats correctly-rear facing, use head-cushions in car seat, prevent falls - infants rol, and no baby walkers near stairs
• Toddler: Forward facing car-seat, prevent falling into water- risk for drowning, and prevent tricycle injuries-helmet
• Preschool: Safety devices and protective sports equipment, never go into street- must be supervised at all times, and use foam padding to prevent falls from play structures
• School-Age: consistent helmet use with chin strap buckled, snug-fitting sports safety devices and protective equipment, and injuries from playing - golf clubs, baseball bats
• Adolescents: Proper seatbelt use, no texting and driving, head injuries when diving into natural water sources, and use protective equipment when needed and in contact sports

Concussion

• Brief loss of consciousness from shearing/compression of brain’s nerve tissue
• Mild traumatic brain injury
• Post concussion syndrome occurs when patients have headaches, difficulty with memory, problems at school, photophobia, and possible personality changes
• Patients with concussions from contact sports must seek healthcare immediately
• Families need education about what to expect for symptoms, rest and treatments

Contusion

• Localized bruising of the brain tissue
• Traumatic brain injury
• Often associated with blunt trauma which tears vasculature and tissu

Evaluating TBI

• Assess airway for patency and effective breathing patterns
• Monitor vitals and neuro checks, signs of shock, poor perfusion and increased ICP
• Cushing’s triad is considered a late sign of ICP: widening, pulse, pressure, irregular, breathing pattern, bradycardia
• Monitor LOC with the GCS
• Assess cranial nerves as ordered
• Learn to C.U.S

TBI Interventions

• Airway management
• Low stimulation environment
• Steroids
• Possible ventilator
• Raising HOB to decrease ICP
• Transducer monitoring
• Possible hyperosmolar saline
• Monitor for post traumatic hypothermia

TBI Nursing Considerations

• Monitor for subtle changes in clinical presentation
• Manage airway
• Possible NPO status
• Prevent aspiration
• Turning schedules

Other Neurological Disorders

• Brain Tumors
• Migraines
• Cognitive Impairment
• Hydrocephalus
• Increased Intracranial Pressure
• Seizure Disorders

Brain Tumors

• The most common solid malignancy during childhood with a frequency, second to leukemia
• Tumors are classified according to location and grade
• Brain tumors are graded as either low (localized) or high (invasive)
• Most prevalent brain tumor in children under seven is medulloblastoma

Brain Tumors Nursing

• Evaluate for increased intracranial pressure, focal neurological signs, behavioural/personality alterations and physiological symptoms
• Interventions include surgery, radiation, chemotherapy
• Provide nursing support for the family, educate on follow up care, follow neuro exams as ordered and prepare the family for post operative clinical presentation

Migraine Headaches

• Chronic daily headaches
• Cluster headaches
• Tension headaches
• Psychogenic headaches

Evaluate Migraine Headaches

• Use health family hisotry
• Evalute risk facts
• Perform physical examaination and look for signs signs of infection
• Order a head CT

Migraine Headaches Interventions

• Treat any infections
• Observation through hospitalization
• Check eyesight for vision strain
• Counseling
• Consult a pediatric neurologist

Migraine Headaches Nursing Considerations

• Take a holistic approach
• Avoid nitrates
• Avoid caffeine
• Prescribed medication
• Rest and relation
• Warm/ cold packs

Cognitive Impairment (CI)

• Manifests as significant limitations in intellectual functioning and adaptive behaviors
• An intelligent quotient (IQ) identifies the degree of impairment
• Mild CI has an IQ of 50-55 (up to 70), is 80% of those with CI, and has a mental age of 12-13 years
• Moderate CI has an IQ of 35-35 (up to 50-55), is 15% of those with CI, and has a mental age of 8-10 years; it is common in children with down syndrome
• Severe CI had an IQ of 20-25 (up to 35-40) and has a toddler mental age, requiring custodial care
• Profound CI has an IQ of below 20-25 and is at an infant mental age, requiring complete care

Cognitive Impairment Evaluations, Interventions & Nursing Considerations

• Evaluation: Focus on developmental status, not chronological age, assess motor/psychosocial tasks, determine a patients level of functioning over 2+ testing periods
• Interventions: Safety through Maslow's, realistic goals achieved through breaking down tasks to be mastered over time & participation in ADLs
• Nursing Considerations: acknowledge successes as the child accomplish his goals & encourage joining local support organizations

Hydrocephalus

• Too much CSF in the brain
• Manifests as noncommunicating hydrocephalus (CSF flow is obstructed) and communicating hydrocephalus (impaired CSF absorption)

Evaluating and Addressing Hydrocephalus

• Frequent measuring of the head circumference is critical
• Check the patient by palpating the fontanel and noting irritability/lethargy/high pitched cry
• Check for "sunset eyes" and note whether the patient is experiencing acute vomiting
• Intervention: Placement of a VP shunt and parent education to assess changes associated with increased ICP and how to maually pump the shunt for patency
• Nursing Considerations: patients may have hydrocephalus as a result of shaken baby syndrome (retinal hemorrhage, cognitive impariment with learning disabilities) May need constant head support and Families need to know how to care for a child with abnormally large head

Increased Intracranial Pressure (IICP)

• Caused by cerebral edema from abscesses, meningitis, tumors, water intoxication, hypoxia, hydrocephalus, etc.
• Can cause brain to be herniated, deterioration of brain, stem, apnea, and death
• Health histories associated are trauma, bleeding disorders, extensive feats and overhyrdation children with DKA and SIADH

Evaluating IICP

• Evaluation includes sunset eyes, posturing (Decebrate/Decorticate) , Seizures, Macewen's Side, Diplopia, and Unequal pupils

Nursing Management for IICP

• stabilize airway and administer CPR if needed
• Maintain Peyton airway
• Maintain stable, oxygen sat. and ABGs while preforming suction as needed
• Monitor GCS score and intube if less than 8
• Elevate HOB/treat seizure activities
• Turn down lights/Tranfesr to PICU for rapid CT/MRI scans
• Maintain IV patency and administer diuretics/corticosteroids

Nursing Considerations

• IICP can be life-threatening so it's important to stabilize and monitor for sudden changes in clinical status and report new symptoms or changes to prevent anozia and brain damage
• Monitor for signs of diabetes insipidus and SIADH

Seizure Disorder

• Is a disruption of electrical communication among neurons with subsequent abnormal electrical activity
• The Brain fires electrical stimulation between neurons when it should not
• Expected patterns of electrical currents between neurons are disrupted leading to excitatory or inhibitory mechanism causing seizures
• A recurrent seizure is also known as epilepsy
• Close to 40% of all childhood seizures are partial
• The cause of most neonatal and infant seizures remain unknown and aren't considered medical diagonsis, but rather a symptom of an underlying CNS injury or disorder

Types or Seizures

• (3-12 months) Infanttile Spasms- Uncommon and generalized Infanttile Seizures peaks at 4-8 months that you can treat by administration of anticonvulsants and steroid therapy
• Simple Partial Seizures- Affect a specific brain region
• Complex Partial Seizure -Starts with motor activity and progress to loss or alternation of consciousness
• Tonic-Clonic (Grand Mal)- Is severe, generalized seizure with full-body neuromuscular activity that requires airway support, positioning, and seizure precautions and administer anticonvulsant if needed
• Abesnt Seizure- Are brief episodes of staring or 'checking out' with possible twitching and is commin in children that can be treated with medications
• Myclonic Seizure- Is a Generalized seizure causing sudden jerks or body twitching, may co-occur with other seizure types and be treated with anticonvulsant therapy
• Febrile Seizure- Is induced by a fever and occurs common in young children, generally brief and not considered epilepsy that need to be monitored, treated for infection and antipyretics for fever management
• Status Epilepticus (SE)- Is prolonged or clustered seizures without regaining consciousness and needs emergency treatment with anticonvulsants/oxygennation and airway support
• Cause by factors lile fever, trauma, infections, drugs. Also remember that kids outgrow them.

Common Cause of Seizures

• Trauma
• Hemorrhage
• Brain Malformations
• Genetic disorders
• Brain dysmaturity
• Fever
• Electrolyte imbalance
• Infection (meningitis)
• Hyper/hypoglycemia
• Metabolism errors
• Drug-related injuries
• Significant Exposures
• Structural CNS Lesions

Evaluating Seizures

• Check child's family history, complications during the prenatal/perinatal/ postnatal period, child's developmental motor milestones or exposure to enviromental toxin/ infections and or physical trauma, history of domestic abuse, child abuse, or any form of nonaccidental injury
• Note child's age at which the first seizure occurred and any precipitating /surrounding factors occurring prior
• Carefully note child's clinical presentation during the seizure, presence of an aura, a loss of consciousnesss or any injury including in the postical state
• Note the current medications the child is on and previous anticonvulsant therapies as well as current compliance in regard to following the set regimen

Seizure Interventions

• During seziures its key to maintin a safe enviroment while utilizing seizure precautios and making you do not restrict any movements as well as minitainting a patents airway
• It important to administer perscribed medication while monitoring therapeutic blood levels and checking serum electroltyes ordering an electroencephalogram
• Keep the child on a ketogic during the activity