Neurological Conditions - Past Student Notes PDF

Neurological Conditions CHAPTER 50 Objectives 1. Describe the various modalities for assessment of cerebral function. 2. Differentiate between the states of consciousness. 3. Formulate a care plan for the child with altered level of consciousness 4. Distinguish between the types of hea...

Neurological Conditions CHAPTER 50 Objectives 1. Describe the various modalities for assessment of cerebral function. 2. Differentiate between the states of consciousness. 3. Formulate a care plan for the child with altered level of consciousness 4. Distinguish between the types of head injuries and potential complications. 5. Describe the nursing care of a child with a tumour of the central nervous system. 6. Outline a care plan for the child with bacterial meningitis. 7. Differentiate between the various types of seizure characteristics. 8. Demonstrate an understanding of the manifestations of a seizure disorder and the management of a child with such a disorder. 9. Describe the preoperative and postoperative care of a child with hydrocephalus. Assessment of Cerebral Function  Infantsand young children: observe spontaneous and elicited reflex responses  Children younger than 2 require special evaluation as they are not able to respond to directions to elicit specific responses.  Developmental level  Family history  Health history  Physical examination  Increased Intracranial Pressure 4 (ICP)  Irritability, restlessness, poor feeding  Early signs and  Macewen sign symptoms may be subtle  High-pitched cry, crying when  Aspressure increases, disturbed signs and symptoms  Fontanels: tense, bulging become more  Cranial sutures: separated pronounced, and level of  Eyes: setting-sun sign consciousness (LOC)  Scalp veins: distended deteriorates  Increased fronto-occipital circumference Clinical Manifestations of 5 Increased ICP in Children Late Signs  Headache  Bradycardia  Forceful vomiting, nausea  Decreased motor response to command;  Seizures decreased sensory response to painful stimuli  Diplopia, blurred vision  Alterations in pupil size and reactivity  Indifference, drowsiness  Papilledema  Decline in school performance  Flexion or extension posturing  Decreased activity, increased sleep  Cheyne-Stokes respirations  Lethargy  Decreased consciousness  Inability to follow simple commands  Coma Neurological Examination  Vital signs  Skin  Eyes  Motor Function  Posturing  Reflexes 6 Special Diagnostic Procedures 8  Laboratory tests  Glucose, urea nitrogen, complete blood count (CBC), electrolytes, blood culture if fever, clotting studies, evaluate for toxic substances, liver function, urine toxicology screen, blood lead levels  Imaging  Computed tomography (CT) scan and magnetic resonance imaging (MRI) are two most common  Lumbar puncture  Electroencephalogram (EEG) Nursing Care of the Unconscious 9 Child Emergency management Assessments:  Patent airway,  LOC breathing, and  Pupillary reaction circulation  Vital signs  Reduction of ICP  Abnormal movements  Treatment of shock  Frequency of assessment  Stabilize spine if depends on condition: ranges required from every 15 minutes to every 2 hours  Pain Respiratory Management  Airway management is the primary concern  Cerebral hypoxia lasting more than 4 minutes may cause irreversible brain damage.  CO2causes vasodilation, increased cerebral blood flow, and increased ICP  The child may have minimal gag and cough reflexes  Risk of aspiration of secretions ICP Monitoring  Indications for ICP monitoring:  GCS of less than 8  GCS evaluation greater than 8 with respiratory assistance  Deterioration of condition  Subjective judgement regarding clinical appearance and response  Types of ICP monitors  Intraventricular catheter  Subarachnoid bolt (Richmond screw)  Epidural sensor  Anterior fontanel pressure monitor Additional Nursing Care of the Unconscious Child  Nutrition and hydration  Altered pituitary secretion  Syndrome of inappropriate antidiuretic hormone secretion (SIADH) and diabetes insipidus (DI)  Medications  Thermoregulation  Elimination  Hygienic care  Positioning and exercise  Stimulation  Regaining consciousness  Family support  13 Young children are especially vulnerable to acceleration– deceleration injuries Child's response is different from adult because of larger head size and insufficient musculoskeletal support Coup: bruising at site of impact FIGURE 50-5. Mechanical distortion Contrecoup: bruising at a site far of cranium during closed-head injury. A: Preinjury contour of skull. removed from site of impact B: Immediate postinjury contour of skull. C: Torn subdural vessels. D: Shearing forces. E: Trauma from contact with floor of cranium.  Head Injury Concussions Guidelines https://pedsconcussion.com/?_gl=1*cqv7sb*_ga*Mjk2MzIxMjU5LjE2NTIzODc5 MjI.*_ga_6QDXBSD3H2*MTY1MjM4NzkyMS4xLjEuMTY1MjM4NzkyMS4w&_ga= 2.266780043.42586769.1652387922-296321259.1652387922 Rowan’s Law https://www.ontario.ca/page/rowans-law-concussion-safety 14 Traumatic Head Injury due to Child Maltreatment (THI-CM)  Previously known as shaken baby syndrome or abusive head trauma  May have lifelong complications including neurological, visual, cognitive, behavioural, and sleep abnormalities  Subdural hematoma and retinal hemorrhages  Often not an isolated event Head Injury: Therapeutic Management  Therapeutic management  Concussion Cognitive and physical rest  Carein hospital for severe injuries, LOC for several minutes, prolonged or continued seizures  NPO initially  Possible surgical therapy  Submersion Injuries 19  Submersion injury has  Hypoxia, replaced the term near- asphyxiation drowning.  Aspiration  Itis a major cause of  Hypothermia accidental death in children.  Children  LOC,decreased aged 1 to 4 years are one of the major risk cardiac output, and groups. cardiac arrest  Itcan occur with even a small quantity of water (as little as 2.5 cm of water). Brain Tumours  Mostcommon solid tumours in children and second most common childhood cancer  60% are infratentorial  Occur in area of brain below the tentorium cerebelli  Primarily in cerebellum or brainstem  Clinical manifestations  Signs and symptoms are related to the anatomical location and size of tumours and the child's age.  Neuroblastoma  Most common malignant  Accurate clinical staging extracranial solid tumour of to establish treatment childhood plan  Most tumours develop in the  Surgery to remove adrenal gland or tumour and obtain retroperitoneal sympathetic biopsies chain  Radiation, chemotherapy  Other sites: head, neck, chest, pelvis  “Silenttumour”: metastasis may have already occurred before diagnosis is made 21  Intracranial Infections  CNS has limited response to injury  Difficult to distinguish etiology by looking at clinical manifestations  Laboratory studies are required to identify the causative agent  Inflammation can affect the meninges or brain  Can include viral and bacterial causes What manifestations do you expect? 22  Bacterial Meningitis  Acuteinflammation of the meninges and cerebrospinal fluid (CSF)  Decreased incidence following use of Hib vaccine in all age groups except for children under 2 months of age  Canbe caused by various bacterial agents  Medical emergency 23  Management of Bacterial Meningitis 24  Diagnostic evaluation LP is definitive diagnostic test  Therapeutic management Isolation precautions Antimicrobial therapy Restrict hydration and maintain ventilation Management of systemic shock Reduction of ICP Control of seizures and temperature Treatment of complications Bacterial Meningitis  Nursing care  Quiet with minimal stimuli  HOB elevated  Side-lying position  Monitor pain  Treatments depend on symptoms  Family support  Encephalitis 26  Inflammatory process of CNS with altered function of brain and spinal cord  Variety of causative organisms; viral most frequent  Therapeutic management  Hospitalized for observation  Treatment is supportive.  ICP monitoring may be required.  Follow-up care with re-evaluation and rehabilitation  Very young children may exhibit increased neurological disability.   A disorder defined as toxic encephalopathy associated with other characteristic organ involvement  Characterized by fever, profoundly impaired consciousness, and disordered hepatic function Reye  Etiology is not well understood Syndrom  Most cases follow common viral illness e (RS)  Influenza  Varicella  Potential association between ASA therapy for fever and development of RS  Avoid using aspirin and non-aspirin-containing salicylates during febrile illnesses in children. 27  Seizure Disorders  Caused by excessive and disorderly neuronal discharges in the brain  Determined by site of origin  Most common treatable neurological disorder in children  Occur with wide variety of CNS conditions  Epilepsy  Two or more unprovoked seizures  Caused by a variety of pathological processes in the brain  Optimal treatment and prognosis require an accurate diagnosis and determination of cause.  Seizure Disorders  Etiology  Acute symptomatic Associated with head trauma or meningitis  Remote symptomatic Prior brain injury such as encephalitis, meningitis, or stroke  Cryptogenic No clear cause  Idiopathic Genetic in origin Seizure Disorders  Therapeutic management  Thegoal is to control seizures or reduce their frequency and severity.  Discover and correct the cause.  Management: Medication therapy Ketogenic diet Vagus nerve stimulation Surgical therapy Treatment for status epilepticus  Seizure Disorders  Prognosis  Sudden unexpected death in epilepsy (SUDEP)  Nursing care Long-term care Triggering factors Febrile Seizures  Transient disorder of childhood  Affect approximately 2 to 5% of children  Usually occur between ages 6 and 60 months  Cause is uncertain  Tepid sponge baths are not recommended  Simple febrile seizures are benign 32 Cranial Deformities  Suture and fontanel ossification 8 weeks: posterior fontanel closed 6 months: fibrous suture lines and interlocking of serrated edges 18 months: anterior fontanel closed After12 years: sutures unable to be separated by increased ICP Craniosynostosis Craniosynostosis Microcephaly Positional Plagiocephaly  Cranial asymmetry  Increased frequency since recommendation that infants be put in supine position to sleep  Unilateral flattening of the occiput  Teach parents to position infant’s head to the side when lying in the supine position  Prone position when awake; tummy time at least 10 to 15 Hydrocephalus  Caused by an imbalance in production and absorption of CSF  Pathophysiology  Impairedabsorption of CSF within the subarachnoid space  Obstruction through the ventricular system  Communicatingand noncommunicating hydrocephalus Hydrocephalus Clinical manifestations Diagnostic evaluation Therapeutic evaluation  Relief of hydrocephalus  Treatment of complications  Problems related to the effects of psychomotor development  Treatment is most often surgical. Removal of obstruction Ventriculoperitoneal shunt  39 FIGURE 50-8. Hydrocephalus: a block in flow of cerebrospinal fluid. A: Patent cerebrospinal fluid circulation. B: Enlarged lateral and third ventricles caused by obstruction of circulation—stenosis of aqueduct of Sylvius. FIGURE 50-9. Ventriculoperitoneal shunt. Catheter is threaded beneath the skin. Hydrocephalus  Signs and symptoms of shunt infection  Period of greatest risk is 1 to 2 months after placement  Infections Septicemia Bacterial endocarditis Wound infection Shunt nephritis Meningitis  Treatment: Massive-dose antibiotics or shunt removal