Chapter 23: The Child with a Sensory or Neurological Condition PDF
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This chapter covers the care of children with sensory or neurological conditions. Key details, especially on topics like ear anatomy, and common childhood injuries and developmental difficulties, are discussed.
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Chapter 23 THE CHILD WITH A SENSORY OR NEUROLOGICAL CONDITION 2 Ears Contains the receptors of the eighth cranial (acoustic) nerve Two main functions Hearing Balance Three divisions External Middle Internal 3 Ears Newborn Tympanic More membrane almost horizontal v...
Chapter 23 THE CHILD WITH A SENSORY OR NEUROLOGICAL CONDITION 2 Ears Contains the receptors of the eighth cranial (acoustic) nerve Two main functions Hearing Balance Three divisions External Middle Internal 3 Ears Newborn Tympanic More membrane almost horizontal vascular Inconsistent Eustachian adult light reflex tube is shorter and straighter than in Eustachian tube functions Ventilation Protection Drainage 4 Ears Ear alignment is observed Top of ear should cross imaginary line drawn from outer canthus of eye to the occiput Low-set ears may be associated with kidney disorders Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 5 Ears Before instilling ear drops in infants, gently pull the pinna of the ear down and back In children, gently pull the pinna of the ear up and back to straighten the external auditory canal Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 6 Otitis Externa An acute infection of the external canal Often referred to as swimmer’s ear Pain and tenderness on manipulating the pinna or tragus Signs Tympanic membrane is normal Rule out the presence of a foreign body, cellulitis, diabetes mellitus, or herpes zoster Treatment Irrigation and topical antibiotics or antivirals 7 Acute Otitis Media Pathophysiology Inflammation of the middle ear Structures lined by mucous membranes Mastoid sinuses Middle ear Eustachian tube Protects middle ear Provides drainage Equalizes air pressure Infection of the throat can easily spread to the middle ear and mastoid 8 Otitis Media (OM) Occurs most often after upper respiratory infection Caused by various microorganisms, such as Streptococcal pneumoniae and Haemophilus influenzae Infants more prone because of ear anatomy Infant’s humoral defense mechanisms are immature Safety Nursing Tip for OM Signs and symptoms of ear infection can include Rubbing Rolling the head from side to side Hearing Loud or pulling at the ear loss speech Inattentive behavior Articulation Speech problems development problems 9 10 Otitis Media (OM) Manifestations Tympanic membrane is reddened and bulging Eardrum can rupture if an abscess forms OM is considered chronic if the condition persists for more than 3 months Treatment Broad-spectrum antibiotics Eardrops—to instill, pull pinna down and back for infants; for children, pull the pinna up and back Surgical intervention when conventional methods are not successful 11 Nursing Tip Instruct caregivers that the child’s condition may improve dramatically after antibiotics are taken for a few days To prevent recurrence, caregivers must continue to administer the medication until the prescribed amount has been completed 12 Hearing Impairment Can affect speech, language, social and emotional development, behavior, and academic achievement Two types: congenital deafness or acquired Can acquire it from common colds, medications, exposure to loud noise levels, certain infectious diseases Hearing loss can also be from cerumen (earwax) accumulation or from a foreign body being inserted in the ear canal 13 Hearing Impairment Hearing loss can result from Defects in the transmission of sound to the middle ear Damage to the auditory nerve or ear structures A mixed loss involving both a defect in nerve pathways and interference with sound transmission Behavior problems may arise because these children do not understand verbal directions 14 Hearing Impairment Diagnosis Routine newborn hearing screens are performed before discharge Lack of a response by the infant to sounds or music, or the lack of a startle reflex in infants under 4 months of age are the first signs that a hearing impairment may exist Medical or surgical treatment Hearing aids Cochlear implants 15 Hearing Impairment Nursing care Some means of communicating with the hearing-impaired include Lip reading, sign language, writing, visual aids Body language communicates a lot 16 Nursing Tip When addressing a hearingimpaired child, the nurse should do the following Be at eye level with the child Be face-to-face with the child Establish Talk eye contact in short sentences Avoid using exaggerated face or lip movements 17 Barotrauma An injury that occurs when the pressure in the atmosphere between a closed space and the surrounding area changes Airplane descent Underwater diving Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 18 The Eyes Begin to develop in the 4-week-old embryo Newborn sight is not mature Shape of eye is less spherical in the newborn Tears are not present until 1 to 3 months of age Depth perception does not begin to develop until about 9 months of age Nursing Tip At birth, the quiet alert infant will respond to visual stimuli by cessation of movement Visual responsiveness to the mother during feeding is noted The infant’s ability to focus and follow objects in the first months of life should be documented Coordination of eye movements should be achieved by 3 to 6 months of age 19 Visual Acuity Tests Ability of an infant to fixate and focus on an object can be demonstrated by 6 weeks of age The object should not emit a sound Testing should begin at 2 to 3 years of age 20 21 Dyslexia Reading disability Involves a defect in the cortex of the brain that processes graphic symbols Treatment involves remedial instruction Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 22 Amblyopia Reduction or loss of vision that usually occurs in children who strongly favor one eye Treatment Glasses, opaque contact lens, or patching the good eye Forces the weaker eye to be used Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Strabismus Also known as cross-eye Child is not able to direct both eyes in same direction Lack of coordination between the eye muscles that direct movement of the eyes When coordination does not occur, the brain will disable one eye to provide a clear image The disabled eye can develop permanent visual impairment due to sensory deprivation Several types: nonparalytic and paralytic 23 Nursing Tip Symptoms of strabismus include the following Eye “squinting” or frowning to focus Missing objects that are reached for Covering Tilting one eye to see the head to see Dizziness and/or headache 24 Strabismus Treatment Nonparalytic If found in infancy, parents are instructed to patch the unaffected eye, as it may improve through use Glasses and eye exercises usually correct the problem Surgery if none of the above work Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 25 26 Eye Strain Symptoms Nursing Inflammation Interventions Aching Observe or burning of the eyes Squinting A short attention span Frequent headaches Difficulties with schoolwork Inability to see the board at the front of the class Teach Prevent Refer Rehabilitate Conjunctivitis 27 Inflammation of the conjunctiva or mucous membrane that lines the eyelids Caused by a variety of bacterial and viral organisms or from a blocked lacrimal duct Acute form is commonly called pink eye Common forms respond to warm compresses, topical antibiotic eye drops, or eye ointments Symptoms include Itching Tearing of one or both eyes Edema of the eyelids and periorbital tissues Child may appear distracted or irritable Hyphema 28 Presence of blood in the anterior chamber of the eye One of the most common ocular injuries Appears as a bright-red or dark-red spot in front of the lower portion of the iris Treatment Bedrest with HOB elevated 30 to 45 degrees decreases intraocular pressure and intracranial pressure if there is an associated head injury Topical medications may also be prescribed Retinoblastoma A malignant tumor of the retina Manifestations Yellowish white reflex is seen in the pupil because of a tumor behind the lens Called the cat’s eye reflex or leukokoria May be accompanied by loss of vision, strabismus, hyphema, and in advanced tumors, pain 29 Retinoblastoma Treatment Laser photocoagulation Chemotherapy External beam irradiation Usually removal of the affected eye if no possibility exists to save the vision Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 30 31 The Nervous System The body’s communication center Transmits Records messages to all parts of the body experiences Integrates certain stimuli Most neurological disabilities in childhood result from congenital malformation, brain injury, or infection NURSING ALERT--The sudden appearance of a fixed and dilated pupil is a neurologic emergency. Causes of Altered Level of Consciousness (ALOC) 32 A fall to 60 mm Hg, or below, of PaCO2 A rise above 45 mm Hg of PaCO2 Low blood pressure causing cerebral hypoxia Fever (1° rise in fever increases oxygen need by 10%) Drugs (sedatives, antiepileptics) Seizures (postictal state) Increased ICP Reye’s Syndrome 33 Acute noninflammatory encephalopathy and hepatopathy that follows a viral infection in children May be a relationship between the use of aspirin during a viral flu or illness Some studies show that a genetic metabolic defect triggers Reye’s syndrome when the stress of a viral illness produces vomiting and hypoglycemia Reye’s Syndrome Manifestations Ammonia accumulates in the blood due to liver involvement In children, effortless vomiting and altered behavior, or ALOC after a viral illness, are characteristic of Reye’s syndrome Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 34 Reye’s Syndrome Treatment If early, can result in complete recovery Goals are Reducing ICP Maintaining Cerebral Fluid a patent airway oxygenation and electrolyte balance Observe for signs of bleeding due to liver dysfunction 35 Medication Safety Alert! Discourage 36 the use of aspirin and other medications that contain salicylates in children with flulike symptoms Advise parents to read medication labels carefully to determine their ingredients Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Sepsis 37 Systemic response to infection with bacteria; also results from viral or fungal infections Causes a systemic inflammatory response syndrome (SIRS) due to the endotoxin of the bacteria that causes tissue damage Untreated can lead to septic shock, multiorgan dysfunction syndrome (MODS), and death Sepsis 38 Manifestations include Fever Chills Tachypnea Tachycardia Neurological lethargy signs, such as Meningitis 39 An inflammation of the meninges (the covering of the brain and spinal cord) Caused by bacterial, viral, or fungal (rare in immune-competent person) infection, Haemophilus influenzae most common Invades the meninges indirectly by way of the bloodstream (sepsis) Bacterial meningitis often referred to as purulent because of pus-forming that can occur Meningitis Manifestations If bacterial, symptoms are a result of intracranial irritation from the purulent toxins released by the bacteria The presence of petechiae suggests meningococcal infection 40 41 Meningitis Symptoms Severe headache Drowsiness Delirium Irritability Restlessness Fever Vomiting Stiffness of the neck (nuchal rigidity) High-pitched cry in infants Seizures are common Coma may occur Meningitis Diagnosis confirmed by examination of the CSF Treatment 42 The child is placed in droplet isolation until 24 hours after the appropriate antimicrobials have been initiated Nursing care Neurological checks as ordered by physician Report findings such as weakness of the limbs, speech difficulties, mental confusion, and behavior problems Maintaining an accurate recording of vital signs and intake/output Maintain a quiet environment to help decrease stimuli Encephalitis 43 Inflammation of the brain Also known as encephalomyelitis when the spinal cord is also infected Symptoms result from the CNS’s response to irritation Headache May followed by drowsiness proceed to coma Convulsions Fever, are seen, especially in infants cramps, abdominal pain, vomiting, nuchal rigidity, delirium, muscle twitching, abnormal eye movements 44 Encephalitis Treatment Supportive Provide relief from specific symptoms Sedatives ordered Seizure and antipyretics may be precautions are taken Provide for adequate fluid and nutrition Supplemental oxygen may be needed Brain Tumors 45 Second most common type of neoplasm in children Most occur in lower part of the brain and commonly in school-age children Signs and symptoms directly related to location and size of tumor Diagnosis is made by clinical presentation, laboratory tests, head CT or MRI, EEG Surgical intervention in some cases, chemotherapy and/or radiation therapy in others Seizure Disorders 46 Most commonly observed neurological dysfunction in children Etiology varies Sudden, intermittent episodes of ALOC that last seconds to minutes and may include involuntary tonic and clonic movements Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Causes of Seizures in Children Intracranial Epilepsy Congenital Birth anomaly injury Infection Trauma Degenerative Vascular disease disorder 47 48 Causes of Seizures in Children Extracranial Fever Heart disease Metabolic disorders Hypocalcemia Hypoglycemia Dehydration and malnutrition Toxic Anesthetics Drugs Poisons 49 Types of Seizures Febrile Epilepsy Classified as Generalized Tonic-clonic Three or grand mal distinct phases Partial Account for 40% Consciousness Can may be intact or slightly impaired have simple or complex seizures 50 Patient Teaching The following are common triggering factors for seizures Flashing of dark/light patterns Startling movements Overhydration Photosensitivity Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 51 Seizure Diagnosis and Treatment Determine type, site, or cause Multiple diagnostic techniques can be used CT/MRI, EEG Laboratory tests to rule out poisoning or electrolyte abnormalities Drug of choice depends on the type of seizure Diet changes may be needed for patients who do not respond well to anticonvulsants Seizures Treatment A 52 fundamental principle of comprehensive seizure management is that the child must become an active member of the health care team Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Safety Alert 53 The nurse is responsible for maintaining seizure precautions Keep Pad side rails up all sharp or hard objects around the bed Make sure child wears a medical ID bracelet Provide supervision during potentially hazardous play, such as swimming Avoid Teach triggering factors the importance of compliance with the medication regimen Other Conditions Causing Decreased Level of Consciousness Can be mistaken for seizures because of the paroxysmal ALOC These conditions do not respond to antiepileptic medications Conditions are Benign paroxysmal vertigo Night terrors Breath-holding spells Cough syncope Prolonged QT syndrome Rage attacks or episodic dyscontrol syndrome 54 55 Cerebral Palsy (CP) A group of motor disorders caused by dysfunction of various motor centers in the brain and often related to antenatal or developmental factors Can be precipitated by many factors, such as birth injuries, congenital anomalies, neonatal anoxia, prematurity, subdural hemorrhage, and prenatal infection Cerebral Palsy (CP) 56 Manifestations Vary with each child May range from mild to severe Intellectual and Developmental Disabilities sometimes seen Suspected during infancy if There are feeding problems Convulsions not associated with high fevers Developmental milestones are not being achieved at expected age level 57 Types of CP Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Treatment of CP 58 Botulinum toxin has been used to manage spasticity problems Levodopa has helped to control some of the athetoid problems Specific treatment is highly individualized Good All skin care is essential precautions taken to prevent contractures Braces are often used to treat these Orthopedic surgery is sometimes indicated Treatment Protocol for CP 59 Establish communication Establish locomotion Use and optimize existing motor functions Provide intellectual stimulation Promote socialization Provide technology to encourage self-care and promote growth and development Provide multidisciplinary approach to care 60 Cognitive Impairment Elements involved in mental functioning Level of consciousness Thought processes Expressive language Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Intellectual Impairment The American Association on Intellectual and Developmental Disabilities (AAIDD): Mild IQ 61 or severe below 70 Numerous test to measure intelligence Stanford-Binet All tests have limitations Accuracy depends on abilities of the person interpreting the results 62 Intellectual Impairment Limitations in at least 2 of the following Communication Self-direction Self-care Health and safety Home living Functional academics Social skills Leisure Work Community use Some Causes of Intellectual Impairment Neonatal 63 period PKU Hypothyroidism Fetal alcohol syndrome Down syndrome Malformations Maternal Birth of the brain infections injuries or anoxia during or shortly after delivery Some Causes of Intellectual Impairment 64 Heredity During childhood Meningitis Lead poisoning Neoplasms Encephalitis Living in a physically or emotionally deprived environment Nursing Tip Intellectually impaired children have the same psychosocial needs as all other children but cannot express or respond as other children do Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 65 The Importance of Success in the Approach to the Intellectually Impaired Child 66 The nurse must assist the parents to understand that providing experiences that the child can be successful in, and concentrating on his or her strengths rather than on weaknesses, are the keys to dealing with a child who is developmentally different A child who experiences constant failure becomes angry The anger causes behavior difficulties that can cloud the problem and therapy Management and Nursing Goals 67 Individualized plan of care Initial step is to present the findings to the family Provide emotional support The child’s competence and adaptive behaviors should be discussed along with the deficiencies If child is in the hospital, the nurse needs to obtain The child’s stage of maturation and ability Self-help Home activities routines Nursing TiP 68 Nursing responsibilities to disabled children Emphasize Maintain Avoid the strengths present communication with the family labels; use simple terms Contact the school nurse; plan for school needs Provide daily experiences in which the child can succeed Refer to local, state, and national support groups Nursing Tip 69 Many intellectually and developmentally disabled children have a normal facial appearance Many children with unusual faces are not intellectually and developmentally disabled Head Injuries 70 Major cause of death in children older than 1 year of age A concussion is a temporary disturbance of the brain that is usually followed by a period of unconsciousness A child’s response to a head injury may differ from that of an adult NURSING ALERT! A concussion with resulting amnesia and confusion can be more serious than the presence of a fractured skull with no clinical symptoms Complications of Head Injuries 71 Hypoxia, increased ICP, cerebral edema, and infection can occur within a few days of a head injury Hypoxia causes the brain to need increased energy, which increases cerebral blood flow Increased edema If blood flow causes cerebral ICP rises too high, cerebral perfusion diminishes, brain damage or death results Shaken Baby Syndrome 72 Infants who are roughly shaken can sustain retinal, subarachnoid, and subdural hemorrhages in the brain, as well as high-level cervical spine injuries Can result in permanent brain injury or death Symptoms can include: Headache (manifested as fussiness in a toddler) Drowsiness Blurred vision Vomiting Dyspnea In severe cases child may be completely unconscious Posturing Seen in Brain Injury Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 73 Observe Child for Signs of Increased ICP Four components of a cranial or neurological check LOC Pupil and eye movement Vital signs Motor activity 74 Nursing Care of a Brain-Injured Child 75 Subtle clues to change can be missed unless the nurse performs aggressive assessment in looking for them The lack of the child’s ability to communicate and cooperate poses a challenge in the neurological assessment of infants, but knowledge of normal growth and development aids the nurse in evaluating the status of the patient Neurological Monitoring of Infants and Children Pain stimuli response LOC 76 Pupil response of the eyes Arousal awareness Bulging fontanels Cranial nerve response Scalp vein distention Ataxia; spasticity of lower extremities Moro/tonic neck with withdrawal reflexes Motor response Posturing Near-Drowning 77 Accidental or near-drowning is the fourth leading cause of death in children under 19 years of age Near-drowning is defined as survival beyond 24 hours after submersion Priorities include immediate treatment of Hypoxia Aspiration Hypothermia CNS injury remains the major cause of death or long-term disability Near-Drowning Submersion 78 for more than 10 minutes with failure to regain consciousness at the scene or within 24 hours is an ominous sign and indicates severe neurological deficits if the child survives Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
