Nursing Care of Children with Neurological & Neuromuscular Conditions PDF

NURSING CARE OF CHILDREN With neurologic & neuromuscular conditions  NEUROMU SCULAR Cerebral Palsy Spina bifida hypotonia Botulism Muscular dystrophy  CEREBRAL PALSY Nonprogressive impairment of motor function, especially that of muscle...

NURSING CARE OF CHILDREN With neurologic & neuromuscular conditions  NEUROMU SCULAR Cerebral Palsy Spina bifida hypotonia Botulism Muscular dystrophy  CEREBRAL PALSY Nonprogressive impairment of motor function, especially that of muscle control, coordination, and posture Can vary in sensation, perception, communication, cognition, behavior Manifests differently in each child, development can vary and are depending on severity of the injury Results from insult during fetal life / birth RISK FACTORS: Extremely low and very low birth weight is single biggest risk factor Existing brain anomalies, cerebral infections, head trauma or anoxia to the brain Maternal infection Interruption of oxygen delivery to the fetus during birth Direct injury to the neonate during birth https://www.youtube.com/watch?v=csKRVW-HN0E TY PE S O F CP  CEREBRAL PALSY EXPECTED FINDINGS DIAGNOSTICS Physical assessment: Complete neuro assessment failure to meet developmental Metabolic and genetic testing milestones General movements assessment: in those persistent primitive reflexes such as older than 2 years old but younger than 5 moro or tonic neck years old gagging or choking with feeds MRI: to evaluate structures or abnormal areas poor head control EEG rigid posture and extremities, abnormal posturing hyperreflexia -not aware of surroundings toe walking arching back  Airway clearance, lungs, gas exchange Mobility and contractures Wheelchair Splints Seizures N URS ING P LAN O F C ARE Skin integrity Altered nutrition Altered elimination Care after surgical procedures Tendon release to help w/stiffening Baclofen pump  TREATMENTS > intrasticket - Baclofen: used as a centrally acting skeletal muscle relaxant that decreases muscle spasms and severity Diazepam: skeletal muscle relaxant used to decrease muscle spasms and severe spasticity Botulinum toxin A: reduces spasticity in specific muscle groups – so usually the quads - Antiepileptics: common ones include valproic acid, gabapentin – all used to help control seizure activity  CEREBRAL PALSY EDUCATION COMPLICATIONS May need to self-cath Aspiration: Understand orthoses if needed Should keep head elevated Use pulmonary hygiene techniques Keep suction available Potential for injury: Bed rails up Pad side rails and wheelchair arms  SPINA BIFIDA Neural tube defect present at birth – characterized by failure of the osseous spine to close with CNS effects Types: Occulta Cystica Meningocele Myelomeningocele Risk factors: Medications and substances taken during pregnancy Maternal malnutrition Insufficient folic acid intake Exposure to radiation or chemicals during pregnancy Diagnostic: Maternal blood test, ultrasound, amniocentesis, chorionic villus sampling  TYPES OCCULTA CYSTICA protrusion of the sac is visible mostly affects the lumbosacral area and is not visible externally Findings: Flaccid muscles Surface of the vertebral bone is missing; NO SPINAL CORD INVOLVEMENT Lack of bowel control Prolapse of the rectum Spinal curvature abnormalities (scoliosis & kyphosis) Protruding sac midline of osseous spine Meningocele: contains spinal fluid and meninges No neurological deficits Are at increased risk for infection if it ruptures Myelomeningocele (most common): sac contains spinal fluid, meninges, and nerves Failure of neural tube to close causes decreased motor and sensory function  SPINA BIFIDA NURSING: THERAPEUTICS: Assess neuro involvement Closure is done ASAP to prevent complications of Prevent infection* injury / infection Educate parents about intermittent bladder Need to prepare family for surgery 24-72 hours catheterization if needed after birth Assess head circumference & fontanels Apply sterile, moist dressing; change every 2 hours Infant should be prone with hips flexed and legs If dressing becomes dry, add more saline prior to abducted removal*** Avoid rectal temps Assess for any signs of infection POST OP: Administer IV antibiotics as prescribed Monitor vitals Assess for increased ICP Provide incision care Maintain prone position until other positions are prescribed  COMPLIC ATIONS Skin ulcerations (caused by prolonged pressure in one area Reposition frequently Latex allergy: at increased risk Watch for signs ranging from wheezing to anaphylaxis Increased ICP: caused by shunt malfunction or hydrocephalus Infants: may see high-pitched cry, lethargy, vomiting, bulging fontanels, widening cranial suture lines, increased head circumference Children: headache, lethargy, nausea, vomiting, double vision, decreased school performance, decreased level of consciousness, seizures Bladder issues: are at increased risk for bladder dysfunction Monitor for signs of infection May need to administer antispasmodics or intermittent caths as needed Bowel control measures: increased risk for constipation Administer laxatives and fiber Ortho issues: may need corrections of associated potential problems such as clubfoot, scoliosis, and mother malformations  HYPOTONIA for - lack of muscle Can be a sign of anoxia, trauma, genetic condition Of great concern with failure to thrive Often generates genetic work up - FTT  POSSIBLE CAUSES I can Spinal muscular atrophy Trisomy 21 15. Earlier onset= more severe Infantile botulism > - connot givenony Respiratory failure by age 2 Can present as constipation, decreased movement Categorized by: Deep tendon reflexes absent Age at onset Weak cry in - spores Severity of symptoms Decreased gag reflex Stool Progression Poor feeding Anterior horn cell pathology Descending weakness, decreased neuro function, respiratory failure Atrophy of spinal muscles over time Diagnosis confirmed by presence of spores in stool Respiratory failure Treatable if diagnosed, long road back Abnormal brain development  SPINAL MUSCULAR ATROPHY Group of hereditary diseases that progressively destroys motor neurons Categorized by: Age at onset Earlier onset= more severe Respiratory failure by age 2 years old Severity of symptoms Progression Anterior horn cell pathology Atrophy of spinal muscles over time Respiratory failure  MUSCULAR DYSTROPHY Group of inherited disorders with progressive degeneration of symmetric skeletal muscle groups causing progressive muscle weakness and wasting; can lead to disability and deformity Thought to be metabolic, not nervous system related Onset of disease, pace of progression, and muscle group affected is dependent on type of dystrophy LABORATORY TESTS & DIAGNOSTICS: Blood polymerase chain reaction to test for gene mutation Blood creatinine kinase: elevated and can be elevated prior to manifestations Genetic analysis Muscle biopsy  MUSCULAR DYSTROPHY FINDINGS: Fatigue, muscle weakness beginning in lower extremities Unsteady gait with a waddle Lordosis Frequent falling Gower’s sign: difficulty getting out of bed, rising from seated position, or climbing stairs Learning difficulties Mild cognitive delays that do not worsen with disease progression  Duchenne is most severe & most common X-linked recessive Normal development until about age 3-5 Rapid progression Life span of only 15- 30 years TY PE S O F MU SC ULAR Fat tissue replaces muscles in lower limbs DYS TROP HY Hypertrophic calf muscles Facioscapulohumeral muscular dystrophy Autosomal dominant inherited Age of onset in early adolescence Progression is slow with normal life span Facial weakness & inversion of the shoulders Limb-girdle muscular dystrophy Autosomal dominant & recessive Appears later in childhood with slow progression  MUSCULAR DYSTROPHY NURSING MANAGEMENT: THERAPEUTICS: Gas exchange: encourage use of incentive spirometer Surgery can be indicated to release or repair contractures or for insertion of g-tube or trach Position child to enhance expansion of lungs Nutrition: encourage low calorie, high protein and fiber MEDICATIONS: Contractures – perform ROM exercises, stretching, Corticosteroids muscle training Prednisone: helps increase muscle strength Skin integrity Monitor for infection Cognitively intact Must be taken on a regular scheduled basis  COMPLIC ATIONS Obesity Contractures Infections Respiratory compromise: progressive weakening of respiratory muscles decrease ability to maintain adequate respirations Need to turn hourly or more frequently Administer oxygen as needed Deep breathing and coughing Use intermittent positive pressure ventilation and mechanically assisted cough devices if indicated Antibiotics if needed  Rare body’s immune system attacks part of its peripheral nervous system GU ILLAIN -B ARR E immune system damages the myelin sheath SY ND RO M E that surrounds the axons of the peripheral nerves nerves cannot transmit signals effectively and muscles begin to lose their ability to respond to brains command which can lead to weakness Recovery varies  GU ILLAIN BARRE SYNDROME SYMPTOMS: Symptoms can range from mild with brief weakness to nearly devastating paralysis leaving the patient unable to breathe independently Unexplained sensations usually occur first such as tingling in hands / feet, or even can have pain that starts in legs or back May start to have difficulty walking or may refuse to walk Most reach the greatest stage of weakness within the first 2 weeks after symptoms appear Can also have difficulty with eye muscles & vision, difficulty swallowing or chewing, coordination problems, abnormal heart rate or blood pressure, and problems with digestion or bladder control  SEIZURE DISORDERS Seizures: abnormal, involuntary, excessive electrical discharges of neurons within the brain Classified according to their etiology: Partial (focal): involves one area of the brain - hypoglycemia Generalized: involve entire brain RISK FACTORS FOR SEIZURES: Some have unknown etiology Febrile episode Cerebral edema Intracranial infection or hemorrhage Brain tumors or cysts Toxins or drugs Lead poisoning Tetanus, shigella or salmonella Younger onset means worse prognosis  Onset without warning Most prevalent type Tonic phase: usually 10-20 seconds GE NE RALIZ ED : Eyes roll upwards Loss of consciousness TO N IC-C LON IC Contraction of entire body, with arms flexed and legs, head, and neck extended Loss of swallowing reflex and increased salivation Apnea leading to cyanosis Clonic phase: usually 30-50 seconds, can last 30 minutes or longer Violent jerking movements of the body Trunk and extremities: rhythmic contraction & relaxation Can having foaming at the mouth Incontinent of feces/urine Gradual slowing of movements until cessation Postictal (30 min) Remains semiconscious but arouses with difficulty Confused for several hours - dont Lack of coordination remember Possible vomiting, headache, visual or speech difficulties - vomitting / Feels tired and complains of sore muscles dif. speech No recollection of seizure https://www.youtube.com/shorts/xweaBApbcCM  Absence seizures: aka petit mal or lapses Onset between ages 4- 12 and ceases by teenage years Motionless, blank stare Affects school work, which is often first indication of problem Resembles daydreaming or inattentiveness GE NE RALIZ ED Automatisms: lip smacking, switching of eyelids or face Unable to recall episodes, but can be momentarily confused Can immediately resume previous activities Myoclonic seizures: Variety of seizure episodes Symmetric or asymmetric involvement https://www.youtube.com/watch?v=JpPQbkMEYW8 Brief contractions of muscle or muscle groups https://www.youtube.com/watch?v=9Z8sKp2V7nQ No postictal state https://www.youtube.com/watch?v=EEusUYl5uQ4 Might not lose consciousness Atonic or akinetic seizure: Aka drop attacks Onset between 2-5 years of age Muscle tone lost for a few seconds which often causes a fall Period of confusion follows Should wear helmet if frequent  Simple partial seizures w/ motor manifestations: Aversive seizure (most common): eyes and head turn away from the side of focus, with or without LOC Rolandic (sylvan): tonic-clonic movments involving face, salivation, arrested sleep, sleep during the day Simple partial seizures with sensory manifestations: Tingling, numbness or pain in one area of the body, then PART IAL (FO C AL/LO C AL) spreads to other parts, with visual sensations Motor development (hypertonia or posturing) Complex partial: psychomotor ⑧ https://www.youtube.com/watch?v=1LP7X_11 points 2lE = complex partial Altered behavior + aura Inability to respond to environment Impaired consciousness but regains in less than 5 minutes Unable to recall event Aura: warning of onset of seizure; can be a strange feeling in the throat, odor or taste; can also produce auditory or visual hallucinations, feelings of fear, distorted sense of time & self  West Syndrome (infantile spasms) Rare disorder, unknown origin Sudden, brief, symmetric muscle contractions Flexed head, extended arms with legs drawn up Possible flushing, pallor, cyanosis U NC LASSIF IED Lennox-Gastaut Syndrome Mixture of different seizures in child with cognitive deficit https://www.youtube.com/watch?v=aVoJtslvqO U = infantile spasms Aggressive / hyperactive behavior Difficult to treat Poor prognosis Febrile Seizures Associated with sudden spike in temp Duration 15-20 seconds  Depends on age, hx, and physical condition Lead level LABS & D IAGN OS TICS CBC (for WBC) Blood glucose* Metabolic panel Toxicology screen EEG MRI LP  NURSING C ARE Seizure precautions* DURING A SEIZURE: Protect from injury (Especially head) Maintain position to provide open airway Be prepared to suction secretions Side lying helps decrease risk of aspiration Do not attempt to open jaw or insert an airway during seizure Prepare to administer oxygen POSTSEIZURE: Maintain in side lying Assess for injuries Perform neuro checks Document onset and duration of seizure  Anti-epileptics Diazepam Phenytoin Fosphenytoin Levetiracetam M ED IC ATIO N S Tegretol Topiramate Lamotrigine clonazepam  EDUCATION: Take medication at same time everyday Dosage needs to be increased as child grows Blood counts, urinalysis, and liver function tests will need to be obtained at frequent intervals Medical alert bracelet Ketogenic diet can be prescribed to promote body use of fat instead of glucose for energy; can help reduce ED U C ATIO N seizure frequency especially if patient has metabolic disorder Must monitor for lethargy, kidney or bladder stones, Y weight loss When to call EMS: Apnea Seizure lasting more than 5 minutes Status epilepticus Pupils are not equal following seizure Vomiting 30 minutes after seizure First seizure episode  COMPLIC ATIONS keppra + drip Status epilepticus Prolonged seizure activity – repeated seizures for 30 minutes One seizure lasting longer than 5 minutes Acute condition Requires immediate emergent treatment to prevent loss of brain function which can become permanent Nursing Administer loading dose of diazepam or lorazepam If seizure continues fosphenytoin then phenobarb Apply oxygen, intubation MENINGITIS  MENINGITIS bacterial worse Affects the covering of the brain and spinal cord = meninges Can be life threatening; should be treated as medical emergency Common symptoms: Severe head ache Sore / stiff neck Kernig’s sign Brudzinski’s sign High fever or hypothermia in infants Photosensitivity Nausea, vomiting Bulging fontanel in infants Altered mental status  DIAGNOSIS TREATMENT Broad spectrum antibiotics CBC If infant born to mothers known to be LP: Lumbar puncture infected with suspected organisms, CSF: elevated WBC (>1000mm), elevated prophylactic antibiotics are needed protein (>50 mg/dL), low glucose(