Peds Neurological Disorders PDF

Care of the Child with a Neurologic Alteration Chapter 52  Neuro Assessment ▪ General Evaluation ▪ Depends on the infant’s or child’s age and level of development ▪ Delay or deviation from expected milestones helps identify high risk children ▪ Level of consciousness...

Care of the Child with a Neurologic Alteration Chapter 52  Neuro Assessment ▪ General Evaluation ▪ Depends on the infant’s or child’s age and level of development ▪ Delay or deviation from expected milestones helps identify high risk children ▪ Level of consciousness ▪ The earliest indicator of improvement or deterioration of neurologic status ▪ Pediatric Glasgow Coma Scale  Neuro Assessment, cont. Pediatric Glasgow Coma Scale Developmentally appropriate cues to assess LOC Parents many times will be the first to notice changes in their child’s LOC. Listen to parents and respond to their concerns. Lack of response to painful stimuli – report immediately!  Neuro Assessment, cont. Vital signs Watch for high temp & rapid changes in pulse & BP Head, face, and neck Check for size, shape, symmetry, ROM, & head circumference Cranial nerve function – see chapter 33 for testing The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency!  Neuro Assessment, cont. Motor Functioning Posturing Gait, muscle tone, strength Assess bilaterally and compare Reflexes Primitive and protective *Three key reflexes in young infants: Moro Tonic neck Withdrawal Also DTRs  Neuro Assessment, cont. Increased ICP Infants: setting-sun, changes in feeding, high-pitched cry, irritable Head: Increased head circumference, bulging fontanel, separated sutures, distended scalp veins Children: headache, n/v, blurred vision, seizures Personality/behavior changes: irritable, restless, drowsy, increased sleep, memory loss, lethargy Late signs: bradycardia, systolic hypertension, apnea, decreased LOC, decreased motor signs and/or flexion or extension posturing, decreased response to pain MOVEMENT OF CEREBRAL SPINAL FLUID  Hydrocephalus Imbalance in the production and absorption of CSF in the ventricular system. Ventriculo-perit oneal Shunt (VP Shunt) External Ventricular Drainage System (EVD) Nursing Care – Hydrocephalus & VP Shunt **Prevent and recognize shunt infection and malfunction Infection: elevated VS, poor feeding, vomiting, decreased responsiveness, seizure Malfunction: vomiting, drowsiness, headache. Malfunction can occur due to kinking, clogging, separation of the tubing Watch for s/s increased ICP and abdominal distention Goals: Maintain cerebral perfusion, minimize neurologic complications, maintain adequate nutrition, promote growth and development, support and educate family  Neural Tube Defects Spina bifida occulta Meningocele Myelomeningocele  Myelomeningocele – spina bifida Spinal cord often ends at point of defect Long term complications Paralysis, orthopedic deformities, bladder and bowel incontinence Neurogenic bladder Hydrocephalus Pathophysiology – cause unknown but risk factors include maternal folic acid deficiency, and maternal drug use. Genetic predisposition is being researched.  Myelomeningocele – spina bifida Therapeutic Management Early surgical closure (within the first 12-18 hours of life is best but can wait up to 24-72 hours) Can sometimes be closed prenatally at 19-25 weeks gestation but this can be risky. The following video shows a successful case: https://youtu.be/hwKXYIiUUmo Nursing Care management Prevent sac trauma & infection!! Promote urine elimination Promote bowel elimination Promote skin integrity  Cerebral Palsy A chronic, nonprogressive disorder of posture and movement Has many comorbidities that vary widely May or may not have intellectual impairments Can be caused by damage prenatally, perinatally, or postnatally CP is one of the most common chronic neurological impairments in children There is no cure only interventions to maximize the child’s abilities  Head Injury Child’s response to head injury Large head, little musculoskeletal support Cerebral edema Types of head injuries Concussion is most common Contusion/hemorrhage/skull fracture Complications of head trauma Hemorrhage (epidural, subdural) Cerebral edema and brain stem herniation Major causes: falls, motor vehicles, bikes  Nursing Management Head Trauma Assessment ABCs – airway, breathing, circulation *Priority - establish an adequate airway Stabilize spine Watch pupils **Watch discharge from nose or ears **Most important assessment: child’s LOC Signs of increased intracranial pressure – ICP Parent education  Non-accidental Head Trauma Shaken baby syndrome, abusive head trauma, Nursing Assessment intentional impacts Look for discrepancies, conflicting stories s/s of increased ICP Can cause profound neurologic Physical exam impairment, seizures, intracranial External bruising, **retinal hemorrhages** hemorrhages, retinal hemorrhages, and Nursing management high cervical spinal cord hemorrhages. Assess for risk factors Average victim is less than 9 months old Single parent, young parent, substance abuse by & frequently there was no intent to harm parent, external factors such as the child. The adult got frustrated or financial/social/physical burdens that place angry about the crying baby. stress, premature or sick infant, infant with colic. Educate all parents on ways to handle stress & the dangers of shaking a baby  Spinal Cord Injury Etiology Infant: aggressive shaking by an older person Children/Adolescents: MVA, falls, diving accidents, sports injuries, tumors, congenital anomalies, gunshot or knife wounds, or attempted suicide. More common in adults than children Infants more prone because of large head size in relation to body 75% of children that sustain spinal cord injuries in a motor vehicle accident were not wearing a seatbelt/properly restrained in the appropriate carseat.  Spinal Cord Injury Therapeutic Management Determined by the level of injury Immediate treatment includes immobilization & steroids Airway assessment is critical Circulation, body temperature, and oxygenation status are closely monitored Neurologic assessment includes evaluating mobility, sensation, & reflexes and is ongoing & carefully documented Throughout the hospital stay and in preparation for discharge the child and family will need a lot of emotional support and help with all of the changes that will need to be made to their vehicle, home, family routine, finances, and medical & therapy practitioners.  Seizure Disorders m i g ht in o log y l T er m c l i n ica Ne w n in ! Classification of Seizures be s e e ice o pract epilepsy.c w. r es/ Generalized Seizures :// w w https rn/types re-classif -se i z u a u Tonic-clonic Seizures m/le r ms-seiz te n new- icatio Atonic Seizures Myoclonic Seizures Absence Seizures Focal Seizures Seizure Disorders Febrile Seizures Not epilepsy Most outgrow by age 5 Rapidity of temperature elevation is the primary contributing factor to a febrile seizure Usually a tonic-clonic type activity Parent education about what to do for subsequent febrile seizures is very important. See handout.  Infantile Spasms https://www.youtube.com/watch?v=zyJhrWP26-s Absence Seizure Seizure https://youtu.be/mWK-oqwrJz0 Videos Tonic-clonic Seizure https://youtu.be/yp5mi9gTg2A Simple Partial Seizure https://youtu.be/rtjPs_B99Bo Complex Partial Seizure https://youtu.be/ejjmYsAYdfM Febrile Seizure https://youtu.be/WaT5cIAH8sc  Seizure Diagnostic Evaluation History What type of seizure was experienced? Precipitating events? Previous history of seizures? Family history of seizures? Testing Physical & Neuro Exam Labs & Lumbar Puncture CT of the head & EEG  Emergency Management of Seizures Airway & Safety are the priority May need to perform jaw thrust to administer oxygen Keep child safe: Side-rails up & padded Oxygen & suction set-up at the bedside No other hard objects in bed or around child Must have direct supervision when ambulating or bathing During seizure remain calm, place child on side, time length of seizure activity and closely observe features of seizure, provide oxygen and suction if necessary. Administer medications as prescribed  Status Epilepticus Medical Emergency!! Continuous seizure lasting greater than 5 minutes or a series of seizures with no regain of consciousness in between Requires immediate intervention to prevent permanent injury to brain, respiratory failure, and death The majority of children will survive with no intellectual impairment if treated Status epilepticus can occur with any type of seizure, including a febrile seizure  Long Term Medical Management of Seizures Treatment objectives: Control or reduce frequency of seizures Discover & correct the cause Help child live as normal a life as possible Medications: Several different options, many times more than one medication has to be tried. Complete control achieved in only 50-75% of children Vagus Nerve Stimulation Ketogenic diet  Bacterial Meningitis Bacterial agents Pneumococcal: Streptococcus pneumoniae Preventable with the Prevnar vaccine Meningococcal: Neisseria meningitidis Mostly in school-age and adolescents Preventable with the Menactra vaccine Haemophilus influenzae type B Preventable with the Hib vaccine E. coli and Group B streptococci in neonates Bacterial Meningitis – Clinical Manifestations Infants and young toddler Early signs: vomiting, irritable, poor feeding, weak cry. Later signs: seizures, tense bulging fontanel, shrill neurogenic cry, setting sun sign. Over 2 years old abrupt onset, fever, chills, HA, vomiting, seizures, stiff neck Signs of meningeal irritation nuchal rigidity, severe headache, loss of consciousness, photophobia, N/V, fever, convulsions. Positive Brudzinskis and Kernigs signs **Hallmark sign – Purpuric or petechial rash with meningococcemia  Brudzinski’s sign – flex the head and neck onto the chest while observing for flexion of the hip and knees indicating a positive response Kernig’s sign – flex the leg at the hip, bring the knee to a 90-degree angle followed by attempting to extend the leg while observing the client for pain and spasms Signs of Meningeal Irritation Opisthotonos  Bacterial Meningitis – Nursing Care Management This is a medical emergency!!! Nursing Care Management Administer antibiotic as soon as ordered & after collecting all specimens Infection control – Droplet isolation Fever reduction (to help maintain optimal cerebral perfusion by reducing metabolic needs of the brain) Quiet room, dim lights (to decrease risk of seizure) **Aseptic Meningitis – usually viral Observe vitals, LOC, I&O Diagnosed with LP. Nursing care similar Maintain IV except for the isolation Provide family/close contacts with prophylactic antibiotics immediately precautions & abx Prevention – immunize!!!  Reyes Syndrome Exact cause unknown Primarily effects children