Pediatric neurologic nurs 3340 fall 2014

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Pediatric neurologic nurs 3340 fall 2014

  1. 1. Alterations in Neurologic Function in Children Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE 1
  2. 2. Objectives Describe the anatomy and physiology of the neurologic system and pediatric differences Choose the appropriate assessment guidelines and tools to examine infants and children with altered level of consciousness and other neurologic conditions Differentiate between the signs of a seizure and status epilepticus in infants and children, and plan appropriate nursing care for each condition Plan family-centered nursing care for the child with hydrocephalus, neural tube defects, and cerebral palsy Describe the nursing management for traumatic brain injury 2
  3. 3. Overview of the Neurologic System 3
  4. 4. Nervous System Consists of the brain, spinal cord, and nerves Seat of intellect and reasoning Communication and coordination system of the body Affects and is affected by all other body systems 4
  5. 5. Figure 27-1 Transverse section of the brain and spinal cord. Knowledge of the anatomy of the brain is helpful in understanding the symptoms of neurologic dysfunction. 5
  6. 6. 6
  7. 7. Cranial Nerves 12 pairs, begin in the brain Many important sensory and motor functions Designated by number and name: I, III II, IV, VI III, VIII V,VII IX, X, XII 7
  8. 8. 8
  9. 9. 9
  10. 10. 10
  11. 11. Spinal Nerves 31 pairs: originate at spinal cord and go through openings in vertebrae Convey sensory information; relay impulses that stimulate motor responses Send and receive information to specific body locations 11
  12. 12. Neuron/ Nerve Impulse Neuron: information processing cells; basic cells of nervous system Make connections with other neurons to form the information processing networks A stimulus creates an impulse The impulse travels into the neuron on the dendrite (s) and out on the axon At the end of the axon, a neurotransmitter is released that carries the impulse across the synapse to the next dendrite 12
  13. 13. Neurilemma (Myelin Sheath) Covering that speeds up the nerve impulse along the axon Myelin is a fatty protein substance that protects the axon Synapse- space between neurons, messages go from one cell to the next Responsible for speed and accuracy of nerve impulses 13
  14. 14. Myelination Progressive covering of axons with layers of myelin Incomplete at birth Proceeds in cephalocaudal direction Accounts for progressive acquisition of gross and fine motor skills, coordination Axon diameters and myelin sheaths undergo conspicuous growth during the first two years of life, but may not be fully mature until a person’s early 20s 14
  15. 15. Cephalocaudal/ Proximodistal 15
  16. 16. Pediatric Differences 16
  17. 17. Anatomic Differences in the Structures of the Nervous System Between Children and Adults (p. 850) 17
  18. 18. Anatomic & Physiologic Differences 18
  19. 19. Neurological System of Children Complete but immature nervous system Top heavy Cranial bones- thin, not well developed Brain highly vascular with small subarachnoid space Excessive spinal mobility Wedge-shaped cartilaginous vertebral bodies 19
  20. 20. “Top Heavy” 20
  21. 21. Unfused Sutures Fibrous union of suture lines and interlocking of edges occurs by 6 months Suture lines between skull bones ossified by age 12 Posterior fontanel closes by 3 months Anterior fontanel closes by 18 to 24 months Prone to brain injury and skull fractures with falls 21
  22. 22. Rapidly-Developing Brain At birth, brain is 25% of adult size Develops rapidly until age 4 Brain increases four-fold in size during preschool period By age 6, brain is 90% of adult size Myelination is complete by early adulthood 22
  23. 23. 23
  24. 24. Developmental Differences Neurological assessment of the child is limited to the child’s developmental level Children progress cognitively through the sensorimotor, preoperational, concrete operational, and formal operational stages Primitive reflexes present at birth disappear by 1 year Children are developing their ability to recognize and manage their emotions or feelings up until and including their late teens or early twenties Children and adolescents are still in a period of social development which involves learning the values, knowledge and skills that enable them to relate to others Adolescents cannot reason as well as adults; they are more inclined to act impulsively and irrationally and take part in high-risk behaviors 24
  25. 25. 25
  26. 26. Assessment of the Neurologic System in Children 26
  27. 27. 27
  28. 28. Neurologic Assessment Normal growth & development parameters/ Developmental milestones Infant: Primitive reflexes “Locomotion:” Gross motor “Manipulation:” Fine motor “Cognitive:” Language & Social Parents’ evaluation of their child History Prenatal Birth history Postnatal 28 Review “Assessing the Nervous System,” pp. 153-161
  29. 29. Birth History 29
  30. 30. Neurologic Assessment Cont’d… Behavior Personality, affect, level of activity, social interaction, attention span Subtle changes Communication skills Speech, language, social skills Table 5-13: Expected Language Development for Age, p. 154 Motor function Muscle - size, tone, strength Gait, balance, coordination Spontaneous movements; abnormal movements Sensory function Discrimination of touch with eyes closed 30
  31. 31. Expected Language Development for Age (p. 154) 31
  32. 32. Expected Balance Development for Age 32
  33. 33. Romberg Procedure (p. 155) 33
  34. 34. Expected Fine Motor Development for Age 34
  35. 35. Tests of Coordination (p. 156) 35
  36. 36. Neurologic Assessment Cont’d… Vital signs: Respiratory status: Assess 1st Changes in BP, HR Eyes: Changes in pupils, focus, gaze 36
  37. 37. Pupillary Response The pupil’s response to light is checked Does the pupil dilate and constrict appropriately? A light beam is directed at and away from the eye and the reaction is noted Observe if the pupils constrict and dilate as expected: CN II & CN III Young children: PERRL Older children: PERRLA 37
  38. 38. 38
  39. 39. Diagnostic Procedures Computer Tomography (CT) Visualizes horizontal and vertical cross section of the brain Distinguishes density MRI Permits tissue discrimination unavailable with other techniques 39
  40. 40. Diagnostic Procedures Lumbar puncture Measure pressure and sample for analysis Subdural tap R/O subdural effusions, relieves ICP EEG Measures electoral activity Detects abnormalities 40
  41. 41. Review Question The nurse places the young child scheduled for a lumbar puncture in a side-lying position with head flexed and knees drawn up to the chest. The mother asks why the child has to be positioned this way. The nurse explains the rationale for the positioning is that: A. Pain is decreased through this comfort measure. B. Injury to the spinal fluid is prevented. C. Access to the spinal fluid is facilitated. D. Restraint is needed to prevent unnecessary movement. 41
  42. 42. Review Question A nurse employed in an outpatient diagnostic laboratory department assesses a preschooler who arrives to have an electroencephalogram (EEG). The nurse determines that the diagnostic test may need to be rescheduled if which of the following noted? A. The child’s hair is shampooed. B. The child took an anticonvulsant. C. The child ate a full breakfast. D. The child drank orange juice for breakfast. 42
  43. 43. Laboratory Tests CSF Blood glucose Electrolytes Ca, Mg, Na Clotting studies Liver function tests Blood cultures Drug titer 43
  44. 44. Altered States of Consciousness 44
  45. 45. Level of Consciousness (LOC) Assess Alertness and cognitive power What stimuli is needed? What is quality of the response? What is length of response? Altered LOC = Neurologic dysfunction 45 **Subtle & most important indicator of neurologic function**
  46. 46. Altered Level of Consciousness (p. 852) 1. Confusion • Disorientation to time, place, or person 2. Delirium • Characterized by confusion, fear, agitation, hyperactivity, or anxiety 3. Lethargy = less than full alertness; senses blunted 4. Stupor = response to vigorous stimuli only 5. Coma = unconscious; cannot be aroused 46
  47. 47. Glasgow Coma Scale/ AVPU Scale Glasgow: Designed as a standardized assessment of the patient with disturbed consciousness Different criteria for infants and older children Decline in LOC follows a pattern of confusion, delirium, lethargy, stupor, to coma The lower the score at time of admission the poorer the outcomes AVPU: Alert, Verbal, Painful and Unresponsive Only ‘Alert’ state is normal 47
  48. 48. 48
  49. 49. AVPU Scale 49Only ALERT state is NORMAL!
  50. 50. The Unconscious Child (pp. 854-855) Unconsciousness is a state in which a child’s cerebral function is depressed Ranges from stupor to coma Care of the unconscious child Monitor vital signs Manage the airway Manage bladder and bowel elimination Maintain hydration & nutrition Provide proper hygiene Position and perform exercise 50
  51. 51. Persistent Vegetative State A complete unawareness of the environment accompanied by sleep–wake cycles The diagnosis is established if it is present for 1 month after acute or nontraumatic brain injury or has lasted for 1 month in children with degenerative or metabolic disorders or developmental malformations Family support is needed Not the same as “Brain Death”! 51
  52. 52. Review Question A child on a pediatric unit has been in a coma for the past two months. When caring for a child in a coma which of the following nursing diagnoses would be most important? A. Risk for Impaired Skin Integrity B. Impaired Physical Mobility C. Risk for Imbalanced Nutrition: Less than Body Requirements D. Ineffective Airway Clearance 52
  53. 53. Pupil Changes (p. 854) 53Fixed and dilated pupil(s) is neuro emergency!
  54. 54. Increased Intracranial Pressure Causes Tumors Accumulation of fluid within the ventricular system Bleeding Edema in cerebral tissues Early signs and symptoms are often subtle and assume many patterns 54
  55. 55. Assess for signs of Increased Intracranial Pressure Level of consciousness (LOC) Earliest indicator of changes in neurological status As ICP increases, LOC decreases Early signs: Confusion, restlessness, lethargy, and disorientation first to time, then to place, and then to person Headache, visual disturbance, nausea/vomiting, pupils unequal or slow Infants: increased head circumference, bulging fontanels, separated sutures, vomiting, high-pitched cry 55SuddenincreasedintracranialpressureisanEMERGENCY!CatchitEARLY!
  56. 56. Assess for signs of Increased Intracranial Pressure Late signs: Stupor and coma Significant LOC decrease Increased systolic BP and pulse pressure Bradycardia Irregular respirations Fixed, dilated pupils Decorticate/ decerebrate posturing 56 See Table 27-4 “Signs of Increased Intracranial Pressure,” p. 852
  57. 57. 57
  58. 58. 58
  59. 59. Review Question Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Restlessness and confusion C. Vomiting D. Widened pulse pressure 59
  60. 60. Increased Intracranial Pressure Posturing Decorticate Adduction and flexion Decerebrate Rigid extension and pronation 60
  61. 61. 61
  62. 62. Review Question The nurse is caring for a child with a head injury and is monitoring the child for decerebrate posturing. Which of the following is characteristic of this type of posturing? A. Flexion of the extremities after a noxious stimulus B. Extension of the extremities after a noxious stimulus C. Upper extremity flexion with lower extremity extension D. Upper extremity extension with lower extremity flexion 62
  63. 63. Common Nursing Diagnoses Ineffective Breathing Pattern Risk for Aspiration Ineffective Airway Clearance Impaired Verbal Communication Impaired Physical Mobility Interrupted Family Processes Risk for Delayed Growth and Development Risk for Impaired Skin Integrity Risk for Injury Risk for Falls 63
  64. 64. Seizure Disorders 64
  65. 65. Epilepsy (p. 855) Seizure disorder of brain; characterized by recurring and excessive discharge from neurons Repeated, unpredictable seizures One in 20 children will have a seizure by age 18 45,000 children develop epilepsy each year 65
  66. 66. Seizure Disorders: Causes (p. 856) Traumatic brain injury (TBI) Infection Congenital brain defects Metabolism disorders (such as phenylketonuria) Brain tumor Abnormal blood vessels (brain) Toxic ingestion Anoxic or hypoxic events Hypoglycemia Fever 66
  67. 67. Classification of Seizures (p. 856) *Partial Simple partial: no loss of consciousness Complex partial: affect level of consciousness Symptoms depend on what area of the brain is involved Often presents as a staring episode or slight twitching of eyes and drooling *Generalized Tonic-clonic (grand mal) Tonic – stiff Clonic – jerking Sudden loss of muscle tone Eye blinking, alter awareness, mouth, or facial movement 67 See “Types of Seizures/ Clinical Manifestations,” pp. 856-857 *Occur as a result of insult to the nervous system
  68. 68. 68
  69. 69. *Febrile Seizures (p. 856) Age Most common between 6 months and 5 years Occurrence Seizure accompanied by fever without CNS infection Occurs during the temperature rise Treatment Fever - Tylenol Seizure - Ativan, Valium (only if second febrile seizure) 69 *Occur as a result of rapidly increasing core temperature
  70. 70. *Status Epilepticus (p. 856) Malignant seizure condition where the patient seizes constantly or has seizure after seizure without abatement Seizures lasting more than 20 minutes without return to baseline Neurologic Emergency! 70 *In children, the major cause of status epilepticus is infections accompanied by fever
  71. 71. Management of Status Epilepticus (p. 858) 71
  72. 72. Seizure Disorders: Nursing Care Maintain airway patency Remain calm and stay with child Reassure and provide support to child and others Protect child from injury Implement seizure precautions (padded side rails, oxygen, suction equipment, IV access, and anticonvulsant medications) Provide continuous cardiac, respiratory, and oxygen monitoring Suction equipment at bedside! 72
  73. 73. Seizure Disorders: Nursing Care Cont’d…. Provide time for child to recover Place on side in recovery position Maintain anticonvulsant therapy See “Medications Used to Treat Seizures,” p. 860 Accurately observe & document events 73
  74. 74. Review Question An eighteen-month-old child is observed having a seizure. The nurse notes that the child’s jaws are clamped. The priority nursing responsibility at this time would be: A. Start oxygen via mask. B. Insert padded tongue blade. C. Restrain child to prevent injury to soft tissue. D. Protect the child from harm from the environment. 74
  75. 75. 75
  76. 76. Documentation When seizures began Duration Warning signs Clinical characteristics Level of consciousness Signs and symptoms when seizure stops Vital signs 76
  77. 77. Collaborative Care (p. 858) Diagnostic Tests CBC, blood chemistry, ABG, urine culture Metabolic screen for glucose, phosphorus, & lead levels Lumbar puncture EEG CT Scan/ MRI Medications (p. 859) Ketogenic diet (p. 858) for intractable seizures 77
  78. 78. Ketogenic Diet 78 Side effects: dyslipidemia, constipation, kidney stones, and slowed growth
  79. 79. Long-Term Goal for Children with Seizure Disorders Identify the cause and eliminate the seizure with minimum side effects using the least amount of medication while maintaining a normal lifestyle for the child 79
  80. 80. Hydrocephalus 80
  81. 81. Hydrocephalus (p. 872) An imbalance of CSF absorption or production caused by congenital anomalies, CNS malformations, tumor, hemorrhage, infection, or head injuries Results in head enlargement & increased ICP Commonly associated with myelomeningocele Brain compressed against the skull 81
  82. 82. Hydrocephalus: Clinical Manifestations (p. 873) Infant Increased HC, separated skull sutures, full or bulging fontanels “Sunsetting eyes” Poor feeding, poor sucking, projectile vomiting Child Behavioral changes – irritability & lethargy HA on awakening, N & V Delays in walking or talking, unstable balance, poor coordination Blurred or double vision 82
  83. 83. Bulging Anterior Fontanel; Sunsetting Eyes 83 Head enlargement with prominent forehead
  84. 84. Diagnostic Tests Prenatal US Daily serial HC measurements CT scan/ MRI MRI/ CT scan Skull X-ray Transillumination 84
  85. 85. Collaborative Care: Surgical Intervention Removing obstruction (e.g., tumor) Creating new pathway Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption Four parts to shunt: ventricular catheter, pumping reservoir, one-way valve, & distal catheter 85
  86. 86. Review Question The parents of an infant who has just had a ventriculoperitoneal shunt inserted for hydrocephalus are concerned about the infant’s prognosis and ongoing care. The nurse should explain that: A. The prognosis is excellent and the shunt is permanent. B. The shunt will need to be revised as the child gets older. C. During the first year of life, any brain damage that has occurred is reversible. D. Hydrocephalus is usually self-limiting by 2 years of age and the shunt will then be removed. 86
  87. 87. Complications: Ventriculoperitoneal Shunts Blocked shunts Infections Seizures 87 See “Signs of Shunt Malfunction or Infection,” p. 875
  88. 88. Review Question Following surgery for the insertion of a shunt for hydrocephalus, the infant demonstrated irritability, high- pitched cry, elevated pulse rate, and temperature of 40 degrees C (104 degrees F). These symptoms are consistent with which of the following postoperative complications? A. Shunt obstruction. B. Increased intracranial pressure. C. Decreased intracranial pressure. D. Infection. 88
  89. 89. Hydrocephalus: Nursing Care (p. 874) Preoperative: Assess ICP, neurological status, VS, HC Reposition head frequently to prevent pressure sores Provide education on the shunt, surgery, & postop care Postoperative: Assess for ICP, neurological status, VS, HC, infection Assess shunt functioning Assess operative site Position child on the unoperated side Keep child flat as ordered & elevate HOB 30° for s/s increased ICP Assess abdominal status (pain, bowel sounds, and circumference) 89
  90. 90. Critical Thinking What is the most important assessment data on a child who has just had a shunt placement for hydrocephalus? What is the most important teaching for the parents or caregivers? 90
  91. 91. Neural Tube Defects 91
  92. 92. Neural Tube Defects Abnormalities of brain, spine, or spinal column; present at birth Failure of the osseous spine to close around the spinal column Spina bifida: most common type Spina bifida occulta Meningocele Myelomeningocele 92
  93. 93. Spina Bifida Occulta 93
  94. 94. Visible Types of Spina Bifida Meningocele: sac filled with spinal fluid and meninges Myelomeningocele: more severe, sac filled with spinal fluid, meminges, nerve roots and spinal cord 94
  95. 95. Spina Bifida: Clinical Manifestations Vary depending on the level of the lesion and defect Motor, sensory, reflex and sphincter abnormalities Lower extremity weakness Ambulation difficulties Flaccid paralysis of legs- absent sensation and reflexes, or spasticity Bowel and bladder control issues Hydrocephalus Learning, attention, memory, and reasoning problems 95See “Clinical Manifestations Myelomeningocele,” p. 877
  96. 96. Spina Bifida: Diagnostic Tests Prenatal detection Ultrasound Alpha-fetoprotein Following Birth: NB assessment Ultrasound CT scan/ MRI X-ray of spine X-ray of skull 96
  97. 97. Spina Bifida: Surgical Intervention Immediate surgical closure Prior to closure keep sac moist & sterile Maintain NB in prone position with legs in abduction preoperatively 97
  98. 98. Review Question A newborn has been admitted to the unit with a myelomeningocele. Preoperative concern would include: A. Measure the head circumference on a daily basis. B. Preventing increased intracranial pressure by laying the baby in semi-Fowler’s position. C. Positioning the infant on his abdomen to protect the spinal defect. D. Monitoring the child for signs of irritability and vomiting. 98
  99. 99. Spina Bifida: Collaborative Care Extensive interdisciplinary treatment Antibiotics, sac closure (neonatal neurosurgery), and ventriculoperitoneal shunt placement Monitoring of head size (hydrocephalus), evaluation of sphincters, and institution of bowel and bladder regimen Dietary fiber, stool softeners, suppositories Clean intermittent catheterization Physical therapy, occupational therapy, speech therapy Braces, assistive devices, weight-bearing exercises Calcium, vitamin D, high-fiber diet 99
  100. 100. Spina Bifida: Nursing Care Pre-OP: Place in prone position Sterile moist dressing with NS or antibiotic solution Maintain proper abduction of legs and alignment of hips Meticulous skin care Protect from injury, feces or urine Keep in isolette Post-OP: Assess surgical site, keep clean & dry Monitor VS and neuro status Institute latex precautions Encourage contact with parents/care givers Positioning Skin care Discharge planning and teaching well in advance of discharge 100**Emphasize the normal, positive abilities of the child**
  101. 101. Review Question An infant undergoes surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should stay alert for which postoperative finding? A. Decreased urine output B. Increased heart rate C. Bulging fontanels D. Sunken eyeballs 101
  102. 102. Critical Thinking Would you expect a 5-year-old with myelomeningocele to have bladder/ bowel sphincter control? Which type of neural tube defect is most likely to have no outward signs or symptoms? 102
  103. 103. Cerebral Palsy 103
  104. 104. Cerebral Palsy (p. 883) Group of permanent disorders of movement, muscle tone or posture that is caused by a nonprogressive insult to the immature, developing brain, most often before birth Primarily a motor disorder (i.e., affects body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance) May also have sensory, perceptual, cognitive, communicative, and behavior problems 1.5 – 2 cases per 1000 live births Most common motor disability in children 104
  105. 105. Types of Cerebral Palsy  Spastic: most common type, 70- 80% of cases; causes increased muscle tone (stiff muscles)  Dyskinetic: affects coordination of movements; two subtypes  Athetoid: uncontrolled movements that are slow and writhing  Ataxic: poor balance/ coordination  Mixed (e.g., spastic-dyskinetic) 105
  106. 106. Cerebral Palsy: Etiology & Pathophysiology (p. 883) Damage to motor control centers of developing brain; may occur prenatally, perinatally, or postnatally Many possible causes: Abnormal brain development/ brain injury prior to birth Prenatal or perinatal asphyxia/ anoxia (severe lack of oxygen in the brain) Low birth weight, preterm birth Bleeding in the brain (intraventricular hemorrhage) Prenatal and postnatal infections, such as cytomegalovirus, rubella, toxoplasmosis, neonatal sepsis, meningitis Head injury (motor vehicle crash, fall, child abuse) Hyperbilirubinemia (kernicterus) http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm 106
  107. 107. 107
  108. 108. CP Clinical Manifestations: Infants (p. 883) Vary individually depending on the area of the brain involved and the extent of damage: Problems with sucking and swallowing A weak or shrill cry Extreme irritability & crying Jittery (easily startled) Unusual positions (either very relaxed and floppy or very stiff) Delay in reaching motor skills milestones (such as sitting up alone or crawling) Delays in speech development or difficulty speaking 108See “Clinical Manifestations Cerebral Palsy,” p. 884
  109. 109. CP Clinical Manifestations: Children (p. 883) Abnormal motor development Persistent primitive infantile reflexes Increased or decreased muscle tone Hypertonia, rigidity, muscles stiff Keeps legs extended or crossed Rigid and unbending Exaggerated deep tendon reflexes Opisthotonus Abnormal increased muscle development in arms & legs Hypotonia, muscles floppy Smaller muscles in affected arms & legs Diminished reflexes 109
  110. 110. Opisthotonus and Hypotonia 110
  111. 111. CP Clinical Manifestations: Children Cont’d... (p. 883) Abnormal posture Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing or a wide-based unsteady gait Persistent fetal position (>5 months) Abnormal voluntary movements Tremors or involuntary movements Slow, writhing movements (athetosis) Difficulty with precise motions (hand movements) Lack of muscle coordination (ataxia) Abnormal sensations Abnormal touch or pain perceptions Seizures 111
  112. 112. Cerebral Palsy: Gait Abnormalities 112
  113. 113. Cerebral Palsy: Diagnostic Tests (p. 883) Clinical findings Neurologic examination Developmental assessment Ultrasound EEG, CT/ MRI, PET Electrolyte levels and metabolic workup 113
  114. 114. Cerebral Palsy: Collaborative Care (p. 883) Early Recognition & Multidisciplinary Approach CP cannot be cured, but disabilities can be managed through planning and timely early intervention (Tertiary Prevention) Physical, Occupational, Speech therapy Nursing Management (p. 884) Assess the child’s developmental level & intelligence Use splints and braces Promote self-care, physical mobility Maintain skin integrity Administer medications (reduce muscle spasms, spasticity, anxiety, and seizure) Surgery (e.g., selective dorsal rhizotomy, tendon releases) Address feeding problems Provide intellectual stimulation Ensure safe environment 114See “Care Plan: The Child with Cerebral Palsy,” pp. 885-887
  115. 115. Baclofen to Decrease Spasticity 115
  116. 116. Selective Dorsal Rhizotomy 116
  117. 117. Cerebral Palsy: Complications Increased incidence of respiratory infection Muscle contractures Skin breakdown Injury/ falls Constipation 117
  118. 118. Review Question Upon performing a physical assessment of a 7-month- old child, the nurse notes an abnormal finding that could suggest cerebral palsy. The finding suggestive of cerebral palsy is that the child has: A. No head lag when pulled to a sitting position. B. No Moro or startle reflex. C. Positive tonic neck reflex. D. Absence of tongue extrusion. 118
  119. 119. Traumatic Brain Injury 119
  120. 120. Traumatic Brain Injury (TBI) (p. 889) Trauma to the head that causes a change in LOC or an anatomic abnormality of the brain Leading cause of death & disability among children Up to 90% of deaths of injured children are associated with TBI Infants: shaken baby syndrome; child abuse; falls; motor-vehicle crash Toddlers/ preschoolers: falls (head-first); motor-vehicle crash School-age/ adolescents: motor vehicle crash; sports & athletic injuries; assaults 120
  121. 121. TBI – Common Causes (p. 889) 121
  122. 122. Coup & Contracoup Brain Injury: Pathophysiology (p. 889) 122
  123. 123. TBI: Clinical Manifestations (p. 890) Obvious signs: blood on the scalp, depression of the skull, penetrating wound, etc. Mild (Concussion) No or brief loss of consciousness Alteration LOC Headache, memory loss, unsteady, tired Moderate Five- to ten-minute loss of consciousness Headache, nausea Glasgow Coma Scale: 9–12 See “Clinical Manifestations: TBI by Severity,” p. 890
  124. 124. TBI: Clinical Manifestations Cont’d... Severe Loss of consciousness of more than ten minutes Glasgow Coma Scale: less than 8 Amnesia for more than 24 hours preinjury Coma Seizures & combativeness
  125. 125. TBI: Diagnostic Tests (p. 890) CBC, blood chemistry, toxicology, UA X-ray: skull, cervical vertebrae CT scan: fractures, intracranial hemorrhage, selling, tearing of nerve fibers throughout the brain MRI: during recovery to determine extent of brain damage PET scan: blood flow to brain 125
  126. 126. TBI: Collaborative Care (p. 891) Detection of primary injury; prevention or treatment of secondary brain injury (prevent hypoxia, hypercapnia, hypotension, hypoglycemia, electrolyte abnormalities) Secure the airway (may need intubation, mechanical ventilation) Minimize cerebral metabolic rate of oxygen consumption (minimal stimulation, quiet environment, cluster care) Prevent elevated ICP (sedation, analgesia; avoid suctioning) Hypertonic saline, mannitol, high-dose barbituate therapy, burr holes, surgical evacuation of intracranial hematoma Elevation of the head to 30° in the midline position (once cervical spine injury has been ruled out) 126
  127. 127. Review Question The nurse is caring for a child admitted to the pediatric intensive care unit after sustaining a head injury. In which of the following positions should the nurse place the child to prevent increased intracranial pressure (ICP)? A. In left Sims position B. In reverse Trendelenburg C. With the head elevated on a pillow D. With the head of the bed elevated 30 degrees 127
  128. 128. TBI: Nursing Management (pp. 892-894) Nursing care focus: maintain cerebral perfusion, minimize increases in ICP, prevent complications, & provide emotional support Maintain airway patency and oxygen administration Continuous cardiopulmonary monitoring Insert IV and administer hypertonic fluid Assess neurological status Assess ICP Cluster care, low-stimulation environment Skin care/ oral care Support/ educate family & caregivers Discharge instructions 128
  129. 129. Review Question The nurse is providing discharge instructions for a child who has suffered a head injury within the last four hours. The nurse will recognize the need for additional teaching when the mother states: A. “I will call my doctor immediately if my child starts vomiting.” B. “I won’t give my child anything stronger than Tylenol for headache.” C. “My child should sleep for at least 8 hours without arousing after we get home.” D. “I recognize that continued amnesia about the injury is not uncommon.” 129
  130. 130. 130
  131. 131. Shaken Baby Syndrome Don’t ever shake a baby! Brain sensitive to injury Shaking can lead to brain rotation within skull Blood vessels tear severe medical problems, long-term disabilities, and sometimes death Subdural hematomas Retinal hemorrhages/ detachment 131 Classic signs of shaken baby syndrome are seizures, slow apical pulse, difficulty breathing, and retinal hemorrhage.
  132. 132. 132
  133. 133. Review Question The pediatric nurse understands that the concepts related to shaken baby syndrome include: (Select all that apply.) A. Infants are susceptible to injury due to their neck muscles being weak B. After this injury infants may have seizures, lethargy, and respiratory difficulties C. The infant will display a sunken fontanel D. Jarring motion causes tearing of the nerve fibers of the brain E. Vision impairment or loss of hearing may result from this injury 133

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