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Neurological Disorders in the Pediatric Patient

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Neurological Disorders in the Pediatric Patient

  1. 1. Neurological Disorders in the Pediatric Patient Presented by Marlene Meador RN, MSN
  2. 2. Neurological System of Children <ul><li>Top Heavy </li></ul><ul><li>Cranial bones- thin, not well developed </li></ul><ul><li>Brain highly vascular with small subarachnoid space </li></ul><ul><li>Excessive spinal mobility </li></ul><ul><li>Wedge-shaped cartilaginous vertebral bodies </li></ul>
  3. 3. Etiology and Pathophysiology
  4. 4. Altered Mental Status Mnemonic = Mitten <ul><li>M etabolic </li></ul><ul><li>I nfections </li></ul><ul><li>T oxins </li></ul><ul><li>T rauma </li></ul><ul><li>E ndocrine </li></ul><ul><li>N eurological /N eoplasm </li></ul>
  5. 5. Neurological Assessment <ul><li>Vital Signs </li></ul><ul><li>Eyes </li></ul><ul><li>Behavior </li></ul><ul><li>Respiratory Status </li></ul><ul><li>Motor Function </li></ul><ul><li>Skin </li></ul><ul><li>Children’s Coma Scale </li></ul>
  6. 6. Assessment: Infant <ul><li>Irritability and restlessness </li></ul><ul><li>Full to bulging fontanelles </li></ul><ul><li>Increase in FOC </li></ul><ul><li>Poor feeding, poor sucking, projectile vomiting </li></ul><ul><li>Distension of superficial scalp veins </li></ul><ul><li>Nuchal rigidity and seizures (late signs) </li></ul>
  7. 7. Assessment: Child early signs- <ul><li>Irritability, lethargy </li></ul><ul><li>Sudden change in mood </li></ul><ul><li>Headache </li></ul><ul><li>Vomiting </li></ul><ul><li>Ataxia </li></ul><ul><li>Nuchal rigidity </li></ul><ul><li>Deterioration of cognitive ability </li></ul>
  8. 8. Assessment Child: Late signs <ul><li>Changes in Vital signs </li></ul><ul><li>Seizures </li></ul><ul><li>Photophobia </li></ul><ul><li>Positive Kernig’s sign </li></ul><ul><li>Positive Brudzinski’s sign </li></ul><ul><li>Opisthostonos </li></ul>
  9. 9. Therapeutic Intervention Nursing care <ul><li>Medications </li></ul><ul><li>Corticosteroid (decadron) </li></ul><ul><li>Osmotic diuretic (Manitol) </li></ul>
  10. 10. Nursing Care <ul><li>Minimize activity </li></ul><ul><li>Monitor IV rate </li></ul><ul><li>Place in semi-fowlers </li></ul><ul><li>Monitor VS, Neuro VS, and behavior </li></ul><ul><li>Treat for pain </li></ul><ul><li>Organize care </li></ul><ul><li>Educate parents </li></ul>
  11. 11. Critical Thinking <ul><li>What would you expect as a first sign of IICP in an infant? </li></ul><ul><li>What would you expect as an initial sign of IICP in a 10 year old child? </li></ul>
  12. 12. Meningitis <ul><li>Bacterial Meningitis </li></ul><ul><li>Vs. </li></ul><ul><li>Viral Meningitis </li></ul>
  13. 13. Bacterial Meningitis <ul><li>Potentially Fatal </li></ul>
  14. 14. Viral Meningitis <ul><li>Same signs and symptoms, may be milder and self-limiting. Usually lasts a few days </li></ul>
  15. 15. Assessment <ul><li>Infants & Young Children </li></ul><ul><li>Fever not always present </li></ul><ul><li>Lethargy </li></ul><ul><li>Alterations in sleep and feeding habits </li></ul><ul><li>Nuchal rigidity (late sign) </li></ul>
  16. 16. Assessment: <ul><li>Childhood & Adolescence </li></ul><ul><li>Hyperthermia </li></ul><ul><li>S&S of IICP </li></ul>
  17. 17. Complications of Meningitis <ul><li>IADH </li></ul><ul><li>Intravascular coagulation with thrombocytopenia </li></ul><ul><li>CSF obstruction </li></ul><ul><li>Nerve Damage </li></ul>
  18. 18. Diagnostic Tests: <ul><li>Lumbar Puncture </li></ul><ul><li>Serum Glucose Level </li></ul><ul><li>Blood Cultures </li></ul>
  19. 19. Therapeutic Interventions Mediation Therapy <ul><li>Antibiotics </li></ul><ul><li>Ampicillin </li></ul><ul><li>Claforan </li></ul><ul><li>Rocephin </li></ul>
  20. 20. Nursing Care <ul><li>Assess </li></ul><ul><li>Antibiotic therapy </li></ul><ul><li>Monitor lab values </li></ul><ul><li>Strict I&O </li></ul><ul><li>Isolation </li></ul><ul><li>Monitor FOC </li></ul>
  21. 21. Nursing Care cont... <ul><li>CSF culture </li></ul><ul><li>Temperature control </li></ul><ul><li>Seizure activity </li></ul><ul><li>Environment </li></ul><ul><li>Planning </li></ul><ul><li>Education </li></ul>
  22. 22. Hydrocephalus <ul><li>Hydro= Water </li></ul><ul><li>Cephaly= of the head/brain </li></ul>
  23. 23. Etiology and Pathophysiology: <ul><li>Congenital anomalies </li></ul><ul><li>Trauma </li></ul><ul><li>Unknown causes </li></ul>
  24. 24. Types of Hydrocephalus <ul><li>Non-communicating or Obstructive </li></ul><ul><li>Communicating </li></ul>
  25. 25. Clinical Manifestations <ul><li>Infants- prior to fusion of cranial sutures </li></ul><ul><li>FOC </li></ul><ul><li>Changes in assessment of skull </li></ul><ul><li>Forehead </li></ul><ul><li>Eyes </li></ul><ul><li>Behavior changes </li></ul>
  26. 26. Clinical Manifestations <ul><li>After closure of cranial sutures: </li></ul><ul><li>Eyes </li></ul><ul><li>S & S of IICP </li></ul>
  27. 27. Diagnostic Tests <ul><li>LP </li></ul><ul><li>MRI/ CT scan </li></ul><ul><li>Skull X-ray </li></ul><ul><li>FOC </li></ul><ul><li>Transillumination </li></ul>
  28. 28. Interventions: Surgical <ul><li>Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption </li></ul>
  29. 29. Complications of Shunts <ul><li>Infections </li></ul><ul><li>Blocked shunts </li></ul><ul><li>Seizures </li></ul>
  30. 30. Nursing Interventions <ul><li>Monitor VS and neurological status </li></ul><ul><li>Assess functioning of the shunt </li></ul><ul><li>Assess operative site </li></ul><ul><li>Assess for infection </li></ul><ul><li>Positioning of the patient </li></ul><ul><li>Activity of patient </li></ul><ul><li>Promote nutrition </li></ul><ul><li>Education </li></ul>
  31. 31. Critical Thinking <ul><li>What is the most important assessment data on a child who has just had a shunt placement for hydrocephalus? </li></ul><ul><li>What is the most important teaching for the parents or caregivers? </li></ul>
  32. 32. Spina Bifida <ul><li>Most common defect of the CNS </li></ul><ul><li>Occurs when there is a failure of the osseous spine to close around the spinal column. </li></ul>
  33. 33. Clinical Manifestations: <ul><li>Visualization of the defect </li></ul><ul><li>Motor sensory, reflex and sphincter abnormalities </li></ul><ul><li>Flaccid paralysis of legs- absent sensation and reflexes, or spasticity </li></ul><ul><li>Malformation </li></ul><ul><li>Abnormalities in bladder and bowel function </li></ul>
  34. 34. Diagnostic Tests: <ul><li>Prenatal detection </li></ul><ul><li>Ultrasound </li></ul><ul><li>Alpha-fetoprotein </li></ul><ul><li>Following Birth: </li></ul><ul><li>NB assessment </li></ul><ul><li>X-ray of spine </li></ul><ul><li>X-ray of skull </li></ul>
  35. 35. Surgical Intervention <ul><li>Immediate surgical closure </li></ul><ul><li>Prior to closure keep sac moist & sterile </li></ul><ul><li>Maintain NB in prone position with legs in abduction </li></ul>
  36. 36. Nursing Interventions: <ul><li>Pre-OP: </li></ul><ul><li>Place in prone position </li></ul><ul><li>Sterile moist dressing with normal saline or antibiotic solution </li></ul><ul><li>Maintain proper abduction of legs and alignment of hips </li></ul><ul><li>Meticulous skin care </li></ul><ul><li>Protect from feces or urine </li></ul><ul><li>Keep in isolette </li></ul>
  37. 37. Post-Op Nursing Interventions <ul><li>Assess surgical site </li></ul><ul><li>Monitor VS and neuro VS </li></ul><ul><li>Institute latex precautions </li></ul><ul><li>Encourage contact with parents/care givers </li></ul><ul><li>Positioning </li></ul><ul><li>Skin Care </li></ul>
  38. 38. Nursing Interventions cont... <ul><li>Antibiotic therapy </li></ul><ul><li>Prevent UTI </li></ul><ul><li>Education </li></ul><ul><li>Emphasize the normal, positive abilities of the child </li></ul>
  39. 39. Critical Thinking <ul><li>Would you expect a 5-year-old with meningomyelocele to have bladder/bowel sphincter control? </li></ul><ul><li>Which type of neural tube defect is most likely to have no outward signs or symptoms? </li></ul>
  40. 40. Cerebral Palsy (CP) <ul><li>Static Encephalopathy- spastic CP most common type (80%) </li></ul><ul><ul><li>Nonspecific term give to disorders characterized by impaired movement and posture </li></ul></ul><ul><ul><li>Non-progressive </li></ul></ul><ul><ul><li>Abnormal muscle tone and coordination </li></ul></ul>
  41. 41. Assessment <ul><li>Jittery (easily startled) </li></ul><ul><li>Weak cry (difficult to comfort) </li></ul><ul><li>Experience difficulty with eating (muscle control of tongue and swallow reflex) </li></ul><ul><li>Uncoordinated or involuntary movements (twitching and spasticity) </li></ul>
  42. 42. Assessment cont... <ul><li>Alterations in muscle tone </li></ul><ul><ul><li>Abnormal resistance </li></ul></ul><ul><ul><li>Keeps legs extended or crossed </li></ul></ul><ul><ul><li>Rigid and unbending </li></ul></ul><ul><li>Abnormal posture </li></ul><ul><ul><li>Scissoring and extension (legs feet in plantar flexion) </li></ul></ul><ul><ul><li>Persistent fetal position (>5 months) </li></ul></ul>
  43. 43. Diagnostic Tests: <ul><li>EEG, CT, or MRI </li></ul><ul><li>Electrolyte levels and metabolic workup </li></ul><ul><li>Neurologic examination </li></ul><ul><li>Developmental assessment </li></ul>
  44. 44. Complications <ul><li>Increased incidence of respiratory infection </li></ul><ul><li>Muscle contractures </li></ul><ul><li>Skin breakdown </li></ul><ul><li>Injury </li></ul>
  45. 45. Goals & Interventions: <ul><li>Early detection </li></ul>
  46. 46. Mental Retardation <ul><li>“Significant sub average, general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period”. </li></ul><ul><li>American Association of Mental Deficiency </li></ul>
  47. 47. Down Syndrome <ul><li>Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation </li></ul>
  48. 48. Assessment <ul><li>See syllabus </li></ul><ul><li>Primary concern with cardiac and GI anomalies </li></ul><ul><li>What are the most obvious indications of Down’s Syndrome in a newborn? </li></ul>
  49. 49. Goals and Interventions <ul><li>Primary focus on the parents and care givers to provide support and achieve a realistic view of the child’s capabilities </li></ul><ul><li>Support siblings </li></ul><ul><li>Refer to family counseling services </li></ul><ul><li>Support parents in feelings of guilt and chronic sorrow </li></ul>
  50. 50. Hyperfunction/Hypofunction <ul><li>Pediatric Seizures </li></ul><ul><ul><li>Febrile seizures- occur as a result of rapidly increasing core temperature (101.8 F– 38.8C) </li></ul></ul><ul><ul><li>General seizures- occur as a result of insult of the nervous system </li></ul></ul>
  51. 51. Clinical Manifestations <ul><li>Tonic-clonic- absence seizures, minor motor-atonic </li></ul><ul><li>Partial seizures- partial simple or partial complex </li></ul>
  52. 52. Diagnostic Tests: <ul><li>EEG </li></ul><ul><li>CT, MRI </li></ul><ul><li>Lumbar puncture </li></ul><ul><li>CBC </li></ul><ul><li>Metabolic screen for glucose, phosphorus and lead levels </li></ul>
  53. 53. Jitteriness –vs- Seizure <ul><li>Jittery </li></ul><ul><ul><li>Responsive </li></ul></ul><ul><ul><li>Gaze Okay </li></ul></ul><ul><li>Seizure </li></ul><ul><ul><li>Not responsive to stimuli </li></ul></ul><ul><ul><li>Abnormal gaze </li></ul></ul>
  54. 54. Goals: <ul><li>Primary focus to 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. </li></ul>
  55. 55. Interventions <ul><li>Febrile seizures </li></ul><ul><li>Seizure precautions </li></ul><ul><li>During seizure activity </li></ul><ul><li>Education </li></ul>
  56. 56. Autism <ul><li>Most severe pervasive developmental disorder of childhood. Moderate to severely incapacitating with lifelong developmental disabilities </li></ul><ul><li>Etiology/Pathophysiology </li></ul><ul><ul><li>Cause unknown </li></ul></ul><ul><ul><li>Possible genetic or prenatal hypoxic event </li></ul></ul>
  57. 57. Clinical Manifestations of Autism <ul><li>Developmental disturbances of verbal and social language skills </li></ul><ul><li>Abnormal response to sensation/stimuli (difficulty distinguishing self from environment) </li></ul><ul><li>Repetition of self-stimuli </li></ul><ul><li>May have savant capabilities </li></ul><ul><li>Does not show pain with injuries </li></ul><ul><li>Dependent on severity of condition </li></ul>
  58. 58. Diagnosis <ul><li>Extensive and thorough interview of family regarding behaviors </li></ul><ul><li>Behaviors classically begin before age 3 </li></ul><ul><li>Direct observation of child </li></ul>
  59. 59. Nursing Care of Hospitalized Child with Autism <ul><li>Attempt to maintain child’s daily routines from home- very ritualistic </li></ul><ul><li>Work closely with family to decrease anxiety </li></ul><ul><li>Provide for the child’s safety-particularly if ritual self stimulation is potentially harmful (head banging, biting) </li></ul>
  60. 60. Shaken Baby Syndrome <ul><li>Intracranial & retinal bleeding </li></ul><ul><li>Physical abuse causing a whip-lash induced trauma to the child’s brain </li></ul>
  61. 61. Nursing Interventions <ul><li>Assessment- observe for S&S of: </li></ul><ul><ul><li>Hemorrhage to sclera </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Respiratory irregularities </li></ul></ul><ul><ul><li>Increased intracranial pressure (ICP) </li></ul></ul><ul><ul><li>Drowsiness or lethargy </li></ul></ul>
  62. 62. Long Term Prognosis <ul><li>Complete recovery is rare </li></ul><ul><li>Mental retardation </li></ul><ul><li>Cerebral Palsy </li></ul><ul><li>Death </li></ul>
  63. 63. Legal Implications <ul><li>Nurses must report suspected child abuse to Child Protective Services (CPS). </li></ul><ul><li>It is not your obligation to prove the abuse you must report any suspicion. CPS will document and follow through on the case </li></ul><ul><li>*remember…the abuser may not be the person you suspect, and disclosure to the wrong individual may endanger the child. </li></ul>
  64. 64. <ul><li>Please contact me with any further questions. </li></ul><ul><li>Marlene >^,,^< </li></ul><ul><li>[email_address] </li></ul>

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