Neurological disorders

1. NRSG 364
NEUROLOGICAL DISORDERS

2. Cognitive Impairment
• Cognitive impairment is a general term that
encompasses any type of mental difficulty or
deficiency.
• It is synonymously used with mental
retardation.
• If a child is significantly retarded in his
psychomotor development (milestones), a
subnormal intelligence and possibility of
mental retardation should be suspected.

3. Cognitive impairment
• Clinical features:
– He cannot sit without support at age 9 months,
cannot stand at age 15 months, cannot walk at
age 18 months.
– He cannot laugh loudly at age 6 months, speak
three words at age 2 years and follow a few simple
directions at age 3 years.
– He cannot grasp actively at age 6 months, does
not pull mother’s hair at age 9 months and take
small objects with thumb and finger at age 1 year.

4. Cognitive impairment
• Clinical features:
– Dysmorphic features e.g. down’s syndrome,
microcephaly.
– Irritability or nonresponsiveness to contact.
– Abnormal eye contact during feeding.
– Gross motor delay.
– Decreased alertness to voice or movement.
– Language difficulties or delay.
– Feeding difficulties.

5. Cognitive impairment
• Causes:
– Inherited/congenital abnormalities.
– Inherited subnormalities of the brain.
– Down’s syndrome.
– Perinatal problems (prematurity, asphyxia) or diseases
acquired after the neonatal period (meningitis,
cerebral malaria).
– Hypothyroidism.
– Emotional deprivation/neglect.
– Malnutrition.

6. Cognitive impairment
• Management:
– No treatment of the cause is possible.
– Symptomatic management.
– Moderate retardation may be limited to simple
habit training – eating, walking, putting on
clothes.
– In mild retardation – special attention in school.
– Provide family emotional support.

7. Autism
• This is a mental condition, present from early
childhood, characterized by difficulty in
communicating and forming relationships with
other people and in using language and
abstract concepts.

8. Autism
• Clinical features:
– Children with ASD demonstrates several peculiar
and often seemingly bizarre characteristics,
primarily in social interactions, communication,
and behaviour.
– Inability to maintain eye contact with another
person.
– Display limited functional play.
– Lack of social or emotional reciprocity.

9. Autism
• Clinical features:
– Delay in spoken language.
– Inability to initiate or sustain a conversation with
others.
– Persistent preoccupation with parts of objects.

10. Autism
• Management:
– Decrease stimulation by playing with the child in a
private room, avoiding strenuous auditory and
visual distractions and encouraging parents to
bring in possessions to which the child is attached.
– Minimize eye contact and physical contact.
– Care must be taken when performing procedures
on, administering medicine to, or feeding these
children.

11. Autism
• Management:
– Introduce new situations slowly.
– Keep visits with staff caregivers as short as
possible.
– They need to be told directly what to do.
– Provide family support.

12. Neural tube defects
• These are defects derived from the embryonic
neural tube.
• Normally the spinal cord and cauda equina are
encased in a protective sheath of bone and
meninges.
• Failure of neural tube closure produces
defects of varying degrees.
• They may involve the entire length of the
neural tube or may be restricted to a small
area.

13. Neural tube defects
• Anencephaly:
– The most serious neural tube defect.
– It is a congenital malformation in which both
cerebral hemispheres are absent.
– The condition is incompatible with life, and many
affected children a stillborn.
– The infants have an intact brainstem and are able
to maintain vital functions for a few hours to
several weeks but eventually die of respiratory
failure.

14. Neural tube defects
• Spina bifida and myelodysplasia:
– Spina bifida are midline defects involving failure of
the osseous spine to close.
– These can be categorized into two: spina bifida
occulta and spina bifida cystica.
– Spina bifida occulta refers to a defect that is not
visible externally.
– Spina bifida cystica refers to a visible defect with
an external saclike protrusion.

17. Neural tube defect
• Myelomeningocele:
– It develops during the first 28 days of pregnancy
when the neural tube fails to close and fuse at
some point along its length.
– It may be detected prenatally or at birth and may
be located at any point along the spinal column.
– Usually the sac is encased in a fine membrane that
is prone to tears through which CSF leaks.
– In other instances the sac may be covered by dura,
meninges or skin, in which case there is rapid and
spontaneous epithelization.

18. Neural tube defect
• Management:
– Prevent infection.
– Perform neurologic assessment.
– A variety of neurosurgical and plastic surgical
procedures are employed.
– Prevent joint contructures.
– Correct existing deformity.
– Minimize effects of motor and sensory deficits.
– Prevent skin breakdown.

19. Neural tube defect
• Management:
– Place the child in the incubator.
– Keep the child in prone position before surgery.
– Prepare the child pre- and post-operatively.

20. Hydrocephalus
• This is a syndrome, or a sign, resulting from
disturbances in the dynamics of CSF, which
may be caused by various conditions.
• The result is:
– Either impaired absorption of CSF fluid within the
subarachnoid space, obliteration of the
subarachnoid cisterns, or malfunction of the
arachnoid villi,
– Or obstruction to the flow of CSF through the
ventricular system.

21. Hydrocephalus
• Clinical features:
– Head enlargement.
– Bulging fontanelle.
– Marked and dilated scalp veins.
– Bones of the skull become thin.
– Sutures become palpably separated.
– Frontal protrusion.
– Depressed eyes, which may be rotated downward.

22. Hydrocephalus
• Management:
– Surgery.
– Involves direct removal of the obstruction.
– Insertion of ventriculoperitoneal shunt or
ventriculoatrial shunt.
– Pre- and postoperative care.
– Provide family support.
– Observe for signs of increasing ventricular size and
increasing ICP.

23. Hydrocephalus
• Management:
• Measure the head circumference daily.
• Fontanels and suture lines are palpated for
size, signs of bulging, tenses and separation.
• Prepare the child for MRI or CT scan.

24. Hydrocephalus
• Complications:
– Infections.
– Malfunction.
– Subdural hematoma.
– Peritonitis.
– Abdominal abscess.
– Perforation of abdominal organs.
– Fistulas.
– Hernias.
– Ileus.

25. Craniosynostosis
• This is the premature closure of one or more
cranial sutures.
• The clinical picture depends on which sutures
close, the duration of the closure process, and
the success or failure of the other sutures to
compensate by expansion.
• Fetal hydrodynamic mechanisms are involved
in the compensatory skull changes seen in
craniosynostosis.

26. Craniosynostosis
• Clinical features:
– Brain atrophy and underlying motor delay account
for the position-induced skull changes.
– Increased ICP.
– Progressive papilledema.
– Optic atrophy.
– Eventual blindness.
– Malocclusion.

27. Craniosynostosis
• Management:
– Surgery to release the fused suture and direct
growth.
– The advised timing of suture release is before 6
months of age for best cosmetic and
neurodevelopmental results.
– Do neurologic observations.
– Observe for hemorrhage and infection.
– Manage the pain.
– Monitor CBC.

28. Seizures
• Seizure is the word given to a sudden attack
due to such a burst of abnormal activity of
brain cells.
• A seizure may be single and due to some
harmful agent acting for a short time on the
brain cells or recurrent, as part of an epileptic
disorder.

29. Seizures
• It may come in many different forms,
depending on the part of the brain involved,
such as:
– A period of strange behaviour.
– A sudden absence or loss of consciousness.
– Local/generalized jerks.
– Peculiar sensations felt by the patient that may
form the “aura” or warning to the main seizure.
– The classical “tonic-clonic” convulsions.

30. Seizures
• Causes:
– A high fever in children between 6 months and 6
years of age.
– Cerebral malaria.
– Meningitis, encephalitis, brain abscess.
– Tumours, bleeding, head injury.
– Asphyxia.
– Hypoglycemia.
– Poisoning.
– Electrolyte disturbances.

31. Seizures
• Management:
– Give anticonvulsants.
– During a convulsion, the child should be kept on
his side.
– Give oxygen.
– Convulsive movement should not be restricted.
– Prevent child from injuring itself.
– Control temperature.
– Manage cause of seizures.

32. Seizures
• Management:
– Stress importance of adherence to medication
regimen even if the child has no evidence of
seizure activity.
– Pad side rails of bed, crib or wheelchair.
– Keep bed relatively free from objects.
– Set up suction and oxygen in room.
– Remain with the patient during a seizure.
– Encourage family involvement in care of child.

33. Meningitis
• Bacterial meningitis is the acute inflammation
of the meninges and CSF.
• It remains a significant cause of illness in the
paediatric age-groups because of the residue
damage caused by undiagnosed and
untreated or inadequately treated cases.
• The majority of reported cases occur in
children between 1 month and 5 years of age,
with an increased mortality risk in adolescent
and young adults.

34. Meningitis
• Causes:
– Bacteria.
– Viruses.
– Fungi.
• Complications:
– Blindness.
– Deafness.
– Hydrocephalus.

35. Meningitis
• Clinical features:
– Fever.
– Headache.
– Loss of appetite.
– Vomiting.
– Drowsiness.
– Neck stiffness.
– Kernig’s sign.
– Convulsions.

36. Meningitis
• Clinical features:(In children under 2 years)
– Fever.
– Drowsiness.
– Vomiting.
– Irritability.
– Convulsions.
– Startled expression.
– Bulging fontanelle.

37. Meningitis
• Clinical features: (In young babies)
– Fever.
– Cyanosis.
– Vomiting.
– High-pitched cry.
– Drowsiness.
– Inability to suckle.
– Convusions.
– Full fontanelle.
– Slight neck retraction.

38. Meningitis
• Management:
– It is a medical emergency.
– Take isolation precautions.
– Initiate antibiotics.
– Maintain ventilation.
– Reduce increased intracranial pressure.
– Manage systemic shock.

39. Meningitis
• Management:
– Control seizures.
– Control temperatures.
– Treat complications.
– Provide family with emotional support.

40. Encephalitis
• Is the inflammatory process of central nervous
system.
• Causes:
– Bacteria.
– Spirochetes.
– Fungi.
– Protozoa.
– Helminths.
– Viruses.

41. Encephalitis
• Clinical features:
– Headche.
– Vomiting.
– Drowsiness.
– Convulsions.
– Coma.
– Malaise.
– Dizziness.
– Apathy.
• Clinical features:
– Nuchal rigidity.
– Nausea.
– Vomiting.
– Ataxia.
– Tremors.
– Hyperactivity.
– Speech difficulties.

42. Encephalitis
• Management:
– Treatment is primarily supportive.
– Provide total nursing care.
– Control of cerebral manifestations.
– Adequate nutrition.
– Adequate hydration.
– Monitor intracranial pressure.
– Provide follow up care with periodic re-evaluation
and rehabilitation.

43. Cerebral palsy
• A term used for all permanent,
nonprogressive, generalized brain damage in
children, irrespective of the cause.
• Usually some degree of spasticity or
extrapyramidal symptoms and signs are
combined with intellectual damage.
• But often there is no or very little damage to
the thinking part of the brain and therefore no
reduction in intelligence.

44. Cerebral palsy
• If the child’s potential intelligence is not
recognized because of the difficulty in
communication, speech, expression, movement
or appearance, then the child is often rejected,
neglected or deprived and becomes frustrated
and retarded because of this.
• It is very important always in these children to try
to discover the full potential hidden beneath
their disability.

45. Cerebral palsy
• Causes:
– Prenatal: hydrocephalus and congenital infections.
– Perinatal e.g. asphyxia and cerebral haemorrhage.
– Childhood causes e.g. head trauma, meningitis, toxic
ingestion or inhalation.
• Clinical features:
– Spastic paralysis.
– Scissors-type contractures of the abductor muscles of the
legs.
– Spastic hemiplegia, paraplegia or tetraplagia.
– Mental retardation.
– Chorea and athetosis.
– Ataxia.

46. Cerebral palsy
• Management:
– Regular exercises to prevent flexion deformities.
– Give practical help.
– Help them to learn skills.
– Refer to social worker in the community.