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Chapter 13
Neurologic and Sensory Disorders
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
Key Terms
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Audiometry
Aura
Choroid plexus
Cover test
Habilitation
Idiopathic
Ketogenic diet
Multifactorial
Myelinization
Neural tube defects (NTD)
Occlusion
Opisthotonos
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Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
Petechiae
Postictal
Uncover test
Shunt
Syndrome of inappropriate
antidiuretic hormone
(SIADH)
TORCH
Transillumination
Tympanography
Vesicostomy
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Chapter 13
Lesson 13.1
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Learning Objectives
• Define the vocabulary terms listed
• List the differences found in the neurological system of a child
• Describe the signs of increased intracranial pressure in a child
with a head injury, including nursing observations necessary to
establish a baseline of information
• Discuss care of the child with intracranial hemorrhage
• Discuss use of the pediatric coma scale
• Differentiate between communicating and noncommunicating
hydrocephalus
• Outline the pre- and postoperative nursing care of a neonate
with spina bifida cystica
• Explain how to care for a child with bacterial meningitis or viral
encephalitis
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The Nervous System
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The Nervous System
• Grows rapidly before birth and during the first year
• Central nervous system (CNS)
– Cerebrum, cerebellum, brainstem, spinal cord
– Myelinization is cephalocaudal and proximodistal
– Primary focus of Chapter 13
• Peripheral nervous system (PNS)
– Cranial and spinal nerves
• Autonomic nervous system (ANS)
– Sympathetic/parasympathetic systems
• Choroid plexus: primary site of CSF formation
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Neurological Disorders
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Increased Intracranial Pressure
• Caused by volume increase of brain, CSF, or
blood which exceeds cranial capacity
• Signs and symptoms
– Cushing triad
• Increase in systolic blood pressure, widening pulse
pressure, decrease in pulse, altered respiratory pattern
– Possible temperature elevation from
inflammation, systemic infection, damage to
hypothalamus
– More pronounced as consciousness deteriorates
– As ICP increases, cerebral perfusion decreases
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Intracranial Hemorrhage
• Description
– Broken blood vessels within the skull cause
bleeding in the brain
– May result from trauma or anoxia
– Complete recovery is likely if symptoms are
mild
– Death results if there is a massive
hemorrhage
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Intracranial Hemorrhage
• Signs and symptoms
– Inability to move normally, lethargy, poor sucking
reflex, irregular respirations, cyanosis, twitching,
forceful vomiting, high-pitched shrill cry,
convulsions
– Opisthotonic posture
– Tense, pressurized fontanel
– Pupil of one eye sometimes smaller than the
other
• Diagnosis
– History of delivery, CT, MRI, increased CSF
pressure, symptoms and course of the disease
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Intracranial Hemorrhage
• Treatment and nursing care
– Newborn placed in an isolette
• Allows temperature control, ease in administering
oxygen, continuous observation
– Head is elevated
– Doctor may prescribe medication to control
bleeding and convulsions
– Nurse observes for signs of increased ICP and
convulsions
• Nurse’s observation of convulsion aids the physician in
determining the exact location of bleeding
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Head Injuries
• Description
– Falls, motor vehicle injuries, shaken baby
syndrome, bicycle injuries, etc.
– Infants and toddlers have soft skulls to absorb
impact
– By 2 years of age, both fontanels have
completely closed; impact absorption decreases
• Complications
– Hemorrhage, infections, cerebral edema (swelling
of the brain), and compression of the brainstem
– Increased ICP
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Head Injuries
• Treatment and nursing care
– ABCs (airway, breathing, circulation), assess for
spinal cord injury, document baseline vital signs
– Level of consciousness (LOC)
– Record type and amount of any drainage from
ears/nose
– Fluids are carefully monitored to control cerebral
edema
– Feeding difficulties should be noted as the child’s
diet is increased
– Patients should be observed for signs of shock
– Watch for decerebrate/decorticate posturing
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Hydrocephalus
• Description
– Increased CSF in the ventricles of the brain
• Causes increased head size, pressure changes in the
brain
– May occur in conjunction with a
meningomyelocele or as a sequela of infections,
including encephalitis, meningitis, or TORCH
• Toxoplasmosis, other, rubella, cytomegalovirus, herpes
simplex
– Can also be caused by perinatal hemorrhage
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Hydrocephalus
• Signs and symptoms
– Depend on site of obstruction and the child’s age
– Impairment of CSF absorption within
subarachnoid space
– Obstruction of CSF flow within ventricles
– Increase in head size
– Bulging anterior fontanel
– Separation of cranial sutures
– Shiny scalp, dilated veins
– Eyes may appear deviated downward
• “Setting sun” sign
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Hydrocephalus
• Diagnosis and treatment
– Head measured daily
– Echoencephalography, CT, MRI locate
enlarged ventricles and level of obstruction
– Ventriculoperitoneal (VP) shunt or
ventriculoatrial (VA) shunt
– Prognosis has improved with modern drugs
and surgical techniques
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Hydrocephalus
• Nursing care
– The position of the infant must be changed
frequently to prevent hypostatic pneumonia and
pressure sores
– In addition to routine postoperative care and
observations, the nurse observes the patient for
signs of increased intracranial pressure (ICP) and
for infection at the operative site or along the
shunt line
– If the fontanels are sunken, the infant should be
kept flat
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Myelodysplasia and Spina Bifida
• Both categorized as neural tube defects (NTD)
• Myelodysplasia
– CNS disorders characterized by abnormal
development of the spinal cord and associated neural
tube structures
• Spina bifida (divided spine)
– Congenital embryonic NTD; imperfect closure of
spinal vertebrae
– Cause unknown; multifactorial
– Development of a cystic mass in the midline of the
spine
• Meningocele or meningomyelocele
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Myelodysplasia and Spina Bifida
• Treatment
– Spina bifida: surgical closure to prevent
meningeal infection
• Observe for hydrocephalus, place shunt if
necessary
• Prognosis depends on lesion location, involvement
of spinal cord, presence of other anomalies
• Habilitation
• Vesicostomy may be necessary
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Myelodysplasia and Spina Bifida
• Nursing care
– Objectives of extensive nursing care
• Preventing infection of or injury to the sac
• Correct positioning to prevent pressure on the sac and
deformities from developing
• Good skin care, particularly if incontinent of urine and
feces
• Adequate nutrition
• Tender, loving care
• Accurate observations and charting
• Education of the parents
• Continued medical supervision
• Habilitation
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Bacterial Meningitis
• Description
– Inflammation of the meninges
– Infective organisms invade via teeth, sinuses,
tonsils, lungs, directly through the ear (otitis
media), from neurological procedures, or from
a fracture of the skull
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Bacterial Meningitis
• Signs and symptoms
– Onset generally follows two courses
• Typically URI or gastrointestinal problem followed by
irritability and lethargy
• Sudden rapid onset: shock, purpura, changes in level of
consciousness, disseminated intravascular coagulation
– Other nonspecific reactions: headache, drowsiness,
delirium, irritability, restlessness, fever, vomiting, and
stiffness of the neck and spine
• Petechiae: Small hemorrhages beneath the skin
• May have high-pitched cry, bulging tense fontanel
– Convulsions are common
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Question 13.1
Which of the following can cause increased
ICP?
A. Volume increase of cranial CSF
B. Intracranial hemorrhage
C. Shaken baby syndrome
D. All of the above
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Bacterial Meningitis
• Treatment
– Spinal tap at first indication of meningitis
– Isolation is used until the patient has received
at least 24 hours of antibiotic therapy
– Antibiotics are given in combination and are
adjusted on the basis of culture and sensitivity
reporting
– Dilantin may also be necessary if the child is
having seizures
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Bacterial Meningitis
• Nursing care
– Frequent monitoring of the patient’s vital signs is
necessary
– Fever may be controlled with the use of antipyretics,
sponge baths, and a hypothermia blanket
– The patient’s intake and output are carefully observed
and recorded
– Syndrome of inappropriate antidiruetic hormone
(SIADH)
• Determined by weight, serum electrolytes, serum and urine
osmolarities
• Treated by fluid restriction
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Encephalitis
• Description
– An inflammation of the brain parenchyma
• Typically more severe than bacterial meningitis
– Can be caused by arboviruses, enteroviruses,
and herpes virus types 1 and 2
– Can be aftermath of upper respiratory tract
infections, measles, an untoward reaction to
vaccinations, lead poisoning
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Encephalitis
• Signs and symptoms
– Headache followed by drowsiness, may
proceed to coma
– Convulsions occur, particularly in infants
– Fever, cramps abdominal pain, vomiting, stiff
neck, delirium, muscle twitching, and
abnormal eye movements are other
manifestations of the disease
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Encephalitis
• Treatment and nursing care
– Corticosteroids/immune globulin
– Acyclovir for herpes virus encephalitis
– Parenteral antibiotics until bacterial cause is ruled
out
– Sedatives, IV fluids, seizure control, monitoring
for increased intracranial pressure
– Antipyretics as ordered, seizure precautions
instituted
– Oxygen as needed, mouth and nose kept free of
mucus
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Question 12.2
Which is typically more severe?
A. Encephalitis
B. Bacterial meningitis
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Chapter 13
Lesson 13.2
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Learning Objectives
• Differentiate the types of generalized and
partial seizures
• Describe the nursing measures necessary
for a child during and after a tonic-clonic
seizure
• Discuss care of the near-drowning victim
• Differentiate two types of hearing loss
• Differentiate amblyopia and strabismus
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Seizure Disorders
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Seizure Disorders
• Febrile seizures
– Occur in association with a fever
– Are a common pediatric neurological disorder and
are generally transient in nature
– They usually occur between the ages of 6 months
and 5 years and are common in toddlerhood
– Generally, the parents are educated on fever
management and seizure precautions, although
fever management (such as administering
acetaminophen) does not typically reduce the risk
for a seizure
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Seizure Disorders
• Epilepsy
– Recurrent paroxysmal attacks of
unconsciousness or impaired consciousness
• May be followed by alternating contraction and
relaxation of the muscles or disturbed feelings/behavior
– Disorder of the CNS in which the neurons or
nerve cells discharge in an abnormal way
– Idiopathic epilepsy: unknown cause
– Symptomatic epilepsy: cerebral abnormality is
found
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Epilepsy
• Signs and symptoms
– Vary according to seizure type
• Convulsive seizures
– Tonic phase, clonic phase, postictal state
– Abrupt onset preceded by aura; dizziness, visual
images, nausea, headache, or abdominal discomfort
– Status epilepticus: series of convulsions, typically caused
by withdrawal of anticonvulsants
• Nonconvulsive seizures
– Could be lapse in consciousness, loss of muscle tone,
distorted sensations, automatisms
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Epilepsy
• Treatment and nursing care
– First aid for a convulsive seizure includes protecting
the child from harm, loosening clothing around the
neck, turning on the side to maintain an airway,
reassuring the child when consciousness returns
– Seizure precautions in the hospital setting include
padding side rails and having oropharyngeal suction,
oxygen, and an oral airway at the bedside
– Anticonvulsants
– A ketogenic diet is sometimes prescribed for children
who do not respond well to anticonvulsant therapy
– Surgery considered with intractable seizures not
responding to medication
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Reye’s Syndrome
• Description
– A pediatric disease characterized by a nonspecific
encephalopathy with fatty degeneration of the viscera
and altered ammonia metabolism
– Triggered by a virus, particularly influenza or varicella
• Signs and symptoms
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Typically recovering from URI or chickenpox
Recuperation interrupted by general malaise
Sudden onset of persistent vomiting and lethargy
Diagnosis based on history, symptoms, laboratory
data
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Reye’s Syndrome
• Treatment and nursing care
– Admission to ICU
– Medications include osmotic diruetics,
sedatives, barbiturates
– Fluid management in conjunction with
treatment of increased intracranial pressure
(ICP) is crucial
– Nursing care similar to increased ICP with
greater awareness of respiratory status
– Most survivors recover completely
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Near-Drowning
• Signs and symptoms
– Prognosis affected by length of submersion,
physiologic response, exposure to hypothermia
– Hypoxia is the primary problem
– Pulmonary edema, pneumonia
• Treatment and nursing care
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–
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On-site CPR
Immediate transportation to a trauma facility
Intensive pulmonary care
Risk of cerebral edema and anoxia
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Question 13.3
Which of the following is an example of a
nonconvulsive seizure?
A. Automatism
B. Status epilepticus
C. Aura
D. Both A & B
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Sensory Disorders
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Ears
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Deafness
• Description
– Hearing loss falls into two major categories
• Sensorineural hearing loss results from damage to
the structures of the inner ear or auditory nerve
• Conductive hearing loss occurs due to an
interruption in the transmission of sound waves
(from structural problems) from the external or
middle ear
– Some children have mixed hearing loss,
which combines conductive and sensorineural
causes
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Deafness
• Signs and symptoms
– Infant does not startle with sudden loud sounds
– Infant does not turn his or her head toward a
sound by 3 or 4 months
– Infant does not begin babbling by 6 months of
age
– Infant does not respond by reacting to music
around 8 months of age
– Infant does not attempt to speak syllables such
as “da” by around age 1 year
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Deafness
• Treatment and nursing care
– The auditory brainstem response (ABR) and
the otoacoustic emissions (OAE) provide
identification of infants with hearing losses
– Audiometry—the measurement of hearing
with an audiometer
– Tympanogram—measures the movement of
the eardrum in response to sound waves
– Nurses should stress the importance of
placing NO objects into the ear canal
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Deafness
• Treatment and nursing care (continued)
– Lip reading, sign language, writing, closed
captioning (on television), computers, visual
aids, music, and amplified sound are some
means of communication
– Flashing lights on the telephone and doorbell,
hearing aide dogs, and telecommunications
devices can facilitate communication
– Hearing aids and cochlear implants can boost
hearing
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Eyes
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Amblyopia
• Description
– A decrease in or loss of vision, usually in one eye
– The vision loss is not caused by structural eye
damage but results from the brain “turning off”
confusing visual images
• Signs and symptoms
– An observant parent might notice that the child sits
closer to the television or appears to have difficulty
seeing
• Treatment and nursing care
– Glasses for significant refractive errors (hyperopia,
myopia) and occlusion of the unaffected eye are
used
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Strabismus
• Description
– Ocular misalignment; a condition in which the
child is not able to direct both eyes toward the
same object
– Most children with strabismus have esotropia,
or an inward deviation of one or both eyes;
some children have exotropia, which is
outward turning
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Strabismus
• Signs and symptoms
– Malalignment during the uncover/cover tests
• Uncover test: Eye is covered, child looks at a light
source; a quickly uncovered eye should not move
• Cover test: one eye is covered, movement of the other
is observed while looking at a distant object
• Treatment and nursing care
– Eye exercises and glasses
– Occlusion therapy
– Surgery is reserved for patients in whom
nonsurgical methods are likely to be unsuccessful
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Question 13.4
_____ measures the movement of the
eardrum in response to sound waves.
A. Audiometry
B. Tympanography
C. Otoscopy
D. None of the above
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