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CARE OF THE PEDIATRIC
PATIENT WITH COGNITION OR
PERCEPTION PROBLEMS
Elizabeth Allen RN, MSN
LEARNING OBJECTIVES
Describe the neurologic anatomic and physiologic
differences between infants and children and
adults
 Identify aspects of the pediatric neurologic
assessment including Glasgow Coma Scale and
signs of meningitis
 Identify and create a treatment plan for pediatric
neurologic infectious diseases
 Compare pediatric traumatic brain injuries for
different age groups
 Describe pediatric pain management

ANATOMIC DIFFERENCES

Brain & spinal cord



Cranial Nerves



Head to toe
Cranial bones


Present, must mature
Myelination


Intact from birth
Reflexes


Large head
Brain growth
Not complete
Head vs. chest size
Blood brain barrier
NEUROLOGICAL DEVELOPMENT
Neurological system of the infant is incompletely
developed.
 First year the neurons become myelinated.
 Myelinization occurs in a cephalocaudal and
proximodistal manner.

NEUROLOGIC ASSESSMENT
Cerebellar
Noting
Functioning
milestones
Fine and gross motor skill

Behavioral
assessment
Waking activity
Responses to environment
Social interaction

Cranial
nerves
Motor system
Head control
Reflexes
Primitive reflexes
Stepping
Tonic-Neck
Moro/Startle
Sucking

NEUROLOGIC ASSESSMENT
Brudzinski’s sign
 Kernig’s sign
 Nuchal rigidity - neck
 Photophobia
 ICP
 LOC
 Glasgow Coma Scale

Glasgow Coma
Scale
Including Pediatric
Assessment
INCREASED INTRACRANIAL PRESSURE


Increased ICP creates
decreased CPP
(Cerebral Perfusion
Pressure)
Causes





Head injury
Bleeding
Space occupying lesion
Infection
Hydrocephalus

Infant Signs & Symptoms
Fontanels (bulging)
 Sutures (widened)
 Scalp veins (dilated)
 Sunset eyes


Older child Signs &
Symptoms





Normal ICP < 20 mmHg


Headache
Nausea, vomiting
Decreased LOC, irritability
Pupil changes
Sunset eyes
Posturing
Cushing’s Triad (Late sign)
AMBLYOPIA
Amblyopia: Reduced
vision in 1 or both
eyes
 From visual
deprivation of eye
 Most often from
strabismus
 Visual assessment
and correction by age
6 years

Strabismus
NEUROLOGIC INFECTIOUS DISEASES
Bacterial Meningitis

Infant Signs &
Symptoms
Poor
feeding/suck
Vomiting
High-pitched cry
Bulging fontanel
Fever or hypothermia
Poor muscle tone
Bacterial Meningitis

Child & Adolescent Signs
& Symptoms
Abrupt onset
Fever & chills
HA
Nuchal rigidity
Vomiting
Irritability
Seizures
Photophobia/alterations
in sensorium
BACTERIAL MENINGITIS
 Nursing
Interventions
Droplet Isolation!
 Maintain patent airway, ventilation support prn
 Post-LP care
 Assessment


Increased ICP
Nutrition
 Pain control
 Monitor IV antibiotic therapy
 Monitor for complications- seizures, immobility

VIRAL MENINGITIS (ASEPTIC MENINGITIS)

Infant and Toddler
Signs & Symptoms
Irritability
Lethargy
Vomiting
Change in appetite

Children & Adolescent
Signs & Symptoms
Preceded by nonspecific
febrile illness
HA
Malaise
Muscle aches
N&V
Photophobia
Nuchal/spinal rigidity
VIRAL MENINGITIS
 Treated
symptomatically
 Hospitalized?
 Decease stimulation
 Hydration
 Comfort measures
NEUROLOGIC INFECTIOUS DISEASES
 Reye
Syndrome
Usually develops after mild viral illness
 Strongly associated with Aspirin (salicylates) use
in viral infections
 Acute encephalopathy and fatty infiltration of the
liver and other organs
 Poor liver function
 Hypoglycemia
 Prolonged Prothrombin time
 Developmental and neurologic deficits may occur

REYE SYNDROME
 Stages
Progress with decreasing LOC
1.
Vomiting and drowsiness, listlessness
2.
Personality changes: irritable, aggressive
3.
Disorientation: confusion, irrational, combative
4.
Delirium, seizures, coma, loss of deep tendon
reflexes, respiratory arrest
 Symptoms of Reye Syndrome in infants do not
follow a typical pattern
 Symptoms appear most commonly after a viral
illness

(National Reye Syndrome Foundation, 2013)
REYE SYNDROME
 Signs
& Symptoms
Abrupt change in LOC
 Vomiting
 Liver enzymes, ammonia levels elevated
 Blood sugars low
 PT prolonged
 Bilirubin remains normal
 Liver biopsy shows small fat deposits

REYE SYNDROME
 Nursing
Interventions
Monitor
ICP
Fluid restrictions
Neurological
assessments
Monitor lab values
Ammonia
Glucose
Blood gases

Provide
emotional
support
Medications
Vitamin
K
Phenytoin
Corticosteroids
Family
education
ACCIDENTS & HEAD INJURIES
Shaken baby syndrome
 Head trauma

Falls
 Child abuse
 MVA


Near-Drowning
SHAKEN BABY SYNDROME
Pathophysiology – central nervous system injury
from repeated coup and contra-coup injury
 Symptoms
 blindness or eye damage





delay in normal development
seizures
damage to the spinal cord



Retinal hemorrhage
paralysis
brain damage
death
SHAKEN BABY SYNDROME
Maintain cardiopulmonary function
 Prevent complications- Secondary Brain Injury
 Promote recovery


Maximize developmental function
Provide emotional support
 Role of Social Work
 Discharge planning and home care teaching
 Resources

HEAD INJURY
Mild to Severe
 Highest rate of death in adolescents 15-19 years,
then <5 years
 Side effects of trauma = cerebral edema &
increased ICP
 Major cause falls
 Child abuse, shaken baby syndrome <1yr.
 Other causes




MVA
Bicycle, skateboard, snowboard, skiing
Alcohol or drug-related MVAs, sports injuries in
teens
HEAD INJURY
Primary Brain Injury
Develop
at time
of trauma
Direct blow
Inc. ICP
Apnea
Loss of
consciousness
Secondary Brain Injury
Results
as
response to injury
Few hours to
weeks post injury
Inc. ICP can
result in
irreversible brain
damage by
decreased CPP
(cerebral perfusion
pressure)
HEAD INJURY
 Nursing
Interventions
Assessment
 Seizure precautions
 Decrease environment stimulus
 Coordinate rehabilitation
 Coordinate resource services
 Administer meds as ordered



Corticosteroids
Seizure medications
Fosphenytoin
 Phenobarbital


Child and Family Education
OTHER HEAD INJURIES
Skull fractures
 Contusion
 Concussion


http://www.cdc.gov/headsup/basics/index.html
Subdural hematoma
 Epidural hematoma

SEIZURE DISORDER
Most are idiopathic
 Genetic factors- associated with syndromes
 Head injury
 Stroke/cerebrovascular disorders
 Metabolic disturbances






Electrolyte
Hypoglycemia
Renal failure
Hepatic failure
Hypoxia
SEIZURE DISORDER
Chronic disorder characterized by recurrent
seizures, result of underlying brain abnormality
 Intractable seizures
 Can suffer from poor self-esteem, academic
failure, poor social relationships
 Anti-epileptic Drugs
 For some surgery may be an option to control
seizures
 Prolonged, uncontrolled seizures often result in
developmental delays, neurological damage

SEIZURE DISORDER
Priority Nursing
Diagnoses
Risk for aspiration
 Risk for injury r/t type
of seizure and possible
loss of consciousness
 Altered family
processes r/t having
child with chronic
illness

Nursing Interventions




Keep calm
A = Airway
Safety
Seizure Medications
Benzodiazepine (lorazepam,
intranasal midazolam)
 Phenobarbital
 Tegretol




Assessment
Provide emotional support
for patient/family
Resource information and
F/U
CONGENITAL NEUROLOGIC PROBLEMS

Neural tube defects
Spina bifida occulta
 Meningocele
 Myelomeningocele

Hydrocephalus
 Cerebral Palsy

SPINA BIFIDA
Congenital neural tube defect affects head and
spinal column
 Approximately 1500 births in US per year
 Higher the defect the greater the neurologic
dysfunction
 Cause unknown (possibly chemicals, medications,
maternal low folic acid levels, genetic)

SPINA BIFIDA
Pre Op Nursing Care
Sac care
 Position
 Assess motor function
 Assess bowel and
bladder function
 Nutrition/Hydration

Post Op Nursing Care
Monitor VS
 Assess

Infection
 CSF Leak
 ICP

Positions
 Pain management
 Education

SPINA BIFIDA
 Associated



Musculoskeletal

Talipes (clubfoot), dislocated hip, scoliosis, kyphosis

neurogenic bladder, hydronephrosis, renal damage, UTI,
incontinence
Genitourinary
Gastrointestinal



Hydrocephalus
cognitive deficit, visual perceptual problems, sensory
dysfunction, paralysis, muscle weakness, feeding
difficulties, swallowing problems, sleep apnea
Integumentary


constipation, impaction, incontinence
Neurologic



Problems
Skin breakdown related to immobility, incontinence
Psychosocial
Latex sensitivity/ allergy
SPINA BIFIDA
 Nursing
Interventions
Assistance with bowel and bladder function
 Promote Mobility
 Maintain skin integrity


Positioning & turning
Provide emotional support
 Resources
 Child and Family Education

HYDROCEPHALUS
Imbalance between production and absorption of
CSF
 Most common congenital defect (50%)
 Etiology

Congenital
 Acquired from meningitis, trauma, hemorrhage in
premature infant
 Idiopathic (50%)


If untreated can cause permanent brain damage
related to increased ICP
HYDROCEPHALUS
Ventriculoperitoneal
Shunt
HYDROCEPHALUS
Signs & Symptoms

All Children




Vomiting
Lethargy
Cheyne-Stokes
respiratory pattern
Infant






Inc. head circumference
Split cranial sutures
High-pitched cry
Bulging fontanels
Irritability when awake
Seizures
Signs & Symptoms

Toddlers & Older
Children








Setting-sun eyes
Seizures
Irritability
Papilledema
Decreased LOC
Inc. B/P
HA
Difficulty with balance
& coordination
HYDROCEPHALUS
Priority Nursing
Diagnoses
Altered tissue
perfusion (cerebral)
 High risk for infection
 Risk for impaired skin
integrity r/t large size
of head and inability
to move

Nursing Care


Ventriculoperitoneal
Shunt
Provide post-op care

Assess






Infection
ICP
HOB?
Antibiotic therapy
Provide emotional
support
Child and Family
Education
CEREBRAL PALSY
Non-progressive motor and posture dysfunction
secondary to anoxic damage to motor centers in
fetal or infant brain( up to 2 yrs.)
 70% prenatal (fetal), 20% perinatal, 10% <2 years
 2- 2.5:1000
 Abnormal muscle tone and lack of coordination
 4 types: spastic, dyskinetic, ataxic & mixed
 Symptoms depend on area of brain involved

CEREBRAL PALSY

All infants that show developmental delays,
feeding difficulties, abnormal muscle tone should
be evaluated


Turn infant’s head to one side, persistent asymmetric
tonic neck reflex beyond 6 mo. Indicates pathologic
condition, if any primitive reflexes persist should
suspect CP
Other complications:

Intellectual disabilities, vision impairment, hearing
loss, delays in speech and language, seizures
CEREBRAL PALSY
Priority Nursing
Diagnoses






Impaired physical
mobility
Self-care deficit
Impaired verbal
communication
Altered nutrition: less
than body requirements
High risk for injury r/t
neuromuscular,
perceptual, or cognitive
impairments
Fatigue
Nursing Interventions








Provide adequate
nutrition
Maintain skin integrity
Promote physical
mobility
Developmental
progression
Safety
Emotional support
Team effort
Child and Family
Education
DEVELOPMENTAL DEFICITS
 Pervasive

Developmental Disorders
Autistic spectrum disorders
Asperger’s syndrome, Rett’s disorder, childhood
disintegrative disorder
 Approximately 1% of children, 1 in 100-150


Neurodevelopmental Disorder
Screening at well checks
 Early intervention

PERVASIVE DEVELOPMENTAL DISORDERS
 Priority
Nursing Diagnoses
Communication, verbal, impaired
 Social interaction, impaired
 Injury, risk for
 Caregiver role strain, risk for
 Coping, family, compromised

COGNITIVE DISORDERS
Learning
Disabilities

Alteration in information reception and processing

Not low IQ
Mental
Retardation
Intellectual functioning and adaptive behavior
 Congenital developmental disability



Low IQ
Trisomy 21 (Down Syndrome)
COGNITIVE DEFICITS
Expected Outcomes:
 Learning Disabilities



Will compensate through new strategies
Mental Retardation
Reach highest level of independence
 Encourage optimal family use of resources

COGNITIVE DEFICITS
Nursing Care:
 Language, Motor Delays = Risk for Learning
Disabilities



Refer for testing
Early Developmental Testing

Identify cognitive delays
Support Group Referral
 Help Families

Set goals: life and learning skills
 Promote self-esteem


Partner with Families

Plan health interventions together
PEDIATRIC PAIN MANAGEMENT
Non-pharmacological

Distraction

Play
Position
Heat/cold
Guided Imagery
Sucrose




Pharmacological

Non-narcotic
Acetaminophen
 Ibuprofen (>6 months)
 NO aspirin


Narcotic
Morphine
 Fentanyl
 Acetaminophen with
codeine
