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Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 29
Caring for the Child with a
Neurological or Sensory Condition
A & P Review
 Nervous system
 Central nervous system
 Brain and spinal cord
 Peripheral nervous system
 Sensory-somatic
 Autonomic
Altered States of Consciousness
 Arousal or level of consciousness:
awareness of the environment
 Content of thought: all cognitive functions
that ensure awareness of affective states,
self, and environment
The Unconscious Child
 Unconsciousness is a state in which a
child’s cerebral function is depressed and
ranges from stupor to coma
Caring for the Unconscious Child
 Evaluating neurological status
 The pediatric Glascow Coma Scale
 Eye opening, verbal response, and motor
response
Caring for the Unconscious Child
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Monitor vital signs
Manage the airway
Manage bladder and bowel elimination
Maintain hydration & nutrition
Provide proper hygiene
Position and perform exercise
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
Increased Intracranial Pressure
 Intracranial pressure (ICP) is the pressure of the
cerebral spinal fluid (CSF) in the subarachnoid
space between the skull and the brain. A child
can have increased ICP as a result of many
internal or external factors.
 Signs and symptoms
 See Table 29-2
Increased Intracranial Pressure
 Nursing care
 Close monitoring (neurologic status)
 Maintenance of a patent airway
 Monitor vital signs closely (hyperthermia)
 Administer IV fluids
 Monitor fluid balance (I & O)
 Protect child from injury
 Administer antiseizure medications
 Provide emotional support
 Administer medications to decrease cerebral edema
 Analgesia and sedation
 A craniotomy is recommended when all other measures have been
unsuccessful
Seizure Disorders
 Signs and symptoms
 See Table 29-3
 Nursing care
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Complete a detailed history
Ensure airway management
Maintain anticonvulsant therapy
Implement seizure precautions (padded side rails, oxygen, suction
equipment, IV access, and anticonvulsant medications)
Provide continuous cardiac, respiratory, and oxygen monitoring
Instruct caregivers instructed in CPR
Keep school nurses and teachers informed about the condition
Encourage medical alert identification bracelet
Inflammatory Neurological
Conditions
Meningitis
 Signs and symptoms
 Mildly ill with general vague or subtle symptoms (lethargy,
malaise, irritability, vomiting, fever, and diarrhea)
 Kernig and/or Brudzinski sign
 Nursing care
 Assess neurological status, anterior fontanel in infants, and
seizure activity
 Provide comfort care
 Educate family and child about disease and treatment options
 Explain long-term parenteral access and IV antibiotics
Encephalitis
 Signs and symptoms
 Disorientation, confusion,
headache, high fever,
photophobia, lethargy, aphasia,
hallucinations, seizures, nuchal
rigidity, and coma
 Nursing care
 Viral is treated with antiviral
medication
 Bacterial is treated with a narrowspectrum antibiotic
 Other medications include
antipyretics, anticonvulsants,
analgesics, and anti-inflammatories
 Provide intravenous fluids and
nutrition
 Implement seizure precautions
 Monitor fluid & balance
 Do not suction or give percussion
Brain Abscess
 Signs and symptoms
 Localized headache, fever, drowsiness, stupor, confusion,
general or focal seizures, focal motor or sensory impairments,
ataxia, nausea and vomiting, papilledema, and hemiparesis
 Nursing care
 Assess neurological status, assess response to treatment,
administer medications, and provide supportive care
 Monitor serum labs
 Surgery required if no response to antimicrobial therapy
(postoperative care) or does not meet criteria for medical therapy
Reye Syndrome
 Signs and symptoms
 Lethargy, vomiting, drowsiness, liver dysfunction
 Nursing care
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Conduct neurological assessment
Administer IV fluids
Administer corticosteroids and/or diuretics
Monitor oxygen saturation (supplemental oxygen)
Insert arterial line (blood gases)
Take seizure precautions
Limit invasive procedures
Provide emotional support
Guillain-Barré Syndrome
 Signs and symptoms
 Three phases: acute, second, recovery
 Nursing care
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Plasma exchange and IV immunoglobulin therapy
Give corticosteroids
Monitor progression
Insert indwelling urinary catheter
Assess pain level
Prevent contractures and loss of function (passive ROM)
Provide skin care
Suggest age-appropriate activities
Developmental Neurological
Conditions
Spina Bifida
Neural tube defects (NTDs)
 Signs and symptoms
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Vary depending on the level of the lesion and defect
Spina bifida occulta
Meningocele
Myelomeningocele
 Types
 Meningocele
 Myelomeningocele
 Spina bifida occulta
Spina Bifida
 Nursing care
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Place newborn in prone position (prevent injury to sack)
Provide postoperative care for laminectomy & closure of defect
Evaluate orthopedic function
Prevent joint contractures
Assess bladder and bowel function
Provide skin care
Assess neurological status
Measure head circumference and assess fontanel
Manage pain
Hydrocephalus
 Signs and symptoms
 Increased ICP
 Macewen sign
 Nursing care
 Understand shunt function and complications
 Obtain history and physical (life-threatening conditions)
 Discuss pharmacological measures or surgical procedure
 Perform nursing actions related to ICP
 Measure head circumference
 Give preoperative and postoperative antibiotics
 Assess neurological status
 Assess for shunt malfunction (eye assessment)
 Assess abdominal status (pain, bowel sounds, and circumference)
 Elevate HOB 30°
Cerebral Palsy
 Signs and symptoms
 Vary individually depending on the area of the brain
involved and the extent of damage
 Four categories
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Spastic
Ataxic
Athetoid or dyskinetic
Mixed
Cerebral Palsy
 Nursing care
 Use splints and braces
 Promote self-care
 Administer medications (reduce muscle spasms, spasticity,
anxiety, and seizure)
 Surgery (selective dorsal rhizotomy)
 Address feeding problems
 Provide intellectual stimulation
 Ensure safe environment
Neurological Injuries
Near Drowning
(Submersion)
 Signs and symptoms
 Cerebral edema, alteration in LOC, respiratory distress,
cardiovascular complications, hypovolema
 Nursing care
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Assess and maintain airway
Provide life support measures
Suction secretions
Insert NG tube
Administer oxygen
Assess other injures (head or spinal trauma)
Head Injury
Traumatic Brain Injury (TBI)
 Signs and symptoms
 Obvious signs: blood on the scalp, depression of the skull, and an
obvious penetrating wound
 Other signs and symptoms: loss of consciousness, alteration LOC,
seizures and combativeness
 Nursing care
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Provide immediate care to prevent life-threatening complications
Maintain airway patency and oxygen administration
Insert IV and administer hypertonic fluid
Assess neurological status
Assess ICP
Shaken Baby Syndrome
 Signs and symptoms
 Seizure activity, apnea, budging fontanels, coma, hemorrhage,
bradycardia & cardiovascular collapse
 Nursing care
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Provide respiratory and cardiovascular support
Assess for ICP
Insert NG tube
Maintain seizure precautions
Maintain adequate fluid and nutritional intake
Assess and document visible injuries
Discuss short- or long-term care
Assess parental concerns
Spinal Cord Injury
 Signs and symptoms
 Numbness, tingling, or loss of function
 Nursing care
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Maintain airway management and respiratory function
Provide cardiovascular and circulatory support
Give steroid therapy
Monitor fluid intake and output
Maintain gastrointestinal function
Provide nutritional support
Provide emotional and social support
Be attuned to an adolescent’s unique needs
Explain lifelong care and support, circulation support, disability identification,
and exposure of known and unknown physical limitations
Nontraumatic Neurological
Conditions
Headaches
 Types
 Primary headaches
 Secondary headaches
 Tension
 Migraine
 Cluster
Headaches
 Signs and symptoms
 Primary (triggers — i.e., stress)
 Secondary (organic disorder — i.e., trauma)
 Subtypes (tension, migraine, cluster)
 Nursing care
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Provide pharmacologic and nonpharmacologic care
Discuss prophylactic measures
Give intramuscular or intranasal medications
Promote rest and stress reduction strategies
Sensory Conditions
Eye Disorders
 Hyperopia (farsightedness)
 Myopia (nearsightedness)
 Correction
 Concave lenses or contact lenses
 Laser assisted surgery
Astigmatism
 Irregular curvature or uneven contour of
the eye
 Correction
 Corrective lenses
 Surgery
 Complaints of headache, blurry vision, or
dizziness; ophthalmologist referral
Amblyopia
 Signs and symptoms
 Strabismus or anisometropia are the most
common causes
 Correction
 Occlusion therapy (patching of the normal
eye) is done to restore strength and function
of the “lazy eye”
Strabismus
 Nonparallelism in the different fields of
gaze causing visual lines to cross even
when focused on the same object
 Correction
 Ocular patching of the stronger eye, glasses,
and pharmacotherapy
 Early identification and recognition
Color Blindness
 X-linked recessive inheritable color vision
deficiency
 Color blindness is detected using colored charts
called the Ishihara Test plates
 Child can learn to compensate with support from
family members, teachers, and friends
Nystagmus
 Rapid irregular involuntary eye movement
caused by a disorder of the central
nervous system
 Correction
 Extraocular surgery
Cataracts
 Signs and symptoms
 Excessive tearing, extraocular movements, photophobia, lens appears
cloudy, or there is a white or dulled red reflex
 Correction
 Prevent loss of visual acuity
 Laser procedure
 Postoperative (monitor nausea, emesis, pain, hemorrhage and signs of
infection)
 Postoperative eye drops
 Follow-up care for visual acuity
 Educate family
 Early identification and recognition
Glaucoma
 Signs and symptoms
 Bupthalmos (enlarged eye globe), epiphora
(excessive tearing), and photophobia (sensitivity to
light)
 Correction
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Preoperative maintain quiet environment
Antiglaucoma medications
Analgesia and anxiety reduction strategies
Pre- and postoperative care (teach parents)
Retinoblastoma
 Signs and symptoms
 Absence or abnormality of the red reflex
 A whitish or yellow color of the pupil called
leukocoria
 Correction
 Laser, radiation, cryotherapy, or enucleation
Eye Injuries
Foreign Bodies
 Penetration
 Immediate transport to ER for removal
 Corneal abrasion
 Treatment
 Topical antibiotic solutions or ointments,
analgesics, eye patch
Hyphema
 Hemorrhage into the anterior chamber of the
eye
 Treatment
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Rest, possible evacuation
Monitor increased intraocular pressure
Promote decreased activity
HOB 30°
Patch both eyes
Chemical burns
 Usually occur as a result of an accident
 Treatment
 Rapid eye flushing for 15 to 30 minutes
followed by pH analysis of the chemical agent
 Eye patching
Hearing Loss
Hearing Loss
 Causes
 1/3 of all cases are due to genetic causes
 1/3 of all cases are due to non-genetic
influences
 1/3 of all cases are due to unknown causes
Hearing Loss
 Diagnostic testing
 Universal infant hearing screening before 1 month of age is
recommended
 Treatment
 Based on underlying pathologic conditions, presence of organic
diseases, the severity of hearing loss, the degree of frequency
loss, and any CNS abnormalities
 Amplification aids (hearing aid)
 Nursing care
 Provide emotional, educational, and collaborative support for the
child and family
Language Disorders
 Communication
 A process of complex interaction involving the
exchange of information, feelings, ideas, and
interactions
 Receptive language
 Expressive language
 Nursing care
 Recognize speech and language developmental
delays