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Neurological Disorders
in the Pediatric Patient
Presented by
Marlene Meador RN, MSN, CNE
Review of CNS of the
Pediatric Patient
 Head to torso ratio
 Cranial bones- thin, pliable, suture lines
not fused
 Brain vascularity and small
subarachnoid space
 Excessive spinal mobility
 Wedge shaped cartilaginous vertebral
bodies
Neurological Assessment:
 LOC & behavior
 Vital Signs and respiratory status
 Eyes
 Reflexes and motor function
 Cranial nerve function
(p 842 table 33-4)
page 1467 discuses Modified Glasgow Coma Scale for
ages 3 and younger ( p 1469, table 52-1)
Increased Intracranial PressureIICP or ICP (p 1468, Box 52-1)
Infants
 Irritability &
restlessness
 Fontanelles / FOC
 Poor
feeding/sucking
 Skull & scalp veins
 Nucal rigidity,
seizures (late signs)
Children
 Headache
 Vomiting
 Irritable, lethargic, mood
swings
 Ataxia, spasticity
 Nucal rigidity
 Deterioration in
cognitive ability
 Vital sign changes
Priority nursing diagnosis for a
child with IICP?
 What assessment findings should the
nurse monitor?
 What emergency equipment should the
nurse have on hand at all times for a
child with IICP?
Nursing interventions:
 What diagnostic procedures would the
nurse anticipate for this child?
 What priority interventions must the
nurse include with respect to these
diagnostic procedures?
 What
specific teaching is required?
 What additional lab/serum tests would you
anticipate?
Medications used to treat IICP:
Corticosteroids
 Anti-inflammatory
 Contraindications-acute
infections
 Monitor I&O
 Protect from infection
 Add K+ foods
 Discontinue gradually
 Osmotic diuretic
 Reduce fluid
 Contraindicationsintracranial bleeding
 Monitor I&O carefully
 Monitor electrolytes
 Teaching
Quick Review:
Priority nursing interventions/
rationale
 What equipment is essential?
 Vital signs & neuro signs
 Additional assessment findings
 Activity level
 Hydration status
 Positioning
 Parent teaching
Pediatric Seizures
International Classification of
Seizures ( p 1489 Box 52-5)
 Febrile- rapid temp rise above 39°C (102°F)
 Generalized- loss of consciousness, involves
both cerebral hemispheres onset at any age
 Tonic/Clonic- impaired consciousness,
abnormal motor activity, posturing,
automatisms
 Absence- may confuse with daydreaming or
inattentiveness
Diagnostic Tests:
 EEG
 CT, MRI
 Lumbar puncture
 CBC
 Metabolic screen for glucose,
phosphorus and lead levels
Nursing Interventions:
 Assessment findings
 Priority interventions
 Prevention
 During
seizure
 Following seizure
p 1490 Nursing Care Plan
Medications used to control
seizures in children
 Phenobarbital- CNS depressant- monitor:
sedation, VS, serum levels,

Teach- S&S of toxicity, no ETOH, adhere to
regime
 Carbamazepine- sedative/anticonvulsant
 hold med if lab values =
 Teach- S&S of toxicity
 Phenytoin- anticonvulsant
 Safety measures- on-hand equipment
 Teach- oral care, sun exposure
Quick Review:
 What is most important nursing
intervention when a child is
experiencing a seizure?
 What is most important teaching
regarding seizure medication?
Meningitis
Meningitis
Bacterial
 Potentially fatal; abx given
prophylactically if bacterial
suspected. May kill within
24 hrs
 C/S take 72 hrs to process
 Infants at greatest risk
 Nuchal rigidity
 Severe headaches
 Contagious






Viral
Same s/s but milder and
shorter duration
May follow a viral infection
May be accompanied by
rash
Nuchal rigidity
Ataxia
Not contagious
Meningitis:
 Why does bacterial meningitis present
more of a risk than viral meningitis?
(p. 1494)
 How do the manifestations of meningitis
differ between infants and young
children (p. 1494)
Meningitis:
Infant
 Fever (not always
present)
 Poor feeding
 Vomiting
 Irritability
 Seizures
 High-pitched cry








Child/Adolescent
Fever
Headache
Photophobia
Nuchal rigidity
Altered LOC
Anorexia/ vomiting
Diarrhea
Drowsiness
Lumbar Puncturenursing interventions
 What findings differentiate between
bacterial and viral meningitis?
 What specific interventions does the
nurse include for this procedure?
 Monitor
VS & neuro VS
 LOC
 Teaching
Nursing Care & Medications for
treatment of meningitis:
 Ceftriaxone Sodium (Rocephin®)- who
must receive this medication?
 Cefatoxime Sodium (Claforan ®) Dexamethasone- special nursing care
 Antipyretics
Clinical Judgment:

What intervention must the nurse
initiate to protect the patients and staff
when a diagnosis of bacterial meningitis
is suspected?
Hydrocephalus
Hydro= Water
Cephaly= of the head/brain
Hydrocephalus:
 What priority nursing assessment of a
newborn monitors for this condition?
 What assessment findings occur in the
older child?
 What diagnostic measures confirm this
diagnosis?
Diagnostic of Hydrocephaly:
 LP-dangerous
 MRI; CT scan
 Skull X-ray
 Measure FOC
 Provide for safety, informed consent, support
for child and family, accurate H&P
(added 2010)
Correction of Hydrocephaly:
 Shunt placement- surgical procedure to
place a tube that drains CSF into the
atrioventricular or peritoneal cavity.
 Atrioventricular- drains into atrium (not
used as frequently)
 Ventricular peritoneal- drains into the
peritoneal cavity
Nursing Care:
 Pre Operatively:
 Baseline VS, monitor for IICP,
 What teaching/interventions for parents?
 Post-op:
 Monitor shunt function (how?)
 Positioning and activity
 VS, neuro VS & I&O
 Teaching
Long Term Nursing Care for the child
with hydrocephaly
 Home care needs
 S&S of IICP
 S&S of infection
 S&S of seizures
 Emergency numbers of Pediatrician &
neurosurgeon
 Refer to home care, social services and
support groups
Spina Bifida
Spina Bifida
 Most common defect of the CNS
 Occurs when there is a failure of the
osseous spine to close around the
spinal column.
Spina Bifida: (see p 1470)
 What common nutritional supplement is encouraged
for all women of childbearing age?
 Discuss the 3 types of neural tube defects:
 Spina
bifida occult
 Meningocele
 Meningomyelocele
Spina Bifida
Clinical Manifestations
 Visualization of the defect
 Motor sensory, reflex and sphincter
abnormalities
 Flaccid paralysis of legs- absent
sensation and reflexes, or spasticity
 Malformation
 Abnormalities in bladder and bowel
function
Surgical Intervention
 Immediate surgical closure
 Prior to closure keep sac moist & sterile
 Maintain NB in prone position with legs
in abduction preoperatively
Nursing Interventions:
Pre-OP:
 Meticulous skin care
 Protect from feces or urine
 Keep in isolette
Post-Op Nursing Interventions
 Assess surgical site
 Monitor VS and neuro VS
 Institute latex precautions
 Encourage contact with parents/care
givers
 Positioning
 Skin Care
Nursing Interventions cont...
 Antibiotic therapy
 Prevent UTI
 Education
 Emphasize the normal, positive
abilities of the child
Priority nursing diagnosis and
interventions:
 At risk for infection Protect
 Position
 At risk for injury Protect
 Position
Cerebral Palsy
Nursing care of the child with
Cerebral palsy: (p.1477)
 Static Encephalopathy- spastic CP most
common type (80%)
 Nonspecific
term give to disorders
characterized by impaired movement and
posture
 Non-progressive
 Abnormal muscle tone and coordination
Assessment
 Jittery (easily startled)
 Weak cry (difficult to comfort)
 Experience difficulty with eating (muscle
control of tongue and swallow reflex)
 Uncoordinated or involuntary
movements (twitching and spasticity)
Assessment cont...
 Alterations in muscle tone
 Abnormal resistance
 Keeps legs extended or crossed
 Rigid and unbending
 Abnormal posture
 Scissoring and extension (legs feet in
plantar flexion)
 Persistent fetal position (>5 months)
Diagnostic Tests:
 EEG, CT, or MRI
 Electrolyte levels and metabolic workup
 Neurologic examination
 Developmental assessment
Complications of CP
 Increased incidence of respiratory
infection
 Muscle contractures
 Skin breakdown
 Injury
What is the priority nursing
goal for a patient with cerebral
palsy (CP)?
Head Injuries
Head injuries in the Pediatric
Client
 Anatomy predisposes infant/young to
injury
 Pathophysiology of “Shaken Baby
Syndrome”
Nursing care of child experiencing a
closed head injury: (p 1483)
 Assessment findings Immediate nursing interventions-
 Legal implications
 Why is it not prudent for the nurse to
discuss suspicions of abuse with the
parents or primary caregiver?
Autism
Autism
 Not clearly understood
 Characterized by impaired social,
communicative, and behavioral
development
 Usually noted in the first year of life
Pervasive Developmental Disorders /
Autism (p. 1549)
Home Setting
Acute Care Setting
 Reduce environmental
 Keep at least 1 constant




stimuli
Communicate via ageappropriate touch &
verbalization
Keep toys or other items out
of reach if child uses them
for harmful self-stimuli
Ritualistic ADLs
Encourage therapists &
support groups




caregiver. Encourage
parents to stay with,keep
room quiet & limit number of
staff
Anxiety/aggression when
touched by strangers
Constant monitoring by
nurse or parents
Allow to maintain rituals of
ADLs
Encourage therapists &
support groups
Downs Syndrome
Down syndrome
 Trisomy 21- the most common
chromosomal abnormality resulting in
mild to profound mental retardation
What are some of the identified
causes of Down syndrome?
 Failure of chromosomes to separate
 Advanced maternal age
 No other socio-economic or geographic
factors have been identified
Assessment
 Primary concern with cardiac and GI
anomalies
 What are the most obvious indications
of Down’s Syndrome in a newborn
Health Promotion
How does the nurse promote health of the child
with Down’s syndrome?
 Primary focus on the parents and care givers
to provide support and achieve a realistic
view of the child’s capabilities
 Support siblings
 Refer to family counseling services
 Support parents in feelings of guilt and
chronic sorrow
For questions or concerns
Contact Marlene Meador RN, MSN, CNE
Email: [email protected]