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Common Neurological Disorders in Children Hydrocephalus Neural Tubes Defects Bacterial Meningitis Guillain-Barre Syndrome Reye’s Syndrome Seizures Hydrocephalus “Water on the Brain” Imbalance between the production and absorption of CSF. Often from congenital CNS malformations Results in rapid head enlargement in infants Can lead to irreversible neurological damage Hydrocephalus Symptoms in the infant Early Signs Projectile vomiting not associated with feeding Scalp veins become prominent Shrill, high pitched cry Increasing irritability Late Signs Bulging anterior fontanel Head circumference that increases at an abnormal rate Enlargement of the forehead Depressed eyes rotated downward “sunset eyes” (pupils sink downward) Symptoms in the Child No enlargement of head (skull is closed) Begins with generalized neuro symptoms HA in morning Nausea Vomiting Followed by signs of increased ICP Relief of hydrocephalus Create a new pathway to divert excess CSF. A catheter or shunt is placed in the ventricle and passes the CSF to the peritoneal cavity Needs to be replaced PRN Post-op Nursing Care Shunt Placement Keep child flat unless ICP is present the bed slightly elevated Slowly increase HOB over few days Support head when moving child Pain management Vital Signs Post-op Nursing Care Shunt Placement Observe for signs of increasing ICP – neurologic assessment Observe for abdominal distention Strict I & O Antibiotics Meticulous skin care Support family Discharge Management Post Shunt Placement Teach parents to monitor for shunt complications: Headache, progressive or worsening Drowsiness or inappropriate sleepiness during the day, irritability Nausea, vomiting Personality changes or changes in school performance Fever Redness or swelling along the shunt tract Neural Tube Disorders Defects of closure of neural tube during fetal development Congenital (present at birth) Believed to be caused by genetic or environmental factors, but exact etiology is unknown Common in women with poor folic acid intake before and during pregnancy Neural Tube Disorders Types: Spina Bifida Occulta Cystica Meningocele Myelomeningocele Spina Bifida Most common CNS defect Caused by failure of neural tube to close at some point along spinal column Types: spina bifida occulta spina bifida cystica Spina Bifida Occulta Not visible externally Lamina fail to close but spinal cord does NOT herniate or protrude through the defect No motor or sensory defects Spina Bifida Cystica Meningocele External sac that contains meninges and CSF Protrudes through defect in vertebral column Meningocele Not associated with neurologic deficit – good prognosis Hydrocephalus may be an associated finding, or aggravated after repair Spina Bifida Cystica Myelomeningocele Same as above, but the spinal cord and meninges protrude through the defect in the bony rings of the spinal cord Contains nerves therefore the infant will have motor and sensory deficits below the lesion Myelomeningocele Visible at birth, most often in the lumbaosacral area Covered with a very fragile thin membrane/sac which can tear easily, allowing CSF to leak out Nursing Interventions Protect the sac from injury Keep free from infection Position: prone or side lying Cover sac with sterile, moist non-adherent dressing, sterile technique imperative Parents need emotional support & education regarding short and long term needs of infant Nursing Interventions Surgical repair usually within first 24 hours observe for early signs of infection: elevated temp, irritability, lethargy, nuchal rigidity observe for signs of increasing ICP (may indicate hydrocephalus) Habilitation Emphasizes constructive use of ‘normal’ parts of body & minimizes the disabilities making the child as self-helpful as is possible in the activities of daily living Major problems: incontinence, constipation, obesity or malnutrition Meningitis Acute inflammation of the cerebral meninges as a result of a bacterial or viral infection Bacterial Meningitis Haemophilus influenzae type b was the most common cause of bacterial meningitis in children prior to the use of the Hib conjugate vaccine Still may be caused by Strep pneumoniae in child < 24months as not fully vaccinated with PCV vaccine Meningococcal predominantly in unvaccinated school-age children & adolescents Symptoms Abrupt onset of fever Chills Increasing irritability Headache Nuchal Rigidity Poor feeding Weak Cry Bulging fontanel Opisthotonic position Symtoms Kerning’s Sign Brudzinski’s Sign Nursing Management Lumbar puncture Administer IV antibiotics Respiratory isolation Promote hydration- monitor I + O Frequently assess vital signs, LOC, neurologic assessment to identify changes in the child’s condition Measure head circumference frequently- risk for hydrocephalus Prepare for seizures Nursing Management Promote comfort • reduced stimulation (dim lights, quiet room) Side-lying position Identify parents’ concerns, provide support Prevention is a major role for nurses Encourage parents to get their infants and children fully immunized! Complications Life Threatening Condition If Survival Hearing loss Blindness Paresis Intellectual impairment Guillain-Barre Syndrome Immune-mediated disease of motor weakness that is often associated with viral or bacterial infection of respiratory or GI tract or vaccine administration Adults have increased susceptibility, can affect children usually ages 4-10 Inflammation of nerve fibers, impairs nerve conduction though demyleination Ascending paralysis from lower extremities Initial Symptoms Peripheral neuritis occurs several days after primary infection Muscle tenderness Tendon reflexes decreased or absent Paresthesia & cramps Proximal symmetric muscle weakness Urinary incontinence or retention Decreased swallowing & respiratory effortsmay lead to respiratory failure Treatment Wait for disease to stabilize Intravenous immune globulin IVIG Physical Therapy Rarely fatal, often residual paralysis Nursing Care Monitoring respiratory status Managing autonomic nervous system dysfunction Preventing complications associated with immobility Providing emotional support Teaching the parents how to care for the child after discharge Reye’s Syndrome A life threatening acute encephalitis Occurs after viral infection if given aspirin Education efforts has helped to reduce incidence (use Tylenol or Ibuprofen not ASA) Reye’s Syndrome Begins with mild viral infection that worsens w/i 2448 hours Lethargy Vomiting Followed by Agitation Anorexia Combativeness Confusion leading to stupor, coma, seizures, respiratory arrest Reye’s SyndromeNursing Care If Survival in PICU Monitor: Neurological status Respiratory effort Hypoglycemia Cerebral edema Seizures Involuntary contraction of muscle caused by abnormal electrical brain impulses They are episodic and abrupt Often triggered by environmental of physiological stimuli Exact location of the electrical foci and the number of brain cells involved determines the nature of the seizure (sterotypical) Some seizures in children are acute, not believed to re-occur Re-ocurring seizures will be diagnosed as epilepsy Seizures: 2 categories Partial Simple Complex Only 1 area of brain involved Symptoms are associated with the area affected No LOC or consciousness is impaired Generalized Infantile spasms Febrile Absence Tonic Clonic Entire brain Usually have loss of consciousness May have aura Postical State Seizure Terms Aura sensation experienced before the seizure activity it often manifests as the perception of a strange light, an unpleasant smell or confusing thoughts or experiences Postictal altered state of consciousness that a person enters after the seizure, lasts between 5 and 30 minutes emergence from this period is often accompanied by amnesia or other memory defects Simple Partial Seizures Complex Partial Seizures Simple Partial Seizures • Seizure is short, lasts < 30 seconds • No loss of consciousness, aura, or postical state Seizure Activity is either: Abnormal motor activity • One extremity or part of extremity, uncontrolled movement Abnormal sensory activity Numbness, tingling, paresthesia or pain starting in 1 area of body, may spread to other parts of body May include abnormal auditory, olfactory and visual sensations Complex Partial Seizures Seizure is longer, 30 seconds-5 minutes Consciousness is impaired immediately May have slight aura Seizure Activity Sudden change in posture Abnormal motor activity, twitching, loss of tone, tingling or numbness Automatisms-lip smacking, chewing, sucking Circumoral pallor Afterward: drowsiness Infantile spasms Absence Tonic Clonic Febrile Infantile Spasms Age: 4 months to 2 years Occur in clusters 5-150/day, worse at night Altered consciousness Abrupt flexion/extension of neck, trunk, extremities Eye rolling May have permanent cognitive & developmental delays Absence Seizure Lasts 5-10 seconds, multiple times a day 50-100 per day Seizure is a brief loss of consciousness Appears to look like a staring spell Rhythmic blinking & twitching of mouth or arm Mistaken for daydreaming or behavior problems Interferes with learning 1/3 of children will grow out of them by adolescence Tonic Clonic 4 stages of Seizure 1. Prodromal: Drowsiness, dizziness, malaise, lack of coordination, “not himself” 2. Aura May precede seizure, reflects portion of brain where seizure originates Tonic-clonic stage 3. Tonic-Clonic Tonic: 20 seconds, all muscles cx (rigid), child falls to ground, LOC, respiratory muscles affected, grunting, airway compromised Clonic: 20-30 seconds, jerky muscle contract & relax rapidly, froth or bloody sputum, urinary or bowel incontinence 4. Postictal Appears to relax, semi-conscious, sound sleep for hrs, no recollection of event Acute Febrile Seizure Due to increased temperature > 102 F (but may occur as low as 100 F) Higher fever=higher risk Occur between 6 months and 5 years, with a peak incidence between 18 and 24 months of age Tonic-clonic pattern Lasts 15-20 seconds Epilepsy Chronic disorder with recurrent seizures in children 3 and older Symptoms depend on type of seizure No association with illness, injury Seizure may be triggered by something Epilepsy Management Anticonvulsants-monotherapy is desired Dosage increased as child grows Control the seizures or reduce their frequency Discover and correct the cause when possible, know triggers Help child live a normal life Epilepsy Management Instruct parents on importance of giving meds to achieve therapeutic drug levels Med can be withdrawn when child is seizure free for 2 yrs with normal EEG TAPER! Gradually decreased over 1-2 weeks Triggers Changes in dark-light patterns Sudden loud noises, specific voices Sudden or startling movements Extreme changes in temperature Dehydration, fatigue Hyperventilation Hypoglycemia Caffeine, insufficient protein in diet If A Patient is Admitted for Seizure Activity or has PMH of Seizures Ensure IV access and Patency Check MD orders for Seizure Medication Check that medication is on the Unit Check Suction at bedside, ambu bag, mask and 02 tubing, SaO2 is available and working! Are Side Rails Padded? ID band- correct? Indicate Seizure Risk? Know how to initiate emergency or rapid response Nursing Management during Seizures 1. Maintain Patent Airway Place nothing in the child’s mouth during a seizure Loose teeth may be knocked out and aspirated. Position side so secretions can drain Pulse oximetry reading (SpO2) Oxygen for < 95%- use mask Suction prn Nursing Management during Seizures Ensure Safety • If OOB gently assist to floor • Bed in lowest position • Stay near child • Protect head from injury Nursing Management during Seizures Administer Mediation Initial order is intravenous medications IV push slowly Benzodiazopene IV push slowly to avoid apnea Diazepam (Valium) or lorazepam (Ativan) Followed by anticonvulsant Nursing Management during Seizures Observe and Record Type of seizure activity Vital Signs Time seizure started and stopped Dilantin Toxicity: nystagmus, ataxia, decresed mental capacity Low levels: seizure activity Side Effects gingival hyperplagia (discuss oral hygiene), drowsiness, thrombpcytopenia, leukopenia, increased liver enzymes Nursing responsibility: Monitor CBC, LFT, therapeutic drug levels A 10-year old is diagnosis is Guillain-Barre Syndrome. It would be imperative for the nurse to inform the physician after observing which of the following? 1. 2. 3. 4. Weak muscle tone in the feet Weak muscle tone in the legs Increasing hoarseness and cough Tingling in the hands A 4-year-old is being evaluated for hydrocephalus. The nurse notes which of the following as an early sign of hydrocephalus in a child? 1. 2. 3. 4. Bulging fontanels Rapid enlargement of the head Shrill, high-pitched cry Early morning headache A child with a history of a seizure was admitted 2 hours ago. The history indicates fever, chills, and vomiting for the past 3-4 hours. In report the nurse is told that the child had a positive Brudzinski’s sign. The nurse infers this is most likely caused by: 1. 2. 3. 4. Increased intracranial pressure Meningeal irritation Encephalitis Intraventricular hemorrhage A nurse is assessing a new admission. The 6-month-old infant displays irritability, bulging fontanels, and setting-sun eyes. The nurse would suspect: 1. 2. 3. 4. Hydrocephelus Hypertension Skull fracture Myelomeningocele An 8-year-old client with a ventriculoperitoneal shunt was admitted for shunt malfunction. He presents with symptoms of increased intracranial pressure. The mechanism of the development of his symptoms is most probably related to: 1. 2. 3. 4. Increased flow of CSF Increased reabsorption of CSF Obstructed flow of CSF Decreased production of CSF The nurse is taking a history of a child admitted for EEG testing to determine seizure activity. The parent reports that the child has “odd” behavior, including periods of lip smacking, and muscle twitching. The nurse suspects: 1. Simple Partial Seizures 2. Complex Partial Seizures 3. Absence Seizures 4. Tonic-Clonic Seizures
