Islamic University Nursing College

NEUROLOGICAL DISORDERS

Neurologic System

Neurologic System Nervous system consists of

Brain Spinal cord Cranial and spinal nerves Cerebrospinal fluid

The Central Nervous System (brain & spinal cord)

The Peripheral Nervous System The Autonomic Nervous System Sensory-somatic Nervous System

Neurologic System

The brain is covered by three membranes. The dura mater is a fibrousconnective tissue

structure containing several blood vessels. The arachnoid membrane is a delicate serous

membrane The pia mater is a vascular membrane

The Peripheral Nervous System is composed of the cranial nerves and the spinal nerves

Neurologic System The spinal cord extends from the

medulla oblongata to the lower border of the first lumber vertebrae. It contains millions of nerve fibers, and it consists of cervical, thoracic, lumber, and sacral nerves

Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroids plexus of the pia mater. it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord.

Neurologic System : function

Consciousness, thought, emotions, memory, sensory input and motor activity

Regulates BP, Temp, breathing, digestion, cardiovascular function..etc

Coordination of muscle movements

Neurologic System :Cardinal signs & symptoms

Headache, fainting and dizziness abnormal gait, movements, or coordination developmental lags or loss of milestones Symptoms of increased ICP

Increased HC Bulging fontanels Headache for older children Confusion and altered mental status; A change in the

child’s normal behavior pattern may be an important early sign

Tachypnea (late sign): Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length

altered level of consciousness (LOC)

Neurologic System :Cardinal signs & symptoms

Altered level of consciousness (LOC)

Disoriented; lack of ability to recognize place or person.

Obtunded ; individual who sleeps unless aroused and once aroused has limited interaction with the environment.

lethargy; when a child awakens easily but exhibits limited responsiveness.

Stupor; requiring considerable stimulation to arouse the individual.

Neurologic System : Assessment

Prenatal, personal and family history Prenatal: maternal malnutrition, drug use,

alcohol use, and illness prematurity, perinatal hypoxia, birth trauma,

delayed developmental milestones, head injury, meningitis, chronic illness, child abuse, chromosomal anomalies and substance abuse.

Family: chromosomal anomalies, mental illness, neurologic disease, seizure disorders, mental retardation, learning problems, and neural tube defects

Neurologic System : Physical Exam

HC: (head circumference in children younger than 2 years)

Assess LOC, general appearance, behaviour, interactions, speech, behavioural changes

Assess development milestone Assess cranial nerve function Assess taste, olfaction, and tactile sense Observe abnormal movements such as

tremors, seizure activity

Neurologic System : Physical Exam

Assess gait, balance, coordination & Assess reflexes

Palpate the fontanels with infant upright position

Assess muscle tone and strength

Assess sensation and position sense

Assess deep tendon and superficial reflexes

Neurologic System :Lumber puncture

Position: The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture

Meningitis Meningitis is inflammation of protective

membranes that covering brain and spinal cord (meninges).

Meningitis may extends to the ventricles and the exudation (fibrin) obstruct the flow of CSF

Caused by: Virus Bacteria Other microorganism Drugs

Bacterial Meningitis The most common are group B

streptococci during the 1st 2 mo of life H. influenzae (type B) Meningococcal;

occurs most often in the 1st year of life tends to occur in epidemics among closed

populations Streptococcus pneumoniae

(pneumococci); the most common cause of meningitis in

adults people at risk: chronic otitis, sinusitis,

mastoiditis, CSF leaks

Bacterial Meningitis Bacteria typically reach the meninges by:

hematogenous spread from sites of colonization in the nasopharynx or other site such as lungs

Bacteria can also enter CSF by direct extension from nearby infections (e.g, sinusitis, mastoiditis)

through exterior openings in normally closed CSF pathways such as Meningomyelocele penetrating injuries neurosurgical procedures Ventricular shunt

Bacterial Meningitis: Infant

Abrupt & nonspecific signs Extremely irritable Lethargic difficult to comfort ; a high-pitched cry jaundice (a yellowish tint to the skin) stiffness of the body and neck(Nuchal

rigidity) fever or lower-than-normal temperature poor feeding/ a weak suck/ vomiting bulging fontanelles / Seizures

Bacterial Meningitis: Clinical Manifestation

pre-infection; respiratory illness/sore throat

Fever, headache, stiff neck, vomiting Kernig’s & Brudzinski’s Seizures Cranial nerves abnormalities Changes in consciousness, irritability …

coma Purpura/petechia (meningococcal

meningitis)

Bacterial Meningitis

Bacterial Meningitis: diagnosis & Treatment

The primary diagnostic test for meningitis is lumber puncture (LP)

Treatment Antibiotics (Ampicillin/vancomycin) corticosteroids Supportive care Isolation

Pressure & color

Glucose WBC protein

Normal 100-200mmH2O

50-100 mg/dL

0-5 20-45 mg/dL

Bacterial Meningitis

>300Cloudy/milky

< 40 Elevated

> 100

Viral/aseptic

N or increased N N or mild elevated

N or < 100

Bacterial Meningitis: Nursing diagnosis

Potential for injury: secondary brain injury R/T increase intracranial pressure or disease process

Altered comfort: pain R/T headache, muscular rigidity and I.V therapy

Fear/ anxiety child and the family R/T diagnosis of series disease.

Bacterial Meningitis: Nursing Care

Isolation (contact isolation ) Monitor V/S and neuro assessment Provide quiet environment Control fever and pain Prevent complications of increased ICP

and dehydration

Viral Meningitis

Common in children younger than 4 years Mostly caused by entero viruses Associated with mumps or herpes CM

Gradual signs of headache, fever, malaise, vomiting Meningeal irritation (signs) develop 1-2 days after the onset

of illness

Treatment Symptomatic (rest, fluids, antipyretic, analgesics) Isolation is not necessary Signs and symptoms subside within 3-10 days with no

residual effects (complications)

Encephalitis

Acute inflammatory disease of the brain Usually viral; Herpes Simplex: most common

sporadic type Acute febrile illness with symptoms of meningitis

AND neurologic signs such as aphasia, seizures, cranial nerve involvement

Patient may present with fever, facial paralysis, headache, seizures, nausea and vomiting

CT scan usually initially normal; MRI more helpful Death occurs in 70-80% of patients if treatment

not begun before patient becomes comatose

Spina Bifida

Vertebral column fails to close during intrauterine development with no definitive cause identified

There are three forms: Spinal bifida occulta Meningocele Myelomeningocele

Spina Bifida

Spinal bifida occulta Failure of vertebral arch

to close, a dimple occurs on the sacral area, may be covered by a tuft of hair.

Spina Bifida

Meningocele Protrusion of the

meninges. Meninges consist of: dura mater, arachnoid, and pia mater covered by thin membrane

No paralysis because spinal cord is not involved.

Spina Bifida

Myelomeningocele Protrusion of the

meninges and spinal cord. Covered by thin membrane

Extent of paralysis depends on the location of the defect.

Results in hydrocephalus.

Spina Bifida

Spina Bifida: Prevention & Management

Encourage folic acid 4mg Po with future pregnancies (conception-6 weeks)

Primary intervention after birth of infant with meningocele & myelomeningocele is to cover defect with a sterile, saline-soaked dressing to

prevent cracking in the sac thus decrease infection Prone position keeps pressure off the exposed sac Head circumference measurement is essential because

hydrocephalus can develop in these infants. Surgery

Primary reason of surgical repair is to prevent infection Correct defect Minimize complications such as hydrocephalus

Spina Bifida: Prevention & Management

Encourage parents to become involved with infant care ASAP

Teach parents the techniques of feeding, ROM exercises, positioning, catheterization, skin care

Explain to the parents about possible complications

Spina Bifida: Nursing Diagnosis

Risk for infection R/T presence of infective organisms, non-epitheliazed meringue sac

Potential for trauma R/T delicate spinal lesion

Potential for complications R/T impaired circulation of CSF or neuro-muscular impairment

Hydrocephalus

Impaired circulating and reabsorption of CSF

It can be congenital or acquired

It can be communicating or non-communicating (obstructive hydro) One of the most causes of

hydr0 is aqueductal stenosis

Other causes include meningitis, tumors, lesions/ malformation

Hydrocephalus

Hydrocephalus: Clinical Manifestation

Enlarged head (earliest sign) & Bulging fontenells

Poor feeding & Vomiting

Irritability Lethargy Dilated & distended

scalp vein and setting sun eyes

Positive Babinski’s reflex (fanning of toes)

In older children Headache Changes in

personality Cognitive

deterioration

Hydrocephalus: Treatment & complications

Treatment V_P shunt placement Diuresis

Complication Infection Visual problems Memory problems and

reduced IQ

Phenylketonuria (PKU) Is inability of the body to

utilize Phenylalanine (amino acid) due to deficit in Phenylalanine hydroxylase enzyme

It is an autosomal recessive inherited disease

Normal phenylalanine in the blood is 1-2 mg/dI in PKU it ranges from 6-80 mg/dI

Phenylketonuria (PKU)

Infant’s symptoms of untreated PKU Microcephaly, prominent cheek and poor

development of teeth Vomiting Irritability & hyperactivity Eczema-like rash Musty odor of the urine Increased muscle tone Poor body growth (failure to thrive) Fair skin Later signs of seizure and mental retardation

Phenylketonuria (PKU): treatment

The goal of treatment is to: prevent mental retardation by maintaining

normal level of phenylalanine (< 10 mg/dl) Provide nutrition for optimum growth

When the level of phenylalanine is more than 10 mg/dI brain damage occurs

Screening for PKU is a routine test which is usually done at 3 days of age

Phenylketonuria (PKU): treatment

Treatment is dietary management (lower amount of phenylalaine)

Food such as meat, fish, poultry ,eggs, cheese, milk, dried beans and peas should be avoided or taken in low amount.

Cereals, starches, fruits , vegetables and milk substitute is recommended

If treatment started before 3 months of age this can limited brain damage

Seizure Disorders

Seizure is an abnormal unregulated excessive electrical discharge (firing) that interrupts normal brain function

This electrical firing may last from a few seconds to minutes

50% of seizures the causes are unknown Seizures before 2 yrs usually caused by

developmental defects, birth injuries or metabolic disorders

Seizure could partial (affect part of the brain) or generalized

Seizure may be due to disorder such as epilepsy OR to reversible stressors such as: Hypoxia; Hypoglycemia; Fever in children, hypcalcemia,

hyponatremia

Seizure Disorders

Seizure usually lasts from few seconds to 1-2 minutes

Seizure usually causes Alteration in awareness, sensation & emotion Involuntary movements Convulsion

Mostly seizure followed by deep sleep, headache, confusion, paralysis ( postictal)

Postictal may lasts from minutes to hours

Seizure Disorders

Seizure disorders are symptoms to underlying cause such as brain tumor, stroke or could be idiopathic

Types are: Generalized

Absence (petit mal) Tonic-clonic (grand mal) Atonic Myoclonic Infantile spasm

Partial seizures Simple partial seizures Complex partial seizure Secondarily generalized partial seizures

Seizure Disorders: partial seizures

Simple partial seizure No complete loss of consciousness May affect the face or a hand first May developed to be generalized seizure

Complex partial seizure Starts with aura Purposeless movements & unintelligible

sounds Consciousness is impaired

Secondary generalized partial seizure Either simple or complex partial seizure may

develop into a tonic-clonic seizure

Seizure Disorders: generalized seizures

Abnormal motor function & loss of consciousness

Types are; Tonic-clonic (grand

mal) Tonic phase; cry, falling down

and stiffness . Followed by clonic ( jerk

rapidly and rhythmically, bending and relaxing at the elbows, hips, and knee) contractions of the muscles

Frothing at the mouth, urinary and fecal incontinence may occur

Seizure Disorders: generalized seizures

Absence (petit mal) Mostly for children between 6-12 years Lasts for a few seconds Abrupt & brief lapse of consciousness (staring into

space or absence spells), blank expression, twitching of mouth, blank stare ,daydreams

May occur many times a day

Atonic seizure Complete loss of muscle tone and consciousness Risk for head injury

Seizure Disorders: generalized seizures

Myoclonic (contraction and relaxation) Jerk y repetitive movement of a limb/trunk Consciousness is not lost May followed by tonic-clonic seizure

Infantile spasm Sudden flexion of the arms and trunk and

extension of the legs Occurs during the first 5 yrs

Status Epileptics Tonic-clonic Seizure that is lasting 5-

10 minute

Epilepsy is 2 or more seizures episodes that are not related to reversible stressors

Longer epileptics seizures may

cause permanent brain damage (more than 60 minutes.

Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

Seizure Disorders: Epilepsy

Assessment History

Duration, frequency, sequential evolution longest and shortest interval between seizures aura, postictal state precipitating factors Risk factors; CNS infection, drug use withdrawal, head

trauma, neurologic disorders

Physical exam: usually normal between the seizure CBC, serum glucose, creatinine, electrolytes, CT and

MRI, LP, video and EEG monitoring

Seizure Disorders: Epilepsy

Treatment by anticonvulsant drugs Well controlled seizures the drugs can eventually

stop and the child remain seizure free (60%) Drugs such as amphetamines can trigger

seizures thus should be avoided Alcohol and some drugs as phenothiazines lower

the threshold of seizure thus should be avoided Avoid activity that the loss of consciousness can

be life threatening such as driving, swimming and climbing or leaving a child in a bathtub

Seizure Disorders: Epilepsy

Drugs to control seizures

Parents should be advised not to stop the anticonvulsant suddenly or without consulting the physician. Such action could result in seizure activity

Parents should be advised about the side effect of Valporic acid (Depakene) such as Thrombocytopenia

that causes bruising and bleeding Phenytoin (Dilantin); gingival hyperplasia. Good oral

hygiene will minimize this adverse effect. Hepatic dysfunction thus serum therapeutic level of phenytoin should be carefully monitored

Seizure Disorders: Epilepsy

Nursing care during a tonic-clonic seizure Stay with the child until the seizure subsides Patent airway: suction and O2 supply Prevent injury by removing sharp objects DO not put any objects in the child’s mouth Loosening clothing around the neck Roll the child to the side to prevent aspiration V/S (temperature) and neurologic Administer diazepam (may cause apnea)

Seizure Disorders: Epilepsy

Nursing care after tonic cloinc seizure The child may be lethargic and confused If patient is febrile sponge bath Check blood glucose level

Seizure Disorders: febrile seizure

Benign seizure Occurs between 6 months and 6 years Is a convulsive event lasts 1-5 minutes due

to rapid rise in body temperature (fever) Usually consists of jerking of extremities,

eye rolling, unresponsiveness and sometimes cyanosis

Sometimes it can be non-convulsive such as loss of tone and consciousness or stiffness of the body

No brain damage and treatment is unnecessary

Pertussis immunization

It is wise to avoid Pertussis immunization for infants who had neurological problems in the neonatal period, until it is clear that they do not have progressive neurological disorders.

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