neurological disorders in the pediatric patient presented by marlene meador rn, msn, cne
TRANSCRIPT
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 Pressure- IICP 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 Contraindications-
intracranial 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 givenprophylactically if bacterialsuspected. May kill within24 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 Puncture- nursing 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 occultMeningoceleMeningomyelocele
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 EducationEmphasize 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 Reduce environmental
stimuli Communicate via age-
appropriate touch & verbalization
Keep toys or other items out of reach if child uses them for harmful self-stimuli
Ritualistic ADLs Encourage therapists &
support groups
Acute Care Setting Keep at least 1 constant
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
