49

Nursing Care of a Family When a Child Has

a Neurologic Disorder

Tasha is a 3-year-old girl you meet in an emergency department because she’s had
a seizure. Her mother grabs your arm, visibly upset. “Her sister has cerebral palsy
and seizures. Does this mean Tasha has cerebral palsy too?” she asks you.
Previous chapters described normal growth and development in children and
nursing care of children with disorders of other systems. This chapter adds
information about the dramatic changes, both physical and psychosocial, that occur
when a child is born with or develops a neurologic disorder. Such information
builds a base for care and health teaching for children with these disorders.

What education does this parent need about cerebral palsy or recurrent
seizures?

KEY TER MS
astereognosis
automatism
autonomic dysreflexia
choreoathetosis
choreoid
decerebrate posturing
decorticate posturing
diplegia
dyskinetic
graphesthesia
hemiplegia
infantile spasms
kinesthesia
paraplegia
pulse pressure
quadriplegia
status epilepticus

3000
stereognosis

OBJ EC TIV ES
After mastering the contents of this chapter, you should be able to:
1. Describe common neurologic disorders in children.
2. Identify 2020 National Health Goals related to neurologic disorders in children that
nurses can help the nation achieve.
3. Assess a child with a neurologic disorder.
4. Formulate nursing diagnoses for a child with a neurologic disorder.
5. Establish expected outcomes for a child with a neurologic disorder to help the
family manage seamless transitions across differing healthcare settings.
6. Using the nursing process, plan nursing care that includes the six competencies of
Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork
& Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI),
Safety, and Informatics.
7. Implement nursing care, such as monitoring medicine effectiveness, for a child with
a neurologic disorder.
8. Evaluate expected outcomes for achievement and effectiveness of care.
9. Integrate knowledge of neurologic disorders and the interplay of nursing process,
the six competencies of QSEN, and Family Nursing to promote quality maternal
and child health nursing care.

Neurologic disorders encompass a wide array of problems resulting from congenital

disorders, infection, or trauma. Many of these disorders severely alter the child’s life;
some result in life-threatening complications. Whenever possible, prevention must be
the highest priority for keeping the nervous system healthy because, in the future, stem
cell research may offer a cure for neurologic disorders, but for now, because neural
tissue does not regenerate like other body tissue, any nervous system degeneration is
likely to be permanent. Therefore, nursing care focuses on prevention or measures to
help the child and family develop strategies for dealing with the associated loss in
mental or physical functioning, making the child comfortable, and providing an
environment conducive to the child’s development and self-esteem (Parachuri &
Inglese, 2013). The 2020 National Health Goals related to neurologic disorders in
children are shown in Box 49.1.

BOX 49.1
Nursing Care Planning Based on 2020 National Health Goals

Neurologic disorders are major causes of long-term disability in children. The 2020

3001
National Health Goals that address these disorders are:
• Increase the proportion of children or youth with disabilities who spend at least
80% of their time in regular education programs from a baseline of 56.8% to a
target level of 73.8%.
• Reduce the number of people 21 years of age and younger with disabilities who
are in congregate care facilities from a baseline of 28,890 to 26,001.
• Increase the proportion of people with epilepsy or uncontrolled seizures who
receive appropriate medical care.
• Reduce emergency department visits for nonfatal traumatic brain injuries from
407.2/100,000 population to 366.3/100,000 (U.S. Department of Health and
Human Services, 2010; see www.healthypeople.gov).
Nurses can help the nation achieve these goals through helping to prevent neurologic
injury by educating children and parents about the use of helmets for bicycle and
motorcycle safety, by administering and teaching paramedical personnel to
administer safe care at accident scenes so children’s heads and necks are protected,
and by decreasing the possible spread of bacterial meningitis through good hand
washing and infection control precautions in hospitals.

Nursing Process Overview

FOR CARE OF A CHILD WITH A NEUROLOGIC SYSTEM DISORDER
ASSESSMENT
Neurologic disorders often begin with vague symptoms. Parents may report that their
child seems to be “walking strangely” or is “just not herself,” making a thorough
history and neurologic examination imperative for isolating the cause of the concern.
The neurologic examination covers six areas of neurologic functioning as well as
motor and sensory functioning. If more information is needed following an exam,
additional diagnostic tests will be prescribed. The parents and child need considerable
support throughout the assessment process because, although the neurologic
examination can be made “fun” for a child, other procedures such as a computed
tomography (CT) scan or lumbar puncture can be frightening. Additionally, the
anxiety of not knowing what is wrong and fearing the worst can make the waiting
period for test results especially difficult for the child’s parents.
NURSING DIAGNOSIS
Nursing diagnoses for children with neurologic disorders vary according to the
child’s needs and level of functioning. Initially, a child may need emergency care and
constant observation; later on, maintenance care to retain function is the priority. If
the child has surgery, nursing diagnoses need to address not only immediate
preoperative and postoperative care but also long-term care such as rehabilitation and
home care. Three common nursing diagnoses that apply to almost all neurologic
disorders are:

3002
 Risk for disuse syndrome related to neurologic deficit affecting one area of
functioning
Interrupted family processes related to stress associated with the long-term
effects of neurologic involvement
Health-seeking behaviors related to care of a child with neurologic involvement
Other nursing diagnoses are specific for disorders and thus are described along
with specific disorders.
OUTCOME IDENTIFICATION AND PLANNING
Be realistic when establishing expected outcomes because children who have
permanent limitations will not be able to achieve progress in all areas. When
neurologic disorders are first diagnosed, parents may be so stressed that they may be
able to focus only on short-term aspects of care, such as whether the child will
survive meningitis or whether the child has stopped convulsing. Later, they’ll be able
to concentrate on the long-term picture: What type of education setting will be best
for their child? What type of exercise program will be required?
Before a diagnosis is confirmed, parents may attribute their child’s functional
deficits to immaturity (she is not walking yet because she is simply too young). This
can make them unable to make plans because they have not fully acknowledged their
child’s neurologic deficits. Only when parents begin to adjust to the new reality are
they ready to participate in planning and problem solving.
Numerous organizations are available for assistance and support, such as the
Epilepsy Foundation of America (www.epilepsyfoundation.org), the National
Dissemination Center for Children With Disabilities (www.parentcenterhub.org), the
Children’s Tumor Foundation (www.ctf.org), the United Spinal Association
(www.spinalcord.org), and the United Cerebral Palsy Association (www.ucp.org).
IMPLEMENTATION
Nursing interventions for a child with a neurologic problem must address both short-
and long-term needs. A lot of nursing care involves modeling care, such as how to
gently handle an infant with increased intracranial pressure (ICP) and how to turn an
infant on the side during a seizure to prevent choking, and reviewing needed
medications with parents—actions that give parents confidence to be able to care for
their child at home.
OUTCOME EVALUATION
Evaluation of a child with a neurologic disorder should address not only the child’s
progress in regaining physical function but also the child’s level of self-esteem. Some
examples indicating achievement of possible outcomes are:
The child states he or she is aware of potential for injury related to recurrent
seizures.
The parent/caregiver states understanding of potential for injury related to
recurrent seizures.
Family members state they are able to maintain family cohesiveness yet sustain

3003
 contact with hospitalized child.
The child practices exercises daily to reduce possibility of contracture from
disuse syndrome.

Anatomy and Physiology of the Nervous System

Nerve cells (neurons) are unique among body cells in that, instead of being compact,
they consist of a cell nucleus and extensions: one axon and several dendrites. The
dendrite transmits impulses to the cell nucleus; the axon transmits impulses away from
the cell nucleus to body organs. These cells vary in size, ranging from a few inches to
several feet long, reaching from distant body sites such as the feet, through the spinal
cord, and to the brain. Although their great length is vital to motor and sensory function,
it also makes nerve cells more susceptible than other body cells to injury.
The nervous system is not fully functioning at birth; it continues to mature through
the first 12 years of life. Two separate systems are involved: the peripheral nervous
system (PNS) and the central nervous system (CNS). The PNS consists of the cranial
nerves, the spinal nerves, and the somatic and visceral divisions. The CNS includes the
brain and the spinal cord (Fig. 49.1) surrounded by the cerebrospinal fluid (CSF), the
skull, and three membranes or meninges (the dura mater, a fibrous, connective tissue
containing many blood vessels; the arachnoid membrane, a delicate serous membrane;
and the pia mater, a vascular membrane) that protect the brain and spinal cord from
trauma.

Figure 49.1 Meninges of the (A) brain and (B) spinal cord.

The properties of CSF are shown in Table 49.1. Basically, it is a colorless, alkaline
fluid with a specific gravity of approximately 1.004 to 1.008, containing traces of
protein, glucose, lymphocytes, and body salts.

TABLE 49.1 NORMAL PROPERTIES OF CEREBROSPINAL FLUID

Parameter Normal Abnormal Finding: Possible Significance

3004
 Finding
Opening pressure Newborns: 8– Lowered pressure usually indicates there is
10 cm subarachnoid obstruction in the spinal column
H2O; above the puncture site.
children: Elevated pressure suggests intracranial
10–18 cm compression, hemorrhage, or infection.
H2O Pressure increases if a child coughs or pressure is
applied to the external jugular vein (Valsalva
maneuver).
Appearance Clear and If cloudy, indicates possible infection with an
colorless increased number of white blood cells
(WBCs).
If reddened, color is probably because of red
blood cells (RBCs).
Cell count 0–8/mm3 Granulocytes suggest cerebrospinal fluid (CSF)
infection.
Lymphocytes suggest meningeal irritation and
inflammation.
A few RBCs and WBCs are normally present in
the newborn CSF due to the trauma of birth.
Protein 15–45 Elevated count (>45/100 ml) occurs if RBCs are
mg/100 ml present.
If both protein content and RBC count are
elevated, meningitis or subarachnoid
hemorrhage is suggested.
If protein content alone is elevated, it more likely
suggests a degenerative process such as
multiple sclerosis.
Glucose 60%–80% of Bacterial meningitis causes a marked decrease in
serum CSF glucose; invasion of fungi, yeast,
glucose tuberculosis, or protozoans into the CSF results
level in some decrease in glucose level.
Viral infections do not cause a decrease in CSF
glucose and may occasionally cause a slight
increase.
Albumin/globulin 8:1 Increased level suggests infection or an A/G ratio
(A/G) ratio neurologic disorder.

Assessing the Child With a Neurologic Disorder

3005
Because neurologic symptoms, such as headache, unsteady gait, or lethargy, are often
insidious, both a thorough history and a neurologic examination are needed to reveal the
cause and extent of such symptoms (Box 49.2).

BOX 49.2
Nursing Care Planning Using Assessment

ASSESSING A CHILD FOR SIGNS AND SYMPTOMS OF A NEUROLOGIC

DISORDER

HEALTH HISTORY
A child’s history may first reveal symptoms of a neurologic disorder. Because many
neurologic problems that are evidenced in infants and young children result from injury
that occurred in utero, it is important to obtain the mother’s pregnancy history as well.

3006
 At primary care visits, always ask parents about their child’s developmental
milestones and ability to perform age-appropriate tasks successfully. A screening test
can be used to indicate whether a parent’s concern about a preschool child is well
founded. The ability to perform well in school is important documentation for an older
child.

NEUROLOGIC EXAMINATION
A complete neurologic examination takes at least 20 minutes and requires both patience
and skill to keep a child’s attention while observing for possible indications of
neurologic disease. For a full examination, six areas are assessed: cerebral, cranial
nerve, cerebellar, motor, sensory, and reflex function.

Cerebral Function
Both general and specific cerebral functions need to be evaluated by assessing level of
consciousness, orientation, intelligence, performance, mood, and general behavior
(Rust, 2011). Children do best when these types of tests are presented as a game. Be
certain to convey that there are no right or wrong answers because children who believe
that they have failed these tests may not respond well to further testing.
The best way to evaluate a child’s level of consciousness is through conversation.
Note any drowsiness or lethargy. Allow the child to answer questions without
prompting and listen carefully to be certain the answer is appropriate to the question.
Orientation refers to whether children are aware of who they are, where they are,
and what day it is (person, place, and time). Be certain to take into account a child’s
age, making questions age-appropriate to the child’s developmental abilities. Children
younger than 4 years of age, for example, may not know both their first and last names.
Children may be of school age before they know their address. Children younger than 7
or 8 years of age may have difficulty with the days of the week, confusing “yesterday”
with “today” or “tomorrow.” Intellectual performance (IQ) can be determined by the
child’s score on a standard intelligence test. Estimates of intellectual function can be
made by asking the child questions on common topics.
Immediate recall is the ability to retain a concept for a short time, such as being able
to remember a series of numbers and repeat them (a child of 4 years can usually repeat
three digits; a child older than 6 years can repeat five digits). Recent memory covers a
slightly longer period of time. To measure this, show the preschool child an object such
as a key and ask the child to remember it because later you will ask him or her to tell
you what it was. After about 5 minutes, ask whether the child remembers what object
you showed him or her. Ask older children what they ate for breakfast to test recent
memory.
Remote memory is long-term recall. Ask preschoolers what they ate for breakfast
that morning or for dinner the night before because, for them, that was a long time ago;
ask older children what was the name of their first-grade teacher because most people

3007
remember this information their whole life.
Specific cerebral function can be measured by assessing language, sensory
interpretation, and motor integration. When assessing language, listen to the child’s
ability to articulate. Remember, when listening to speech, many preschoolers substitute
“w” for “r,” saying “west time” instead of “rest time”; be aware that pronunciation is
altered if English is not the child’s primary language.
Stereognosis refers to the ability of a child to recognize an object by touch; it is a
test of sensory interpretation. For this, ask a child to close his or her eyes and then place
a familiar object, such as a key, a penny, or a bottle cap, in her hand and ask her to
identify it. This is a skill even preschoolers are able to do successfully.
Graphesthesia is the ability to recognize a shape that has been traced on the skin.
Ask a child to close his or her eyes; trace first a circle and then a square on the back of
his or her hand and then ask him or her whether the shapes are the same or different. Be
sure the child understands the concept of “different” by first showing him or her objects
such as two keys and a bottle cap and documenting that he or she is able to identify the
keys as being the same and the bottle cap as being different. For older children, trace
numbers (8, 3, 0, and 1 work well) and ask the child to identify each one.
Kinesthesia is the ability to distinguish movement. Have a child close her eyes and
extend her hands in front of her. Raise one of her fingers and ask her whether it is up or
down. Hold the finger by its sides so that your other fingers do not brush against the
child’s palm or the back of her hand and reveal the finger position. Repeat the same
movement with a toe on each foot. For preschoolers, be certain to first determine
whether the child understands the concept of up and down.
To measure motor integration, ask a child to perform a complex motor skill, such as
folding a piece of paper and putting it into an envelope. A child of 4 years or older
should be able to do this neatly.
Remember, children do best when these tests are presented as a game. Be certain to
convey that there are no right or wrong answers. A child who believes that he or she has
failed these tests may not respond well to further testing.

Cranial Nerve Function

Testing for cranial nerve function consists of assessing each pair of cranial nerves
separately. Cranial nerves and methods of cranial nerve testing are described in Table
49.2. Methods to test pupil constriction and ability to follow into fields of gaze are
described in Chapter 34.

TABLE 49.2 CRANIAL NERVE FUNCTION

Cranial Nerve Function Assessment
I (olfactory) Sense of smell Assess child’s ability to recognize common
odors such as peanut butter or an orange
while eyes are closed.

3008
II (optic) Vision Assess vision fields and visual acuity; examine
retinas.
III (oculomotor) Motor control Assess pupillary size, equality, reaction to light,
and and ability to follow an object in all
sensation for directions. Note any nystagmus (an abnormal
eye muscles jerking motion).
and upper
eyelid
IV (trochlear) Movement of As for nerve III
major eye
globe
muscles
V (trigeminal) Mastication Assess ability to discern light touch to test
muscles and sensory component; assess symmetry and
some facial strength of bite to test motor component.
sensations
VI (abducens) Movement and As for nerves III and IV
muscle sense
of eye globe
VII (facial) Impulses for Assess motor strength by asking child to close
facial eyes while you attempt to open them. Note
muscles, symmetry of facial expression (such as
salivation, smile) and movement (such as wrinkling
and taste forehead). Assess taste by asking child to
identify salt or sugar.
VIII (acoustic) Equilibrium Assess hearing by the response to a whispered
and hearing word or a Weber or Rinne test. Equilibrium
is not tested routinely.
IX Motor impulses Assess gag reflex by pressing on back of tongue
(glossopharyngeal) to heart; with tongue blade. Note midline uvula (tested
sensation together with nerve X).
from
pharynx,
thorax, and
abdominal
organs
X (vagus) Swallowing Assess ability to swallow; elicit gag reflex by
and gag pressing a tongue blade on posterior tongue.
reflexes

3009
XI (accessory) Impulses to Ask child to turn head to the side; try to turn it
striated to center. Ask the child to elevate shoulders
muscles of while you press down on them.
pharynx and
shoulders
XII (hypoglossal) Motor impulses Ask child to protrude tongue. Assess for
to tongue tremors.
and skeletal Ask child to press on side of cheek with tongue;
muscles; assess tongue strength.
sensation
from skin
and viscera

Cerebellar Function
Tests for cerebellar function are tests for balance and coordination. To test these,
observe the child walk to assess whether the walk is natural (most children walk at least
a little self-consciously when they know they are being observed, so watch them also as
they enter the exam room and move around for other activities). Ask the child to stand
on one foot; a child as young as 4 years should be able to do this for as long as 5
seconds. Ask the child to attempt a tandem walk (walk a straight line, one foot directly
in front of the other, heel touching toe) (Fig. 49.2A). A child older than 4 years of age
should be able to do this for about four consecutive steps. Ask the child to touch his or
her nose with his or her finger and then to reach and touch your finger with the same
hand (held about 1½ feet in front of the child) (see Fig. 49.2B). Tell the child to repeat
this action and move your finger to a new position each time. The average child rarely
reaches past your finger or stops before touching it.

3010
 Figure 49.2 Cerebellar function tests. (A) A child attempting a
tandem walk. (B) Nose-to-finger test. (© Lesha Photography.)

Ask the child to pat one knee with the palm of the hand and then quickly turn the
hand over and pat the knee with the back of the hand; repeat over and over, one hand at
a time. The majority of children are able to do this rapid, coordinated motion without
much difficulty. Preschoolers will “mirror” the movement of the actively moving hand
by moving the inactive hand as well. Older children should not demonstrate this (or
should show only a small amount of movement).
Other tests are to ask the child to touch each finger on one hand with the thumb of
that hand in rapid succession or ask the child to run the heel of one foot down the front
of his or her other leg while he or she is lying supine (children should be able to do this
without “running off” the leg). With the child lying on the examining table, ask the
child to close his or her eyes and draw a circle or figure 8 in the air with his or her foot
(children should also be able to do this without difficulty).
Tests of cerebellar function such as these are fun for children to do as long as they
know that there are no passes or failures. Show approval for effort even if they are
having difficulty with a task so that they have confidence to try another one.

Motor Function
Motor function is measured by evaluating muscle size, strength, and tone. Begin by
comparing the size and symmetry of extremities. If in doubt about either of these,
measure the circumference of the calves and thighs or upper and lower arms with a tape
measure. Palpate muscles for tone. Move the extremities through passive range of
motion to evaluate symmetry, spasticity, and flaccidity bilaterally. To test for strength,
ask the child to extend her arms in front of her and then resist your action as you push

3011
down or up on her hands or push them out to the side. Do the same with the lower
extremities.

Sensory Function
If children’s sensory systems are intact, they should be able to distinguish light touch,
pain, vibration, hot, and cold. Have a child close his or her eyes and then ask the child
to point to the spot where you touch him or her with an object. Light touch is tested by
using a wisp of cotton, deep pressure by pressure of your finger, pain by a safety pin,
and temperature by water bottles filled with hot or cold water. Vibration is tested by
touching the child’s bony prominences (iliac crest, elbows, knees) with a vibrating
tuning fork. Warn the child that on pin testing, he or she will feel a momentary prick.
Otherwise, the child may be unwilling to close his or her eyes again for further testing.

Reflex Testing
Deep tendon reflex testing, which is part of a primary physical assessment (see Chapter
34), is also a basic part of a neurologic assessment. In newborns, reflex testing is
especially important because the infant cannot perform tasks on command to
demonstrate the full range of neurologic function (see Chapter 18).

QSEN Checkpoint Question 49.1

PATIENT-CENTERED CARE
Tasha, 3 years old, is scheduled for a full neurologic examination. What explanation
would best prepare her for this?
a. “You’ll need to answer questions carefully so you can pass this test.”
b. “I’ll be asking you to move in different ways, almost like a game.”
c. “I need to find out how healthy or unhealthy your brain seems to be.”
d. “Seizures can be caused by a brain tumor, so that needs to be ruled out.”
Look in Appendix A for the best answer and rationale.

DIAGNOSTIC TESTING
A variety of diagnostic tests may be prescribed to provide additional information should
any abnormalities be detected in the health history, physical examination, or neurologic
examination. Many of these tests are invasive, so if you are scheduling these, be certain
both the child and family are well prepared for these procedures; try to schedule the
least invasive procedures first to better elicit the child’s cooperation. So explanations
will be well understood, take into account not only the child’s chronologic age but also
the child’s level of cognitive functioning. Provide an explanation that includes not only
physically what will happen but also a description of any sensory experiences the child
might undergo such as anything he or she might feel, hear, smell, or taste.

3012
Lumbar Puncture
Lumbar puncture, the introduction of a needle into the subarachnoid space (under the
arachnoid membrane) at the level of L4 or L5 to withdraw CSF for analysis, is used
most frequently with children to diagnose hemorrhage or infection in the CNS or to
diagnose an obstruction of CSF flow. The procedure is contraindicated if the skin over
the needle insertion site is infected (to avoid introducing pathogens into the CSF) or if
there is a suspected elevation of CSF pressure (if intracranial pressure [ICP] is elevated,
the higher pressure in the intracranial space could cause the brainstem to be drawn down
into the spinal cord space, compressing the medulla and compromising the action of the
cardiac and respiratory centers). To limit pain, EMLA or lidocaine cream should be
applied to the puncture site 1 hour before the procedure. Alternatively, the child may be
administered conscious sedation for the procedure (see Chapter 39).
For a lumbar puncture, a newborn is seated upright with the head bent forward (Fig.
49.3A). The older infant or child is placed on one side on the examining table. Help the
child flex the head forward, flex the knees against the abdomen, and arch the back as
much as possible; this position opens the space between the lumbar vertebrae,
facilitating needle insertion (see Fig. 49.3B). You might describe the position as “rolling
into a ball” or “folding up like an astronaut in a small spaceship” to associate it with
something the child knows about. Children younger than school age need to be held in
this position because they may be so frightened by someone working on their back
unseen that they are unable to hold this arched position (they try to turn over or turn
their head to see what is happening). It helps a school-age child or adolescent if you
stand by the table facing him or her and gently rest your hand on the back of the head,
as a reminder to keep it bent forward. Talking quietly with the child not only assists in
calming the child but also helps assess the child’s respiratory status as the child is
“curled up.” Closely observe an infant for any respiratory distress.

Figure 49.3 (A) Positioning an infant for a lumbar puncture. (©

Barbara Proud.) (B) Positioning an older child for a lumbar puncture.

Children need good preparation for a lumbar puncture because they cannot see what
is happening. Be certain they know the healthcare provider performing the procedure
will wash their back with a solution that feels cold and then inject a local anesthetic that
might sting for a moment (if an analgesic cream was not applied before the procedure).

3013
Caution children they will feel pressure but not pain as the lumbar puncture needle is
inserted. Occasionally, the needle will press against a dorsal nerve root and the child
will experience a shooting pain down one leg. If this happens, reassure the child this
feeling passes quickly and does not indicate an injury.
When the insertion stylette is removed and CSF drips from the end of the needle, the
procedure has been successful. An initial pressure reading is made. To confirm the
subarachnoid space in the cord is patent with that in the skull, the examiner may ask a
child who is older than 3 years of age to cough; for an infant, the examiner may ask you
to press on the child’s external jugular vein. If either of these measures causes an
increase of CSF pressure, it indicates that fluid is flowing freely through the
subarachnoid space. Typically, three tubes of CSF, containing 2 to 3 ml each, are
collected; a closing pressure reading is taken; and the needle is withdrawn. Samples are
usually sent for culture, sensitivity, glucose level, and presence of red blood cells. The
first sample obtained may contain blood or skin pathogens from the puncture, so it
should not be the sample sent for determination of red blood cell content or culture.
Additional evaluations requested might be albumin/globulin ratio or gamma-globulin
level (an increased level of gamma-globulin is suggestive of multiple sclerosis or
meningitis).
Lumbar puncture involves at least momentary pain, so children need to be
comforted afterward. A few children may develop a headache after a lumbar puncture as
a result of the reduction in CSF volume or invasion of a small air pocket during the
puncture, although this is rare because of the small-sized needle used. Encourage the
child to lie flat for at least 30 minutes and to drink a glass of fluid afterward to help
prevent cerebral irritation caused by air rising in the subarachnoid space and to help
increase the amount of CSF quickly. Encourage parents to hold an infant in a flat
position across their knees. If the child develops a headache despite the precautions
taken, an analgesic can be given for pain relief.
If a child had minimally increased CSF pressure at the time of the puncture, closely
observe the child after the procedure to detect respiratory and cardiac difficulty from
medulla pressure. An increase in blood pressure or a decrease in pulse and respiration
rates, a change in consciousness, pupillary changes, or a decrease in motor ability are all
important signs of increased intracranial compression.

QSEN Checkpoint Question 49.2

TEAMWORK & COLLABORATION
Tasha’s diagnostic workup will include a lumbar puncture. When collaborating with
the physician to perform this procedure, what nursing action should the nurse
prioritize?
a. Explain to Tasha that her back will be washed with a cold liquid.
b. Apply EMLA cream to Tasha’s lumbar region 5 to 10 minutes before the
procedure.

3014
 c. Reassure Tasha that the procedure will not hurt.
d. Help Tasha into a prone position on the procedure table.
Look in Appendix A for the best answer and rationale.

Ventricular Tap
In infants, CSF may be obtained by a subdural tap into a ventricle through the anterior
fontanelle. A small space on the scalp over the insertion site is shaved or clipped, and
the area is prepared with an antiseptic. The infant’s head must be held firmly in a supine
position to prevent movement during the procedure so the needle does not strike and
lacerate meningeal tissue.
Fluid must always be removed from this site slowly, rather than suddenly, to prevent
a sudden shift in pressure that could cause intracranial hemorrhage. After the procedure,
a pressure dressing is applied to the site, and the infant is placed in a semi-Fowler’s
position to prevent additional drainage from the puncture site. After the procedure,
comfort the infant or allow the parents to do so to both reduce the stress of a painful
procedure and prevent the infant from crying excessively, an action that could increase
ICP and loss of additional CSF.

X-Ray Techniques
A flat-plate skull X-ray film may be used to obtain information about increased ICP or
skull defects such as fracture or craniosynostosis (premature knitting of cranial sutures).
Increased ICP is suggested if skull sutures appear separated on the X-ray. If the ICP is
chronic, other subtle changes, such as a flattening of the sella turcica or an increase in
the convolutions of the inner table of the skull, may be present.

Cerebral Angiography
Cerebral angiography is an X-ray study of cerebral blood vessels that involves the
injection of a contrast material into the femoral or carotid artery. Serial X-rays are then
taken as the dye flows through the blood vessels of the cerebrum, and any vessel defects
or space-occupying lesions occluding cranial blood vessels are revealed.

Myelography
Myelography is the X-ray study of the spinal cord following the introduction of a
contrast material into the CSF by lumbar puncture to reveal the presence of space-
occupying lesions of the spinal cord. After the procedure, keep the head of the child’s
bed elevated to prevent contrast medium from reaching the meninges surrounding the
brain and causing irritation.

Computed Tomography and Magnetic Resonance Imaging

Computed tomography (CT) involves the use of X-rays to reveal densities at multiple

3015
levels or layers of brain tissue and is helpful to confirm the presence of a brain tumor or
other encroaching lesions. Single-photon emission computed tomography (SPECT) is a
similar procedure used mainly for blood flow evaluation. Magnetic resonance imaging
(MRI) uses magnetic fields to show differences in tissue composition, revealing normal
versus abnormal brain tissue. Both CT and MRI are discussed in greater detail in
Chapter 37.

Nuclear Medicine Studies (Brain Scan and Positron Emission

Tomography)
Brain Scan
For a brain scan, a radioactive material is injected intravenously, and after a fixed time
during which the injected material is deposited in cerebral tissue, radioactivity levels
over the skull are measured. If the blood–brain barrier is not functioning, the radioactive
material will accumulate in specific areas, suggesting possible tumor, subdural
hematoma, abscess, or encephalitis.

Positron Emission Tomography

The diagnostic technique of positron emission tomography (PET) involves imaging
after injection of positron-emitting radiopharmaceuticals into a vein. These radioactive
substances accumulate at diseased areas of the brain or spinal cord. PET is extremely
accurate in identifying seizure foci.

Echoencephalography (Ultrasound of Head or Spinal Cord)

Echoencephalography involves the projection of ultrasound (high-frequency sound
waves above the audible range) toward the child’s head or spinal cord (a type of
ultrasound). The technique may be used to outline the ventricles of the brain. Because
this technique of scanning is noninvasive, produces no discomfort, and has no known
complications, it may be repeated frequently to monitor changes in the size of ventricles
or an invading lesion and is particularly effective in infants with open fontanelles. This
noninvasive technique is often used in neonatal intensive care units to monitor
intraventricular hemorrhages and other problems frequently encountered by preterm
infants.

Electroencephalography
The electroencephalogram (EEG) reflects the electrical patterns of the brain
summarizing the physical and chemical interactions within the brain at the time of the
test (Rapin, 2011). An EEG tracing typically indicates four types of waves: delta (1 to 3
waves per second), theta (4 to 7 waves per second), alpha (8 to 12 waves per second),
and beta (13 to 20 waves per second).
To reduce extraneous movements of the eyes, head, or muscles that would affect the

3016
tracing, the child must be cooperative and quiet during the procedure. Traditionally,
therefore, parents are asked to keep their child up later than usual the night before the
exam so the child will fall asleep during the test. Educate children and their families that
the room will be darkened to help them rest. Use terminology to describe the procedure
in terms that the child can understand depending on age and development. Reassure
them that attaching the small suction cups or leads is not painful. Use of terminology
that is age appropriate will help to keep the patient and family at ease during the
procedure.
Sedation or conscious sedation may be necessary for children who are unable to lie
still during the procedure. The goals of sedation are to (a) assure the patient’s safety and
welfare, (b) assure minimal pain and discomfort during the procedure, (c) control the
patient’s anxiety with minimal psychological trauma, and (d) modify behavior and
movements during the procedure (Coté & Wilson, 2016). For example, chloral hydrate,
a frequently used sedative for this procedure, may increase the fast activity of brain
waves; chlorpromazine (Thorazine) is known to increase slow activity. Because some
seizure medications also cause changes in brain waves, be certain to note on the child’s
electronic record what medications the child is currently receiving. Parents should
receive specific instructions whether antiseizure medication should be given on the
morning of testing.
Although EEGs can show important information about brain activity, they are not
helpful in all circumstances because about 15% of children who have no cranial trauma
or seizure activity demonstrate some abnormality on an EEG. They may not reveal a
brain tumor because most brain tumors in children are in the posterior fossa, which is
not revealed on an EEG. On inspection of the symmetry of brain waves in different
hemispheres, local lesions such as a hematoma may be suggested. An EEG is most
beneficial in diagnosing absence seizures. The typical pattern with this disorder is
discussed later in this chapter.
Visual stimulation, such as having a child look at a whirling disk, may be used in
connection with an EEG because various types of electrical discharges increase with
rapid eye movements. In a child who is sensitive to this type of stimulation, the testing
may produce a seizure; therefore, it is up to the prescriber to decide if the benefits
outweigh the possible effects. Following an EEG, children will be sleepy if they have
been sedated or had an EEG while sleep-deprived. Allow them to sleep as long as
needed.

Health Promotion and Risk Management

Health promotion for the nervous system begins prenatally with measures to ensure
optimal fetal growth and development and prevention of problems associated with
anoxia. It continues throughout childhood with routine health maintenance visits,
screening for possible neurologic or developmental problems, and timely
immunizations to prevent sequelae of childhood infections such as measles or

3017
chickenpox. Nurses play a key role in providing education to parents about the
importance of prenatal care, obtaining immunizations, and completing medication
therapy to ensure complete resolution of an infection.
Nurses are able to provide parents with anticipatory guidance about safety measures
to prevent injury, specifically, head and spinal cord injury by the use of seat belts or
child restraints while riding in automobiles and protective gear when playing contact
sports. Remind parents and children to wear helmets when riding or using anything that
can move faster than the child can run such as scooters, roller skates/rollerblades, ice
skates, horses, skis, skateboards or snowboards, bicycles, or motorcycles (Riesch,
Kedrowski, Brown, et al., 2012). For a child with a long-term neurologic disorder,
rehabilitation and early intervention play a major role in reducing the risk of
complications and in promoting the child’s and family’s optimal level of functioning.

Increased Intracranial Pressure

Increased ICP is not a single disorder but a group of signs and symptoms that occur
with many neurologic disorders (Table 49.3). It is important to assess for signs and
symptoms when caring for a child with a potential neurologic disorder (Sigurtà,
Zanaboni, Canavesi, et al., 2013). Increased ICP occurs because of an increase in the
CSF volume, blood entering the CSF, cerebral edema, head trauma or infection, space-
occupying lesions such as brain tumors, or the development of hydrocephalus or
Guillain-Barré syndrome.

TABLE 49.3 SIGNS AND SYMPTOMS OF INCREASED INTRACRANIAL

PRESSURE
Sign or Indication of Increased Intracranial Pressure
Symptom
Increased head An increase >2 cm per month in first 3 months of life, >1 cm per
circumference month in the second 3 months, and >0.5 cm per month for the
next 6 months
Fontanelle Anterior fontanelle tense and bulging; closing late
changes
Vomiting Occurring in the absence of nausea, on awakening in morning or
after nap; possibly projectile
Eye changes Diplopia (double vision) from pressure on abducens nerves; white of
sclera evident over pupil (setting sun sign); limited visual fields,
papilledema
Vital sign Elevated temperature and blood pressure; decreased pulse and
changes respiration rates
Pain Headache, often present on awakening and standing; increasing with

3018
 straining at stool (Valsalva maneuver) or holding breath
Mentation Irritability, altered consciousness such as sleepiness

The rate at which symptoms develop depends on the cause and the ability of the
child’s skull to expand to accommodate the increased pressure. Children with open
fontanelles, for example, can withstand more pressure without brain damage than older
children, whose suture lines and fontanelles have closed.

ASSESSMENT
Assessment of ICP may involve only a few quick procedures, such as obtaining vital
signs, evaluating pupil response, and determining levels of consciousness, motor, and
sensory function, or it may include more elaborate electronic monitoring.
Because symptoms are subtle at first, the initial signs children may show are
headache, irritability, or restlessness. Growing pressure on the brainstem, which
controls respiration and cardiac activity, soon causes pulse and respiration rates to slow.
Compression of cranial vessels leads to a compensatory increase in blood pressure (or
pulse pressure, the gap between the systolic and diastolic blood pressures). Pressure on
the hypothalamus, the temperature-regulating center of the body, causes an increase in
body temperature. An older child may be able to report symptoms such as diplopia
(double vision). On funduscopic examination, papilledema may be detected. Compare a
new assessment against all recordings taken in the last 24 hours so a progressive change
can be detected.
If ocular changes such as a dilated pupil occur, this indicates pressure is increasing
posterior to the eye globe, causing compression of the second cranial nerve. Record any
tendency toward strabismus, nystagmus (constant eye movement), or “sunset eyes”
(white sclera showing over the top of the cornea) or inability to follow the light into any
quadrant. Be sure to be specific about what you document. “Inability to follow light,”
for example, is not as informative as “Inability to follow light into left superior field;
vertical nystagmus noted as child follows light into other fields.”
An additional test for ICP is a “doll’s eye” reflex. If a child lies supine and you turn
his or her head gently but rapidly to the right, the eyes will normally turn toward the
left, and vice versa. If a child has increased ICP, this phenomenon will be absent (a test
useful in assessing a comatose child who is unable to cooperate by following a light).
Assess the child’s level of consciousness because if the child is alert but unable to
comprehend surroundings, time, or place, this may be the first indication of increased
ICP. As pressure continues to increase, a pseudo-awake state will occur, in which the
child is awake but unable to follow light or locate a noise. Finally, the child becomes
fully comatose, unable to be roused by any stimuli. Levels of coma are rated by the
Glasgow Coma Scale, discussed in Chapter 52 in connection with assessment for head
trauma.
Children, like adults, generally become disoriented about time first, then place, and

3019
then self. Explain to the parent and child that you will be periodically asking seemingly
simple questions, such as asking the child for his or her name or to identify the day of
the week. Let them know that it is important for the child to answer the questions if the
child is able in order to understand the child’s level of consciousness.
Be aware that many children, even when healthy, are groggy when they first
awaken, especially if they have been dreaming. Make sure children are fully awake,
therefore, before attempting to determine level of consciousness. Ask questions
appropriate to the child’s age. Preschoolers, for example, do not usually know their
whole name or the day of the week and may not know concepts such as morning or
night. To assess consciousness in children this age, it is often more productive, every
hour, to show them a colored block, a piece of fruit, or a cartoon character known to the
child and ask them to name it.
A good way to test an infant’s level of consciousness is to determine whether the
child responds to sounds, such as a familiar music box or voices, or reaches for an
attractive object you offer. Motor ability can be assessed by asking a child to perform
some simple motor tasks, such as squeezing your hands, pushing against your hands
with both feet, or performing rapid, alternating hand movements, such as turning a hand
over and back several times. Evaluate cranial nerves grossly by having the child make a
face, close the eyes tightly, or smile. Evaluate whether the facial responses are equal
and symmetric bilaterally. Test deep tendon reflexes because these decrease in intensity
with decreased level of consciousness.
As a final assessment, carefully observe the child’s resting posture because when
motor control grows weaker because of loss of cell function, characteristic posturing
(primitive reflexes) occurs. Cerebral loss is shown mainly by decorticate posturing:
the child’s arms are adducted and flexed on the chest with wrists flexed, hands fisted;
the lower extremities are extended and internally rotated; the feet are plantar flexed
(Fig. 49.4A). Decerebrate posturing, which occurs when the midbrain is not
functional, is characterized by rigid extension and adduction of the arms and pronation
of the wrists with the fingers flexed; the legs are held extended with the feet plantar
flexed (see Fig. 49.4B).

3020
 Figure 49.4 (A) Decorticate posturing. (B) Decerebrate posturing.

Seizures are a sign of increased ICP, so if these occur, the child’s ICP is becoming
greatly compromised.

INTRACRANIAL PRESSURE MONITORING

ICP can be measured by several additional methods:
• An intraventricular catheter inserted through the anterior fontanelle
• A subdural screw or bolt inserted through a burr hole in the skull
• A fiberoptic sensor implanted into the epidural space (or the anterior fontanelle in
an infant) (Fig. 49.5)

3021
 Figure 49.5 Devices used to monitor intracranial pressure. (A)
Subarachnoid screw. (B) Epidural sensor. (C) Intraventricular
catheter. (D) Intraparenchymal monitoring.

Intraventricular catheters (see Fig. 49.5C) are threaded into the lateral ventricle,
filled with normal saline, and then connected to an external pressure monitor (Bailey,
Liesemer, Statler, et al., 2012). As pressure in the ventricle fluctuates, it registers
through the filled catheter onto an oscilloscope screen plus a written printout. This
method is advantageous over simple scanning because it also enables CSF drainage and
administration of medication through the catheter.
ICP in children normally ranges from 1 to 10 mmHg; a level greater than 15 mmHg
needs further assessment. As blood pressure rises and falls with the influx of blood
through vessels, so does ICP. On a monitor, this appears as A waves (plateau waves), B
waves (short-duration waves), or C waves (small, rhythmic bursts). If brain ischemia is
present, wave patterns change even before there is a deviation in blood pressure or pulse
rate (Fig. 49.6). Because A waves appear to reflect brain ischemia, they can be used to
signal when a child needs more oxygen.

3022
 Figure 49.6 Normal intracranial pressure (ICP) waveform and
generalized shapes of the three types of ICP waves: A waves or
plateau waves, B waves, and C waves.

ICP monitoring also supplies information on cerebral perfusion pressure (CPP) or

the amount of cerebral blood flow available to the brain (Box 49.3) because, if ICP ever
exceeds arterial blood pressure (arises above about 50 mmHg), cerebral vessels can
become obstructed (Budohoski, Zweifel, Kasprowicz, et al., 2012).

BOX 49.3
Calculating Cerebral Perfusion Pressure

Cerebral perfusion pressure (CPP) ranges from about 60 to 150 mmHg. If it is too
low, it suggests blood is having difficulty circulating to brain cells; if it rises too high,
it can also result in brain ischemia from the increased intracranial pressure (ICP).

3023
 CPP is calculated by subtracting the mean ICP from the mean arterial pressure
(MAP) or:
MAP − ICP = CPP
MAP is determined by subtracting the diastolic blood pressure (DBP) level from
the systolic blood pressure (SBP) level, then dividing the result by 3, and adding that
sum to 80 or:

To calculate CPP in a child with a blood pressure of 100/70 mmHg and an ICP of
10 mmHg, for example, first calculate the MAP:

Next, calculate the CPP:

90 − 10 = 80 mmHg (the child’s CPP or a normal value)

Parents can have difficulty accepting procedures such as the insertion of

intraventricular catheters or screws. Explaining the brain’s anatomy can help them
understand that the catheter or screw is inserted into a hollow space and thus does not
puncture or tear brain tissue. Be sure to explain that this type of monitoring is
advantageous not only because it enables early detection should problems arise but also
because it helps to reduce the risk of further injury or complications.

THERAPEUTIC MANAGEMENT
The cause of ICP must be identified and remedied as quickly as possible to prevent
brain injury or compression to the brainstem, which can lead to both cardiac and
respiratory failure. Actions such as coughing, vomiting, and sneezing and rapid
administration of intravenous (IV) fluid increase ICP. When a parent is burping an
infant after a feeding, caution them to be careful not to put pressure on the jugular veins
because this is another action that increases ICP. Placing a child in a semi-Fowler’s
position (use an infant seat for babies) or administering a corticosteroid such as
dexamethasone (Decadron) can effectively reduce cerebral edema and its accompanying
pressure. An osmotic diuretic, such as mannitol, given IV, causes a shift of fluid from
extravascular compartments into the vascular stream (from brain tissue into blood
vessels), so it also reduces pressure. Children usually have an indwelling urinary
catheter inserted before beginning an osmotic diuretic to ensure that the child’s kidneys
are able to successfully excrete the intravessel fluid and prevent back pressure on the
heart. If the ICP is caused by excessive fluid accumulating in the brain’s ventricles, a
ventricular tap may be necessary for immediate reduction of pressure.
Because increased ICP is a sign of an underlying disorder, after the pressure is
reduced, the underlying cause must then be identified and rectified or the pressure will
rise again from the original disorder.

3024
Neural Tube Disorders
The neural tube is the embryonic structure that matures to form the CNS. Because this
structure first forms in utero as a flat plate and then molds to form the brain and cord, it
is susceptible to malformation. The disorders that occur as a result, such as spina bifida,
are present at birth and are discussed in Chapter 27.

Neurocutaneous Syndromes
Neurocutaneous syndromes are characterized by the presence of skin or pigment
disorders with CNS dysfunction.

STURGE-WEBER SYNDROME
A child with Sturge-Weber syndrome (encephalofacial angiomatosis) has a congenital
port-wine birthmark on the skin of the upper part of the face that follows the distribution
of the first division of the fifth cranial nerve (trigeminal nerve). Because the lesion is
usually unilateral, the port-wine stain ends abruptly at the midline, although it may
extend inward at that point to the meninges and choroid plexus. If the disorder is limited
to the ophthalmic branch of the fifth nerve, the lesion is usually confined to the upper
aspect of the face.
Because of involvement of the meningeal blood vessels, blood flow can be sluggish,
and anoxia may develop in some portions of the cerebral cortex. The child will develop
symptoms of hemiparesis (numbness) on the side opposite the lesion from destruction
of motor neurons. Intractable seizures, a cognitive challenge, or blindness caused by
glaucoma may also be present. A CT scan or an MRI of the skull usually demonstrates
calcification of the involved cerebral cortex, which appears as a “railroad track” or
double-groove pattern on the CT or MRI screen. An EEG usually shows decreased
voltage in the affected areas.
When this syndrome is first diagnosed, parents may ask to have the skin lesion
surgically removed in the belief that this will correct their child’s condition.
Unfortunately, because the lesion is not just a surface phenomenon, it’s important that
parents understand the need for long-term follow-up, particularly if the child has
accompanying seizures that require long-term antiseizure therapy (Lo, Marchuk, Ball, et
al., 2012).

NEUROFIBROMATOSIS (VON RECKLINGHAUSEN DISEASE)

Neurofibromatosis is the unexplained development of subcutaneous tumors. The
disorder can occur as a mutation or it can be inherited as an autosomal dominant trait
carried on the long arm of chromosome 17. It occurs in approximately 1 of every 4,000
live births and may be diagnosed prenatally (Ardern-Holmes & North, 2011). As an
infant, the child typically shows irregular but excessive skin pigmentation. Later in
childhood, pigmented nevi or café-au-lait (“coffee with cream”) spots appear that tend

3025
to follow the paths of cutaneous nerves (six or more spots larger than 1 cm in diameter
are diagnostic). By puberty, multiple soft cutaneous tumors begin to form in the child’s
skin along nerve pathways, and the child may develop seizures. Subcutaneous tumors
develop by young adulthood. The acoustic nerve (cranial nerve VIII) is frequently
involved, leading to hearing impairment. Involvement of the optic nerve can lead to
vision loss. Approximately 8% of patients become cognitively challenged as a result of
cerebral tumor formation or deterioration. Girls especially need to be aware of the
disorder not only because of its inheritance pattern but also because tumor formation
can increase with pregnancy (Chetty, Shaffer, & Norton, 2011). Little therapy is
available to halt the tumor growth. If lesions are causing acoustic or optic degeneration,
surgical removal of the tumors may be attempted to preserve hearing or sight. Be certain
that both the parents and child have a source of emotional support through the disease’s
slow but invariably fatal course.

Cerebral Palsy
Cerebral palsy (CP) is a group of nonprogressive disorders of upper motor neuron
impairment that result in motor dysfunction. Affected children also may have speech or
ocular difficulties, seizures, cognitive challenges, or hyperactivity. Muscle spasticity
can lead to orthopedic or gait difficulties (Crosbie, Alhusaini, Dean, et al., 2012).
CP is caused by abnormal brain development or damage to the developing brain,
leading to cell destruction of the motor tracts. Nutritional deficiencies, drug use, and
maternal infections such as cytomegalovirus or toxoplasmosis, as well as direct birth
injury, may also contribute to the cause.
CP occurs in approximately 2 of every 1,000 births, most frequently in very-low-
birth-weight infants and those who are small for gestational age; it is increasing in
incidence because of the number of very-low-birth-weight infants who survive today.
Head injury such as from child maltreatment or automobile accidents also may lead to
CP symptoms. Infections such as meningitis or encephalitis can result in CP symptoms
as well.

TYPES OF CEREBRAL PALSY

There are four main types of CP: a pyramidal or spastic type (approximately 40% of
affected children), an extrapyramidal (dyskinetic) type, ataxic, and mixed (Centers for
Disease Control and Prevention, 2017).

Spastic Type
Spasticity is excessive tone in the voluntary muscles that results from loss of upper
motor neurons. A child with spastic CP has hypertonic muscles, abnormal clonus,
exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski
reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the

3026
age at which these usually disappear. If infants with CP are held in a ventral suspension
position, they arch their backs and extend their arms and legs abnormally. They fail to
demonstrate a parachute reflex if lowered suddenly and tend to assume a “scissors gait”
because tight adductor thigh muscles cause their legs to cross when held upright. This
involvement may be so severe that it leads to a subluxated hip. By school age,
tightening of the heel cord can become so severe that children walk on their toes, unable
to stretch their heel to touch the ground (Fig. 49.7).

Figure 49.7 Physical therapy can help a child with cerebral palsy to
lengthen the heel cords. (© Tina Manley/Alamy.)

Spastic involvement may affect both extremities on one side (hemiplegia), all four
extremities (quadriplegia), or primarily the lower extremities (diplegia or paraplegia).
Children with hemiplegia usually have greater involvement in the arm than the leg. The
involved arm may be shorter and may have a smaller muscle circumference than the
other arm. Most children with hemiplegia have difficulty identifying objects placed in

3027
their involved hand when their eyes are closed (astereognosis).
In older children, leg involvement may be detected most easily by examining the
child’s shoes as, because the child does not put the heel all the way down on the
involved side, one shoe heel will be much more worn than the other. On physical
examination, it may be difficult to abduct the involved hip fully, extend the knee, or
dorsiflex the foot.
A child with quadriplegia invariably has impaired speech (pseudobulbar palsy) but
may or may not be cognitively challenged. Swallowing saliva may be so difficult that
the child drools and has difficulty swallowing food (Lewis, 2011).

Dyskinetic or Athetoid Type

The athetoid type of CP involves abnormal involuntary movement (athetoid means
“wormlike”). Early in life, the child appears limp and flaccid. Later, in place of
voluntary movement, children make slow, writhing motions. This can involve all four
extremities plus the face, neck, and tongue. Because of the poor tongue and swallowing
movements, the child drools and speech is difficult to understand. Under emotional
stress, the involuntary movements may become irregular and jerking (choreoid) with
disordered muscle tone (dyskinetic).

Ataxic Type
Children with ataxic involvement have an awkward, wide-based gait. On neurologic
examination, they are unable to perform fine coordinated motions, the finger-to-nose
test, or rapid, repetitive movements (tests of cerebellar function).

Mixed Type
Some children show symptoms of both spasticity and athetoid or ataxic and athetoid
movements. This combination obviously results in a severe degree of physical
impairment.

ASSESSMENT
The diagnosis of CP is based on history and physical assessment. Any episode of
possible anoxia during prenatal life or at birth should be documented. Determining the
extent of involvement in an infant is difficult, so the full extent of the disorder may not
be recognized until the child attempts complex motor skills, such as walking or
coloring.
Children with all forms of CP may have sensory alterations such as strabismus,
refractive disorders, visual perception problems, visual field defects, and speech
disorders such as abnormal rhythm or articulation. They may show an attention deficit
disorder or autism spectrum syndrome. Cognitive challenge and recurrent seizures also
frequently accompany all types of the disorder. A skull X-ray or ultrasound may show
cerebral asymmetry. An EEG may be abnormal, although the pattern is highly variable.

3028
 Nursing Diagnoses and Related Interventions

Parents who are reacting to the news that their child has multiple physical disabilities
often find it difficult to make long-range plans. Therefore, try to focus expected
outcomes on short-term concerns to assist with family functioning.
Nursing Diagnosis: Deficient knowledge related to understanding of complex
disease condition
Outcome Evaluation: Parents state that they understand the cause of the disease is
unknown but it is not progressive.

It’s important for parents to understand that CP is nonprogressive and that the brain
damage that occurred during pregnancy or at birth will not extend. The child’s
condition may seem to grow more apparent with age, however, as the child is
expected to complete fine motor tasks. Without follow-up care, contractures from
spasticity can result, further reducing existing motor function.
Caution parents also that CP is a single name for a wide variety of disorders of
varying consequence. Although another child they know may have such severe CP
that he has no useful function in his extremities, this does not mean their own child
will be affected to the same extent. Conversely, although they know someone with
CP who is able to hold a full-time job, their child may not be able to do so as well.
Each child needs individual assessment so the child’s maximum potential can be
evaluated.
Nursing Diagnosis: Risk for disuse syndrome related to spasticity of muscle groups
Outcome Evaluation: Child walks with a minimum of support or equipment; skin
and tissue remain intact.
Children with CP need promotion of any function that is not already impaired to
prevent further loss of function and allow them to master the highest level of self-
care, communication, ambulation, education, nutrition, and establishment of self-
esteem they can achieve.
Learning to be ambulatory is an important part of self-care because it plays a
large role in determining how independent the child can become. Walking can be
difficult for the child to master because of lack of muscle coordination. Following
surgery to lengthen heel tendons, assisted ambulation devices such as wheeled
walkers may be necessary (Fig. 49.8). There are no drugs that cure CP, but a number
can help relieve spasticity. Dopaminergic drugs, such as carbidopa/levodopa
(Sinemet), widely used in Parkinson disease, increase the level of dopamine and,
therefore, reduce rigidity. Muscle relaxants such as baclofen (Lioresal), given either

3029
orally or administered continuously by an infusion pump, and benzodiazepines such
as diazepam (Valium) can also help with smoother muscle movement (Gray, Morton,
Brimlow, et al., 2012). Administration of botulinum toxin (Botox) has been
successful in some children to relieve spasticity and aid in walking (Placzek, Siebold,
& Funk, 2010). Cerebellar pacemakers and vagal stimulation are future therapy
options.

Figure 49.8 Wheeled walkers give a child added stability for walking
and keep heel cords from shortening. (© fotosearch.com.)

Preventing contractures is vitally important to maintain motor function. To help

avoid these, teach parents that the passive exercises and games their child has been
prescribed are an important part of their child’s therapy and must be done
consistently each day. To further prevent contractures, partial lightweight leg braces
may be prescribed to encourage children to bring their heels down and to keep heel
cords from tightening. If leg braces are prescribed, parents may need some
encouragement and support to insist a child wears them because it is the constant

3030
stretching that offers best results.
Nursing Diagnosis: Risk for self-care deficit related to impaired mobility
Outcome Evaluation: Child feeds and dresses self and manages elimination
independently.
Children need to learn self-care measures such as dressing, tooth brushing, bathing,
and toileting, so they can not only gain self-esteem by accomplishing these tasks but
also achieve optimal independence. Modifications such as straps attached to their
toothbrush or feeding utensils may be necessary so they can hold them more securely.
Advise parents to always supervise children during bathing because lack of
coordination could cause them to slip under water and drown. Toileting is often
difficult because the child does not have the muscle group coordination necessary to
achieve successful bowel evacuation. A high-fiber diet helps prevent constipation and
aids bowel evacuation. Voiding may be equally difficult because the child may lack
sufficient voluntary muscle control.
Parents may need considerable support and guidance to allow a child to complete
self-care tasks independently because doing so often requires extreme patience.
Letting a child perform these activities, however, helps to instill confidence and self-
esteem in the child and helps allow the child to reach his or her maximum potential.
Nursing Diagnosis: Risk for delayed growth and development related to activity
restriction secondary to CP
Outcome Evaluation: Child receives environmental stimulation; expresses interest
in people and activities around him or her; attends school setting that is as free of
restrictions as possible.
Children with CP may be unable to pursue stimulating activities and surroundings
because they are not fully mobile. Therefore, encourage parents to bring these things
to them as well as be certain that toys and activities are appropriate to the child’s
intellectual, developmental, and motor levels, not the child’s chronologic age. Some
children need more stimulating activities than others because they have difficulty
concentrating on one activity for any length of time.
A preschool program is important to provide exposure to the outside world. If at
all possible, school-age children with CP should be mainstreamed so that they can
learn alongside other children. You may need to advocate that a child be placed in a
school setting that is consistent with intellectual abilities.
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements,
related to difficulty sucking in infancy or difficulty feeding self in an older child
Outcome Evaluation: Child’s weight remains within 5th to 95th percentile on
height–weight chart; skin turgor remains good; specific gravity of urine is 1.003 to
1.030.

3031
 Providing adequate nutrition to children with CP can be difficult because they often
have difficulty sucking because uncoordinated movements of the tongue, lips, and
jaw and tongue thrusting make this difficult. They may tend to push food out of their
mouth (a retained primitive reflex) rather than swallow smoothly. Older children may
have difficulty holding and controlling a spoon to bring food to their mouths. Parents
may need guidance in finding a feeding pattern that works for their child. Manually
controlling the jaw may help control the head, correct neck and trunk hyperextension,
and stabilize the jaw to assist with feeding. If a child cannot chew or swallow well, a
liquid or soft diet may be necessary. A hyperactive gag reflex or symptoms of
gastroesophageal reflux may cause children to vomit after feeding. Positioning
infants upright after feeding helps to prevent aspiration if vomiting occurs.
Nursing Diagnosis: Impaired verbal communication related to neurologic
impairment
Outcome Evaluation: Child can verbally make needs known to strangers and family
members.
Most children with CP benefit from speech therapy, which helps them learn to speak
slowly and to coordinate their lips and tongue to form speech sounds. Be patient
when talking to them so they feel comfortable taking their time to form words
deliberately. For the child who cannot speak clearly, provide an alternative form of
communication, such as flash cards, a picture board, or a touch-screen computer, to
aid communication.

LONG-TERM CARE
Because CP is not always diagnosed early in infancy, parents may not learn their child
has a chronic disorder until 2 to 4 years later. Listen to parents during healthcare visits
and encourage them to discuss the difficulties of daily living, such as feeding problems.
Offer them support as needed if they grieve because their child is not able to accomplish
all of the major things they had wished for during pregnancy or feel defeated by the
day-to-day strain of caring for their child’s multiple special needs. Care of a child with a
chronic illness is discussed further in Chapter 56.

QSEN Checkpoint Question 49.3

INFORMATICS
Tasha’s sister Wanda was diagnosed with CP as an infant. What information would
the nurse want her parents to know about her prognosis?
a. Symptoms of CP typically begin to wane just after puberty.
b. The severity of cognitive deficits parallels the severity of physical deficits.
c. CP may occasionally be caused by a childhood vaccine reaction.
d. Symptoms may seem to grow worse as fine motor skill is needed.

3032
 Look in Appendix A for the best answer and rationale.

Infection
Infection of the nervous system is always potentially serious. It typically occurs from
illnesses such as meningitis, encephalitis, Guillain-Barré syndrome, Reye syndrome,
and botulism.

BACTERIAL MENINGITIS
Meningitis is, as the name implies, infection of the cerebral meninges. It tends to occur
most frequently in children younger than 24 months of age and most often in winter.
The organisms most frequently seen are Streptococcus pneumoniae or group B
Streptococcus. In children younger than 2 months of age, Escherichia coli is a common
cause. If children with myelomeningocele develop meningitis, Pseudomonas infection
may be the causative agent. Children who have had a splenectomy are particularly
susceptible to pneumococcal meningitis unless they have received a pneumococcal
vaccine. Haemophilus influenzae, once a major cause of meningitis, is now rarely seen
because of routine immunization against this organism (Greenberg-Kushnir, Haskin,
Yarden-Bilavsky, et al., 2012).
Pathologic organisms usually spread to the meninges from upper respiratory tract
infections by lymphatic drainage possibly through the mastoid or frontal sinuses or by
direct introduction through a lumbar puncture or skull fracture. Once organisms enter
the meningeal space, they multiply rapidly and then spread throughout the CSF to
invade brain tissue through the meningeal folds, which extend down into the brain itself.
Brain abscess or invasion of the infection into cranial nerves can result in blindness,
hearing impairment, or facial paralysis. If a thick exudate accumulates in the narrow
aqueduct of Sylvius, it can cause obstruction leading to hydrocephalus. Brain tissue
edema can put pressure on the pituitary gland, causing increased production of
antidiuretic hormone, resulting in the syndrome of inappropriate antidiuretic hormone
secretion (SIADH), causing hyponatremia.

Assessment
Children usually have had 2 or 3 days of upper respiratory tract infection prior to the
development of meningitis. They then grow increasingly irritable because of an intense
headache. They experience sharp pain when they bend their head forward. In the
newborn, symptoms such as poor sucking, weak cry, or lethargy develop. As the disease
progresses, signs of meningeal irritability then occur, as evidenced by positive
Brudzinski and Kernig signs.
Children may hold their back arched and their neck hyperextended (opisthotonos). If
third and sixth cranial nerve paralysis occurs, a child will not be able to follow a light
through full visual fields. If the fontanelles are open, they bulge upward and feel tense;

3033
if they are closed, papilledema may develop. If the meningitis is caused by H.
influenzae, the child may develop septic arthritis. If it is caused by Neisseria
meningitidis, a papular or purple petechial skin rash may occur (Pace & Pollard, 2012).
After this beginning of a myriad of general symptoms, sudden cardiovascular shock,
seizures, nuchal rigidity, or apnea can occur. Because the infant has open fontanelles,
nuchal rigidity appears late and is not as useful a sign for diagnosis as in the older child.
As a rule, a child with a high temperature who then has a seizure is assumed to have
meningitis until CSF findings prove otherwise.
CSF analysis obtained by lumbar puncture confirms the diagnosis. CSF results
indicative of meningitis include increased white blood cell and protein levels, increased
ICP, and a glucose level less than 60% of blood glucose (because bacteria have fed on
the glucose). In addition to supplying blood for glucose level, blood is cultured and
examined for increased WBC count. If the child has had close association with someone
with tuberculosis, a tuberculin skin test to rule out tuberculosis meningitis will be done.
A CT scan, MRI, or ultrasound study will be prescribed to examine for brain abscess.

Therapeutic Management
Antibiotic therapy as indicated by sensitivity studies is the primary therapy. Intrathecal
injections (directly into the CSF) may also be necessary, especially because the blood–
brain barrier may prevent the chosen antibiotic from passing freely into the CSF. In
some children, it takes a month before the CSF cell count returns to normal. A
corticosteroid such as dexamethasone or the osmotic diuretic mannitol may be
administered to reduce ICP and help prevent hearing loss.
In addition to standard precautions, children with meningitis are placed on
respiratory precautions for 24 hours after the start of antibiotic therapy to prevent
transmission of the infection to other family members or healthcare providers. In
addition, an antibiotic may be prescribed prophylactically for the child’s immediate
family members or for playmates who have been in close contact with the child.
Meningitis is always a serious disorder because it can run a rapid, fulminating, and
possibly fatal course. If symptoms are recognized early and treatment is effective,
however, a child will recover with no sequelae. Neurologic sequelae, such as learning
problems, seizures, hearing and cognitive challenges, and inability to concentrate urine
from lessened antidiuretic hormone secretion, must be assessed in the weeks to come
because these can be long-term consequences.

What If . . . 49.1
The cause of Tasha’s seizure is found to be bacterial meningitis. Because she
has severe neck pain whenever she is moved, her mother asks the nurse not to
be so concerned about measuring intake and output, so her daughter can rest.
How should the nurse respond? The nurse calls Tasha’s name and she does not
answer. Why is this a particular cause of concern in a child with meningitis?

3034
 Nursing Diagnoses and Related Interventions

If a child has meningitis, the parents may feel responsible for the illness because they
knew the child had an upper respiratory infection. They may ask if they could have
prevented meningitis if only they had taken the child to their primary care provider as
soon as the respiratory symptoms began. You can assure them the symptoms of
meningitis occur so insidiously that no one can appreciate what disease process is at
work from the first generalized signs.
Be certain to orient parents to infection control techniques if the child is isolated
so they can feel comfortable caring for their child.
Nursing Diagnosis: Pain related to meningeal irritation
Outcome Evaluation: Child states pain is tolerable and shows no facial grimacing or
other signs of discomfort.
For a child with meningitis, dealing with the number of invasive procedures, such as
lumbar puncture, venipuncture, and IV therapy, necessary can make a hospital stay
difficult. Remember that children feel pain when their head is flexed forward, so they
usually are more comfortable without a pillow. Be careful not to flex their neck
forward when turning or positioning them.
Although children would probably benefit from puppet play or coloring, activities
that could help them express how they feel about so many intrusive procedures,
frequently, they are too uncomfortable to play and thus are not able to be comforted
by these measures. Be certain that children receive a good explanation of everything
that is happening and extra attention from healthcare personnel not just when they
perform painful procedures but so children can feel secure. Help parents understand
that their child’s acute irritableness is caused by the disease process and not by
anything they did or are doing so they can continue to interact with the child. You can
assure them that, as their child recovers, irritability will lessen and the child will
begin to show more interest in communicating feelings. Promote rest by keeping
stimulation in the room to a minimum.
Nursing Diagnosis: Risk for ineffective tissue perfusion (cerebral), related to
increased ICP
Outcome Evaluation: Child’s vital signs return to normal; child is alert and oriented;
motor, cognitive, and sensory functions are within acceptable parameters for the
child’s age; specific gravity of urine is 1.003 to 1.030.
Observe the child carefully for signs of increased ICP such as increased blood
pressure or slowed pulse rate. Carefully monitor the rate of all IV infusions to prevent
overhydration and increased ICP. Measure urine specific gravity to detect

3035
 oversecretion or undersecretion of antidiuretic hormone because of pituitary pressure.
Measure the child’s head circumference and weigh the child daily. Monitor hearing
acuity (reduced if there is compression of the eighth cranial nerve) by asking an older
child a question or observing whether an infant listens to a music box or to your
voice.

GROUP B STREPTOCOCCAL INFECTION

A major cause of meningitis in newborns is group B streptococci. The organism is
contracted either in utero or from secretions in the birth canal. It can spread to other
newborns in a hospital nursery if good hand washing technique is not used.
Colonization can result in either an early-onset or a late-onset illness. With the
early-onset form, symptoms of pneumonia become apparent in the first few hours of
life. The late-onset type leads to meningitis instead of pneumonia.
With meningitis, at approximately 2 weeks of age, the infant gradually becomes
lethargic and develops a fever and upper respiratory tract symptoms. The fontanelles
bulge from increased ICP. The disease is extremely serious as mortality from the
infection is approximately 25%; surviving infants may develop neurologic
consequences such as hydrocephalus or seizures (Libster, Edwards, Levent, et al.,
2012). Treatment is with antibiotics that are effective against the group B Streptococcus,
such as ampicillin and cephalosporins. Because it can be difficult for parents to
understand how their infant suddenly became so ill, they may need considerable support
in immediately caring for the infant or if the infant is left neurologically challenged.

QSEN Checkpoint Question 49.4

QUALITY IMPROVEMENT
Tasha is diagnosed as having bacterial meningitis, and her plan of care is being
amended in light of this diagnostic finding. How long should the care team maintain
respiratory precautions for this condition after Tasha begins an antibiotic?
a. 4 hours
b. 24 hours
c. Until her core body temperature returns to normal
d. Until her arterial blood gases return to normal
Look in Appendix A for the best answer and rationale.

ENCEPHALITIS
Encephalitis is an inflammation of brain tissue and, possibly, the meninges as well
(Kneen, Michael, Menson, et al., 2012). It can arise from protozoan, bacterial, fungal, or
viral invasions. Enteroviruses are the most frequent cause, followed by arboviruses.
Several encephalitis viruses, such as those that cause St. Louis encephalitis, West Nile

3036
encephalitis, and Eastern equine encephalitis, are borne by mosquitoes and thus are seen
most often during the summer months. Encephalitis also can result from direct invasion
of the CSF during lumbar puncture. Yet, another cause is as a complication of
childhood diseases such as measles, mumps, or chickenpox. In order to prevent the
disease, therefore, it is crucial children receive immunization against childhood diseases
and use mosquito repellents when in mosquito-infested areas.

Assessment
Symptoms of encephalitis begin either gradually or suddenly and include symptoms
such as headache, high temperature, ataxia (loss of usual muscle movements), muscle
weakness or paralysis, diplopia, confusion, and irritability; if meninges are also
involved, signs of meningeal irritation, such as nuchal rigidity and a positive Brudzinski
or Kernig sign, may also be present. A child becomes increasingly lethargic and
eventually comatose.
The diagnosis is made by the history and physical assessment. CSF evaluation will
reveal an elevated leukocyte count and an elevated protein level. An EEG will
demonstrate widespread cerebral involvement. A brain biopsy, usually taken from the
temporal lobe or infected CSF, identifies the virus.

Therapeutic Management
Treatment for a child with encephalitis is primarily supportive. An antipyretic is
prescribed to control fever. Mechanical ventilation may be required to maintain the
child’s respirations during the acute phase. A variety of medications, such as acyclovir
(Zovirax), an antiviral agent, and carbamazepine (Tegretol), an anticonvulsant, may be
prescribed. A steroid such as dexamethasone or an osmotic diuretic such as mannitol
may be needed to decrease brain edema and ICP.
Encephalitis is always a serious diagnosis because although a child may recover
from the initial attack without further symptoms, there can be residual neurologic
damage, such as seizures or learning disabilities. Parents may find it hard to believe
their child is so seriously ill at first because in the beginning of the illness, their child
only seemed tired and had a slight headache. They can find it even harder to accept that
permanent impairment, such as a learning disability, could result. This makes follow-up
care after hospitalization important both for the child’s rehabilitation and to help parents
deal with their grief, shock, and possible anger over this devastating turn of events in
their life.

REYE SYNDROME
Reye syndrome is acute encephalopathy with accompanying fatty infiltration of the
liver, heart, lungs, pancreas, and skeletal muscle. It occurs in children from 1 to 18 years
of age regardless of gender (Ninove, Daniel, Gallou, et al., 2011).
The cause is unknown, but symptoms such as lethargy, vomiting, confusion, and

3037
combativeness usually occur after a viral infection such as varicella (chickenpox) or
influenza that was treated with acetylsalicylic acid (aspirin). Treatment is supportive.
Untreated, the condition leads to coma and death. Anticipatory guidance to parents and
children about avoiding the use of aspirin during viral infections has almost prevented
the syndrome (Bennett, Starko, Thomsen, et al., 2012).

GUILLAIN-BARRÉ SYNDROME
Guillain-Barré syndrome (inflammatory polyradiculoneuropathy) is a perplexing
syndrome that occurs in about 1 in every 100,000 children. Both motor and sensory
portions of peripheral nerves are affected. Boys develop it more often than girls (Yuki
& Hartung, 2012). With successful widespread polio eradication efforts, Guillain-Barré
syndrome is now the most common cause of acute and subacute flaccid paralysis in
childhood (Rosen, 2012).
The cause of the condition is unknown, but it is suspected that the reaction is
immune mediated, occurring after upper respiratory tract or gastrointestinal illnesses or,
rarely, immunizations. Inflammation of the nerve fibers apparently causes temporary
demyelization of the nerve sheaths.

Assessment
Children experience peripheral neuritis several days after the primary infection. Tendon
reflexes begin to decrease and then become absent. Muscle paralysis and paresthesia
(loss of sensation) begin first in the legs and then spread to involve the arms, trunk, and
head. The symmetric nature of the disorder helps to differentiate it from other types of
paraplegia. Cranial nerve involvement leads to facial weakness and difficulty in
swallowing. As the respiratory muscles become involved, spontaneous respirations are
no longer possible, leading to respiratory involvement severe enough to warrant
mechanical ventilation.
A significant laboratory finding is an elevated CSF protein level. An EEG may
show denervation and decreased nerve conduction velocity.

Therapeutic Management
Treatment of Guillain-Barré syndrome is supportive until the paralysis peaks at 3 weeks
and then is followed by gradual recovery. A course of prednisone to halt the
autoimmune response may be tried, but its use is controversial. Plasmapheresis or
transfusion of immune serum globulin may shorten the course of the illness. Cardiac
and respiratory function must be closely monitored. All patients should be given
subcutaneous fractionated or unfractionated heparin and support stockings until they are
able to walk independently to prevent deep vein thrombosis.
Other necessary measures include prevention of the effects of extreme immobility
while guarding respiratory function. An indwelling urinary catheter is usually inserted
to monitor urine output. Enteral or total parenteral nutrition may be used to support

3038
protein and carbohydrate needs. If the child has discomfort from neuritis, adequate
analgesia is necessary.
To prevent muscle contractures and effects of immobility, turning and repositioning
every 2 hours is important in addition to passive range-of-motion exercises about every
4 hours. Be certain to provide adequate stimulation for the long weeks when the child is
unable to perform any care independently. Fortunately, despite the long period of
mandatory ventilation therapy, most children recover completely, without any residual
effects of the syndrome, although some may continue to have minor problems such as
residual weakness.

BOTULISM
Botulism occurs when spores of Clostridium botulinum colonize and produce toxins in
the intestine. Infant botulism is not transmitted from person to person and occurs
predominantly in infants younger than 6 months of age (American Academy of
Pediatrics, 2015). Honey has been identified as a common source for infant botulism
and should not be given prior to 12 months of age (American Academy of Pediatrics,
2015).
Symptoms occur within a few hours after ingestion of the contaminated food.
Almost immediately, there is generalized weakness, hypotonia, listlessness, a weak cry,
and a diminished gag reflex, followed by a flaccid paralysis of the bulbar muscles that
leads to diminished respiratory function. The organism can be cultured from stools or
serum. Electromyography may be helpful to support the diagnosis. Treatment is
supportive care. Human-derived botulinum immune globulin may stop the progress of
the disease.

Inflammatory Disorders
Two neurologic inflammatory disorders are found frequently in adolescents.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is nerve compression of the median nerve that passes through
the carpal tunnel at the wrist (Luckhaupt, Dalhamer, Ward, et al., 2013). Compression
of the nerve causes numbness and sharp pain and burning in the thumb and the second,
third, and fourth fingers of the hand. Word processing, texting, and video games have
turned this previously adult disorder into a disorder that occurs in children as well. Pain
usually occurs at night and is enough to keep a child awake. The usual therapy is
application of a splint to the wrist, which holds the wrist in a neutral (not flexed and not
extended) position. An oral anti-inflammatory medication and perhaps a corticosteroid
injection into the inflamed wrist both help to relieve pain. If these therapies are not
successful, the stricture at the carpal canal can be relieved surgically.

3039
FACIAL PALSY (BELL PALSY)
Facial palsy is facial paralysis of the seventh (facial) cranial nerve, the nerve that
innervates the muscles of facial expression. The syndrome occurs abruptly and may be
associated with herpes or Lyme disease infection or occur as a result of cold air from
skiing or from riding in a convertible. Therapy in adults consists of prednisone to reduce
inflammation and acyclovir if the syndrome is herpes related. In children, prednisone
use is variable. If the child is unable to close the eye on the affected side, eye drops
three or four times daily will be needed. Although recovery is slow, usually takes about
4 months, most children recover without any permanent disability (McNamara, Doyle,
McKay, et al., 2013).

Paroxysmal Disorders
A paroxysmal disorder is one that occurs suddenly and recurrently. Seizures, headaches,
and breath-holding spells are the most frequent types seen in childhood.

EPILEPSY (RECURRENT SEIZURES)

A seizure is an involuntary contraction of muscle caused by abnormal electrical brain
discharges. Approximately 5% of children will have at least one seizure by the time
they reach adulthood (Sidhu, Velayudam, & Barnes, 2013). These episodes are always
frightening to parents and other children because of the intensity. Although about 50%
of seizures are idiopathic (unknown cause), they also can be attributed to infection,
trauma, or tumor growth. Familial or polygenic inheritance may be responsible. Because
they are not so much a disease as a symptom of an underlying disorder, all seizures need
to be investigated.
The term epilepsy comes from a Greek word meaning “to take hold of.” Because the
word has stigmas of cognitive challenge, behavioral disorders, institutionalization, or
unexplainable strangeness attached to it, a preferred term is recurrent seizures because
this term explains the disease process without the effect of discrimination (Box 49.4).

BOX 49.4
Nursing Care Planning to Respect Cultural Diversity

The degree of understanding about the cause of disorders such as recurrent seizures
varies in different cultures. The often unknown cause of recurrent (idiopathic)
seizures has led to them being attributed to an invasion by evil spirits or the effect of
curses. Many people today still fear that recurrent seizures will lead to cognitive
impairment. Many parents worry that their child will be refused admission to a school
or refused a job as an adult because their child is viewed as so unpredictable. Being
aware of these common misconceptions can help you appreciate parents’ anxiety
about the diagnosis of recurrent seizures, an anxiety that can accentuate the need for

3040
 parent education and careful planning to maintain self-esteem in their child.

The types and causes of seizures vary with age and are classified into two major
categories: partial and generalized seizures. As the name implies, with partial seizures,
only one area of the brain is involved; with generalized seizures, the disturbance appears
to involve the entire brain; loss of consciousness usually occurs. It’s important that
seizures be differentiated by their degree of severity and type so that parents can know
any special precautions they need to take for their child and appropriate management
and drug therapy can be instituted.

Seizures in the Newborn Period

Seizure activity in the newborn period may be difficult to recognize because it may
consist only of twitching of the head, arms, or eyes; smacking of the lips; slight
cyanosis; and perhaps respiratory difficulty or apnea. Afterward, the infant may appear
limp and flaccid. Whereas seizures in older children are often of unknown cause, 75%
of seizures in neonates have a known cause such as trauma and anoxia from intrauterine
life or birth; metabolic disorders, such as hypoglycemia, hypocalcemia, or lack of
pyridoxine (vitamin B6); neonatal infection; or acute bilirubin encephalopathy caused
by a blood incompatibility.
Because of the nervous system’s immaturity, EEGs in the newborn may be normal
despite extensive disease. A noticeably abnormal EEG in the newborn period, therefore,
generally means a poor prognosis, indicating that involvement this early in life must be
severe. Because almost 20% of all newborns have abnormal CSF values compared with
adult standards (protein is increased, and there may be a few red blood cells from
rupture of subarachnoid capillaries from the pressure of birth), lumbar puncture also is
not conclusive.
High doses of antiseizure medication may be needed to control seizures in newborns
because they metabolize drugs more rapidly than older children. In adults, for example,
phenobarbital may be administered in the range of 1.5 mg/kg body weight per day. In
newborns, the dose might be as high as 3 to 10 mg/kg/day.

Seizures in the Infant and Toddler Periods

Seizures commonly seen in this age group are infantile spasms, a form of generalized
seizure often called “salaam” or “jackknife” seizures, or infantile myoclonic seizures.
These are characterized by very rapid movements of the trunk with sudden strong
contractions of most of the body, including flexion and adduction of the limbs, or the
infant suddenly slumps forward from a sitting position or falls from a standing position.
The episode may occur singly or in clusters as frequently as 100 times a day.
In approximately 50% of affected children, there is an identifiable cause such as
trauma, a metabolic disease such as phenylketonuria, or a viral invasion such as herpes
or cytomegalovirus. In other children, the spasms apparently result from a failure of

3041
normal organized electrical activity in the brain. Approximately 90% of infants with this
type of involvement will be developmentally delayed as intellectual development
appears to halt and even regress after the pattern of seizures begins. Most children with
infantile spasms show high-amplitude slow waves and spikes, a chaotic discharge called
hypsarrhythmia on an EEG tracing.
These seizures occur slightly more often in males than females, occur in 2 to 3 per
10,000 live births, have a family history in 3% to 6% of cases, and only spontaneously
stop in 30% of children (Go, Mackay, Weiss, et al., 2012). Because the response to
treatment with antiseizure therapy tends to be poor, parenteral adrenocorticotropic
hormone (ACTH) therapy, prednisone, or high-dose vigabatrin, an amino acid, are used
in its place. High-dose valproate or a newer antiseizure agent such as topiramate
(Topamax) may be used in children who do not respond to usual therapy, as well as
pyridoxine (vitamin B6) or a ketogenic diet (see following discussion), but research
shows none to be as effective as ACTH, especially for preserving neurodevelopmental
outcomes (Go et al., 2012). In most children, the seizure phenomenon seems to “burn
itself out” by 2 years of age. Any associated cognitive or developmental delay remains,
however, so children need good follow-up planning and care.

Seizures Caused by Poisoning or Drugs

The possibility of poisoning has to be considered in any child who has a first seizure.
Although this is most likely to occur between 6 months and 3 years of age, it must be
considered again in adolescence, when drugs may be intentionally self-administered.
Seizures also can be a late symptom of encephalopathy caused by lead poisoning (see
Chapter 52).

Seizures in Children Older Than 3 Years of Age

Febrile Seizures
Seizures associated with high fever (102° to 104°F [38.9° to 40.0°C]) are the most
common type seen in preschool children, although these can occur as late as 7 years of
age. They are most serious if they occur under 6 months of age. Such seizures may
occur after immunization with live vaccines because these most commonly produce
fevers. The seizure is usually a generalized tonic–clonic pattern, which lasts for 15 to 20
seconds. An EEG tracing afterward is usually normal. There also is usually a history of
other family members having had similar seizures.
The seizure is due to a sudden spike of temperature, not a gradual incline. The
seizure only lasts 1 to 2 minutes or less. Further evaluation is necessary after a febrile
seizure to exclude underlying conditions or infections (Sidhu et al., 2013).

Prevention of Febrile Seizures

Because these seizures arise with high fever, they are largely preventable. If ibuprofen
or acetaminophen is given to keep a developing fever below 101°F (38.4°C), the

3042
seizures rarely occur. They happen most often when a child develops a fever at night,
when a parent is not aware of it, or when a parent is reluctant to give ibuprofen or
acetaminophen in large enough doses to be therapeutic. Because the recommended
doses of these medicines vary with the type (liquid or pills), caution parents to read the
bottle label carefully before administration to be certain they are administering the
correct dosage. Family history and younger age at onset of first seizure are risk factors
for reoccurrence of a febrile seizure.
Teach parents that every child who has a febrile seizure must be seen by a
healthcare provider to rule out meningitis and to be aware that it will be assumed by
emergency room personnel that the child has meningitis until it is ruled out by a
complete neurologic workup.

Therapeutic Management
After a febrile seizure subsides, parents should sponge the child with tepid water to
reduce the fever quickly. Advise them not to put the child in a bathtub of water to do
this because it would be easy for the child to slip under water should a second seizure
occur. Caution parents not to apply alcohol or cold water because extreme cooling
causes shock to an immature nervous system; in addition, alcohol can be absorbed by
the skin or the fumes can be inhaled in toxic amounts, compounding the child’s
problems. Parents should not attempt to give oral medications such as acetaminophen
because the child will be in a drowsy, or postictal, state after the seizure and might
aspirate the medicine. Suppositories may be given at the appropriate dose. If attempts to
reduce the child’s temperature by sponging are unsuccessful, advise parents to put cool
washcloths on the child’s forehead, axillary, and groin areas and transport the child,
lightly clothed, to a healthcare facility for immediate evaluation.
At the healthcare facility, a lumbar puncture will be performed to rule out
meningitis. If warranted, antipyretic drugs to reduce the fever below seizure levels will
be administered. Appropriate antibiotic therapy will be prescribed if an infection is
documented.
Many parents need to be reassured that febrile seizures do not lead to brain damage
and that the child is almost always completely well afterward.

What If . . . 49.2
Tasha’s mother refuses to allow her to play with other children because
she’s worried Tasha will contract an upper respiratory infection from one of
them and then have a febrile seizure. Is the mother taking a safe precaution or
overreacting to the possibility of a seizure?

Complex Partial (Psychomotor or Temporal Lobe) Seizures

More than half of children who develop recurrent seizures during school age have an

3043
idiopathic type or the cause of the seizures cannot be discovered. Despite this,
medication can effectively control these seizures in almost all affected children. Some
seizures in this age group occur because of organic causes such as laceration of brain
tissue from an automobile accident or fall, an enlarging brain tumor, hemorrhage due to
a blood dyscrasia, infection (meningitis or encephalitis), anoxia, or toxic conditions
such as lead poisoning that have left residual damage. The possibility that brain trauma
could have been caused by child maltreatment is always another possibility to consider.
Complex partial (psychomotor) seizures vary greatly in extent and symptoms and
tend to be a difficult type to control. The child may notice a slight aura, or sensation a
seizure is about to occur, but this is rarely as definite as that seen with tonic–clonic
seizures. Results of a CT or MRI scan and EEG will invariably be normal.
This type of seizure often begins with a sudden change in posture, such as an arm
dropping suddenly to the side. Other motor, sensory, and behavioral signs might include
automatisms (complex purposeless movements, such as lip smacking, fumbling hand
movements, intense running, or screaming). A few children may then slump to the
ground, unconscious. Circumoral pallor develops due to a halt in respirations. The child
begins breathing again almost immediately and usually regains consciousness in less
than 5 minutes. He or she may feel slightly drowsy afterward but does not have an
actual postictal stage or a period of sustained unconsciousness as seen with tonic–clonic
seizures.
Common drugs used to treat this type of seizure include carbamazepine (Tegretol)
(Box 49.5) or valproate (Depakene). Carbamazepine can lead to neutropenia, so white
blood cell counts need to be monitored during therapy. If these drugs are not effective,
surgery to remove the epileptogenic focus or the implantation of a vagus nerve
stimulator can be used to significantly reduce seizure frequency. If seizures cannot be
controlled fully, parents need to anticipate potentially hazardous situations during their
child’s day, such as having to cross a busy street on the way to school or riding a
bicycle. State regulations vary, but the majority of adolescents are not eligible to secure
a permit to drive until they are cleared by their primary care provider (after about a year
free of seizures) to protect their own safety and that of others.

BOX 49.5
Nursing Care Planning Based on Responsibility for Pharmacology

CARBAMAZEPINE (TEGRETOL)
Classification: Carbamazepine is an antiseizure medication.
Action: Exact mechanism of action is unknown, but it is believed to inhibit
polysynaptic responses and block post-tetanic potentiation (Karch, 2013).
Pregnancy Risk Category: C
Dosage: Initially in children 6 to 12 years of age, 10 mg/kg/24 hr orally twice a day
on the first day (maximum dose 100 mg), increased gradually in 100-mg increments

3044
 at 1-week intervals until best response is achieved, or 10 to 30 mg/kg/day in divided
doses three or four times a day. Not to exceed 1,000 mg/day.
Possible Adverse Effects: Dizziness, drowsiness, behavioral changes, nausea,
vomiting, abnormal liver function tests, bone marrow depression, rash,
photosensitivity
Nursing Implications
• Advise parents to administer the drug with food to minimize gastrointestinal
upset.
• Remind parents to obtain serum drug levels as prescribed to monitor for
effectiveness and to prevent possible toxicity; also, obtain liver function
studies and blood cell counts to detect marrow depression.
• Suggest that parents obtain a medical alert bracelet and have the child wear it
in case of a seizure.
• Instruct parents to not give sleep-inducing or over-the-counter drugs because
these can interact with antiseizure medication to cause dangerous synergistic
effects. Caution adolescents to avoid alcohol.
• Caution parents not to discontinue the drug abruptly or change the dose unless
ordered by the healthcare provider.
• Instruct parents to notify their healthcare provider if the child develops
bruising, bleeding, or signs of infection because these could be signs of bone
marrow depression.

Partial (Focal) Seizures

Partial seizures originate from a specific brain area. A typical partial seizure with motor
signs begins in the fingers and spreads to the wrist, arm, and face in a clonic
contraction. If the movement remains localized, there will be no loss of consciousness.
If the spread is extensive, the seizure can cross the midline and become generalized and,
at that point, is impossible to differentiate from a full generalized tonic–clonic seizure.
This makes it important, therefore, to observe children carefully as a seizure begins to
distinguish whether it began with local signs such as numbness, tingling, paresthesia, or
pain all associated with one brain area. Documenting the spread can help localize the
spot in the brain that first initiated the abnormal electrical discharge or be instrumental
in detecting the location of a rapidly growing brain tumor.

Absence Seizures
Absence seizures are one form of generalized seizures, formerly known as petit mal
seizures (Sidhu et al., 2013). They occur more often in girls than boys, usually occur in
school-age children between 4 and 12 years, and consist of a staring spell that lasts for a
few seconds. A child might be reciting in class, for example, when he or she pauses and
stares for 1 to 5 seconds and then continues the recitation as if he or she is unaware time

3045
has passed. Rhythmic blinking and twitching of the mouth or an extremity may
accompany the staring. As many as 100 seizures can occur during a day.
Children with absence episodes usually have normal intelligence but may have
failing school marks, be accused of daydreaming in school, or be referred to the school
nurse for behavior problems because they miss so many of a teacher’s instructions.
On a neurologic exam, the presence of absence seizures can usually be demonstrated
by asking a child to hyperventilate while the child counts out loud. If the child is
susceptible to such seizures, he or she typically breathes in and out deeply, possibly 10
times, stops and stares for 3 seconds, and then continues to hyperventilate and count,
unaware that he or she paused.
No first aid measures are necessary for absence seizures, and downplaying the
importance of these episodes helps children maintain a positive self-image. They can be
controlled by ethosuximide (Zarontin), valproate, or “off-label” lamotrigine (Robotham,
2011). If seizures are fully controlled by medication, children can participate in normal
school activities and ride a bicycle or motorcycle. If seizures cannot be controlled fully,
parents need to anticipate potentially hazardous situations during the child’s day to
prevent risky activities such as swimming alone.
Approximately one third to one half of all children with absence seizures “outgrow”
them by adulthood. This does not mean that treatment is not necessary during
childhood, however, in order to keep the child safe and maintain self-esteem. Follow-up
health supervision is necessary during adolescence because some children’s seizure
pattern changes from absence involvement to tonic–clonic involvement as they
approach adulthood.

Tonic–Clonic Seizures
Typical tonic–clonic seizures (formerly termed grand mal seizures) are generalized
seizures usually consisting of three stages: a prodromal period of hours or days or an
aura, or warning, immediately before the seizure that a seizure is about to occur; a
tonic–clonic stage; and, finally, a postictal stage.
The prodromal period may consist of drowsiness, dizziness, malaise, lack of
coordination, or tension. As a child reaches school age, the child may be able to predict
from these vague preliminary feelings when a seizure is about to occur.
An aura reflects the portion of the brain in which the seizure originates. Smelling
unpleasant odors (often reported as feces) denotes activity in the medial portion of the
temporal lobe. Seeing flashing lights suggests the occipital area, repeated hallucinations
arise from the temporal lobe, numbness of an extremity relates to the opposite parietal
lobe, and a “Cheshire-cat grin” relates to the frontal lobe. Young children, unable to
describe or understand an aura, may scream in fright or run to their parent at its onset.
Noting exactly what symptoms the child experiences during this time helps to localize
the involved brain portion.
The next phase is the tonic stage. All muscles of the body contract, extremities
stiffen, the face distorts, air is pushed through the glottis from contraction of the chest

3046
muscles to produce a guttural cry, and the child falls to the ground. Although this phase
lasts only about 20 seconds because the respiratory muscles remain contracted during
this time, the child may experience hypoxia and begin to appear cyanotic. Contraction
of the throat prevents swallowing, so saliva collects in the mouth. A few children bite
their tongue when the jaws contract and thus have bleeding from their mouth.
The seizure then enters a clonic stage, in which muscles of the body rapidly contract
and relax, producing quick, jerky motions. The child may blow bubbles from foamy or
bloody saliva and will be incontinent of stool and urine. This phase usually lasts 20 to
30 seconds.
Following this tonic–clonic period, the child falls into a sound sleep, the postictal
period. He or she will sleep soundly for 1 to 4 hours rousing only to painful stimuli.
When children awake, they often experience a severe headache. They have no memory
of the seizure.
In some children, seizures occur only at night. The child wakes in the morning with
a sore tongue, blood on the pillow, or a bed wet with urine. In a child with persistent
bed-wetting, the possibility this may be occurring from nocturnal seizures should be
considered.
Children with this type of seizure may or may not have an abnormal EEG pattern. If
an abnormal pattern is found, other family members may be found to have similarly
abnormal EEG patterns, although they do not have symptoms.
Therapy includes the daily administration of an antiseizure medication such as
valproate (Depakene) and carbamazepine (Tegretol). Phenobarbital may be
administered to young children.
Medications are usually continued until the child has been seizure free for 2 to 3
years. No antiseizure medication should be stopped suddenly (it should be tapered)
because rapid withdrawal may precipitate a seizure. In addition to medication, some
children may be prescribed a ketogenic diet or a diet high in fat and low in protein and
carbohydrate. This diet is proven to be highly effective in 40% to 50% of children who
are started on it. This diet is difficult for parents to adhere to and to incorporate into the
family’s lifestyle and may need to be “fine-tuned” to improve seizure control (Selter,
Turner, Doerrer, et al., 2014).

Status Epilepticus
Status epilepticus refers to a seizure that lasts continuously for longer than 30 minutes
or a series of seizures from which the child does not return to the previous level of
consciousness. This is an emergency situation requiring immediate treatment before
exhaustion, respiratory failure, permanent brain injury, or death occurs. An IV
benzodiazepine drug such as diazepam (Valium) or lorazepam (Ativan) halts seizures
dramatically. Diazepam must be administered with extreme caution, however, based on
the child’s drug history because the drug is incompatible with many other medications,
and any accidental infiltration into subcutaneous tissue causes extensive tissue
sloughing. Parents can be instructed on how to administer diazepam by enema at home.

3047
Lorazepam (Ativan), a long-acting benzodiazepine used for children older than 2 years
of age, provides a longer duration of action and also less respiratory depression (Karch,
2013). Both oxygen to relieve cyanosis and administering a medication to halt the
seizure may be necessary; obtaining blood to monitor for glucose may reveal that
hypoglycemia needs to be corrected.

QSEN Checkpoint Question 49.5

EVIDENCE-BASED PRACTICE
Recurrent seizures can be depressing for children and parents if the seizures are
difficult to eliminate with therapy. A 2015 study looked at parents’ coping behaviors
and stressors, and their ability to care for their child with chronic disease. The parents
were given the Coping Inventory for Parents (CHIP) survey along with the Pediatric
Inventory for Parents (PIP). Significant correlations were found in the study showing
the need for early identification by nurses of disease-related challenges, stressors, and
parental coping methods to improve the outcomes of the children (Senger, Ward,
Barbosa-Leiker, et al., 2015).
Based on this study, if Tasha is found to have recurrent seizures, which statement
by her mother at a healthcare visit would concern a nurse the most?
a. “I forgot to give Tasha her medicine twice last week; I have to try harder.”
b. “I feel really sad when children call Tasha names because of her seizures.”
c. “I don’t like having to miss work due to Tasha’s clinic visits.”
d. “I think Tasha’s medicine is giving her headaches; maybe she needs glasses.”
Look in Appendix A for the best answer and rationale.

Unfolding Patient Stories: Jackson Webber • Part 2

Think back to Chapter 31 where you met Jackson Webber. Jackson

was diagnosed with generalized seizures 2 years ago at age 3 years. He
had another seizure and his mother brought him to the hospital. How
would the nurse differentiate tonic–clonic seizures from other types of
seizures? Compare and contrast the characteristics of each type of seizure.
Care for Jackson and other patients in a realistic virtual environment: for
Nursing (thepoint.lww.com/vSimMaternityPed). Practice documenting these patients’
care in DocuCare (thepoint.lww.com/DocuCareEHR).

Assessment of the Child With Seizures

It’s important that a thorough pregnancy history be obtained on any child with seizures.
Events that occurred immediately before the seizure and an accurate description of the
seizure itself also should be recorded. Investigate the child’s overall behavior in the last
few weeks such as bed-wetting or failing marks in school because these might be signs

3048
of absence or nocturnal seizures that have occurred but gone unnoticed.
A complete physical and neurologic examination and blood studies are necessary to
rule out metabolic or infectious processes. Prepare a child for a lumbar puncture to rule
out meningitis or bleeding into the CSF. A CT scan, MRI, skull radiograph, or EEG
may be obtained as indicated. Caution children during the EEG that they may be
stimulated with rhythm patterns or flashing lights or asked to hyperventilate to see
whether a seizure can be provoked.

Nursing Diagnoses and Related Interventions

Nursing Diagnosis: Risk for injury related to recurrent seizures

Outcome Evaluation: Child exhibits no signs of aspiration or traumatic injury.
Help a child having a partial seizure to a sitting position to protect against falling.
Turn a child who has fallen to the floor onto the side so fluid will drain from the
mouth and not be aspirated. Protecting a child from being hurt during a tonic–clonic
seizure is crucial, but restraining the child’s thrashing extremities is not advisable
because it is difficult for an adult to do so and could result in injury to the parent or
child because of the amount of force needed to keep the child still (Box 49.6). Do not
insert anything between the child’s teeth to stop tongue biting because this is rarely
necessary and can result in broken and aspirated teeth.

BOX 49.6
Nursing Care Planning Based on Family Teaching
SAFETY DURING SEIZURES
Q. Tasha’s mother asks you, “What can we do to be certain she doesn’t get hurt
during a seizure?”
A. Here are the usual actions to help keep her safe:
• Remain calm.
• Move away furniture or any sharp objects.
• Turn your child gently on her side, or on her abdomen with her head turned to the
side, to prevent aspiration of unswallowed mouth secretions.
• Do not restrain her other than to keep her head turned to the side. Restraining a
child could result in injury because of the amount of force necessary.
• Do not attempt to place an object between the child’s teeth to prevent tongue
biting. Trying to force an object into the mouth could break or loosen teeth.
• Be aware that a child having this type of seizure may have some slight cyanosis
during the tonic and clonic stages, but these stages are so short that administering

3049
 oxygen is not needed.
• After any seizure, telephone your primary care provider about the seizure so
arrangements for any necessary follow-up care can be initiated.
• If your child should pass rapidly from one seizure into another (status epilepticus),
she may need supplemental oxygen or medicine to stop the seizure. If this
happens, telephone your emergency medical service number (911).

Remaining calm is an important responsibility because it is reassuring for parents

to see someone calm and in control of a situation that seems to be very out of control.
If the child passes rapidly from one seizure into another (status epilepticus), be
prepared to provide supplemental oxygen and administer antiseizure therapy as
needed.
Nursing Diagnosis: Interrupted family processes related to diagnosis of long-term
illness in child
Outcome Evaluation: Child, parents, and other family members express fears and
questions about disease to healthcare team; parents discuss ways to accommodate the
illness in their daily life, such as medication schedules, school accommodations,
sports activities, plans for vacation, and discipline.
As soon as the diagnosis of a seizure disorder is made, parents and children need to
be told that it is likely to signify a long-term disorder because although seizures can
be controlled with medication, these do not change or cure the underlying cause of
the seizures. Box 49.7 shows an interprofessional care map illustrating both nursing
and team planning for a child with recurrent seizures. Most children are given tablets
rather than liquid medication because the latter tends to settle at the bottom of the
bottle, resulting in over diluted or over concentrated doses that can allow seizures to
break through at the end of the prescription period. To avoid this happening, caution
parents to shake liquid medication thoroughly before every dose. Parents need to
establish ways to remember to buy medicine so they always have an adequate supply,
especially if they are taking a trip away from home or need to provide enough for
holidays.

BOX 49.7
Nursing Care Planning

AN INTERPROFESSIONAL CARE MAP FOR A CHILD WITH

RECURRENT SEIZURES
Tasha is a 3-year-old girl who was brought to the emergency department by her
mother because she had a seizure. Her mother grabs your arm, visibly upset. “Her
sister has cerebral palsy and seizures. Does this mean Tasha has cerebral palsy too?”
she asks you.

3050
Family Assessment: Parents are divorced. Child lives in a two-bedroom apartment
with mother and a 6-year-old sibling; attends child care daily from 9 AM to 3 PM.
Neighbor watches her from 3 to 6 PM, when mother returns from work as a research
librarian.
Patient Assessment: Well-proportioned preschooler sleeping soundly on left side
since admission. Had first seizure 2 hours ago; a second one 30 minutes ago.
Temperature at 103.4°F. Other vital signs within age-appropriate parameters. Reacts
to painful stimuli only. Deep tendon reflexes depressed. Mother reports, “I kept her
home from child care because she has a cold. Suddenly, she fell to the floor and
started shaking. I called 911, and they brought her here.” Apparent pain on forward
flexion of the neck. Lumbar puncture performed; pressures within normal limits;
specimens sent for cell count, glucose, and culture.
Nursing Diagnosis: Risk for injury related to diminished level of consciousness
resulting from seizure episode
Outcome Criteria: Child is conscious within the hour. Exhibits no signs of
aspiration or traumatic injury.

Team Assessment Intervention Rationale Expected

Member Outcome
Responsible
Activities of Daily Living, Including Safety
Nurse Assess Keep child on Side-lying position Mother states
whether side to help reduces risk for she understands
mother was ensure an open aspiration. Pain on importance of
aware child’s airway until dorsiflexion of taking
temperature alert and neck and temperature in
was elevated. responsive. irritability are the future;
Assess Ask if mother symptoms of difficult to
whether child has a meningitis. evaluate pain as
has continued thermometer child is
pain on to take any unconscious.
dorsiflexion of future fevers.
neck.
Teamwork and Collaboration

Nurse/primary Assess in light Consult with A second seizure Neurologic

care provider of this second neurologic suggests this may service meets
seizure and service, if be more than a with mother and
spinal tap indicated, simple response to child as
results about elevated fever. appropriate
whether management based on

3051
 neurologic of child. findings.
service should
be consulted.
Procedures/Medications for Quality Improvement

Nurse Assess Assist with Lumbar puncture Mother states

whether child lumbar is a frightening she understands
has had a puncture and procedure for both reason for
lumbar specimen child and parent. procedure and
puncture or collection. IV line supplies an gives consent.
intravenous Begin IV fluid emergency IV line is
(IV) fluid administration medicine route if established and
administration as prescribed. needed for seizure safeguarded
before. control or with board for
infection therapy. unresponsive
child.
Nurse Assess Obtain Diagnosis could Mother states
whether equipment for be meningitis, she understands
mother respiratory which is the importance
understands precautions as contagious by of precautions.
why needed. contact with nasal Respiratory
respiratory secretions. precautions are
precautions readied.
are necessary.
Nutrition

Nurse Assess child’s Do not give Giving oral fluids Child receives
level of anything by too early increases no oral fluid
consciousness mouth until risk for aspiration. until she is
using a the child is awake and
Glasgow fully awake, aware.
Coma Scale. alert, and
oriented and
the gag reflex
is intact.
Patient-Centered Care
Nurse/nurse Assess what Teach that a Understanding the Mother states
practitioner mother knows febrile seizure basis for febrile she understands
about febrile is more of a seizures and child’s current
seizures and symptom of meningitis can status and
meningitis. fever than a help the parent possible future

3052
 long-term understand the implications.
condition. A basis for
meningeal emergency care.
infection could
be very
serious.
Psychosocial/Spiritual/Emotional Needs
Nurse Assess Help mother A support person Mother contacts
whether contact a can be vital to help support person
mother needs support person a parent withstand as needed.
to contact a if she feels this an ominous
support person would be diagnosis.
if her child’s helpful.
diagnosis is
found to be
serious.
Informatics for Seamless Healthcare Planning
Nurse Assess Answer any A parent gains Mother states
whether parent remaining confidence in she understands
has any further questions to emergency that if
questions make transfer department staff meningitis or
about child’s as comfortable and may find it recurrent
condition for parent and difficult to change seizures are
before transfer child as to new healthcare diagnosed, her
to pediatric possible. providers. child needs
intensive care ongoing care.
unit.

Be certain the child receives health maintenance care during childhood to be

certain that the medication dosage remains adequate with continued growth. To
document that serum levels of drugs are adequate, children need periodic blood
sampling.
Provide parents with as much information as possible about the cause of their
child’s seizures because it’s almost always easier to deal with a known disease, not an
unexplainable and unpredictable one. Although the cause of the seizures is unknown,
you can assure them that treatment is known; new antiseizure medications are being
introduced yearly into therapy.

General guidelines for safe administration of antiseizure medications to stress with

parents include:

3053
 • Caution children to be careful around motor vehicles and electrical equipment
because many antiseizure medications cause drowsiness.
• Advise the child and parents to observe for easy bruising because some
antiseizure medicines may suppress bone marrow function.
• Caution the adolescent to avoid alcohol while taking antiseizure medications
because alcohol can potentiate the CNS effects of these medications.
• Use caution when administering antiseizure medications to children with liver
disease. Because many of these drugs are metabolized by the liver, they may not
be fully effective in such children.
• Caution the child and parents not to discontinue antiseizure therapy abruptly
because this may lead to uncontrolled seizures.
• Remind parents about the need for follow-up blood tests to evaluate the drug
level. Maintaining a therapeutic blood level enhances the drug’s effectiveness
and minimizes the risk for toxicity.
Discuss with parents the need to treat children with seizures the same as other
family members. Scolding children, asking them to do household chores, or insisting
they do their homework will not cause seizures. A few children with absence seizures
can initiate them by hyperventilating and may try to manipulate those around them by
doing this to gain sympathy. The few children who use this extreme form of
manipulation may need to be referred for counseling.
Assure parents also that occasional seizures in children are not harmful. Unless
status epilepticus occurs and the child becomes anoxic, the chance their child will be
injured during a seizure is remote. Knowing this helps parents not to worry about the
child becoming cognitively challenged or about other misconceptions regarding
seizures. Although some children who have seizures are cognitively challenged, this
impairment and the seizures were caused by the same event; the seizures did not cause
the impairment. At every healthcare visit, be certain parents have time to ask questions
about their child’s care and to express concerns. There are so many “scare stories” about
seizures that every parent is likely to believe some of these stories unless counseled
otherwise (Box 49.8).

BOX 49.8
Nursing Care Planning Tips for Effective Communication

Tasha, 3 years old, had a febrile seizure and was diagnosed as having meningitis. You
talk to her mother about the seizure.
Tip: Be sure to identify the parent’s concern and attempt to clarify it, providing an
opportunity for patient teaching. In the following scenario, the nurse responds with a
therapeutic statement (“That must have been frightening.”) and identifies a
misconception verbalized by the mother.
Nurse: Mrs. Jarman, can you describe what happened?
Mrs. Jarman: She started shaking all over. It was really frightening.

3054
 Nurse: Did she voice any symptoms before the seizure?
Mrs. Jarman: No, just started shaking.
Nurse: That must have been frightening.
Mrs. Jarman: Thinking about what it did to her is scarier.
Nurse: Did to her?
Mrs. Jarman: I know seizures cause mental retardation. Our neighbor’s son has
them, and he’s severely retarded.
Nurse: Let’s talk about this a little more.

As a rule, children with seizures should attend regular school and participate in
physical education classes and active sports (with possible exceptions such as scuba or
sky diving or rock climbing). Many teachers are concerned about the responsibility of
having a child with seizures assigned to their class. Contact the school nurse (with the
parents’ permission) to help them learn about the success of modern seizure control.
In many children, seizures increase or intensify at puberty, probably as the result of
glandular changes or the need for an increased medicine dosage because of
preadolescent growth. All antiseizure medications are potentially teratogenic to a fetus,
so be certain adolescent girls are aware of this so they can choose to delay childbearing
until later in life, when their medication can be reduced or even discontinued.

QSEN Checkpoint Question 49.6

SAFETY
Suppose Tasha has a tonic–clonic seizure while in the hospital. Which of the
following items should the nurse keep available at the bedside for a child known to
have generalized seizures? (Select all that apply.)
a. Suction
b. Tracheostomy tube
c. Oxygen
d. Call bell
e. Padded tongue blade
Look in Appendix A for the best answer and rationale.

BREATH HOLDING
Breath holding is a phenomenon that occurs in young children when they are stressed or
angry. The child breathes in and, because of anger or stress, does not breathe out again
or else breathes out and then does not inhale again. As brain cells become anoxic, the
child appears cyanotic and slumps to the floor, momentarily unconscious. With loss of
consciousness, the child begins breathing again, color returns, and the child awakens.
Breath holding this way is frightening to parents but results from the immaturity of the

3055
child’s neurologic control. This differs from a temper tantrum, in which a child
deliberately attempts to hold his or her breath and then passes out (see Chapter 30). The
child needs no immediate therapy except reassurance the episode is over. Breath
holding may be associated with iron-deficiency anemia; if this is discovered, iron
supplementation may be prescribed to decrease the breath-holding episodes.

HEADACHE
Headaches in children younger than school age used to be considered rare, but young
children can report “hair hurt” or have fussiness from allergies and viral inflammation
of the upper respiratory tract that cause headaches. A toddler who has both vomiting
and a headache should be evaluated because these are common signs of brain tumor,
one of the most common tumors of childhood (Cleves & Rothner, 2011). Headache may
also occur with a fever because of increased ICP caused by increased cerebral blood
flow. As children reach school age, headaches may occur as a result of conditions as
simple as eyestrain and sinusitis or, again, as serious as a brain tumor.
Headache pain results because of meningeal or vascular irritation, not from the brain
itself because brain tissue is insensitive to pain. Because of this insensitivity, a cerebral
tumor can be present for a lengthy time before meningeal irritation is enough that pain
symptoms become apparent. With a brain tumor, pain becomes intense on changing
body position, so a young child who reports a headache shortly after getting up in the
morning should be carefully evaluated. Pain from a brain tumor is also usually occipital,
so asking the child to indicate where it hurts helps determine whether a tumor could be
the cause.

Tension or Stress Headache

When children are studying intently or taking a test, contraction of their neck muscles
from tension can cause temporary ischemia to the head. This type of headache is usually
experienced as a dull, steady pain across the forehead, the temporal area, or the back of
the neck. Children with these symptoms should have their vision tested because poor
eyesight may be the reason they hunch over their books. Stress headaches are relieved
by simple analgesics, such as acetaminophen or ibuprofen, or by sleep or application of
a cool compress. Advising children to take frequent “stretches” while studying can help
avoid muscle tension and stress and reduce the number of headaches experienced.

Sinus Headache
Sinus headache usually accompanies sinusitis or is associated with inflammation and
possible obstruction of the sinuses and is discussed in Chapter 40.

Migraine Headache
Migraine headache refers to a specific type of headache that may or may not begin with
an aura or visual disturbance such as diplopia or a zigzag pattern across the visual field.

3056
The pain that follows is usually unilateral and extremely intense, with throbbing that is
moderate to severe. The headache is aggravated by routine physical activity or
menstrual periods; it may be compounded by nausea and vomiting and intolerance to
bright lights and noise (Cleves & Rothner, 2011).
The cause of migraine headache is not well understood but probably results from
abnormal constriction of intracranial arteries that temporarily reduces cerebral blood
supply. The reduction in blood flow is then followed by compensating over distention
of cranial blood vessels. The aura accompanying such headaches results from the
temporary ischemia that occurs in between those two processes. Some children who
have migraine headaches have an abnormal EEG, but a normal EEG does not rule out
the reality of the headaches.
Most children with migraine headache have a positive family history, or someone
else in the family also has the same type of headache. A migraine syndrome may be
inherited as a dominant trait.

Assessment
To help assess the cause of a headache, obtain a thorough history, including:
• When the headache usually occurs
• The events preceding it (to detect an aura)
• Its usual duration, frequency, intensity, description, and associated symptoms
• Any actions taken to treat the headache
The child needs a thorough physical examination, including funduscopic
examination, to rule out papilledema. Blood pressure must be measured to rule out
hypertension. If an aura is documented, an EEG will be prescribed to investigate a
seizure as the basis of the headache.

Therapeutic Management
At the time of the headache, sleep or lying down may be necessary to relieve the pain
and vomiting. Acetaminophen and nonsteroidal anti-inflammatory drugs are the first-
line medical treatment for headaches in children, including migraines. Ergotamine
tartrate (Cafergot), a vasoconstrictor, may be prescribed in addition for some children.
Almotriptan, a member of the triptan family of drugs, is approved by the U.S. Food and
Drug Administration for migraine in adolescents and may also be helpful. Frequent
headaches interfere with a child’s ability to achieve in school. Children may need to be
reassured that even though their headaches are intense and even incapacitating, migraine
headaches are benign and will not lead to any other condition so they can keep their
headaches in perspective. Follow-up visits are necessary to confirm that they are not
growing worse so treatment is remaining adequate (El-Chammas, Keyes, Thompson, et
al., 2013).
If other family members have migraine headaches, counsel them that their reactions
to their headaches influence their child’s reaction to a headache. If the mother goes to

3057
bed for the day when she has a migraine headache, for example, she cannot expect her
child to go to school when the child has a headache.

Spinal Cord Injury

Because of the resilience of their vertebrae, children have fewer spinal cord injuries than
adults. However, the incidence among adolescents is increasing, especially among male
adolescents, because more teenagers are involved in motor vehicle accidents,
particularly motorcycle or off-road vehicle accidents, than previously (Martin-Herz,
Zatzick, & McMahon, 2012). Another frequent cause of spinal cord injury is diving into
too shallow water at beaches or backyard pools. Spinal cord injury without radiologic
abnormality (SCIWORA) syndrome may occur, so any child with a multiple traumatic
injury needs to be assessed for spinal cord damage. Stabilizing the neck at the accident
scene is the best protection against further injury in these children (Hazinski, 2012).

RECOVERY PHASES
Spinal injuries result when the spinal cord becomes compressed or severed by the
vertebrae; further cord damage can result from hemorrhage, edema, or inflammation at
the injury site as the blood supply becomes impeded. Table 49.4 summarizes functional
ability that will probably be present after spinal cord injury at different vertebral levels.
Predictions such as these of useful body function cannot be made accurately at the time
of the injury, however. Three phases of recovery must first take place.

TABLE 49.4 FUNCTIONAL ABILITY AFTER SPINAL CORD INJURY

Injury Highest Key Functions Effects and Possible Interventions
Site Still Present
C1–C3 Head and neck muscles Respiratory paralysis from loss of phrenic nerve
intact innervation; will need ventilatory assistance
No voluntary motion below chin; possibly able
to learn to use mouth to control pen for writing
and mouth stick to reach objects
C4 Diaphragm intact Loss of motor function of upper and lower
extremities and trunk; able to learn to use
abdominal muscles to breathe independently
C5 Shoulder control; biceps, Able to feed self and operate wheelchair if fitted
deltoid function with self-care aids
C6 Forearm pronation; wrist Use of upper extremities for self-care; can
extension transfer to wheelchair and so have increased
independence
C7 Triceps function Able to transfer to wheelchair readily; increasing

3058
 independence
C8 Thumb and finger Able to do fine motor tasks; increases self-care
function ability
T1–T7 Intercostal muscles (able Full use of upper extremities but is still
to breathe with chest, dependent on wheelchair
not abdominal, Possibly able to drive car with hand controls
muscles) Possibly able to have high leg braces fitted for
standing
T10–12 Abdominal muscles Use of long leg braces and four-point crutch to
ambulate
L2–L4 Hip flexion Use of long or short leg braces to ambulate
Leg extension
L5–S1 Gluteus maximus muscle Able to walk without aids
function
S4 Bladder and anal sphincter Able to control bladder and bowel function
control Penile erection and ejaculation possible

First Recovery Phase

Immediately after the injury, the child experiences a spinal shock syndrome or loss of
autonomic nervous system function (loss of nerve fibers traveling through the anterior
horn of the spinal canal), leading to loss of motor function, sensation, reflex activity,
and the presence of flaccid paralysis in body areas below the level of the injury. If a
cervical or high thoracic injury is present, there will be loss of or decreased respiratory
function because of flaccidity of the diaphragm or loss of the accessory muscles of the
chest. At all levels, the child has no ability to sweat or shiver to change body
temperature below the level of the lesion because of loss of autonomic nerve control;
therefore, hypothermia or hyperthermia always becomes a threat. Blood vessels below
the level of the injury are no longer able to constrict, so blood tends to pool in the lower
body, leading to yet another concern—upper body hypotension, especially if the upper
body is elevated. Loss of bladder control occurs if the bladder is left flaccid (it expands
and continually overflows). Loss of control in the bowel allows it to become equally
distended; bowel sounds will be absent. This phase of spinal cord injury lasts from 1 to
6 weeks. As a rule, the shorter the phase of spinal shock, the better is the final outcome.
Administration of a corticosteroid can help reduce edema and possibly protect
function of the spinal cord during this phase. A vasopressor agent such as dopamine
may be prescribed to maintain blood pressure and perfusion to the cord.

Second Recovery Phase

During the second phase of recovery, the flaccid paralysis of the shock phase is replaced
by spastic paralysis. Normally, motor impulses begin in the brain cortex and are

3059
transmitted to the medulla, where they cross to the opposite side of the cord; they then
travel down the descending motor tracts of the spinal cord. They synapse in the anterior
horn of the spinal cord and travel by way of the spinal and peripheral nerves to the
designated muscle group, which they set in motion. The nerve pathways of the brain
and the descending tracts are termed upper motor neurons. Those in the anterior horn
cells and the spinal and peripheral nerves are termed lower motor neurons. Whether a
motor neuron has upper or lower function, therefore, does not depend on its height in
the spinal tract but rather on its position in relation to an anterior horn: Between the
brain and the anterior horn, it is an upper motor neuron; between the anterior horn and
the point of innervation, it is a lower motor neuron (Fig. 49.9).

Figure 49.9 Diagram of motor pathways between the cerebral cortex,

one of the subcortical relay stations, and lower motor neurons in the

3060
 spinal cord. Decussation (crossing of fibers) means that each side of
the brain controls skeletal muscles on the opposite side of the body.

Spasticity in the second phase is caused by the loss of upper level control or
transmission of meaningful innervation to the anterior horn. Lacking upper motor
neuron function because of a severed cord, the lower motor neurons or reflex arcs cause
the muscles to contract and remain that way. Parents and children are quick to interpret
the sudden spastic movement of a lower extremity as meaningful activity. This is
particularly easy to believe with infants, who cannot tell you they have no control or
cannot stop their legs from contracting. Differences between upper and lower neuron
damage are listed in Table 49.5. If the injury is very low in the spinal tract, affecting
mostly lower motor neurons, the muscles will remain flaccid because the lower motor
neurons cannot send impulses for contraction.

TABLE 49.5 CHARACTERISTICS OF UPPER AND LOWER MOTOR NERVE

INJURY AFTER SPINAL SHOCK PHASE
Finding Upper Motor Lesion Lower Motor Lesion
Spasticity Present Absent (flaccidity present)
Clonus Present, increased Absent
Tendon reflexes Increased Absent
Babinski reflex Present Absent
Reflexes below level Present Absent
of lesion
Reflex at level of Absent Absent
lesion
Atrophy of muscles Absent or present only to Present (muscle fasciculations
slight degree may be present)

During this phase, if the child’s bladder is allowed to fill, the resultant sensory
stimulation relayed to the damaged cord can initiate a powerful sympathetic reflex
reaction (autonomic dysreflexia). The child will experience extreme hypertension,
tachycardia, flushed face, and severe occipital headache. This is an emergency situation
because if the severe hypertension is not relieved, cerebrovascular accident can result
(Pellatt, 2010). Assess that the child’s urinary catheter is not obstructed, so urine can
flow freely and reduce the sensory stimulation. Also, frequently assess for signs of
urinary tract infection such as elevated temperature or cloudy urine because urinary
complications remain the leading cause of morbidity and the most common infection for
individuals with spinal cord injury (Eves & Rivera, 2010).

Concept Mastery Alert

3061
 Respiratory function is of great concern in the first stage of recovery. By the second
stage, respiratory function should have stabilized and become predicable.
Contractures can occur during this stage as the flaccid paralysis of the first stage
passes and the spastic paralysis of the second stage begins.

Third Recovery Phase

The third phase of recovery from spinal cord injury is learning to live with the final
outcome or permanent limitation of motor and sensory function. If the compression of
the spinal cord was only caused by edema that is then relieved, no permanent motor and
sensory disability will occur.

ASSESSMENT OF SPINAL CORD INJURY

Cervical and thoracolumbar areas of the spine are the ones most likely to sustain injury,
but spinal cord injury should be suspected whenever a child has sustained a forceful
trauma of any kind. Do not move a child with suspected spinal cord injury at the scene
of the injury until the back and head can be supported in a straight line to prevent
further injury to the spinal column from twisting or bending. In the emergency
department, as a general rule, do not attempt to move the child from a stretcher to an
examining table until spinal X-ray films have been obtained; if helping move the child
onto the X-ray table, use a gentle log-rolling technique to avoid additional movement or
injury. If resuscitation is necessary, be certain to maintain the child’s head in a neutral
position, not hyperextended. To keep the neck immobilized, if a child is wearing a
football, bicycle, or motorcycle helmet or a neck brace, do not remove these (Nayduch,
2010). Help maintain spinal immobilization during such procedures as obtaining blood
samples or a neurologic assessment.

Nursing Diagnoses and Related Interventions

During the first phase of recovery, a child’s major problems are those that result from
almost complete immobility: pressure ulcers on bony prominences, loss of appetite
and subsequent poor nutrition from depression or being kept in a supine position,
urinary calculi caused by excessive calcium loss from bones, atrophy of flaccid
muscle groups, and urinary retention and bladder infection. These effects of
immobility are presented in Figure 49.10.

3062
 Figure 49.10 Effects of immobilization.

Nursing Diagnosis: Impaired physical mobility related to effects of spinal cord

injury
Outcome Evaluation: Child ambulates with a minimum of artificial support and
equipment; participates in exercise program within limitations.
To relieve edema at the injury site and prevent further injury, IV corticosteroids will
be administered. Children may be placed in cervical traction with Crutchfield tongs
and a traction belt (Fig. 49.11) or with halo traction (see Chapter 51). Having tongs
inserted into the skull is a very frightening procedure for children because they worry
the tongs will burrow into their skull and strike their brain. Encourage parents to stay
with children during the procedure both for psychological support and to help them
lie still during the procedure.

Figure 49.11 Crutchfield tongs used to create spinal traction.

3063
 To promote circulation and prevent loss of calcium that results from inactivity,
full range-of-motion exercises must be scheduled approximately three times per day.
Assist with these as necessary as they are time-consuming but important to maintain
joint function.
During the second phase of recovery, when spasticity of muscle groups occurs,
preventing contractures becomes the chief concern. Specialized splints, boots, or even
high-top sneakers may be used to prevent foot drop (Fig. 49.12). If children have
upper extremity mobility but will be left with lower extremity paralysis, exercises to
strengthen the upper extremity muscle groups are needed so children will be strong
enough to lift themselves from a bed to a wheelchair or raise themselves with a
trapeze over the bed when changing positions. Holding legs and arms at the joints
while moving is a good technique to help reduce muscle spasms.

Figure 49.12 Specialized splints are used for a child with a low spinal
cord injury to prevent contractures and foot drop. Here, the physical
therapist prepares to apply the splint to the child’s leg. (Photograph
courtesy of Sue Moses.)

One major problem of ambulation after spinal cord injury is helping a child’s
body readjust to a vertical position after being maintained in the supine position for
so long. In the new upright position, blood tends to pool in dilated blood vessels
below the level of the spinal injury, resulting in a pseudohypovolemia and
hypotension. The first time a child sits up or stands may occur to such an extent that
the child faints. Gradually increasing the angle of the bed helps the child become

3064
acclimated to the upright position without experiencing so much vascular pooling.
Nursing Diagnosis: Self-care deficit related to spinal cord injury
Outcome Evaluation: Child states intention of taking over self-care; practices using
equipment for eating, bathing, and toileting; participates in one new aspect of self-
care each week.
As soon as possible, children should be introduced to self-help methods for activities
of daily living. You may need to encourage parents to allow a child to become as
self-sufficient as possible or not to take over complete care. The child may well
outlive them and will someday need to be able to function as independently as
possible without them.
Remember, without autonomic nervous system function, a child is unable to
sweat and becomes hyperthermic if covered too warmly; if not covered warmly
enough, the capillaries dilate, and the child loses considerable heat into the
environment. If the room temperature cools at night, be careful to dress the child
appropriately for sleeping.
Specific measures for bowel evacuation may be necessary, depending on the level
of the injury. A bowel program incorporating the use of stool softeners, suppositories,
and bowel retraining may be required. The child and parents need support and
instructions in accomplishing this task and gaining independence as it may take
weeks or months to accomplish.
For some children and parents, the first day of using a wheelchair is exciting
(proof that the child can be partially ambulatory). For others, it is the day on which
they are forced to face the reality that they cannot undo the results of the injury and
that their child has a permanent lifelong disability. If parents have almost overcome
their grief and accepted their child’s disability, the introduction of a symbol of
disability such as a wheelchair or long leg braces may bring new grieving and a sense
of loss.
When the child reaches sexual maturity, limitations in this area may become a
child’s chief concern. If a male has had an upper motor neuron injury, he will not be
able to achieve spontaneous erection or ejaculation. However, with manual
stimulation of the penis (stimulation of lower motor neuron function), he may be able
to achieve an erection and engage in coitus even though ejaculation and fertility
remain limited. With most spinal cord injuries, a female is not able to experience
orgasm but is able to conceive and bear children.
The limitations caused by a spinal cord injury become especially evident to the
child (and the parents) when choosing a vocation and selecting an appropriate school
program (remember children cannot be denied regular schooling by federal law in the
United States, even with a severe physical disability). Counseling and rehabilitation
are crucial aspects to achieve an optimal level of functioning and independence.
Nursing Diagnosis: Risk for impaired gas exchange related to spinal cord injury

3065
Outcome Evaluation: Respiratory rate is within acceptable parameters; lungs are
clear; airway is patent.
If the cervical level of the cord is involved, a child will need ventilatory assistance.
The child may be intubated at first, but orotracheal or nasotracheal intubation is only
a temporary measure to maintain a patent airway. At a later date, a tracheostomy will
be done for long-term airway management and to prevent sloughing of pharyngeal
tissue from the constant pressure of the intubation tube. If a tracheotomy tube is
required, be certain parents receive thorough instructions on caring for the
tracheostomy and, if necessary, working with a mechanical ventilator. A phrenic
nerve pacemaker may be used to stimulate the diaphragm to contract and initiate
respirations. If the child has a thoracic-level injury (which is rare because the rib cage
gives extra strength to thoracic vertebrae), the child will be able to breathe
independently but will have reduced vital capacity. Periodic positive-pressure
breathing treatments may be necessary to encourage increased lung filling. Be careful
when positioning a child not to compromise chest movement with equipment or other
restricting objects. Other respiratory care measures, such as suctioning and chest
physiotherapy, also help maintain chest function.
Nursing Diagnosis: Risk for impaired skin integrity related to immobility
Outcome Evaluation: Child’s skin remains clean, dry, and intact without signs of
erythema or ulceration.
To prevent skin breakdown, turn children about every 2 hours (always being certain
to logroll or maintain immobilization with a striker frame or a continuously moving,
automatically controlled bed). The use of an alternating-pressure mattress may also
be helpful. With loss of sensation in body parts, the child is unable to report skin
irritation from a wrinkled sheet or wet clothing. If the child is incontinent, change the
linen immediately to prevent skin breakdown. Once children are ambulatory by
wheelchair, check their legs and buttocks regularly to prevent pressure ulcers caused
by sitting or using leg braces (McCaskey, Kirk, & Gerdes, 2011).
Nursing Diagnosis: Risk for impaired urinary elimination related to spinal cord
injury
Outcome Evaluation: Child’s urine output is adequate for intake; child identifies
measures to assist with voiding; child demonstrates procedure for self-catheterization.
To prevent urinary retention during the first phase of recovery, a Foley catheter is
usually inserted, or the bladder can be emptied by periodic suprapubic aspiration or
intermittent catheterization. Second-stage spasticity causes periodic reflex emptying.
The bladder rarely empties completely, however, so problems of stasis and infection
continue. To live independently, the child needs to learn self-catheterization to empty
the bladder (see Chapter 46).
Nursing Diagnosis: Anticipatory grieving related to loss of function secondary to

3066
 spinal cord injury
Outcome Evaluation: Child and parents openly discuss their feelings about the
injury and its effect on their lives.
The second recovery phase is the time for parents and children to begin thinking
about what this degree of disability will mean to them as a family and to face what
adjustments they will need to make. Children and parents typically react to the initial
diagnosis with grief. They may still be in denial or shock when the second phase
begins. With no sudden miracle cure in sight, they may begin to move through stages
of anger, bargaining, depression, and then acceptance (the injury happened; we must
go on from this point). They need assistance and support to work through all of these
feeling, however. Both the parents and the child may need counseling to reach
acceptance (Fig. 49.13).

Figure 49.13 A 6-year-old girl with a cervical spine injury adapts to

her disability by using her mouth to hold a paintbrush and participate
in age-appropriate activities. (© Elisa Peterson/Stock Boston.)

What If . . . 49.3
Tasha’s father, a high school science teacher, asks the nurse to help him
design a program to teach teenagers how to prevent spinal cord injury. What
topics would be best to include?

Ataxic Disorders
Ataxia is failure of muscular coordination or irregularity of muscle action. Ataxic
disorders are often manifested by an awkward gait or lack of coordination. Causes of
ataxia differ, but degeneration of cerebellar or vestibular function is always involved.

3067
ATAXIA-TELANGIECTASIA
Ataxia-telangiectasia, transmitted as an autosomal recessive trait attributable to a defect
of chromosome 11, is a primary immunodeficiency disorder that results in progressive
cerebellar degeneration. This is a multisystem disease with neurologic and immunologic
aspects. In addition, endocrine abnormalities may occur, and there is an increased risk
of cancer, particularly brain tumor. Telangiectasias (red vascular markings) appear on
the conjunctiva and skin at the flexor creases (American Academy of Pediatrics, 2012).
Both immunologic and neurologic symptoms of this disorder vary in severity and
onset. Serum immunoglobulin A (IgA) and immunoglobulin E (IgE) levels may be low,
and there is often evidence of reduced T-cell function. Children develop frequent
infections (primarily sinopulmonary) because of the immunologic deficits. Tonsillar
tissue in the pharynx appears scant.
Neurologic symptoms caused by the degeneration process can usually be detected in
early infancy when developmental milestones are not met. Children develop an
awkward gait when they begin to walk. Choreoathetosis (rapid, purposeless
movements), nystagmus, an intention tremor, or scoliosis may develop. Children may
be unable to move their eyes or follow movement through visual fields. Eye changes
(conjunctival telangiectasia) develop by 5 years of age. Unfortunately, there is no
effective treatment. Children with this disorder often die in late adolescence of
infection, respiratory failure, or a malignant brain tumor.

FRIEDREICH ATAXIA
Friedreich ataxia, which is carried on the short arm of chromosome 9 as an autosomal
recessive trait, involves a variety of degenerative symptoms (Koeppen, 2011).
Symptoms such as progressive cerebellar and spinal cord dysfunction occur in late
adolescence. Teenagers develop a progressive gait disturbance, a lack of coordinated
arm movements, a high-arched foot (pes cavus), hammer toes, and scoliosis. The
combined symptoms of a positive Babinski reflex, absence of deep tendon reflexes in
the ankle, and ataxia are strongly diagnostic. Neurologic examination shows difficulty
in recognizing foot position (whether the foot is moved up or down). If the ataxia
remains untreated, death occurs in young adulthood from myocardial failure.
Antioxidant therapy may help to delay this outcome by reducing ventricular
hypertrophy (Lynch, Regner, Schadt, et al., 2012).

What If . . . 49.4
A nurse is interested in exploring one of the 2020 National Health Goals
related to children with neurologic disorders (see Box 49.1). Most government-
sponsored funding for nursing research is allotted based on these goals. What
would be a possible research topic pertinent to these goals that would be
applicable to Tasha’s family and also advance evidence-based practice?

3068
KEY POINTS FOR REVIEW
Nerve cells are unique in that they do not regenerate if damaged, tending to make
neurologic diseases long-term illnesses. Parents and children alike need support from
healthcare providers to cope with problems that continue to occur over a long period.
Planning nursing care to achieve this not only meets Quality & Safety Education for
Nurses (QSEN) competencies but hopefully also meets the family’s total needs.
Increased ICP arises from an increase in the volume of CSF or from blood
accumulation, cerebral edema, or space-occupying lesions. Vital sign changes such
as increased temperature and blood pressure and decreased pulse and respirations
begin as subtle changes. Always compare assessments with previous levels to detect
that a consistent, although minor, change is occurring.
CP is a nonprogressive disorder of upper motor neurons. The exact cause is usually
unknown, but the condition is caused by abnormal brain development or damage to
the developing brain. Four major types are identified: spastic (excessive tone in the
voluntary muscles), dyskinetic or athetoid (abnormal involuntary movement), atonic
(decreased muscle tone), and mixed (symptoms of both spasticity and athetoid
movements).
Meningitis is infection of the cerebral meninges, caused most frequently by bacterial
invasion. Children need follow-up afterward to monitor for hearing acuity and
impaired secretion of antidiuretic hormone.
Encephalitis is inflammation of brain tissue. This is always a serious diagnosis
because the child may be left with residual neurologic damage, such as seizures or
learning disabilities.
Reye syndrome is acute encephalitis with accompanying fatty infiltration of the liver,
heart, and lungs; it most frequently occurs if a child with a viral infection is
administered acetylsalicylic acid (aspirin) and is the reason children should not be
administered aspirin for fever.
Guillain-Barré syndrome is inflammation of motor and sensory nerves. The reaction
may be immune mediated, occurring after an upper respiratory tract illness.
Temporary demyelization of the nerve sheaths causes loss of function.
Botulism occurs when spores of C. botulinum produce toxins in the intestine.
Because honey can be a source of the organism, it should not be given to infants.
Recurrent seizures are involuntary contractions of muscles caused by abnormal
electrical brain discharges. Common types seen in children include febrile seizures,
infantile spasms, partial (focal) seizures, absence seizures, and tonic–clonic seizures.
Therapy is administration of antiseizure drugs.
Spinal cord injury is occurring at increased rates in children involved in sports and
motor vehicle accidents. Children pass through a first, second, and third recovery
phase after the injury until they reach a final outcome.

CRITICAL THINKING CARE STUDY

3069
 Darien Fisher is a 12-year-old boy you see in the emergency room because he was
brought to the hospital by ambulance after having a tonic–clonic seizure at basketball
practice. His parents are divorced, so Darien lives with his mother and two younger
brothers in a trailer park during weekdays. On the weekend, he lives with his father
on a houseboat.
1. The emergency room physician asked Mrs. Fisher for permission to do a lumbar
puncture on Darien but she refused because she remembered what a terrible
headache she had after receiving spinal anesthesia for Darien’s birth. Would you
agree that lumbar punctures often lead to severe headaches? What are some things
you could do to help prevent a headache in Darien?
2. Darien is prescribed carbamazepine (Tegretol) for recurrent seizures. His mother
is concerned he won’t take it on weekends because his father is “all fun—nothing
serious.” Would you agree with her that she’s right in refusing to allow Darien to
visit his father on weekends?
3. Darien is concerned that he won’t be allowed to play on his school basketball
team if he has another seizure. Are recurrent seizures aggravated by strenuous
activity? Would preventing him from playing be good advice?

RELATED RESOURCES
Explore these additional resources to enhance learning for this chapter:
• Student resources on thePoint, including answers to the What If . . . and Critical
Thinking Care Study questions, http://thepoint.lww.com/Flagg8e
• Adaptive learning powered by PrepU, http://thepoint.lww.com/prepu

REFERENCES
American Academy of Pediatrics. (2012). Telangiectasias. Retrieved from
https://pediatriccare.solutions.aap.org/Content.aspx?gbosid=165682
American Academy of Pediatrics. (2015). Botulism and infant botulism. In D. W.
Kimberlin, M. T. Brady, M. A. Jackson, et al. (Eds.), Red book: 2015 Report of the
Committee on Infectious Diseases (30th ed., pp. 294–296). Elk Grove Village, IL:
Author.
Ardern-Holmes, S. L., & North, K. N. (2011). Therapeutics for childhood
neurofibromatosis type 1 and type 2. Current Treatment Options in Neurology,
13(6), 529–543.
Bailey, B. M., Liesemer, K., Statler, K. D., et al. (2012). Monitoring and prediction of
intracranial hypertension in pediatric traumatic brain injury: Clinical factors and
initial head computed tomography. Journal of Trauma and Acute Care Surgery,
72(1), 263–270.
Bennett, C. L., Starko, K. M., Thomsen, H. S., et al. (2012). Linking drugs to obscure
illnesses: Lessons from pure red cell aplasia, nephrogenic systemic fibrosis, and
Reye’s syndrome. A report from the Southern Network on Adverse Reactions

3070