ARAGON

CANEO
CAPISPISAN
SPINA BIFIDA
The term spina bifida (Latin for “divided spine”) is most often used
as a collective term for all spinal cord disorders, but there are well-
defined degrees of spina bifida involvement, and not all neural tube
disorders involve the spinal cord.

Simple spina bifida occulta is a benign disorder; it occurs as

frequently as in one of every four children.

The term “spina bifida” is often used to denote all spinal cord
anomalies. Because of this usage, parents, when told that their child
has a spina bifida occulta, may interpret this as meaning their child
has an extremely serious disorder.
Spinafida occulta occurs when the posterior laminae of the
vertebrae fail to fuse. This occurs most commonly at the fifth
lumbar or first sacral level but may occur at any point along the
spinal canal.
Assessment
Infants may be born by cesarean birth to avoid pressure and injury to the spinal cord.
Observe and record whether an infant born with a neural tube disorder has spontaneous
movement of the lower extremities to assess if the child has lower motor function.
Also assess the nature and pattern of voiding and defecation. A normal infant appears to
be “always wet” from voiding but actually voids in amounts of approximately 30 mL and
then is dry for 2 or 3 hours before voiding again.
An infant without motor or sphincter control voids continually. This pattern is the same
for defecation. Observing these features aids in differentiating between meningocele and
myelomeningocele. Differentiation will be further established by ultrasound or MRI.
Therapeutic Management
Children with spina bifida occulta need no immediate surgical correction. The
parents should be made aware of the deffect, however, so they are not
surprised if it is revealed on a spinal x-ray taken for some reason later in life.
Some children may eventually need surgery to prevent vertebral deterioration
because of the unbalanced spinal column
 HYDROCEPHALUS
• an excess of cerebrospinal fluid (CSF) in the ventricles and subarachnoid spaces of
the brain
• In the infant whose cranial sutures are not firmly knitted, this excess fluid causes
enlargement of the skull.
• If fluid can reach the spinal cord, the disorder is called communicating
hydrocephalus or extraventricular hydrocephalus.
• If there is a block to such passage of fluid, the disorder is an obstructive
hydrocephalus or intraventricular hydrocephalus.
• Hydrocephalus is also classified regarding whether it occurs at birth (congenital)
or from an incident later in life (acquired). The cause of congenital hydrocephalus
is unknown, although maternal infection such as toxoplasmosis or infant
meningitis may be factors
An excess of CSF in the newborn occurs
for one of three main reasons:

• Overproduction of fluid by a choroid (rare).

• Obstruction of the passage of fluid in the narrow aqueduct of Sylvius
(the most common cause).
• An interference with the absorption of CSF from the subarachnoid
space
Assessment
• Hydrocephalus occurs in approximately 3 to 4 per 1000 live births
• With an obstruction present, excessive fluid accumulates and dilates the system
above the point of obstruction.
• If the atresia is in the aqueduct of Sylvius, the first, second, and third ventricles
will dilate.
• If it is at the exit from the fourth ventricle, all ventricles will dilate.
• Symptoms may develop rapidly or slowly, depending on the extent of the atresia
• If hydrocephalus is present prenatally, it can sometimes be detected on a prenatal
sonogram and can even be shunted in utero. The condition is generally not
evident during pregnancy or even at birth, however, because of the effect of
intrauterine pressure. It becomes evident in the first few weeks or months of life.
Assesment cont..
• Treatment is most effective when the disorder is recognized early,
because once intracranial pressure becomes so acute that brain tissue is
damaged and motor or mental deterioration results, even the best
shunting procedure cannot replace and repair this damage to the brain
cells.
• Assisting with detection of hydrocephalus is an important role for nurses
in ambulatory child health settings.
• All children under age 2 years should have their head circumference
recorded and plotted on an appropriate growth chart at health care
visits, so a child whose head is growing abnormally can be detected
Assesment cont..
• Enlarges, because of both neurologic impairment and atrophy caused by the
inability to move such a heavy head. However, as long as a child has more than 1
cm of cerebral tissue present, motor function often is not impaired. Even with an
extremely enlarged head, children’s intelligence may remain normal, although
fine motor development may be affected.
• That hydrocephalus is present can be demonstrated by ultrasound, computed
tomography (CT), or magnetic resonance imaging (MRI). A skull x-ray film will
reveal the separating sutures and thinning of the skull.
• Transillumination (holding a bright light such as a flashlight or a specialized light
[a Chun gun] against the skull with the child in a darkened room) will reveal the
skull is filled with fluid rather than solid brain (Fig.
Therapeutic Management
• The treatment of hydrocephalus depends on its cause and extent.
• If it is caused by overproduction of fluid, acetazolamide (Diamox), a
diuretic, may be prescribed to promote the excretion of this excess
fluid.
• A shunting procedure involves threading a thin polyethylene catheter
under the skin from the ventricles to the peritoneum.
Therapeutic Management cont..
• Fluid drains via this route into the peritoneum and is absorbed across the
peritoneal membrane into the body circulation. This type of shunt usually
has to be replaced as the child grows or it will become too short. As
another complication, it could become enclosed in a fold of peritoneum
and become obstructed or it could become infected

• The ultimate prognosis for a child with hydrocephalus depends on whether

brain damage occurred before shunting and, if a shunt is in place, whether
the parents can recognize when it needs to be replaced to prevent
increased intracranial pressure.
 ACUTE OTITIS MEDIA
• Inflammation of the middle ear (otitis media) is the most prevalent disease of
childhood after respiratory tract infections (Kelley, 2008). It occurs most often in
children 6 to 36 months of age and again at 4 to 6 years. It is seen most
frequently in males, in Alaskan and Native American children, and in children
with cleft palate. There is a higher incidence of otitis media in formula-fed infants
than those who are breastfed, because formula-fed infants are held in a more
slanted position while feeding, and this allows milk to enter the eustachian tube.
Otitis media is also associated with constant pacifier use. The incidence of otitis
media is highest in the winter and spring and is higher in homes in which a parent
smokes cigarettes (Yates & Anari, 2008).
• Otitis media is an extremely serious disease of childhood, because permanent
damage can occur to middle ear structures, leading to hearing impairment.
Assessment
• Acute otitis media usually occurs after a
respiratory tract infection. Children have a
“cold,” rhinitis, and perhaps a lowgrade fever
for several days. Suddenly, they have a fever of
about 102° F (38° C) and a sharp, constant
pain in one or both ears. Older children can
verbalize reports of pain. Infants become
extremely irritable and frequently pull or tug at
the affected ear in an attempt to gain relief from
pain.
• It is important that the mastoid process behind
the ear does not feel tender to touch. If it does,
the infection probably has spread out of the
middle ear into the mastoid cells, a very serious
complication.
NURSING DIAGNOSIS
• Impaired social interaction related to short attention span and
distractibility .
• Ineffective role performance related to being intrusive or disruptive
with siblings or playmates.
• Impaired social interaction related to inability to perceive
consequences of their action.
• Compromised family coping related to disruptive with siblings, which
causes friction.
Therapeutic Management
• Most otitis media infections resolve spontaneously without therapy, but, to avoid the
possibility of complications, most children in the past were prescribed an antibiotic such
as ampicillin or amoxicillin.
• It is recognized that antibiotic therapy is unnecessary and may add to bacterial
resistance, so it is no longer routinely prescribed.
• Children need an analgesic and antipyretic such as acetaminophen (Tylenol). Some
health care providers may prescribe decongestant nose drops to open the eustachian
tubes and allow air to be admitted to the middle ear. Although not proved, this may be
helpful in preventing the infection from becoming a serous or long-term otitis media.
• Nasal decongestant drops usually are given for only 3 days. If they are given longer, a
rebound effect may occur, causing edema and a subsequent increase in mucous
membrane inflammation.
BACTERIAL MENINGITIS
• Meningitis is an infection of the cerebral meninges.
• It occurs most often in children younger than 24 months of age.
• Although the disease can occur in any month, its peak incidence appears to be in the
winter.
• In the United States, it is caused most frequently by Streptococcus pneumoniae or
group B Streptococcus.
• In children younger than 2 months of age, group B Streptococcus and Escherichia coli
are common causes of meningitis.
• Pathologic organisms usually are spread to the meninges from upper respiratory
tract infections, by lymphatic drainage possibly through the mastoid or sinuses, or by
direct introduction through a lumbar puncture or skull fracture.
Bacterial Meningitis cont..
• Once organisms enter the meningeal space, they multiply rapidly and spread
throughout the CSF.
• Organisms invade brain tissue through meningeal folds that extend down into the
brain itself
• The inflammatory response that occurs may lead to a thick, fibrinous exudate that
blocks CSF flow.
• Brain abscess or invasion of the infection into cranial nerves can result in blindness,
deafness, or facial paralysis.
• Pus that accumulates in the narrow aqueduct of Sylvius 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). This causes increased edema because the
body cannot excrete adequate urine.
Assessment
• The symptoms of meningitis occur either insidiously or suddenly
• Children usually have had 2 or 3 days of upper respiratory tract infection
• They become increasingly irritable because of headaches.
• They have sharp pain on bending their head forward.
• They may have seizures. In some children, seizure or shock is the first
noticeable sign of illness.
• As the disease progresses, signs of meningeal irritability occur, as
evidenced by positive Brudzinski’s and Kernig’s signs
Assessment cont..
• Children’s backs may become arched and their necks hyperextended (opisthotonos).
• Cranial nerve paralysis, most typically of the third and sixth nerves, may occur, so
that the child is not able to follow a light through full visual fields.
• If the fontanelles are open, they If the meningitis is caused by H. influenzae, the child
may develop septic arthritis
• If it is caused by N. meningitidis, a papular or purple petechial skin rash may occur
• In the newborn, symptoms such as poor sucking, weak cry, or lethargy are often
vague.
• After this generalized beginning, sudden cardiovascular shock, seizures, nuchal
rigidity, or apnea may occur.
Assessment cont..
• Because the infant has open fontanelles, nuchal rigidity appears late
and is not as useful a sign for diagnosis as in the older child
• Meningitis is diagnosed by history and analysis of CSF obtained by
lumbar puncture.
• A child with a febrile seizure should be assumed to have meningitis
until CSF findings prove otherwise.
• CSF results indicative of meningitis include increased white blood cell
and protein levels and a lowered glucose level (because bacteria have
fed on the glucose).
Assessment cont..
• In a healthy child, the glucose level in the CSF is 60% of that of the
serum glucose. Because meningitis often spreads and causes
septicemia, a blood culture also is done.
• A CT scan, MRI, or ultrasound study may be ordered to examine for
abscesses. Typically, ICP is severely elevated.
Therapeutic Management
• Usually antibiotics are given IV for rapid effect, but intrathecal
injections (directly into the CSF) may be necessary to reduce the
infection, because the blood–brain barrier may prevent an antibiotic
from passing freely into the CSF.
• If the organism is identified as H. influenzae, ampicillin usually is the
drug of choice.
• In other instances, a third-generation cephalosporin, such as
cefotaxime (Claforan) or ceftriaxone (Rocephin), may be used for 8 to
10 days.
Therapeutic Management cont..
• 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.
 SEIZURE
• A seizure is an involuntary contraction of muscle caused by abnormal
electrical brain discharges.
• Approximately 2% to 3% of children will have at least one seizure by
the time they reach adulthood .
• These episodes are always frightening to parents and other children
because of the intensity.
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; slight
cyanosis; and perhaps respiratory difficulty or apnea.
• Afterward, the infant may appear limp and flaccid.
• Whereas older children often have seizures of unknown cause, 75% of
seizures in neonates have a known cause. Some of these possible causes
are:
• Trauma
• Metabolic disorders
• Neonatal infection
• Kernicterus
Seizures in the Newborn Period cont..
• Because of the nervous system’s immaturity, EEGs in the newborn
may be normal despite extensive disease. Therefore, a noticeably
abnormal EEG 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, lumbar puncture also is not
conclusive.
• Protein is increased, and there may be a few red blood cells from
rupture of subarachnoid capillaries from the pressure of birth.
Seizures in the Newborn Period cont..
• High doses of anticonvulsant medication may be needed to control
seizures in newborns because they metabolize drugs more rapidly
than older infants. 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 per day.
Seizures in the Infant and Toddler Periods
• Seizures commonly seen in this age group are infantile spasms, a form
of generalized seizure (“salaam” or “jackknife”), 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.
• The infant suddenly slumps forward from a sitting position or falls from a
standing position.
• These episodes may occur singly or in clusters as frequently as 100 times
a day.
• They are most common during the first 6 months of life
Seizures in the Infant and Toddler
Periods cont..
• In approximately 50% of children affected, 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 cause is unknown, but the spasms apparently result
from a failure of 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
• The response to treatment with anticonvulsant therapy is poor.
• Parenteral adrenocorticotropic hormone (ACTH) and pyridoxine (vitamin
B6) therapy is commonly used.
• Highdose valproic acid or a newer anticonvulsant agent such as
topiramate (Topamax) may be used in children who do not respond to
usual therapy.
• The infantile seizure phenomenon seems to “burn itself out” by 2 years
of age.
• The associated cognitive or developmental delay remains, however, so
children need good follow-up planning and care.
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 (5 months to 5 years), although these
can occur as early as 3 months or as late as 7 years of age.
• Febrile seizures may occur after immunization because of an accompanying fever.
• The EEG tracing usually is normal. There usually is a history of other family
members having had similar seizures.
• Febrile seizures usually occur due to a sudden spike of temperature.
• The seizure only lasts 1 to 2 minutes or less. Such seizures must be taken
seriously, however, and investigated for a possible cause, because meningitis
often manifests initially with high fever and a seizure
Prevention of Febrile Seizures
• Because these seizures arise with high fever, they are largely
preventable
• If acetaminophen is given to keep a developing fever below 101° F
(38.4° C), 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
acetaminophen in large enough doses to be therapeutic
Prevention of Febrile Seizures cont..
• If a second febrile seizure occurs, diazepam (Valium) may be
prescribed for the parents to administer the next time the child has a
high fever
• Instruct parents that every child who has a febrile seizure must be
seen by a health care provider to rule out meningitis. A good rule is to
assume that the child in this situation has meningitis until it is ruled
out by a complete neurologic workup.
Therapeutic Management
• Teach parents that, after a seizure subsides, to sponge the child with
tepid water to reduce the fever quickly.
• Advise them not to put the child in the bathtub, however, because it
would be easy for the child to slip under water should a second
seizure occur.
• Applying alcohol or cold water is also not advisable.
• 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.
Therapeutic Management cont..
• 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.
• 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 health care facility for immediate evaluation.
• Additional treatment depends on the underlying cause of the fever.
• A lumbar puncture will be performed to rule out meningitis.
Therapeutic Management cont..
• Antipyretic drugs to reduce the fever below seizure levels will be
administered.
• Appropriate antibiotic therapy will be started, depending on the type
of infection.
• 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.
 ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER (ADHD)
• Attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of
inattention and/or hyperactivity-impulsiveness revealed before the age of 7
years (APA, 2000). It is estimated to occur in about 3% to 7% of school-age
children in the United States. Boys are affected more frequently than girls.
The disorder is characterized by three major behaviors: inattention,
impulsiveness, and hyperactivity (Sykora, 2008).

• Inattention makes children unable to complete tasks effectively. They

become easily distracted and often may not seem to listen.
• Impulsiveness causes them to act before they think and therefore to
have difficulty with such tasks as awaiting turns at games.
• Hyperactivity, children may shift excessively from one activity to
another, exhibiting excessive or exaggerated muscular activity, such as
excessive climbing onto objects, constant fidgeting, or aimless or
haphazard running.
Etiology
• Although the cause is unknown, it occurs more frequently among
some families than in the general population, indicating a possible
genetic etiologic component.
• ADHD has also been associated with child neglect, lead poisoning,
and drug exposure in utero (APA, 2000). Both drug and behavior
modification treatment methods have been used with success, a fact
that may support the theory of varying causes.
Assessment
• The disorder is diagnosable by 36 months of age (3 years old),
although parents may excuse the behavior as “active” or “always
on cannot sit still in school” or concentrate on problem solving for
long periods.
• When the disorder is first suspected, a thorough initial history to
reveal the extent of the problem needs to be obtained. The history is
important, because some children have enough control in a one-to-
one situation that their extremes of behavior are not apparent in an
ambulatory health care setting.
• As a rule, children with ADHD do not have a deficit in intelligence, although they
may seem to because of their impulsive behavior. They may be unaware that their
behavior is upsetting to family, friends, and teachers and therefore are not anxious
about their inability to conform to society’s rules.
• IQ testing is used to document intelligence. The Wechsler Intelligence Scale for
Children (WISC), the test most often chosen, consists of two portions: a verbal
scale and a performance scale. A child is given three final scores: verbal IQ,
performance IQ, and combination or full-scale IQ.
• The child with perceptual and motor deficits tends to do poorly on the
performance scale but average or better on the verbal scale.
• Children with language difficulty typically do poorly on the verbal scale but
average or greater on the performance scale.
 Therapeutic Management
A variety of treatment methods are used, often in combination, in the management of ADHD.

ENVIRONMENT.
• Construction of a stable learning environment is crucial for children with ADHD.
• Decorating with pastel colors rather than primary colors reduces environmental stimuli.
• Encourage parents to be fair but firm and to set consistent limits.
• Assign age-appropriate chores with the understanding that a parent must give many reminders to
them to get the job completed.
• Teach parents to give instructions slowly and to make certain that they have their child’s attention
before beginning instructions.
• Breaking down a chore into several steps may help (get the toy box is one step; pick up toys is a
second).
• Encourage parents to be sure, when they correct behavior, that their anger is about something the
child has deliberately done wrong, not about some incident that happened
• Help parents to build, not hinder, the development of self-esteem at every stage possible.
MEDICATION. Several medications are helpful in reducing the excessive activity of children with
ADHD and in lengthening the attention span or decreasing the distractibility so that they can
function in normal classrooms. All of these medications have advantages and disadvantages.
• Methylphenidate hydrochloride (Ritalin, Concerta [extended-release form]) is frequently
prescribed for this disorder achieve a more regular nerve transmission. Insomnia and anorexia
are side effects. The insomnia may be relieved by administering the drug early in the day. The
extended-release form is advantageous in that it needs to be administered only once a day.
Children receiving the drug for extended periods of time need careful height and weight
assessment to evaluate that long-term anorexia is not causing weight loss. Caution parents that
Ritalin gives a “high” to children who do not have ADHD, so their child must be careful that his
medication is not stolen to be used by other children for its drug euphoria effect (Kuehn, 2007).
Other medications that may be useful are atomoxetine, norepinephrine reuptake inhibitors, and
tricyclic antidepressants (Goldson & Reynolds, 2008).
FAMILY SUPPORT. Parents of a child with ADHD often need frequent health care visits while their
child is growing up. A responsive, listening ear is crucial to their ability to handle the challenge of
raising a child with these symptoms. Any parents can grow short-tempered and irritable at times
with a child who does not seem to hear them or follow what they say. They may need reminders at
intervals that their child does not act this way on purpose. Help them to understand that, because
of a very complex and as yet ill-understood syndrome, the behavior is the best their child can
achieve.
Methylphenidate Hydrochloride (Ritalin, Concerta)
• Classification: Methylphenidate is a central nervous system stimulant.
• Action: Acts paradoxically in children with ADHD, possibly by stimulating dopamine
receptors to calm rather than stimulate activity (Karch, 2009).
• Pregnancy Risk Category: C
• Dosage: Initially, 5 mg orally before breakfast and lunch, gradually increased in 5-
to 10-mg increments weekly, not to exceed 60 mg/day. The extended-release form
(Concerta) is administered once daily; dosage is determined by weight and
symptoms.
• Possible Adverse Effects: Nervousness, insomnia, anorexia, pulse rate changes,
hypertension or hypotension, tachycardia, leukopenia, anemia, and growth
suppression.
• Nursing Implications
 Administer the drug exactly as prescribed, and instruct parents to do the
same. Reinforce proper administration of once-daily extended-release form;
instruct parents to have child swallow extended-release tablets whole and to
refrain from chewing or crushing them.
Advise the parents and child to avoid over-the-counter drugs, such as cold
remedies and cough syrups that contain alcohol.
Obtain baseline vital signs and monitor on follow-up visits for changes.
Arrange for follow-up laboratory tests, including complete blood count for
children on long-term therapy.
Stress the need for adequate nutrition in light of possible anorexia. Monitor
child’s weight closely for changes.
Keep in mind that the safety of using methylphenidate for children younger
than 6 years of age has not been established.