Neurological Disorders in the Pediatric Patient

Presented by Hassan Adroub

Meningitis
Bacterial Meningitis Vs. Viral Meningitis

Bacterial Meningitis

Potentially Fatal

Viral Meningitis

Same signs and symptoms, may be milder and self-limiting. Usually lasts a few days

Assessment
Infants & Young Children  Fever not always present  Lethargy  Alterations in sleep and feeding habits  Nuchal rigidity (late sign)

Assessment:

Childhood & Adolescence

 Hyperthermia  S&S

of IICP

Complications of Meningitis
Intravascular coagulation with thrombocytopenia  CSF obstruction  Nerve Damage


Diagnostic Tests:

Lumbar Puncture

Serum Glucose Level



Blood Cultures

Therapeutic Interventions Mediation Therapy Antibiotics

Ampicillin Claforan Rocephin

Nursing Care
Assess  Antibiotic therapy  Monitor lab values  Strict I&O  Isolation  Monitor FOC


Nursing Care cont...

CSF culture  Temperature control  Seizure activity  Environment  Planning  Education


Hydrocephalus
Hydro= Water Cephaly= of the head/brain

Etiology and Pathophysiology:



Congenital anomalies


Trauma

Unknown causes

Types of Hydrocephalus

Non-communicating or Obstructive Communicating

Clinical Manifestations
 1. 2. 3. 4.

Infants- prior to fusion of cranial sutures Changes in assessment of skull Forehead Eyes Behavior changes

Clinical Manifestations


After closure of cranial sutures: Eyes S & S of IICP

1. 2.

Diagnostic Tests
LP  MRI/ CT scan  Skull X-ray


Interventions: Surgical


Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption

Complications of Shunts


Infections Blocked shunts Seizures

Nursing Interventions
       

Monitor VS and neurological status Assess functioning of the shunt Assess operative site Assess for infection Positioning of the patient Activity of patient Promote nutrition Education

Critical Thinking


What is the most important assessment data on a child who has just had a shunt placement for hydrocephalus? What is the most important teaching for the parents or caregivers?

Spina Bifida
Most common defect of the CNS Occurs when there is a failure of the osseous spine to close around the spinal column.

Clinical Manifestations:
Visualization of the defect  Motor sensory, reflex and sphincter abnormalities  Flaccid paralysis of legs- absent sensation and reflexes, or spasticity  Malformation  Abnormalities in bladder and bowel function


Diagnostic Tests:
Prenatal detection
 

Ultrasound Alpha-fetoprotein Following Birth:

  

NB assessment X-ray of spine X-ray of skull

Surgical Intervention


Immediate surgical closure Prior to closure keep sac moist & sterile Maintain NB in prone position with legs in abduction

Nursing Interventions:
Pre-OP:  Place in prone position  Sterile moist dressing with normal saline or antibiotic solution  Maintain proper abduction of legs and alignment of hips  Meticulous skin care  Protect from feces or urine  Keep in isolette

PostPost-Op Nursing Interventions

Assess surgical site  Monitor VS and neuro VS  Institute latex precautions  Encourage contact with parents/care givers  Positioning  Skin Care


Nursing Interventions cont...

Antibiotic therapy  Prevent UTI  Education


 Emphasize

the normal, positive abilities of the child

Critical Thinking


Would you expect a 5-year-old with meningomyelocele to have bladder/bowel sphincter control? Which type of neural tube defect is most likely to have no outward signs or symptoms?

Cerebral Palsy (CP)



Static Encephalopathy- spastic CP most common type (80%)

Nonspecific term give to disorders

characterized by impaired movement and posture Non-progressive Abnormal muscle tone and coordination

Assessment
Jittery (easily startled)  Weak cry (difficult to comfort)  Experience difficulty with eating (muscle control of tongue and swallow reflex)  Uncoordinated or involuntary movements (twitching and spasticity)


Assessment cont...


Alterations in muscle tone

Abnormal resistance Keeps legs extended or crossed Rigid and unbending

Abnormal posture
Scissoring and extension (legs feet in plantar

flexion) Persistent fetal position (>5 months)

Diagnostic Tests:
EEG, CT, or MRI  Electrolyte levels and metabolic workup  Neurologic examination  Developmental assessment


Complications


Increased incidence of respiratory infection Muscle contractures Skin breakdown Injury

Goals & Interventions:

Early detection

Mental Retardation
Significant sub average, general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.
American Association of Mental Deficiency

Down Syndrome

Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation

Assessment
See syllabus  Primary concern with cardiac and GI anomalies
 

What are the most obvious indications of Downs Syndrome in a newborn?

Goals and Interventions

Primary focus on the parents and care givers to provide support and achieve a realistic view of the childs capabilities  Support siblings  Refer to family counseling services  Support parents in feelings of guilt and chronic sorrow


Hyperfunction/Hypofunction


Pediatric Seizures
Febrile seizures- occur as a result of rapidly

increasing core temperature (101.8 F 38.8C)

General seizures- occur as a result of insult of

the nervous system

Clinical Manifestations


Tonic-clonic- absence seizures, minor motor-atonic Partial seizures- partial simple or partial complex

Diagnostic Tests:
EEG  CT, MRI  Lumbar puncture  CBC  Metabolic screen for glucose, phosphorus and lead levels


Jitteriness vs- Seizure vs Jittery Responsive  Seizure Not responsive to

stimuli
Gaze Okay Abnormal gaze

Goals:
Primary focus to identify the cause and eliminate the seizure with minimum side effects using the least amount of medication while maintaining a normal lifestyle for the child.

Interventions


Febrile seizures Seizure precautions During seizure activity Education

Autism


Most severe pervasive developmental disorder of childhood. Moderate to severely incapacitating with lifelong developmental disabilities Etiology/Pathophysiology
Cause unknown Possible genetic or prenatal hypoxic event

Clinical Manifestations of Autism

     

Developmental disturbances of verbal and social language skills Abnormal response to sensation/stimuli (difficulty distinguishing self from environment) Repetition of self-stimuli May have savant capabilities Does not show pain with injuries Dependent on severity of condition

Diagnosis
Extensive and thorough interview of family regarding behaviors  Behaviors classically begin before age 3


Direct observation of child

Nursing Care of Hospitalized Child with Autism

Attempt to maintain childs daily routines from home- very ritualistic  Work closely with family to decrease anxiety  Provide for the childs safety-particularly if ritual self stimulation is potentially harmful (head banging, biting)


Shaken Baby Syndrome



Intracranial & retinal bleeding

Physical abuse causing a whip-lash induced trauma to the childs brain

Nursing Interventions


Assessment- observe for S&S of:

Hemorrhage to sclera Apnea Seizures Respiratory irregularities Increased intracranial pressure (ICP) Drowsiness or lethargy

Long Term Prognosis

Complete recovery is rare  Mental retardation  Cerebral Palsy  Death


Legal Implications
Nurses must report suspected child abuse to Child Protective Services (CPS). It is not your obligation to prove the abuse you must report any suspicion. CPS will document and follow through on the case *rememberthe abuser may not be the person you suspect, and disclosure to the wrong individual may endanger the child.