NEUROLOGICAL DISORDERS
Islamic University Nursing College
Neurologic System
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Neurologic System
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Nervous system consists of
 Brain
 Spinal
cord
 Cranial and spinal nerves
 Cerebrospinal fluid
The Central Nervous System (brain & spinal
cord)
 The Peripheral Nervous System

 The
Autonomic Nervous System
 Sensory-somatic Nervous System
Neurologic System
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The brain is covered by three membranes.
The dura mater is a fibrousconnective tissue structure
containing several blood vessels.
 The arachnoid membrane is a delicate serous membrane
 The pia mater is a vascular membrane
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The Peripheral Nervous System is composed of the
cranial nerves and the spinal nerves
Neurologic System
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The spinal cord extends from the medulla
oblongata to the lower border of the first lumber
vertebrae. It contains millions of nerve fibers, and it
consists of cervical, thoracic, lumber, and sacral
nerves

Cerebrospinal fluid (CSF) forms in the lateral
ventricles in the choroids plexus of the pia mater. it
circulates to the subarachnoid space of the spinal
cord, bathing both the brain and the spinal cord.
Neurologic System : function
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Consciousness, thought, emotions, memory,
sensory input and motor activity
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Regulates BP, Temp, breathing, digestion,
cardiovascular function..etc
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Coordination of muscle movements
Neurologic System :Cardinal signs &
symptoms
Headache, fainting and dizziness
 abnormal gait, movements, or coordination
 developmental lags or loss of milestones
 Symptoms of increased ICP
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Increased HC
Bulging fontanels
Headache for older children
Confusion and altered mental status; A change in the child’s normal
behavior pattern may be an important early sign
Tachypnea (late sign): Cheyne-Stokes respiration. This pattern of
breathing is characterized by increasing rate and depth, then
decreasing rate and depth, with a pause of variable length
 altered
level of consciousness (LOC)
Neurologic System :Cardinal signs &
symptoms

Altered level of consciousness (LOC)
Disoriented; lack of ability to recognize place or
person.
 Obtunded ; individual who sleeps unless aroused and
once aroused has limited interaction with the
environment.
 lethargy; when a child awakens easily but exhibits
limited responsiveness.
 Stupor; requiring considerable stimulation to arouse the
individual.
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Neurologic System :
Assessment

Prenatal, personal and family history
 Prenatal:
maternal malnutrition, drug use, alcohol
use, and illness
 prematurity, perinatal hypoxia, birth trauma, delayed
developmental milestones, head injury, meningitis,
chronic illness, child abuse, chromosomal anomalies
and substance abuse.
 Family: chromosomal anomalies, mental illness,
neurologic disease, seizure disorders, mental
retardation, learning problems, and neural tube
defects
Neurologic System : Physical
Exam
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HC: (head circumference in children younger than 2
years)
Assess LOC, general appearance, behaviour,
interactions, speech, behavioural changes
Assess development milestone
Assess cranial nerve function
Assess taste, olfaction, and tactile sense
Observe abnormal movements such as tremors,
seizure activity
Neurologic System : Physical
Exam
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Assess gait, balance, coordination & Assess reflexes
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Palpate the fontanels with infant upright position
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Assess muscle tone and strength
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Assess sensation and position sense
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Assess deep tendon and superficial reflexes
Neurologic System :Lumber puncture
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Position: The child should lie on her side with knees bent
and chin tucked in to the knees. This position exposes the
area of the back for the lumbar puncture
Meningitis
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Meningitis is inflammation of protective
membranes that covering brain and spinal cord
(meninges).
Meningitis may extends to the ventricles and the
exudation (fibrin) obstruct the flow of CSF
Caused by:
Virus
 Bacteria
 Other microorganism
 Drugs
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Bacterial Meningitis
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The most common are group B streptococci during
the 1st 2 mo of life
H. influenzae (type B)
Meningococcal;
occurs most often in the 1st year of life
 tends to occur in epidemics among closed populations
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Streptococcus pneumoniae (pneumococci);
the most common cause of meningitis in adults
 people at risk: chronic otitis, sinusitis, mastoiditis, CSF
leaks
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Bacterial Meningitis
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Bacteria typically reach the meninges by:
hematogenous spread from sites of colonization in
the nasopharynx or other site such as lungs
Bacteria can also enter CSF by direct extension
from nearby infections (e.g, sinusitis, mastoiditis)
through exterior openings in normally closed CSF
pathways such as
Meningomyelocele
 penetrating injuries
 neurosurgical procedures
 Ventricular shunt
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Bacterial Meningitis: Infant
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Abrupt & nonspecific signs
Extremely irritable
Lethargic
difficult to comfort ; a high-pitched cry
jaundice (a yellowish tint to the skin)
stiffness of the body and neck(Nuchal rigidity)
fever or lower-than-normal temperature
poor feeding/ a weak suck/ vomiting
bulging fontanelles / Seizures
Bacterial Meningitis: Clinical
Manifestation
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pre-infection; respiratory illness/sore throat
Fever, headache, stiff neck, vomiting
Kernig’s & Brudzinski’s
Seizures
Cranial nerves abnormalities
Changes in consciousness, irritability … coma
Purpura/petechia (meningococcal meningitis)
Bacterial Meningitis
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Bacterial Meningitis: diagnosis &
Treatment
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The primary diagnostic test for meningitis is lumber puncture (LP)
Pressure & color
Glucose
WBC
protein
Normal
100-200mmH2O
50-100
mg/dL
0-5
20-45 mg/dL
Bacterial
Meningitis
>300
Cloudy/milky
< 40
Elevated
> 100
Viral/aseptic
N or increased
N
N or mild N or < 100
elevated
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Treatment
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Antibiotics (Ampicillin/vancomycin) corticosteroids
Supportive care
Isolation
Bacterial Meningitis: Nursing diagnosis
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Potential for injury: secondary brain injury R/T
increase intracranial pressure or disease process
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Altered comfort: pain R/T headache, muscular
rigidity and I.V therapy
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Fear/ anxiety child and the family R/T diagnosis
of series disease.
Bacterial Meningitis: Nursing Care
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Isolation (contact isolation )
Monitor V/S and neuro assessment
Provide quiet environment
Control fever and pain
Prevent complications of increased ICP and
dehydration
Viral Meningitis
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Common in children younger than 4 years
Mostly caused by entero viruses
Associated with mumps or herpes
CM
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Gradual signs of headache, fever, malaise, vomiting
Meningeal irritation (signs) develop 1-2 days after the onset of illness
Treatment
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Symptomatic (rest, fluids, antipyretic, analgesics)
Isolation is not necessary
Signs and symptoms subside within 3-10 days with no residual effects
(complications)
Encephalitis
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Acute inflammatory disease of the brain
Usually viral; Herpes Simplex: most common sporadic
type
Acute febrile illness with symptoms of meningitis AND
neurologic signs such as aphasia, seizures, cranial nerve
involvement
Patient may present with fever, facial paralysis, headache,
seizures, nausea and vomiting
CT scan usually initially normal; MRI more helpful
Death occurs in 70-80% of patients if treatment not begun
before patient becomes comatose
Spina Bifida
Vertebral column fails to close during
intrauterine development with no definitive
cause identified
 There are three forms:
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Spinal bifida occulta
Meningocele
Myelomeningocele
Spina Bifida
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Spinal bifida occulta
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Failure of vertebral arch to
close, a dimple occurs on the
sacral area, may be covered by
a tuft of hair.
Spina Bifida
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Meningocele
Protrusion of the meninges.
Meninges consist of: dura
mater, arachnoid, and pia
mater covered by thin
membrane
 No paralysis because spinal
cord is not involved.
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Spina Bifida
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Myelomeningocele
 Protrusion of
the meninges
and spinal cord. Covered by
thin membrane
 Extent of paralysis depends
on the location of the defect.
 Results in hydrocephalus.
Spina Bifida
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Spina Bifida: Prevention &
Management
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Encourage folic acid 4mg Po with future pregnancies
(conception-6 weeks)
Primary intervention after birth of infant with meningocele &
myelomeningocele is
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to cover defect with a sterile, saline-soaked dressing to prevent cracking
in the sac thus decrease infection
Prone position keeps pressure off the exposed sac
Head circumference measurement is essential because hydrocephalus
can develop in these infants.
Surgery
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Primary reason of surgical repair is to prevent infection
Correct defect
Minimize complications such as hydrocephalus
Spina Bifida: Prevention &
Management
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Encourage parents to become involved with infant
care ASAP
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Teach parents the techniques of feeding, ROM
exercises, positioning, catheterization, skin care
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Explain to the parents about possible complications
Spina Bifida: Nursing Diagnosis
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Risk for infection R/T presence of infective
organisms, non-epitheliazed meringue sac
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Potential for trauma R/T delicate spinal lesion
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Potential for complications R/T impaired circulation
of CSF or neuro-muscular impairment
Hydrocephalus
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Impaired circulating and
reabsorption of CSF
It can be congenital or acquired
It can be communicating or noncommunicating (obstructive
hydro)
One of the most causes of hydr0 is
aqueductal stenosis
 Other causes include meningitis,
tumors, lesions/ malformation
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Hydrocephalus
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Hydrocephalus: Clinical Manifestation
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Enlarged head (earliest
sign) & Bulging
fontenells
Poor feeding & Vomiting
Irritability
Lethargy
Dilated & distended
scalp vein and setting
sun eyes
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Positive Babinski’s reflex
(fanning of toes)
In older children
Headache
 Changes in personality
 Cognitive deterioration
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Hydrocephalus: Treatment &
complications
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Treatment
V_P shunt placement
 Diuresis
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Complication
Infection
 Visual problems
 Memory problems and
reduced IQ
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Phenylketonuria (PKU)
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Is inability of the body to
utilize Phenylalanine (amino
acid) due to deficit in
Phenylalanine hydroxylase
enzyme
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It is an autosomal recessive
inherited disease
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Normal phenylalanine in the
blood is 1-2 mg/dI in PKU it
ranges from 6-80 mg/dI
Phenylketonuria (PKU)
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Infant’s symptoms of untreated PKU
Microcephaly, prominent cheek and poor development
of teeth
 Vomiting
 Irritability & hyperactivity
 Eczema-like rash
 Musty odor of the urine
 Increased muscle tone
 Poor body growth (failure to thrive)
 Fair skin
 Later signs of seizure and mental retardation
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Phenylketonuria (PKU): treatment
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The goal of treatment is to:
prevent mental retardation by maintaining normal level
of phenylalanine (< 10 mg/dl)
 Provide nutrition for optimum growth
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When the level of phenylalanine is more than 10
mg/dI brain damage occurs
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Screening for PKU is a routine test which is usually
done at 3 days of age
Phenylketonuria (PKU): treatment
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Treatment is dietary management (lower amount of
phenylalaine)
Food such as meat, fish, poultry ,eggs, cheese, milk,
dried beans and peas should be avoided or taken in
low amount.
Cereals, starches, fruits , vegetables and milk
substitute is recommended
If treatment started before 3 months of age this can
limited brain damage
Seizure Disorders
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Seizure is an abnormal unregulated excessive electrical
discharge (firing) that interrupts normal brain function
This electrical firing may last from a few seconds to minutes
50% of seizures the causes are unknown
Seizures before 2 yrs usually caused by developmental
defects, birth injuries or metabolic disorders
Seizure could partial (affect part of the brain) or generalized
Seizure may be due to disorder such as epilepsy OR to
reversible stressors such as:
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Hypoxia; Hypoglycemia; Fever in children, hypcalcemia,
hyponatremia
Seizure Disorders
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Seizure usually lasts from few seconds to 1-2 minutes
Seizure usually causes
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Alteration in awareness, sensation & emotion
Involuntary movements
Convulsion
Mostly seizure followed by deep sleep, headache,
confusion, paralysis ( postictal)
Postictal may lasts from minutes to hours
Seizure Disorders
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Seizure disorders are symptoms to underlying cause such as
brain tumor, stroke or could be idiopathic
Types are:
 Generalized
Absence (petit mal)
 Tonic-clonic (grand mal)
 Atonic
 Myoclonic
 Infantile spasm
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Partial seizures
Simple partial seizures
 Complex partial seizure
 Secondarily generalized partial seizures
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Seizure Disorders: partial seizures
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Simple partial seizure
No complete loss of consciousness
 May affect the face or a hand first
 May developed to be generalized seizure
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Complex partial seizure
Starts with aura
 Purposeless movements & unintelligible sounds
 Consciousness is impaired
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Secondary generalized partial seizure
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Either simple or complex partial seizure may develop
into a tonic-clonic seizure
Seizure Disorders: generalized seizures
Abnormal motor function &
loss of consciousness
Types are;
 Tonic-clonic (grand mal)
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Tonic phase; cry, falling down and
stiffness .
Followed by clonic ( jerk rapidly
and rhythmically, bending and
relaxing at the elbows, hips, and
knee) contractions of the muscles
Frothing at the mouth, urinary and
fecal incontinence may occur
Seizure Disorders: generalized seizures
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Absence (petit mal)
Mostly for children between 6-12 years
 Lasts for a few seconds
 Abrupt & brief lapse of consciousness (staring into space or
absence spells), blank expression, twitching of mouth, blank
stare ,daydreams
 May occur many times a day
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Atonic seizure
Complete loss of muscle tone and consciousness
 Risk for head injury
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Seizure Disorders: generalized seizures
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Myoclonic (contraction and relaxation)
Jerk y repetitive movement of a limb/trunk
 Consciousness is not lost
 May followed by tonic-clonic seizure
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Infantile spasm
Sudden flexion of the arms and trunk and extension of
the legs
 Occurs during the first 5 yrs
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Status Epileptics
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Tonic-clonic Seizure that is lasting 5-10
minute
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Epilepsy is 2 or more seizures episodes that
are not related to reversible stressors
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Longer epileptics seizures may cause
permanent brain damage (more than 60
minutes.
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Lorazepam (Ativan) or diazepam (Valium)
is given intravenously to control generalized
tonic-clonic status epilepticus and may also
be used for seizures lasting more than 5
minutes.
Seizure Disorders: Epilepsy
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Assessment
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History
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Duration, frequency, sequential evolution
longest and shortest interval between seizures
aura, postictal state
precipitating factors
Risk factors; CNS infection, drug use withdrawal, head trauma,
neurologic disorders
Physical exam: usually normal between the seizure
CBC, serum glucose, creatinine, electrolytes, CT and MRI, LP,
video and EEG monitoring
Seizure Disorders: Epilepsy
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Treatment by anticonvulsant drugs
Well controlled seizures the drugs can eventually stop and
the child remain seizure free (60%)
Drugs such as amphetamines can trigger seizures thus
should be avoided
Alcohol and some drugs as phenothiazines lower the
threshold of seizure thus should be avoided
Avoid activity that the loss of consciousness can be life
threatening such as driving, swimming and climbing or
leaving a child in a bathtub
Seizure Disorders: Epilepsy
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Drugs to control seizures
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Parents should be advised not to stop the anticonvulsant
suddenly or without consulting the physician. Such action
could result in seizure activity
Parents should be advised about the side effect of
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Valporic acid (Depakene) such as Thrombocytopenia that causes
bruising and bleeding
Phenytoin (Dilantin); gingival hyperplasia. Good oral hygiene will
minimize this adverse effect. Hepatic dysfunction thus serum
therapeutic level of phenytoin should be carefully monitored
Seizure Disorders: Epilepsy
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Nursing care during a tonic-clonic seizure
Stay with the child until the seizure subsides
 Patent airway: suction and O2 supply
 Prevent injury by removing sharp objects
 DO not put any objects in the child’s mouth
 Loosening clothing around the neck
 Roll the child to the side to prevent aspiration
 V/S (temperature) and neurologic
 Administer diazepam (may cause apnea)
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Seizure Disorders: Epilepsy
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Nursing care after tonic cloinc seizure
The child may be lethargic and confused
 If patient is febrile sponge bath
 Check blood glucose level
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Seizure Disorders: febrile seizure
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Benign seizure
Occurs between 6 months and 6 years
Is a convulsive event lasts 1-5 minutes due to rapid
rise in body temperature (fever)
Usually consists of jerking of extremities, eye
rolling, unresponsiveness and sometimes cyanosis
Sometimes it can be non-convulsive such as loss of
tone and consciousness or stiffness of the body
No brain damage and treatment is unnecessary
Pertussis immunization
54
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It is wise to avoid Pertussis immunization for
infants who had neurological problems in the
neonatal period, until it is clear that they do
not have progressive neurological disorders.