Neurological Disorders
in the Pediatric Patient
Why is the CNS function so
important?
What does it do?
What happens with impairment?
What affects the degree of disability?
Changes to be noted in pediatric
neurological disorders
Reflexes: may be hypo/hyper
LOC: may have altered mental status
Cranial nerves:
I, III
II, IV, VI
III, VIII
V,VII
IX, X
Neuro assessment, cont.
Vital signs:changes in BP, HR
Eyes: changes in pupils,focus,gaze
Behavior: subtle
Respiratory status: assess 1st
Motor function: movement?
Spontaneous?
Skin: dry vs. diaphoretic
Neurological System of Children
Top Heavy
Cranial bones- thin, not well developed
Brain highly vascular with small
subarachnoid space
Excessive spinal mobility
Wedge-shaped cartilaginous vertebral
bodies
Assessment findings in children
with neurological dysfunction
Increased Intracranial Pressure
(ICP)
Reflects the pressure exerted by the
blood, brain, CSF and any other spaceoccupying fluid or mass (tumors)
Pressure sustained at 20mm Hg or higher
Changes in pressure present with altered
assessments other than normal
Altered Mental Status
Mnemonic = Mitten
Metabolic
Infections
Toxins
Trauma
Endocrine
Neurological/Neoplasm
Assessment:
Infant
Irritability and restlessness
Full to bulging fontanelles
Increase in FOC
Poor feeding, poor sucking, projectile
vomiting
Distension of superficial scalp veins
Nuchal rigidity and seizures (late signs)
Assessment:
Child early signsIrritability, lethargy
Sudden change in mood
Headache, poor feeding
Vomiting
Ataxia
Nuchal rigidity
Deterioration of cognitive ability
Assessment Child:
Late signs
Changes in Vital signs
Seizures
Photophobia
Positive Kernig’s sign
Positive Brudzinski’s sign
Opisthostonos
Therapeutic Intervention:
Nursing care
Medications
Corticosteroid
Decadron
Osmotic diuretic
Mannitol
Nursing Care
Minimize activity
Monitor IV rate
Place in semi-fowlers
Monitor VS, Neuro VS, and behavior
Treat for pain
Organize care
Educate parents
Critical Thinking
What would you expect as a first sign of IICP in an
infant?
What would you expect as an initial sign of IICP in a 10
year old child?
Hyperfunction/Hypofunction
Pediatric Seizures
Epilepsy vs. “seizure episode”
• Status epilepticus
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
Generalized: Tonic-clonic- loss of
consciousness(formerly called grand mal)
Absence seizures-may have minor motoratonic (formerly called petit mal)
Partial seizures- partial simple or partial
complex (may be focal or r/t tumors)
Diagnostic Tests:
EEG
CT, MRI
Lumbar puncture
CBC
Metabolic screen for glucose,
phosphorus and lead levels
Jitteriness –vs- Seizure
Jittery
Seizure
Responsive
Not responsive
to stimuli
Gaze Okay
Abnormal gaze
Goals:
What is the primary nursing goal when caring
for the individual experiencing a seizure?
What preventive measures does the nurse
provide?
How does the nurse maintain the airway of
an individual experiencing a seizure?
What is the priority nursing intervention
following a seizure?
Long term goal for children with
seizure disorders
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
Meningitis
Bacterial
Potentially fatal; abx given
prophylactically if
bacterial suspected.
May kill within 24 hrs
C/S take 72 hrs to process
Infants at greatest risk
Nuchal rigidity
Severe headaches
Contagious
Viral
Same s/s but milder and
shorter duration
May follow a viral infection
May be accompanied by
rash
Nuchal rigidity
Ataxia
Not contagious
Assessment and diagnostics:
Bacterial Meningitis
Streptococcus pneumoniae most
common pathogen
Diagnostics: LP, CSF eval (↑ WBCs,
gram stain +)
Treatment: ABCDs, cerebral edema,
seizure control, abx, steroids
Prevention: Vaccination (HiB,
Pneumococcal vaccine)
Assessment and diagnostics:
Viral Meningitis
May be preceded by viral infection, rash
Diagnostics: LP, CSF eval (mildly
↑WBCs, negative gram stain)
Treatment: self limiting; resolves in 714 days, monitored in hospital until
ABCs are stable
Medications: antivirals (Acyclovir)
Diagnostic Tests:
Lumbar Puncture
Serum Glucose Level
Blood Cultures
Nursing Care for diagnostics of
possible meningitis
Lumbar puncture
ASO titer
CBC/electrolytes/serum glucose
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
Infants- prior to fusion of cranial
sutures
1.
2.
3.
4.
5.
FOC increased at birth
Changes in assessment of skull
Forehead
Eyes
Behavior changes
After closure of cranial sutures:
1.
2.
Eyes
S & S of ICP
Diagnostic Tests
LP
MRI/ CT scan
Skull X-ray
FOC
Transillumination
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.
Types of spina bifida
Meningocele: sac filled with spinal fluid
and meninges
Myelomeningocele: more severe, sac
filled with spinal fluid, meminges, nerve
roots and spinal cord.
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 preoperatively
Nursing Interventions:
Pre-OP:
Meticulous skin care
Protect from feces or urine
Keep in isolette
Post-Op Nursing Interventions
Assess surgical site
Monitor VS and neuro VS
Institute latex precautions
Encourage contact with parents/care
givers
Positioning
Skin Care
Nursing Interventions cont...
Antibiotic therapy
Prevent UTI
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
Head Injuries
Concussions: Assessment and
Nursing Care
Grades 1-3: higher the number, more severe
the injury
Involves transient impairment
“Second impact syndrome:
Assess and manage according to grade
Treatment is supportive
Usually observed in the ED
If unconscious > 5 minutes, may be admitted
Removal from sports ranges from 1 wk-entire
season
Nurse as Provider: Care Plan
Brian, 10 years old, sustained a head injury when he collided
with a tree while riding his bicycle.He did not have on a helmet.
He is now unconscious in the PICU and is receiving an
intravenous drip of Mannitol, central venous pressure
monitoring, EEG and ECG monitoring, is being mechanically
ventilated, and has a urinary catheter. Brian's parents have just
arrived on the unit. How can the nurse prepare the parents for
Brian's appearance? What are Brian's immediate needs? Fill in
the appropriate steps of the Care Plan below for Brian for the
next 24 hours.
Assessment and Diagnosis
Planning and Implementation
Evaluation
CASE STUDY: The nurse is assigned to an 14-year-old female who is being
observed after a head injury sustained while playing soccer. She lost
consciousness for a few minutes when it happened.
What should the client and her parents be told about the recovery
time after a concussion?
What should the client and her parents be told about playing soccer
again?
What should the nurse tell the parents and the client about second
impact syndrome?
What can the family do to assess her symptoms at home and
determine if she is ready to play competitive sports again?
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
Autism
Not clearly understood
Characterized by impaired social,
communicative, and behavioral
development
Usually noted in the first year of life
Nursing interventions/education
Home setting
-reduce environmental
stimuli
-communicate age
appropriately;
use of touch and
verbalization
-safety with toys and
articles that could be harmful
-routines: ritualism with
ADLs
-long term care to include
therapists and support
groups
Acute care setting
-keep one constant
caregiver; room quiet as
possible
-may become aggressive
when touched by a stranger;
refer to parents for
communication techniques
-monitor for safety at all
times: removing tubes, etc.
-encourage to include
therapists and support
groups in care
Down syndrome
Trisomy 21- the most common
chromosomal abnormality resulting in
mild to profound mental retardation
Assessment
Primary concern with cardiac and GI
anomalies
What are the most obvious indications
of Down’s 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 child’s capabilities
Support siblings
Refer to family counseling services
Support parents in feelings of guilt and
chronic sorrow