ALTERATIONS IN
NEUROLOGICAL FUNCTION
IN PEDIATRICS CH 29
Christine Limann Dyer, RN, MSN, CPN
Pediatric Differences
-Head is larger in proportion
to body
-Insufficient musculoskeletal
support in neck
-Fontenelles not closed in
young child
A & P Review

Nervous system
 Central
 Brain
nervous system
and spinal cord
 Peripheral
nervous system
 Sensory-somatic
 Autonomic
Altered States of Consciousness


Arousal or level of consciousness: awareness of the
environment
Content of thought: all cognitive functions that
ensure awareness of affective states, self, and
environment
The Unconscious Child

Unconsciousness is a state in which a child’s cerebral
function is depressed and ranges from stupor to
coma
Caring for the Unconscious Child

Evaluating
neurological status
 The
pediatric Glascow
Coma Scale
 Eye
opening, verbal
response, and motor
response
Caring for the Unconscious Child






Monitor vital signs
Manage the airway
Manage bladder and
bowel elimination
Maintain hydration &
nutrition
Provide proper
hygiene
Position and perform
exercise
Persistent Vegetative State



A complete unawareness of the environment
accompanied by sleep–wake cycles.
The diagnosis is established if it is present for 1 month
after acute or nontraumatic brain injury or has lasted
for 1 month in children with degenerative or metabolic
disorders or developmental malformations
Family support is needed
Increased Intracranial Pressure


Intracranial pressure (ICP) is the pressure of the
cerebral spinal fluid (CSF) in the subarachnoid space
between the skull and the brain. A child can have
increased ICP as a result of many internal or external
factors.
Signs and symptoms

See Table 29-2
Increased Intracranial Pressure

Nursing care
 Close monitoring (neurologic status)
 Maintenance of a patent airway
 Monitor vital signs closely (hyperthermia)
 Administer IV fluids
 Monitor fluid balance (I & O)
 Protect child from injury
 Administer antiseizure medications
 Provide emotional support
 Administer medications to decrease cerebral edema
 Analgesia and sedation
 A craniotomy is recommended when all other measures have been unsuccessful
Cushing’s Triad
Increased
Systolic
Widening
Pulse
Pressure
Decreased
Diastolic
Irregular
Respirations
Bradycardia
(Ball, Bindler, & Cowen,
2010)
Seizures


Most common neurologic dysfunction in kids
Caused by malfunctions of brain’s electrical system
Infections or high fever
 Chemical imbalance of the body that causes loss of
metabolism
 Congenital conditions or trauma
 Genetic factors and family history
 Brain tumors and neurological problems
 Habits of the mother like smoking, alcohol consumption,
drugs and certain medications

(Hockenbery & Wilson, 2010)
Types of Seizures





Absence – (3-12 years old)5-10 sec. Lip smacking,
staring, twitching, brief loss of consciousness
Partial (focal) – Less than 30 sec., one extremity
Generalized (tonic-clonic or grand mal)
Febrile Dependent
Epilepsy – Chronic disorder
Febrile Seizures



Usually higher than
38.9 C or 101F
Usually short in
duration. Instruct
parents to call 911 if
longer than 5 minutes
Use antipyretics and
cooling measures
(Mayoclinic.com, 2010)
Nursing actions with patients with
seizures

Before


During






Where there triggers such as
change in temperature, light?
Maintain airway
Role to side if possible
Time changes started
Part of the body involved and
movement
Incontinence
After

Do they remember what
happened?
(Ball, Bindler, & Cowen,
2010)
Treatment for Seizures

Common pharmacological choices
 Ativan
-Lorazepan
 Diazepam – Diastat (can be given rectally)
 Phenobarbital or Phenytoin


Remind parents not to stop once the seizures are
controlled until directed by a doctor.
Other types of treatment
 Vagal
Nerve stimulator
 Ketogenic Diet
(Ball, Bindler, & Cowen,
2010)
Seizure Disorders

Signs and symptoms


See Table 29-3
Nursing care








Complete a detailed history
Ensure airway management
Maintain anticonvulsant therapy
Implement seizure precautions (padded side rails, oxygen, suction equipment, IV
access, and anticonvulsant medications)
Provide continuous cardiac, respiratory, and oxygen monitoring
Instruct caregivers instructed in CPR
Keep school nurses and teachers informed about the condition
Encourage medical alert identification bracelet
INFLAMMATORY
NEUROLOGICAL
CONDITIONS
Intracranial Infections -Meningitis
Bacterial Meningitis



More Dangerous



Group B Streptococcus and gramnegative enteric bacilli most likely
cause in newborns

Neisseria Meningitidis 2 mo-12 yr



Viral Meningitis
Can also cause meningococcemia
H influenzae B and Strep
Pneumoniae are now less common
because of vaccination


Does not appear as ill as the child
with bacterial meningitis
Caused by enteroviruses, mumps,
vericella
Irritable, fever, lethargy,
headache, may have stick neck or
back pain
Usually resolves in 3-10 days
Treat with antibiotics until bacterial
meningitis is ruled out
-Fever, vomiting, irritable,
hemorrhagic rash, headache, nuchal
rigidity, seizures, Kernig and/or
Brudzinski sign
Treatment: Antibiotics
Both Diagnosed by Lumbar Puncture-LP
Encephalitis

Signs and symptoms

Disorientation, confusion, headache,
high fever, photophobia, lethargy,
aphasia, hallucinations, seizures, nuchal
rigidity, and coma

Nursing care

Viral is treated with antiviral
medication

Bacterial is treated with a narrowspectrum antibiotic

Other medications include antipyretics,
anticonvulsants, analgesics, and antiinflammatories

Provide intravenous fluids and nutrition

Implement seizure precautions

Monitor fluid & balance

Do not suction or give percussion
Brain Abscess

Signs and symptoms


Localized headache, fever, drowsiness, stupor, confusion, general or focal
seizures, focal motor or sensory impairments, ataxia, nausea and
vomiting, papilledema, and hemiparesis
Nursing care



Assess neurological status, assess response to treatment, administer
medications, and provide supportive care
Monitor serum labs
Surgery required if no response to antimicrobial therapy (postoperative
care) or does not meet criteria for medical therapy
Reye Syndrome

Associated with use of aspirin with viral illness such as chicken pox or
influenza b
May cause permanent tissue damage to brain and liver

Signs and symptoms



Lethargy, vomiting, drowsiness, liver dysfunction
Nursing care








Conduct neurological assessment
Administer IV fluids
Administer corticosteroids and/or diuretics
Monitor oxygen saturation (supplemental oxygen)
Insert arterial line (blood gases)
Take seizure precautions
Limit invasive procedures
Provide emotional support
Guillain-Barré Syndrome

Signs and symptoms


Three phases: acute, second, recovery
Nursing care

Plasma exchange and IV immunoglobulin therapy

Give corticosteroids

Monitor progression

Insert indwelling urinary catheter

Assess pain level

Prevent contractures and loss of function (passive ROM)

Provide skin care

Suggest age-appropriate activities
DEVELOPMENTAL
NEUROLOGICAL
CONDITIONS
Spina Bifida
Neural tube defects (NTDs)

Signs and symptoms





Vary depending on the level of the lesion and defect
Spina bifida occulta
Meningocele
Myelomeningocele
Types



Meningocele
Myelomeningocele
Spina bifida occulta
Spina Bifida

Nursing care









Place newborn in prone position (prevent injury to sack)
Provide postoperative care for laminectomy & closure of defect
Evaluate orthopedic function
Prevent joint contractures
Assess bladder and bowel function
Provide skin care
Assess neurological status
Measure head circumference and assess fontanel
Manage pain
Spina Bifida

Surgery to close the repair
usually occurs within 24-48
hours. Some cases can be
repaired in utero.
 May

need VP shunt.
Ongoing therapy
 Mobility-Braces,
wheelchair
 Neurogenic bowel and
bladder
Hydrocephalus – Cerebrospinal fluid
build up


Communicating hydrocephalus – no blockage.
Either a problem with over production of CSF or
problem with absorption
Non-communicating- obstruction
Aqueduct of sylvius
Hydrocephalus- clinical manifestations

Newborns and infants






Bulging fontanels
Increased head
circumference
Sun set eyes
Irritability
High-pitched, catlike cry
Visible scalp veins

Children







Headache
Visual disturbance
Nausea/vomiting
Pupils sluggish
Decrease in consciousness
Seizures
Cushing’s Triad



Widening pulse pressure
Bradycardia
Irregular respirations
(Ball, Bindler, & Cowen,
2010)
Hydrocephalus Treatment

Ventriculoperitoneal
shunt (VP Shunt)
Hydrocephalus


Signs and symptoms

Increased ICP

Macewen sign
Nursing care

Understand shunt function and complications

Obtain history and physical (life-threatening conditions)

Discuss pharmacological measures or surgical procedure

Perform nursing actions related to ICP

Measure head circumference

Give preoperative and postoperative antibiotics

Assess neurological status

Assess for shunt malfunction (eye assessment)

Assess abdominal status (pain, bowel sounds, and circumference)

Elevate HOB 30°
Abnormal muscle tone, lack of coordination, spasticity. Symptoms
very depending on age and type of CNS injury.
Cerebral Palsy
Nursing Role:
Provide adequate Nutrition
Maintain Skin Integrity
Promote safety and physical mobility
Prevent Constipation
(Ball, Bindler, & Cowen, 2010)
Cerebral Palsy

Signs and symptoms


Vary individually depending on the area of the brain
involved and the extent of damage
Four categories
Spastic
 Ataxic
 Athetoid or dyskinetic
 Mixed

Cerebral Palsy

Nursing care







Use splints and braces
Promote self-care
Administer medications (reduce muscle spasms, spasticity, anxiety, and
seizure)
Surgery (selective dorsal rhizotomy)
Address feeding problems
Provide intellectual stimulation
Ensure safe environment
NEUROLOGICAL INJURIES
Drowning/Near-Drowning
Drowning is the
second leading cause
of accidental death in
children
Death occurs from
asphyxia while
submerged
Can occur with even
small quantity of
water (even as little
as a pail of water)
Near-drowning:
survived at least 24
hours after submersion
Near Drowning (Submersion)

Signs and symptoms


Cerebral edema, alteration in LOC, respiratory distress, cardiovascular
complications, hypovolema
Nursing care






Assess and maintain airway
Provide life support measures
Suction secretions
Insert NG tube
Administer oxygen
Assess other injures (head or spinal trauma)
Head Injuries
-Major cause of childhood deaths
-Who is more at risk?
Head Injury
Traumatic Brain Injury (TBI)

Signs and symptoms



Obvious signs: blood on the scalp, depression of the skull, and an obvious
penetrating wound
Other signs and symptoms: loss of consciousness, alteration LOC, seizures and
combativeness
Nursing care





Provide immediate care to prevent life-threatening complications
Maintain airway patency and oxygen administration
Insert IV and administer hypertonic fluid
Assess neurological status
Assess ICP
Concussion
Signs and Symptoms
-Headache
-Slowness in thinking, acting, speaking
-Fatigue
-Memory problems
-Loss of balance
(Ball, Bindler, & Cowen, 2010)
Cerebral Contusion



Bruising of the brain
secondary to blunt
trauma.
Can be either coup or
countercoup injuries.
May involve tearing of
brain tissue and may
lead to areas of
necrosis or infarction.
(Ball, Bindler, & Cowen, 2010)
Head Trauma
Subdural Hematoma





Between dura and
cerebellum
Result of head trauma
such as falls, MVA, or
shaken child syndrome
Symptoms may appear
after 24-72 hours
Change in LOC,
Headache, N/V, retinal
hemorrhage, pupil on side
of injury may be dilated
Prognosis poor
Epidural Hematoma




Between dura and skull
Almost never occurs in
children less than 4 y/o.
Blunt trauma such as
MVA, assault, baseball
injury
Delayed onset followed
by rapid change in
mental status
Headache, Fixed
dialated pupils, s/s
increased ICP
Prognosis good
Shaken Baby



Countercoup
injury



Physical abuse
Countercoup injury
Subdural Hematoma
Retinal Hemorrhage
Seizure
Check baby for fractures
in the rest of their body
Shaken Baby Syndrome

Signs and symptoms


Seizure activity, apnea, budging fontanels, coma, hemorrhage, bradycardia &
cardiovascular collapse
Nursing care








Provide respiratory and cardiovascular support
Assess for ICP
Insert NG tube
Maintain seizure precautions
Maintain adequate fluid and nutritional intake
Assess and document visible injuries
Discuss short- or long-term care
Assess parental concerns
Spinal Cord Injury

Signs and symptoms


Numbness, tingling, or loss of function
Nursing care









Maintain airway management and respiratory function
Provide cardiovascular and circulatory support
Give steroid therapy
Monitor fluid intake and output
Maintain gastrointestinal function
Provide nutritional support
Provide emotional and social support
Be attuned to an adolescent’s unique needs
Explain lifelong care and support, circulation support, disability identification, and
exposure of known and unknown physical limitations
NONTRAUMATIC
NEUROLOGICAL
CONDITIONS
Headaches

Types
 Primary
headaches
 Secondary headaches
 Tension
 Migraine
 Cluster
Headaches

Signs and symptoms
Primary (triggers — i.e., stress)
 Secondary (organic disorder — i.e., trauma)



Subtypes (tension, migraine, cluster)
Nursing care
Provide pharmacologic and nonpharmacologic care
 Discuss prophylactic measures
 Give intramuscular or intranasal medications
 Promote rest and stress reduction strategies

SENSORY CONDITIONS
Eye Disorders



Hyperopia (farsightedness)
Myopia (nearsightedness)
Correction
 Concave
lenses or contact lenses
 Laser assisted surgery
Astigmatism


Irregular curvature or uneven contour of the eye
Correction
 Corrective
lenses
 Surgery
 Complaints
of headache, blurry vision, or dizziness;
ophthalmologist referral
Amblyopia –lazy eye

Signs and symptoms
 Strabismus
or anisometropia are the most common
causes

Correction
 Occlusion
therapy (patching of the normal eye) is done
to restore strength and function of the “lazy eye”
Strabismus


Nonparallelism in the
different fields of gaze
causing visual lines to
cross even when focused
on the same object
Correction
Ocular patching of the
stronger eye, glasses,
and pharmacotherapy
 Early identification and
recognition

Color Blindness



X-linked recessive
inheritable color vision
deficiency
Color blindness is
detected using colored
charts called the Ishihara
Test plates
Child can learn to
compensate with support
from family members,
teachers, and friends
Nystagmus


Rapid irregular involuntary eye movement caused by
a disorder of the central nervous system
Correction
 Extraocular
surgery
Cataracts


Signs and symptoms
 Excessive tearing, extraocular movements, photophobia, lens appears
cloudy, or there is a white or dulled red reflex
Correction
 Prevent loss of visual acuity
 Laser procedure
 Postoperative (monitor nausea, emesis, pain, hemorrhage and signs of
infection)
 Postoperative eye drops
 Follow-up care for visual acuity
 Educate family
 Early identification and recognition
Glaucoma


Increase in IOP leads to retinal and optic nerve
damage
Signs and symptoms


Bupthalmos (enlarged eye globe), epiphora (excessive tearing),
and photophobia (sensitivity to light)
Correction




Preoperative maintain quiet environment
Antiglaucoma medications
Analgesia and anxiety reduction strategies
Pre- and postoperative care (teach parents)
Retinoblastoma

Signs and symptoms
 Absence
or
abnormality of the red
reflex
 A whitish or yellow
color of the pupil
called leukocoria

Correction
 Laser,
radiation,
cryotherapy, or
enucleation
EYE INJURIES
Foreign Bodies

Penetration
 Immediate
transport to
ER for removal

Corneal abrasion
 Treatment
 Topical
antibiotic
solutions or ointments,
analgesics, eye patch
Hyphema


Hemorrhage into the
anterior chamber of the
eye
Treatment
Rest, possible evacuation
 Monitor increased
intraocular pressure
 Promote decreased
activity
 HOB 30°
 Patch both eyes

Chemical burns


Usually occur as a result of an accident
Treatment
 Rapid
eye flushing for 15 to 30 minutes followed by pH
analysis of the chemical agent
 Eye patching
HEARING LOSS
Hearing Loss

Causes
 1/3
of all cases are due to genetic causes
 1/3 of all cases are due to non-genetic influences
 1/3 of all cases are due to unknown causes
Hearing Loss



Diagnostic testing
 Universal infant hearing screening before 1 month of age is
recommended
Treatment
 Based on underlying pathologic conditions, presence of organic diseases,
the severity of hearing loss, the degree of frequency loss, and any CNS
abnormalities
 Amplification aids (hearing aid)
Nursing care
 Provide emotional, educational, and collaborative support for the child
and family
Language Disorders

Communication
A process of complex interaction involving the exchange of
information, feelings, ideas, and interactions
 Receptive language
 Expressive language


Nursing care

Recognize speech and language developmental delays