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JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 140
Clinical Simulation
Instructor Handout: Child with Neurological Disorder
Remember to try not to lecture or read all of the data to the students – have them get the data.
Scenario: Simon Kidd is a 5-year-old with congenital hydrocephalus who had a V-P shunt placed when
he was an infant. Mom brought him to the ED because he has started to have some irritability and is
complaining of a headache. He also had a temp of 102.7 this am. Mom gave him Motrin. He is admitted
to the pediatric unit for suspected shunt failure secondary to infection and monitoring for increased
intracranial pressure.
1. Upon admission what should be included in the neuro exam?
 Mental Status – Decreased LOC
 Could use Glasgow Coma Scale (Eye opening, verbal response, physical response)
 Could test Cranial Nerves – Contralateral motor or sensory losses
 Pupillary changes – dilation with slowed constriction, visual disturbances such as
diplopia, ptosis
2. What would be your next steps in assessing Simon?
 Vital signs including temp, BP, and pox
Temp = 38.9, HR = 118, RR = 26 BP = 122/70 (pt is crying and it is difficult to
obtain an accurate BP) Pox 98% on RA
 Full physical assessment - should be done on every pt
 Ask parents if they’ve noticed any changes in their child’s personality, mental status.
Sometimes parents will state that their child just isn’t “right”.
 Developmental assessment.
 Getting pt ready for possible diagnostic tests – CT scan if ordered by MD
3. What are the interventions you as the nurse would employ to ensure the safety of this patient?
 Prepare room for seizure precautions:
o Pad side rails
o Have O2 and suction in the room
o Determine what medication will be needed if he does seize – Usually Ativan
during active seizure
 Start an IV for emergencies (Should be ordered)
4. Simon is admitted for us to monitor for increased ICP. What are the signs of increased intracranial
pressure?
 Decreased LOC
 Behavior changes
 Headache
 Nausea and vomiting
 Aphasia
 Pupillary changes
 Cranial nerve dysfunction - III (oculomotor) – movement of eye muscles
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

Seizures
VS – bradycardia, widening pulse pressure – LATE!
Respiratory dysrhythmias (shallow, slowed respirations, irregular patters or periods of
apnea – LATE!)
**Cushing’s Triad: Bradycardia, Hypertension, & resp changes*
 ***Infant assessment – remember sunsetting eyes, bulging fontanelles, increased head
circumference
5. What would be the nursing interventions you would employ to decrease the cranial pressure?
 Remember the 3 components of the head: brain, blood/fluid, CSF
 Elevate the head of the bed to assist venous drainage from the skull
 Align the head straight to assist venous drainage
 Give the pt a diuretic to decrease the circulating volume (usually Mannitol – use filter –
crystallizes very easily)
 Give the pt an anti-inflammatory (usually a steroid – decadron) to decrease brain
swelling if that is the problem
 Shunt revision
 EVD (external ventricular drain – PICU settings) if infected VP shunt
 Hyperventilation – LATE intervention – PICU
6.
While preparing to hang the patient’s IVF the patient begins to seize. What will you do? How
will you respond? What will you document?
 Maintain an airway during an dafter the seizure
 Do not leave the patient
 Maintain safety for the pt during the event – do not put anything in the patient’s mouth
 Note the time the seizure began
 Monitor the type of movements the pt has during their seizure
 Monitor the eye gaze and direction
 Determine if the patient is at all conscious through the seizure
 Monitor for length of the seizure
 Is the patient incontinent during or after the seizure?
 How long is the postictal phase?
7. You walk into the room after caring for this pt for several hours. He has been alert and oriented all
day. He is now confused and has pulled out his IV. What has changed? His level of consciousness has
changed. What will you assess? (Have students assess the pt as they would if they had been the one to
enter his room)
 LOC
 Pupils – one is dilated (see note)
 VS
 Does he have increased ICP?
 Has his shunt stopped working?
 Has his infection gotten worse and affected the shunt function?
**Note: If you can dilate one of Simon’s pupils do that so that will be a finding for the students. If not
then tell them that one of his pupils is dilated.
8. What will you do with this information?
 Stay with the patient
 Monitor for seizure
 Put HOB up and align head
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
Put on oxygen
Call for assistance and for someone to contact the MD immediately
9. The pt is taken to the OR to have her shunt changed. It was occluded from an infection and she is
D/C’d home a week later – nice save! Give yourself a pat on the back.
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JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 140
Clinical Simulation
Student Handout: Child with Neurological Disorder
Simon Kidd is a 5-year-old boy with congenital hydrocephalus who had a V-P shunt placed
when he was an infant. Mom brought him to the ED because he has started to have some
irritability and is complaining of a headache. He also had a temp of 102.7 this am. Mom gave
him Motrin. He is admitted to the pediatric unit for suspected shunt failure secondary to
infection and monitoring for increased intracranial pressure.
1. Upon admission what should be included in the neuro exam?
2. What would be your next steps in assessing Simon?
3. What are the interventions you as the nurse would employ to ensure the safety of this patient?
4. Simon is admitted for us to monitor for increased ICP. What are the signs of increased
intracranial pressure?
5. What would be the nursing interventions you would employ to decrease the cranial pressure?
7. While preparing to hang the patient’s IVF the patient begins to seize. What will you do?
How will you respond? What will you document?
7. You walk into the room after caring for this pt for several hours. He has been alert and
oriented all day. He is now confused and has pulled out his IV. What has changed? What
will you assess?
8. What will you do with this information?
9. The pt is taken to the OR to have his shunt changed. It was occluded from an infection and he
is D/C’d home a week later – nice save! Give yourself a pat on the back.
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PEDIATRIC SIMULATION
NEUROLOGICAL- INCREASED INTRACRANIAL PRESSURE AND SEIZURES
DATE/TIME
July 20, 2007
Time: 4:00PM
SUBJECTIVE AND
OBJECTIVE DATA
MINIMAL EXPECTED
STUDENT BEHAVIOR
PROMPTS AND
QUESTIONS TEACHING
POINTS
Physical Assessment:
Student should have room with
proper equipment. (suction,
oxygen, padding of rails/extra
pillows to prevent injury during
seizure)
What safety precautions should
be initiated in this patient’s
room in relationship to his
condition and history?
Pain Scale: 6
Neuro: Alert and oriented.
Quiet. No acute distress
Pupils- PERRL
HR- 118
Ht-60”
RR- 26
Wt-65lbs
T- 102
BP- 122/70
Pulse Ox- 98%
Student should ask questions to
mother about change in
behavior/personality.
Physician’s Orders
Student should investigate what
the child’s developmental level
is at present prior to illness.
Admit to Ped Unit
Neuro checks q 1hr x 4, then q
4hrs if stable
IV D5 ½ NS at 60cc/hr
Ativan 1mg IV q 4hrs prn
seizure activity
Vital signs q 4 hours
Activity: Bed rest with BR
privileges
CBC,BMP,CXR, CT of head
Complete physical assessment
Should focus on neuro checks
Which order should be done
first?
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Change in Neurological Status:
Pt begins to have a seizure
(will shake pt to simulate
seizure)
Should incorporate measures
that would decrease the cranial
pressure
During seizure pt will vomit.
Pt’s LOC has changed.
Neuro: Decreased LOC
Pupils- Rt pupil is dilated 3cm
with slowed constriction
Lt pupil- dilated no reaction
Confused and combative. C/O
blurred vision.
Vital Signs:
HR- 50
BP- 110/46
RR- 16
T-100
Student should initiate safety
measures: turn to side, protect
from injury, side rails up and
padded, assure airway is patent.
Student should know what to
record about the seizure
activity.
Student should do a complete
assessment, administer ativan
safely with dose calculations,
and notify physician of change
in neuro status and recognize
S/S of ICP
Student should apply oxygen
2L/minute, stay with patient,
Elevate HOB and keep in
alignment.
Designate another team
member to contact physician.
What is the biggest risk for the
patient during the seizure
activity?
What do you do to assure the
airway is patent?
What are S/S of ICP?
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