Pediatric Neurologic Disorders

Ma. Tosca Cybil A. Torres, RN, MAN

Hydrocephalus

An excess of CSF in the ventricles or in the

subarachnoid space

Classification

1. Obstructive/ intraventricular• caused by a block in the passage of fluid.

2. Communicating/ extraventricular• fluid passes between the ventricles and

spinal cord

Assessment

1. Widened fontanelles

2. Separates suture lines in the skull

3. Enlarged head diameter

4. Shiny scalp

5. Prominent scalp veins

6. “Bossing” of forehead

7. Shrill cry

8. Sunset eyes

9. s/sx of increased ICP

10.Hyperactive reflexes

11.Strabismus

12.Optic atrophy

13.Irritable

14.Lethargic

15.Failure to thrive

Diagnostics

• Sonogram • CT scan • MRI • Skull X-ray• Transillumination

Therapeutic Management

• Ventricular endoscopy• Ventriculoperitoneal Shunt

Nursing Diagnoses

• Risk for injury • Risk of infection • Risk for ineffective cerebral tissue perfusion• Risk for impaired skin integrity • Risk for imbalanced nutrition: less than body

requirements • Impaired family processes

Nursing interventions

• Assess infant’s neurologic status closely. Watch for increasing irritability or lethargy.

• Measure and record head circumference every 4H. Assess anterior fontanelle for tenseness and bulging.

• Position infant with the head if the bed elevated 15º to 30° and maintain in neutral position.

• Monitor V/S q2H• Administer O2 as ordered.• Monitor I and O. Administer diuretics as ordered. • Encourage mother to breast-feed. Position properly with head

supported. Avoid flexion or hyperextension. • If vomiting occurs, encourage mother to attempt to refeed the

infant. If vomiting persists, anticipate the need for enteral or parenteral nutrition.

Nursing interventions

• Wash head daily with repositioning q 2H• Encourage parents to verbalize feelings. • Teach parents signs and symptoms of

increasing ICP.

Post operative nursing care

• Elevate head of bed to 30°• Infants are not turned to lie on the side of the

shunt• Assess for signs of increasing ICP • Assess for signs of infection • Keep NGT in place. • Introduce fluids gradually after NGT is removed. • Observe for constipation

Neural Tube Defects

Anencephaly

Absence of the cerebral

hemispheres.

Anencephaly

• Occurs when the upper end of the neural tube fails to close in early uterine life

• Diagnosed by elevated AFP in maternal serum or on amniocentesis

• Confirmed by sonogram.

Anencephaly

100% mortality rate.

Microcephaly • Disorder in which brain growth

is so slow that it fails more than three standard deviations below normal on growth charts.

• Causes: • Intrauterine infection (rubella,

cytomegalovirus, toxoplasmosis) • Severe malnutrition or anoxia in

infancy

Spina bifida ("split spine")

• a developmental birth defect involving the neural tube: incomplete closure of the embryonic neural tube results in an incompletely formed spinal cord.

• the vertebrae overlying the open portion of the spinal cord do not fully form and remain unfused and open

Spina bifida

Categories: 1. spina bifida occulta2. spina bifida cystica (myelomeningocele)3. meningocele

• The most common location of the malformations is the lumbar and sacral areas of the spinal cord

Assessment:• varying degrees of paralysis • absence of skin sensation• poor or absent bowel and/or bladder

control• curvature of the spine (scoliosis) • most cases there are cognitive

problems • hydrocephalus

Types

Spina bifida occulta• Occulta is Latin for "hidden." • no opening of the back, but the outer part of

some of the vertebrae are not completely closed

• The skin at the site of the lesion may be normal, or it may have some hair growing from it; there may be a dimple in the skin, or a birthmark

Spina bifida cystica (myelomeningocele)

• most serious and common form • the unfused portion of the spinal column allows the spinal cord to

protrude through an opening in the overlying vertebrae

• meningeal membranes that cover the spinal cord may or may not form a sac enclosing the spinal elements

Meningocele

• least common form• Meninges covering the spinal cord herniate through

the unformed vertebrae• Protrusion may be covered with a layer or skin just

the clear dura

Encephalocele

Cranial meningocele or myelomeningocele. Most often occur in the occipital area

Medical-Surgical Treatment

• no cure for nerve damage• Closure of the opening on the back • if spina bifida is detected during

pregnancy, then open fetal surgery can be performed

Nursing diagnoses

• Risk for infection • Risk for impaired cerebral tissue perfusion • Risk for impaired skin integrity • Impaired physical mobility

Pre-operative care

• Place infant in supine • If in side lying, place a towel or pillow in between the

infant’s legs• Place a piece of plastic below the meningocele on the

child’s back like an apron and secure it with a tape• Apply a sterile wet compress of saline, antiseptic, or

antibiotic gauze over the lesion • Keep infant warm assess for seepage of any clear liquid

Post operative care

• Place infant in supine until the skin incision is healed

• Same careful precautions are observed. • Assess for signs of increased ICP

Cerebral Palsy

Cerebral Palsy

A group of nonprogressive

disorders of upper motor neuron impairment that

result in motor dysfunction.

Cerebral Palsy

• Cause is UNKNOWN.• Associated with low birth weight, prebirth,

or birth injury • Intrauterine anoxia and direct birth injury

may contribute to the development of CP• Occurs in 2:1000 births

Types of Cerebral Palsy

Spastic S/Sx:

• Hypertonic muscles• Abnormal clonus• Exaggerated DTRs• Abnormal reflexes (eg. Babinski)• When held in ventral position, arching of back and abnormal

extension of arms and legs are observed• Failure to demonstrate parachute reflex when lowered

suddenly • Scissor’s gait • Hemiplegia, tetraplegia or paraplegia • astereognosis

Types of Cerebral Palsy

Dyskinetic or Athetoid S/Sx:

• Abnormal involuntary movement • Athetoid means “wormlike” • Early in life, child is limp and flaccid. Later, in

place of voluntary movements, the child makes slow, writhing motions.

• Drooling• Speech impairment • Choreoid movements • Disordered muscle tone (dyskinetic)

Types of Cerebral Palsy

AtaxicS/Sx:

• Awkward, wide based gait• Unable to perform finger-to-nose exam or perform

rapid, repetitive movements or fine coordinated motions.

Mixed

Assessment

• History• PE-all forms of CP may have sensory

alterations• Strabismus• visual perception problems• Visual field defects• Speech problems • deafness

25% to 75% of children with CP are cognitively

challenged. 50% have recurrent

seizures.

Physical findings that suggest CP

• Delayed motor development • Abnormal head circumference • Abnormal postures • Abnormal reflexes• Abnormal muscle performance or tone

Nursing Diagnoses

• Deficient Knowledge • Risk for disuse syndrome• Risk for delayed growth and development • Risk for imbalanced nutrition: less than body

requirements• Risk for self-care deficit • Impaired verbal communication

Nursing Intervention

Help parents understand their child’s condition

Nursing Intervention

Assist in ambulation.

Prevent contractures.

Choose toys and activities appropriate to the child’s

intellectual, developmental, and motor levels, NOT

chronologic age.

Ensure adequate nutrition.

Provide alternative form of communication

SPINAL CORD INJURY

Causes:

• Trauma• Tumor• Ischemia• Developmental disorders• Neurodegenerative diseases• Transverse myelitis• Vascular malformations

SPINAL CORD INJURY

Effects are less severe the lower the injury.

Manifestations

• C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete dependency for ADLs.C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.

Diagnostic:

1. Clinical evaluation: absence of reflexes, flaccidity, loss of sensation below injury level

2. Spinal x-ray: vertebral fractures, bony overgrowth

3. CT scans/MRI: evidence of cord compression and edema or tumor formation

SPINAL CORD SYNDROME

Central Cord Syndrome

• Central cord syndrome is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs.

• This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.

• This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord

Anterior cord syndrome

• an incomplete spinal cord injury. • Below the injury, motor function, pain sensation,

and temperature sensation is lost; touch, proprioception and vibration sense remain intact..

Brown-Séquard Syndrome

• usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injur, there is a loss of motor function, vibration, and light touch. Contralaterally, there is a loss of pain, temperature, and deep touch sensations.

Assessment

ACTIVITY/REST

May exhibit: Paralysis of muscles (flaccid during spinal shock) at/below level of lesionMuscle/generalized weakness (cord contusion and compression)

Assessment

CIRCULATIONMay report: PalpitationsDizziness with position changesMay exhibit: Low BP, postural BP changes, bradycardiaCool, pale extremitiesAbsence of perspiration in affected area

Assessment

ELIMINATION

May exhibit: Incontinence of bladder and bowelUrinary retentionAbdominal distension; loss of bowel soundsMelena, coffee-ground emesis/hematemesis

Assessment

EGO INTEGRITY

May report: Denial, disbelief, sadness, angerMay exhibit: Fear, anxiety, irritability, withdrawal

Assessment

FOOD/FLUID

May exhibit: Abdominal distension; loss of bowel sounds (paralytic ileus)

Assessment

HYGIENE

May exhibit: Variable level of dependence in ADLs

Assessment NEUROSENSORY

May report: Absence of sensation below area of injury, or opposite side sensationNumbness, tingling, burning, twitching of arms/legsMay exhibit: Flaccid paralysis (spasticity may develop as spinal shock resolves, depending on area of cord involvement)Loss of sensation (varying degrees may return after spinal shock resolves)Loss of muscle/vasomotor toneLoss of/asymmetrical reflexes, including deep tendon reflexesChanges in pupil reaction, ptosis of upper eyelidLoss of sweating in affected area

Assessment

PAIN/DISCOMFORT

May report: Pain/tenderness in musclesHyperesthesia immediately above level of injuryMay exhibit: Vertebral tenderness, deformity

Assessment

RESPIRATION

May report: Shortness of breath, “air hunger,” inability to breatheMay exhibit: Shallow/labored respirations; periods of apneaDiminished breath sounds, rhonchiPallor, cyanosis

Assessment

SAFETYMay exhibit: Temperature fluctuations (taking on temperature of environment)SEXUALITYMay report: Expressions of concern about return to normal functioningMay exhibit: Uncontrolled erection (priapism)Menstrual irregularities

Nursing Diagnoses

• Ineffective breathing pattern • High risk for disuse syndrome• Impaired physical mobility • Altered sensory perception• Risk for infection • Altered elimination• Risk for impaired skin integrity • Ineffective individual coping• Powerlessness

NURSING PRIORITIES

1. Maximize respiratory function.2. Prevent further injury to spinal cord.3. Promote mobility/independence.4. Prevent or minimize complications.5. Support psychological adjustment of patient/SO.6. Provide information about injury, prognosis and expectations, treatment needs, possible and preventable complications.

Therapeutic management:

a. Surgery- laminectomy or fusion for decompression and stabilization, wound debridement, placement of cervical tongs or halo traction for stabilization, tracheotomy for mechanical ventilation as needed

b. medications: massive corticosteroid therapy to improve outcome, vasopressors for shock, prophylactic antibiotics for open wounds, analgesics for pain, anticoagulants to prevent emboli and thrombus formation, anti anxiety to reduce emotional stress.

Therapeutic management

c. General:a. initial:

1. spinal stabilization with backboard or cervical collar on initial transport

2. MV if necessary 3. monitor cardiac status, blood gases, neuro V/S, I&O, V/S4. maintain skeletal traction and body alignment 5. reposition and turn every 2hrs6. passive ROM7. monitor bowel and bladder function, skin integrity and

avoid extreme temperatures

Therapeutic management

b. Long term

1. bowel training

2. bladder training

3. PT to diminish orthostatic hypotension, increase strength and endurance, decrease muscle spasticity, prevent contractures

4. OT to aid adaptation of ADLs

5. respiratory therapy

6. recreational therapy

7. speech therapy

8. case mgt for needed resources

9. long term medical ff up

10. counseling of individual and family support adaptation

Prevention and promotion:

1. Daily skin inspections

2. Diligent use of bowel and bladder programs to prevent bowel obstruction and UTI

3. Influenza and pneumonia vaccines to prevent respiratory complications

4. Early recognition and treatment of urinary tract and respiratory problems

DISCHARGE GOALS

1. Ventilatory effort adequate for individual needs.2. Spinal injury stabilized.3. Complications prevented/controlled.4. Self-care needs met by self/with assistance, depending on specific situation.5. Beginning to cope with current situation and planning for future.6. Condition/prognosis, therapeutic regimen, and possible complications understood.7. Plan in place to meet needs after discharge.

Infection of the CNS

Bacterial Meningitis

Infection of the cerebral meninges

Causes:

• RTI• Lumbar puncture• Skull fracture • Meningocele• Myelomeningocele

Assessment

• History • S/Sx:

• Irritable • Headache• Seizure/shock• Brudzinski’s sign • Kernig’s sign• Opisthotonos• Cranial nerve paralysis (III & VI)• Papilledema

Neonate

• Bulging and tense fontanelles• Poor sucking • Weak cry • Lethargy • Apnea• Seizures

Diagnostics

• Lumbar tap with CSF analysis• Blood culture • Ct scan • MRI • Ultrasound

Therapeutic management

• Antibiotic therapy (IV/intrathecal) • Corticosteroid • Osmotic diuretic

Nursing diagnoses

• Pain • Risk for ineffective cerebral tissue

perfusion• Altered sensory perception

Nursing interventions

• Position in supine without pillows• Place in isolation • Ensure strict medication compliance• Observe for signs and symptoms of increasing

ICP • Monitor I and O with specific gravity of urine • Assess senses

Encephalitis

Inflammation of the brain tissue and possibly the meninges as well

Assessment

S/Sx

Symptoms begin gradually or suddenly • Headache • Fever • Nuchal rigidity((+) brudzinski’s and Kernig’s sign) • Ataxia • Muscle weakness or paralysis • Diplopia • Confusion • Irritability

Therapeuic Management

• Treatment is primarily supportive• Antipyretic • Antibiotic therapy• Corticosteroid • Osmotic diuretic

Reye’s Syndrome• Acute encephalitis with accompanying fatty infiltration of the

liver, heart, lungs, pancreas, and skeletal muscle. • Occurs in children 1-18 years of age • Both sex are equally susceptible • Cause Unknown but generally occurs after a viral infection

such as varicella and influenza• If child was treated with salicylate such as acetylsalicylic acid

(aspirin) during the viral infection

Neurologic Diseases that result from viral infections or neurotoxins

Postpoliomyelitis Syndrome

• Complication of previous poliomyelitis virus (epidemic occurred in USA during 1940’s and 1950’s); persons who recovered are re-experiencing manifestation of acute illness in their advanced age

• Pathophysiology: Process is unknown• Manifestations: Fatigue, muscle and joint weakness, loss of muscle

mass, respiratory difficulties, and pain• Diagnosis: By history and physical examination• Treatment: Involves physical therapy and pulmonary rehabilitation• Nursing Care: Involves emotional support and interventions to deal with

dysfunction; ADL, safety are including in interventions

Rabies Rhabovirus infection of CNS transmitted by

infected saliva that enters the body through bite or open wound

• Critical illness almost always fatal• Source often is bite of infected domestic or wild

animal• Incubation is 10 days to years

Rabies

Manifestations occur in stages• Prodromal: wound is painful, various paresthesias,

general signs of infection; increased sensitivity to light, sound, and skin temperature changes

• Excitement stage: periods of excitement and quiet; develops laryngospasm and is afraid to drink (hydrophobia), convulsions, muscle spasms and death usually due to respiratory failure

Rabies

Collaborative Care• Animal that bit person is held under observation

for 7 – 10 days to detect rabies• Sick animal are killed and their brains are tests

for presence of rabies virus• Blood of client may be tested for rabies

antibodies

Rabies

Post-exposure treatment• Rabies immune globulin (RIG) is administered for passive

immunization• Client often has local and mild systemic reaction;

treatment is over 30 daysTreatment of client with rabies: involves intensive care

treatmentHealth Promotion• Vaccination of pets• Avoid wild animals, especially those appearing ill• Follow up care for any bites

Tetanus (lockjaw)

Disorder of nervous system caused by neurotoxin from Clostridium tetani, anaerobic bacillus present in the soil

• Contract disease from open wound contaminated with dirt, debris• Has high mortality rateIncubation is usually 8 – 12 daysManifestations • Stiffness of jaw and neck and dysphagia• Spasms of jaw and facial muscles• Develops generalized seizures and painful body muscle spasms• Death occurs from respiratory and cardiac complications

Tetanus (lockjaw)Diagnosis is made on clinical manifestationsClients with disease are treated in intensive care with

antibiotics, chlorpromazine (Thorazine) and diazepam (Valium ) for muscles spasms

Health Promotion• Active immunization with boosters given at time of

exposure• Passive immunization is given to persons who are not

adequately immunized

Botulism Food poisoning caused by ingestion of food contaminated

with toxin from Clostridium botulinum, anaerobic bacteria found in soil

• Contracted by eating contaminated foods usually improperly canned or cooked

• Untreated death rate is highPathophysiology: Bacteria produce a toxin, which blocks

release of acetylcholine from nerve endings causing respiratory failure by paralysis of muscles

BotulismManifestations• Visual disturbances• Gastrointestinal symptoms• Paralysis of all muscle groups• Effecting respirationDiagnosis • Based on clinical picture• Verified by laboratory analysis of client’s serum

and stool• Testing the suspected food

Botulism

Treatment• Administration of antitoxin• Supportive treatment including mechanical ventilation

and systemic support in intensive care unit

Health Promotion• Teaching clients to process foods properly when home

canning• Boiling foods for 10 minutes which destroys the toxin• Not eating spoiled foods

End of Concept