Hydrocephalus Neural Tubes Defects Bacterial Meningitis Guillain-Barre Syndrome Reye’s Syndrome Seizures

Common Neurological Disorders in Children

“Water on the Brain” Imbalance between the production and

absorption of CSF. Often from congenital CNS malformations Results in rapid head enlargement in infants

Can lead to irreversible neurological damage

Hydrocephalus

Hydrocephalus

Symptoms in the infant

Early Signs Projectile vomiting

not associated with feeding

Scalp veins become prominent

Shrill, high pitched cry

Increasing irritability

Late Signs Bulging anterior

fontanel

Head circumference that increases at an abnormal rate

Enlargement of the forehead

Depressed eyes rotated downward “sunset eyes” (pupils sink downward)

No enlargement of head (skull is closed)

Begins with generalized neuro symptoms HA in morning Nausea Vomiting

Followed by signs of increased ICP

Symptoms in the Child

Relief of hydrocephalus

Create a new pathway to divert excess CSF.

A catheter or shunt is placed in the ventricle and passes the CSF to the peritoneal cavity

Needs to be replaced PRN

Keep child flat unless ICP is present

the bed slightly elevated Slowly increase HOB over few days Support head when moving child Pain management Vital Signs

Post-op Nursing Care Shunt Placement

Observe for signs of increasing ICP –

neurologic assessment Observe for abdominal distention Strict I & O Antibiotics Meticulous skin care Support family

Post-op Nursing Care Shunt Placement

Teach parents to monitor for shunt

complications: Headache, progressive or worsening Drowsiness or inappropriate sleepiness during the

day, irritability Nausea, vomiting Personality changes or changes in school

performance Fever Redness or swelling along the shunt tract

Discharge Management Post Shunt Placement

Defects of closure of neural tube

during fetal development Congenital (present at birth) Believed to be caused by genetic or

environmental factors, but exact etiology is unknown Common in women with poor folic acid

intake before and during pregnancy

Neural Tube Disorders

Types: Spina Bifida

Occulta Cystica

Meningocele Myelomeningocele

Neural Tube Disorders

Most common CNS defect Caused by failure of neural tube to

close at some point along spinal column

Types: spina bifida occulta spina bifida cystica

Spina Bifida

Spina Bifida Occulta

Not visible externally

Lamina fail to close but spinal cord does NOT herniate or protrude through the defect

No motor or sensory defects

Spina Bifida Cystica Meningocele

External sac that contains meninges and CSF

Protrudes through defect in vertebral column

Meningocele Not associated

with neurologic deficit – good prognosis

Hydrocephalus may be an associated finding, or aggravated after repair

Spina Bifida Cystica

Myelomeningocele Same as above, but the

spinal cord and meninges protrude through the defect in the bony rings of the spinal cord

Contains nerves therefore the infant will have motor and sensory deficits below the lesion

Myelomeningocele Visible at birth,

most often in the lumbaosacral area

Covered with a very fragile thin membrane/sac which can tear easily, allowing CSF to leak out

Protect the sac from injury Keep free from infection

Position: prone or side lying Cover sac with sterile, moist non-adherent dressing,

sterile technique imperative

Parents need emotional support & education regarding short and long term needs of infant

Nursing Interventions

Surgical repair usually within first

24 hours observe for early signs of infection:

elevated temp, irritability, lethargy, nuchal rigidity

observe for signs of increasing ICP (may indicate hydrocephalus)

Nursing Interventions

Emphasizes constructive use of ‘normal’ parts

of body & minimizes the disabilities making the child as self-helpful as is possible in the activities of daily living

Major problems: incontinence, constipation, obesity or malnutrition

Habilitation

Meningitis

Acute inflammation of the cerebral meninges as a result of a bacterial or viral infection

Haemophilus influenzae type b was the most

common cause of bacterial meningitis in children prior to the use of the Hib conjugate vaccine

Still may be caused by Strep pneumoniae in child < 24months as not fully vaccinated with PCV vaccine

Meningococcal predominantly in unvaccinated school-age children & adolescents

Bacterial Meningitis

Symptoms

Abrupt onset of fever

Chills Increasing

irritability Headache Nuchal Rigidity Poor feeding Weak Cry Bulging fontanel

Opisthotonic position

Symtoms

Kerning’s Sign Brudzinski’s Sign

Lumbar puncture Administer IV antibiotics Respiratory isolation Promote hydration- monitor I + O Frequently assess vital signs, LOC, neurologic

assessment to identify changes in the child’s condition

Measure head circumference frequently- risk for hydrocephalus

Prepare for seizures

Nursing Management

Promote comfort

• reduced stimulation (dim lights, quiet room)

Side-lying position Identify parents’ concerns, provide support

Prevention is a major role for nurses Encourage parents to get their infants

and children fully immunized!

Nursing Management

Life Threatening Condition If Survival

Hearing loss Blindness Paresis Intellectual impairment

Complications

Immune-mediated disease of motor weakness that is

often associated with viral or bacterial infection of respiratory or GI tract or vaccine administration

Adults have increased susceptibility, can affect children usually ages 4-10

Inflammation of nerve fibers, impairs nerve conduction though demyleination

Ascending paralysis from lower extremities

Guillain-Barre Syndrome

Peripheral neuritis occurs several days

after primary infection Muscle tenderness Tendon reflexes decreased or absent Paresthesia & cramps Proximal symmetric muscle weakness Urinary incontinence or retention Decreased swallowing & respiratory

efforts-may lead to respiratory failure

Initial Symptoms

Wait for disease to stabilize Intravenous immune globulin IVIG Physical Therapy Rarely fatal, often residual paralysis

Treatment

Monitoring respiratory status Managing autonomic nervous system

dysfunction Preventing complications associated with

immobility Providing emotional support Teaching the parents how to care for the child

after discharge

Nursing Care

A life threatening acute encephalitis

Occurs after viral infection if given aspirin

Education efforts has helped to reduce incidence (use Tylenol or Ibuprofen not ASA)

Reye’s Syndrome

Begins with mild viral infection that worsens w/i 24-48 hours

Lethargy

Vomiting

Followed by Agitation Anorexia Combativeness Confusion leading to stupor, coma, seizures, respiratory

arrest

Reye’s Syndrome

If Survival in PICUMonitor: Neurological status Respiratory effort Hypoglycemia Cerebral edema

Reye’s SyndromeNursing

Care

Involuntary contraction of muscle caused by

abnormal electrical brain impulses They are episodic and abrupt Often triggered by environmental of

physiological stimuli Exact location of the electrical foci and the

number of brain cells involved determines the nature of the seizure (sterotypical)

Some seizures in children are acute, not believed to re-occur

Re-ocurring seizures will be diagnosed as epilepsy

Seizures

Seizures: 2 categories

Partial Simple Complex

Only 1 area of brain involved

Symptoms are associated with the area affected

No LOC or consciousness is impaired

Generalized Infantile spasms Febrile Absence Tonic Clonic

Entire brain Usually have loss of

consciousness May have aura Postical State

Aura

sensation experienced before the seizure activity it often manifests as the perception of a strange

light, an unpleasant smell or confusing thoughts or experiences

Postictal altered state of consciousness that a person enters

after the seizure, lasts between 5 and 30 minutes emergence from this period is often accompanied by

amnesia or other memory defects

Seizure Terms

Simple Partial SeizuresSimple Partial Seizures

Complex Partial SeizuresComplex Partial Seizures

• Seizure is short, lasts < 30 seconds• No loss of consciousness, aura, or postical stateSeizure Activity is either:

Abnormal motor activity• One extremity or part of extremity, uncontrolled

movement

Abnormal sensory activity Numbness, tingling, paresthesia or pain starting in 1

area of body, may spread to other parts of body May include abnormal auditory, olfactory and visual

sensations

Simple Partial Seizures

Seizure is longer, 30 seconds-5 minutes Consciousness is impaired immediately May have slight auraSeizure Activity

Sudden change in posture Abnormal motor activity, twitching, loss of tone,

tingling or numbness Automatisms-lip smacking, chewing, sucking Circumoral pallor

Afterward: drowsiness

Complex Partial Seizures

Infantile spasmsAbsence

Tonic ClonicFebrile

Age: 4 months to 2 years Occur in clusters 5-150/day, worse at night Altered consciousness Abrupt flexion/extension of neck, trunk,

extremities Eye rolling May have permanent cognitive &

developmental delays

Infantile Spasms

Lasts 5-10 seconds, multiple times a day 50-100 per day

Seizure is a brief loss of consciousness Appears to look like a staring spell Rhythmic blinking & twitching of mouth or arm Mistaken for daydreaming or behavior

problems Interferes with learning 1/3 of children will grow out of them by

adolescence

Absence Seizure

1. Prodromal: Drowsiness, dizziness, malaise, lack of

coordination, “not himself”

2. Aura May precede seizure, reflects portion of

brain where seizure originates

Tonic Clonic4 stages of Seizure

3. Tonic-Clonic

Tonic: 20 seconds, all muscles cx (rigid), child falls to ground, LOC, respiratory muscles affected, grunting, airway compromised

Clonic: 20-30 seconds, jerky muscle contract & relax rapidly, froth or bloody sputum, urinary or bowel incontinence

4. Postictal Appears to relax, semi-conscious, sound sleep for hrs, no recollection of event

Tonic-clonic stage

Due to increased temperature > 102 F (but may occur as low as 100 F) Higher fever=higher risk Occur between 6 months and 5 years, with a

peak incidence between 18 and 24 months of age

Tonic-clonic pattern Lasts 15-20 seconds

Acute Febrile Seizure

Chronic disorder with recurrent seizures in

children 3 and older

Symptoms depend on type of seizure No association with illness, injury Seizure may be triggered by something

Epilepsy

Anticonvulsants-monotherapy is desired

Dosage increased as child grows Control the seizures or reduce their

frequency Discover and correct the cause when

possible, know triggers Help child live a normal life

Epilepsy Management

Instruct parents on importance of giving meds

to achieve therapeutic drug levels

Med can be withdrawn when child is seizure free for 2 yrs with normal EEG

TAPER! Gradually decreased over 1-2 weeks

Epilepsy Management

Changes in dark-light patterns Sudden loud noises, specific voices Sudden or startling movements Extreme changes in temperature Dehydration, fatigue Hyperventilation Hypoglycemia Caffeine, insufficient protein in diet

Triggers

Ensure IV access and Patency Check MD orders for Seizure Medication Check that medication is on the Unit Check Suction at bedside, ambu bag, mask

and 02 tubing, SaO2 is available and working! Are Side Rails Padded? ID band- correct? Indicate Seizure Risk? Know how to initiate emergency or rapid

response

If A Patient is Admitted for Seizure Activity or has PMH

of Seizures

1. Maintain Patent AirwayPlace nothing in the child’s mouth during a seizure

Loose teeth may be knocked out and aspirated. Position side so secretions can drainPulse oximetry reading (SpO2) Oxygen for < 95%- use maskSuction prn

Nursing Management during Seizures

Ensure Safety•If OOB gently assist to floor•Bed in lowest position •Stay near child•Protect head from injury

Nursing Management during Seizures

Administer MediationInitial order is intravenous medicationsIV push slowly Benzodiazopene IV push slowly to avoid apneaDiazepam (Valium) or lorazepam (Ativan)Followed by anticonvulsant

Nursing Management during Seizures

Observe and Record

Type of seizure activity Vital Signs Time seizure started and stopped

Nursing Management during Seizures

Toxicity: nystagmus, ataxia, decresed mental

capacity

Low levels: seizure activity

Side Effects gingival hyperplagia (discuss oral hygiene), drowsiness, thrombpcytopenia, leukopenia, increased liver enzymes

Nursing responsibility: Monitor CBC, LFT, therapeutic drug levels

Dilantin

A 10-year old is diagnosis is Guillain-Barre

Syndrome. It would be imperative for the nurse to inform the physician after observing which of the following?

1. Weak muscle tone in the feet2. Weak muscle tone in the legs3. Increasing hoarseness and cough4. Tingling in the hands

A 4-year-old is being evaluated for

hydrocephalus. The nurse notes which of the following as an early sign of hydrocephalus in a child?

1. Bulging fontanels2. Rapid enlargement of the head3. Shrill, high-pitched cry4. Early morning headache

A child with a history of a seizure was

admitted 2 hours ago. The history indicates fever, chills, and vomiting for the past 3-4 hours. In report the nurse is told that the child had a positive Brudzinski’s sign. The nurse infers this is most likely caused by:

1. Increased intracranial pressure2. Meningeal irritation3. Encephalitis4. Intraventricular hemorrhage

A nurse is assessing a new admission. The 6-

month-old infant displays irritability, bulging fontanels, and setting-sun eyes. The nurse would suspect:

1. Hydrocephelus2. Hypertension3. Skull fracture4. Myelomeningocele

An 8-year-old client with a

ventriculoperitoneal shunt was admitted for shunt malfunction. He presents with symptoms of increased intracranial pressure. The mechanism of the development of his symptoms is most probably related to:

1. Increased flow of CSF2. Increased reabsorption of CSF3. Obstructed flow of CSF4. Decreased production of CSF

The nurse is taking a history of a child

admitted for EEG testing to determine seizure activity. The parent reports that the child has “odd” behavior, including periods of lip smacking, and muscle twitching. The nurse suspects:

1. Simple Partial Seizures2. Complex Partial Seizures3. Absence Seizures4. Tonic-Clonic Seizures