Neurological

Common Neurological Disorders in Children

HydrocephalusNeural Tubes DefectsBacterial MeningitisGuillain-Barre SyndromeReye’s SyndromeSeizures

Structural Defects

Hydrocephalus“Water on the Brain”Imbalance between the production and absorption of CSF. Often from congenital CNS malformationsResults in rapid head enlargement in infantsCan lead to irreversible neurological damage

INFANT Hydrocephalus

Early Signs

Projectile vomiting not associated with feedingScalp veins become prominent**Shrill, high pitched cry**Increasing irritability

Infant Hydrocephalus Later signs & symptoms

•Bulging anterior fontanel and a head circumference that increases at an abnormal rate

•Enlargement of the forehead

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

Hydrocephalus Signs & symptoms

in older Child

No enlargement of head (skull is closed)Begins with generalized neuro symptoms

HA in morningNauseaVomiting

Followed by signs of increased ICP

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 cavityNeeds to be replaced PRN

Post-op Nursing Care Shunt Placement

Keep child flat unless ICP is present the bed slightly elevatedSlowly increase HOB over few daysSupport head when moving childPain managementVital Signs

Post-op Nursing Care Shunt Placement

Observe for signs of increasing ICP – neurologic assessmentObserve for abdominal distentionStrict I & O AntibioticsMeticulous skin careSupport family

Discharge Management Post Shunt Placement

Teach parents to monitor for shunt complications:

Headache, progressive or worseningDrowsiness or inappropriate sleepiness during the day, irritability Nausea, vomiting Personality changes or changes in school performance Fever Redness or swelling along the shunt tract

Neural Tube Disorders

Defects of closure of neural tube during fetal developmentCongenital (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

Nursing ImplicationsAdvise all women to adhere to routine screening/diagnostic testingAdvise all women capable of becoming pregnant to consume

0.4 mg of folic acid daily

Neural Tube Disorders

Types:Spina Bifida

OccultaCystica

MeningoceleMyelomeningocele

Spina BifidaMost common CNS defectCaused by failure of neural tube to close at some point along spinal columnTypes:

spina bifida occulta spina bifida cystica

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

MyelomeningoceleSame 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

Nursing Interventions

• 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)

Habilitation

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 livingMajor problems: incontinence, constipation, obesity or malnutrition

Neurologic Infections

Meningitis

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

Bacterial MeningitisFollows 2-3 days of upper respiratory infection •Haemophilus influenzae type b was the most common cause of bacterial meningitis in children prior to the use of the Hib conjugate vaccine

• May be caused by Strep pneumoniae in child < 24months (not fully vaccinated yet)

• Meningococcal predominantly in school-age children & adolescents (vaccine preventable)

Bacterial MeningitisSigns & SymptomsAbrupt onset of feverChillsIncreasing irritabilityHeadacheConvulsionsBlurred visionCranial nerve paralysisOpisthotonic position

Classic Signs and Symptoms

1. Nuchal rigidity

2. (+) Kernig’s sign

3. (+)Brudzinski’s sign

Signs & Symptomsin Newborn

Above slide’s signs plus:• poor suck• weak cry• lethargy• can lead to sudden shock, seizures, apnea

• bulging fontanel

Bacterial MeningitisDiagnosis:

lumbar puncture to analyze CSF increased WBC’s and protein; decreased glucose (bacteria

feed on glucose)

Treatment: ABX x 10 days, IV or Intrathecal Respiratory isolation x 24 hours while on ABX Maintenance of optimum hydration Maintenance of ventilation Reduction of increased ICP Management of bacterial shock Control of seizures Prophylactic ABX for family members

ComplicationsLife Threatening ConditionIf Survival:

Hearing lossBlindnessParesisIntellectual impairment

Nursing ManagementFrequently assess vital signs, LOC, neurologic assessment to identify changes in the child’s condition.Measure head circumference frequently- risk for hydrocephalus.Monitor intake and output

Nursing ManagementPromote comfort • reduced stimulation (dim lights, quiet

room) Side-lying positionIdentify parents’ concerns, provide supportPrevention is a major role for nurses.

Encourage parents to get their infants and children fully immunized!

Guillain-Barre Syndrome

• 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

Initial SymptomsPeripheral neuritis occurs several days after primary infectionMuscle tendernessTendon reflexes decreased or absentParesthesia & crampsProximal symmetric muscle weaknessUrinary incontinence or retentionDecreased swallowing & respiratory efforts-may lead to respiratory failure

TreatmentWait for disease to stabilize Intravenous immune globulin IVIG Physical TherapyRarely fatal, often residual paralysis

Nursing CareMonitoring respiratory statusManaging autonomic nervous system dysfunctionPreventing complications associated with immobilityProviding emotional supporttTeaching the parents how tocare for the child after discharge.

Reye’s Syndrome A life threatening acute encephalitisOccurs after viral infection if tx’d w/ aspirinHigh Mortality RateEducation 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

LethargyVomitingFollowed by

AgitationAnorexiaCombativenessConfusion leading to stupor, coma, seizures, respiratory arrest

Reye’s SyndromeLabs

Increased:Liver enzymesSerum ammoniaPT, PTTWBC

Decreased:Serum glucose

Reye’s SyndromeNursing Care

If Survival in PICUMonitor:

Neurological statusRespiratory effortHypoglycemiaCerebral edema

Seizures

SeizuresInvoluntary contraction of muscle caused by abnormal electrical brain impulsesThey are episodic and abruptOften 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)

Types of SeizuresNonrecurrent – Acute

Febrile episodesDrugsMetabolic alterations

Recurrent – Chronic (Epilepsy)

Idiopathic (primary) epilepsy

Epilepsy secondary to trauma, hemorrhage, infections, congenital defects

Seizures: 2 categories

PartialSimpleComplex

Only 1 area of brain involvedSymptoms are associated with the area affectedNo LOC or consciousness is impaired

GeneralizedInfantile spasmsFebrileAbsenceTonic Clonic

Entire brainUsually have loss of consciousnessMay have auraPostical

Partial Seizures

Simple Partial Seizures Complex Partial Seizures

Simple Partial Seizures• Seizure is short, lasts < 30 seconds• No loss of consciousness, aura, postical

stateSeizure Activity:

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

movement

Abnormal sensory activityNumbness, tingling, paresthesia or pain starting in 1 area of body, may spread to other parts of bodyMay include abnormal auditory, olfactory and visual sensations

Complex Partial SeizuresSeizure is longer, 30 seconds-5 minutesConsciousness is impaired immediatelyMay have slight aura

Seizure Activity:Sudden change in postureAbnormal motor activity, twitching, loss of tone, tingling or numbnessAutomatisms-lip smacking, chewing, suckingCircumoral pallor

Afterward: drowsiness

Generalized SeizuresInfantile spasms

AbsenceTonic Clonic

Febrile

Infantile Spasms

Age: 4 months to 2 years• Occur in clusters 5-150/day,

worse at night• Altered consciousness

Abrupt flexion/extension of neck, trunk, extremitiesEye rollingMay have permanent cognitive & developmental delays

Absence Seizure

• 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 armMistaken for daydreaming or behavior problemsInterferes with learning1/3 of children will grow out of them by adolescence

Tonic Clonic(Grand Mal Seizure)4 stages of Seizure1. Prodromal:

Drowsiness, dizziness, malaise, lack of coordination, “not himself”

2. Aura:May precede seizure, reflects portion of brain where seizure originates

Tonic-clonic stage3. Tonic-Clonic:

Tonic: 20 seconds, all muscles cx (rigid), child falls to ground, LOC, respiratory muscles affected, grunting, airway compromisedClonic: 20-30 seconds, jerky muscle contract & relax rapidly, froth or bloody sputum, urinary or bowel incontience

4. Postictal:Appears to relax, semi-conscious, sound sleep for 1-4h, no recollection of event

Acute Febrile SeizureDue 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 ageTonic-clonic patternLasts 15-20 seconds

Epilepsy

• 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 Management 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

TriggersChanges in dark-light patternsSudden loud noises, specific voicesSudden or startling movementsExtreme changes in temperatureDehydration, fatigueHyperventilationHypoglycemiaCaffeine, insufficient protein in diet

Status Epilepticus(Intractable Seizures)Continuous seizure activity lasting > 30 minutes or a series of seizures from which the child does not regain a premorbid level of consciousness

If A Patient is Admitted for Seizure Activity or has PMH

of SeizuresEnsure IV access and PatencyCheck MD orders for Seizure MedicationCheck that medication is on the UnitCheck 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

Nursing Management during 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 RecordType of seizure activityVital SignsTime seizure started and stopped

Dilantin Toxicity: nystagmus, ataxia, decresed mental capacity

Low levels: seizure activity

S/E: gingival hyperplagia (discuss oral hygiene), drowsiness, thrombpcytopenia, leukopenia, increased liver enzymes

Nursing responsibility:Monitor CBC, LFT, therapeutic drug levels

Practice Questions!

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