Nursing Care of the Child with a Neurological Disorder

1. Nursing Care of the Child with a Neurological Disorder Dr. Manal Al-kloub

2. Introduction • Neurological disorders results from: Congenital anomalies, acquired dysfunction, infection, and trauma • Major causes of neurological damage are meningitis and head injuries. • Degeneration is permanent because, unlike other tissues, neural tissue doesn’t have the regeneration power. • Management mainly focuses on: help the child accommodate with the mental and physical dysfunction, making child comfortable, and support the child’s growth by ensuring helpful environment.

3. Prevention is the highest priority to ensure healthy nervous system • Nursing can help foster prevention by: educate about the use of helmets, provide best/safe care when dealing with head/neck injuries, and apply infection control measures to decrease spread of meningitis (hand washing …etc). • Nurses should consider short term (stop convulsions, regain consciousness, survive meningitis ..etc) and long term outcomes (ability to function, paralysis …etc).

4. The brain is covered by three lyres (the meninges: dura mater, archniod, & pia mater. • Cerebrospinal fluid circulation (6 hrs): produced in pia mater- circulate within the ventricles of the brain & around the brain & spinal cord- then reabsorbed by the archniod layer. CSF is 5 ml in a neonate and 150 ml in an adult • Brain size is 25% of adult size at birth, and 90% of adult size at age 5. • By 12 years of age the sutures are completely ossified & can not be separated.

6. The pediatric skull is thinner, brain is softer due to a higher water content and less myelination, and the subarachnoid space is wider. These allow increased movement of the brain within the skull, which makes the child more susceptible to brain injury, including hemorrhage.

7. Diagnostic tests: 1)Lumber puncture: to obtain CSF for culture or analysis, Side lying position for LP. Insertion of spinal needle into subarachnoid space between the L4-L5 lumbar vertebrae. 1. obtain 3 tubes ( 2-3 ml each); for culture (Bacteriology), sensitivity, glucose (biochemistry) and RBCs (hematology). 2. after 30 min order the child to drink fluid 3. Supine position after L.P (Lie flat for 1 hr after procedure) 4. Assess V/S (inc. B/P with dec. Resp. and heart rates indicates increased IC compression), puncture site, headache & LOC 5. Post-LP headache: give analgesic Contraindications: infection @ insertion site, or raised intracranial pressure (ICP): may draw down the brain stem compromising cardiac and respiratory centers. • Topical anesthetic cream (AMLA) with S/C lignocaine is used. • Give Sugar to infant <3 months decreases anxiety .

8. Position: infant seated upright leaning forward; older child on his side with arched back • Young children need to be held in position not to move. • Explain procedure to child • Strictly Sterile technique

10. Electroencephalogram (EEG) • Records the electrical activity of the brain through a series of electrodes on the scalp. • Used to diagnose and evaluate seizures disorders, identify tumors, brain abscesses or infections and to confirm of brain death X-ray. ( CT .skull x-ray , & MRI ) Ultrasound (Echoencephalography): to create images of blood vessels, tissues, and organs. Assess brain blood flow Glasgow Coma Scale.

13. ICP: Children have a smaller intracranial space hence easy to increase ICP if volume increased. • Monitoring using a pressure monitor inserted through the skull, usually lasts 24-72 hrs. ICP bolt is connected to the computer, regular readings will be taken. Changing position in bed, coughing or sneezing, vomiting or crying increases ICP. Increased ICP: A sign and not a disorder Early signs: headache, visual disturbances, nausea & vomiting, dizziness or vertigo, infants have bulging or firm fontanel and rapidly increasing HC Late signs: Decrease in level of consciousness, bradycardia, irregular respiration, and fixed dilated pupils.

14. Increased ICP occur because of: inc. CSF volume, Blood in CSF, Cerebral edema & tumors. Assessment: • History, seizure, LOC, daily tasks ,headache • Past medical history • Infection during pregnancy • increased H.C greater than normal • Bulging fontanel, close late • High temperature & B/P, dec. Pulse & Resp. • Projectile vomiting/Poor feeding • Spasticity of muscle/Hypotonia

15. Physical Examination Considerations • Level of Consciousness (LOC): confusion, delirium, obtunded, stupor, and coma. • Motor Function: gross and fine • Pupilary Function / Eye Movements • Vital Signs: Respiratory Patterns • Pulse rate decreases as ICP increases • Respiratory rate is initially slow as ICP rises then rate becomes rapid and noisy leading to apnea • Blood pressure rises slowly / late sign is widening pulse pressure (Systolic-diastolic) • Doll’s eye reflex (turn head of child rapidly to the right he will normally turn his eyes to the left): Absent if increased ICP.

16. -Orientation ,performance , mood ,and behavior -Child awareness @ 4 years know the first and last name @ 5 years child know address @ 8 years child complete orientation of days Nervous system function: 1. Cerebellar function (balance, coordination & walking) 2. Motor function ( muscle size ,strength, tone, movement , & range of motion) 3. Sensory function (with closed eyes can distinguish pain ,hot ,cold) 4. Reflex testing- (See Newborn Reflexes)

17. ICP Monitoring • Monitoring can be done through insertion of catheter into different sites in the head (e.g. intra-ventricular, subarachnoid space, intra-parenchymal) connected to an oscilloscope screen. • ICP= 1-10mmHg, >15mmHg is abnormal • ICP rises and falls normally with the influx of blood into the head • Monitoring ICP help determine when the child needs O2 (detect ischemia), and withdraw CSF samples.

18. Neurological conditions A child who has been diagnosed with a condition that directly affects the neurological system is of greater concern to parents. They will be distressed and frightened of their child’s prognosis(guidance and support throughout hospitalization is important). * Decorticate and decerebrate postures

19. HYDROCEPHALUS • Accumulation of excess cerebrospinal fluid in the ventricles of the fetal brain which result from impaired circulation and re-absorption of CSF. (Normal CSF production is 20 ml/h). • TYPES OF HYDROCEPHALUS: 1- OBSTRUCTIVE OR NON-COMMUNICATING (OBSTRUCTION WITHIN THE VENTRICULAR SYSTEM) 2- NON OBSTRUCTIVE OR COMMUNICATING (MALFUNCTION OF ARACHNOID VILLI • S/S: Bulging anterior fontanels; Eyes deviated downward “Setting” Sun sign, irritable, poor feed, vomiting, lethargy, headache

20. Primary causes: 1- Congenital 1% 2- Acquired: Lesion, tumors, infection, intracranial bleed, myelomeningocele (spina bifida)

21. SIGNS: • ANTERIOR FONTANEL WIDE OPEN AND BULGING, INCREASED HEAD CIRCUMFERENCE. • DILATED SCALP VEINS • SETTING SUN SIGN • PROMINENT OCCIPUT (DANDY-WALKER) • Clinical Therapy: Increased ICP makes head enlargement which makes brain damages (death if remains untreated). • Medications: ACETAZOLAMIDE, FUROSEMIDE • Surgical: V-P shunt

22. V-P shunt: This is a device which drains the extra fluid in the brain into the peritoneal cavity where the fluid can be absorbed • Early detection, Surgery is performed to shunt excess fluid to minimize brain damage • Promote family support • Shunt placement requires threading of drainage catheter into peritoneum through abdominal incision. Aim: Placement of shunt to drain CSF from the ventricles to another part of the body. Dx: Risk for infection R/T presence of mechanical drainage system (shunt).

24. Nursing care: • frequent neurologic assessments (mental, cognitive, motor and sensory functioning) and monitoring for infection, IV prophylactic antibiotics. [S/S: fever, lethargy, irritability, redness along shunt device system, abdominal discomfort, or apnea]. • monitor for fluid leak from the incision • patient will complain of postural headaches while sitting up, but that resolves when lying down. • should be encouraged to lead as normal a life as possible • feeding through a naso-gastric tube until bowel sounds return, then fluids can gradually be introduced. Should be held when fed. • Observe for increased ICP S/S.

25. Neural tube abnormalities • Examples: Anencephaly and spina bifida • Genetic and environmental factors involve in their etiology (Folic acid deficiency) • Risk is increased when a previous child has been affected • Affects more girls than boys • A surviving affected girl who become pregnant has a 1 in 30 chance of bearing a child with NTD • Diagnosis: Alpha-fetoprotein screening, termination of the affected fetuses reduce the incidence

26. Anencephaly • is a fatal birth defect that happens when there is absence of cerebral hemispheres. As a result, part of the skull and brain are missing. Babies with anencephaly die before or shortly after birth.

28. Spina Bifida: Failure of osseous spine to close. Vertebral column fails to close during intrauterine development. Two types: 1) Spina bifida occulta: Not visible externally. 2) Spina bifida cystica: Visible defect with a Sac-like protrusion; Two types: a) Meningocele: Sac contains meningies and spinal fluid but no neural elements (with no neurologic defects). No paralysis because spinal cord is not involved. b) Myelomeningocele: Clinically is called “spina bifida”. Sac contains meningies, spinal fluid, and nerves. Extent of paralysis depends on the location of the defect. If below 2nd lumber Flaccid paralysis of lower extremities and Sensory deficit occur.

31. With small sacral lesion no loss of mobility, but urinary and fecal incontinence results because the nerve supply to the bladder and sphincters mechanisms is impaired. Medical Management • Same day surgery: correct defect, minimize complications, and prevent infection. Early closure (12-72hrs) after birth prevent stretching of other nerve roots. • In myelomeningocele, closure of the back is recommended • Folic acid supplements 4mg PO with future pregnancies

32. Nursing care DX: Potential for complications (injury, infection, bleeding, trauma, impared skin integrity) R/t fragile spinal lesion Interventions: • Prevent injury, infection, or rupture of the sac (it can lead to death) • Apply sterile moist dressing on sac until surgery to maintain moisture • Position on back to prevent pressure • Encourage parents to become involved with infant care

33. Meningitis Inflammation of meningies causes engorged cerebral vessels causes cerebral edema, increased ICP, and neurological deterioration Meningitis: Highly incident in children <24 month, and common in winter. Meningitis can kill in less than 24 hours or lead to permanent disabilities such as brain damage Assessment (S/S): • Irritable (seizure) with high temperature/chills/headache • Nuchal (back of the neck)/spinal rigidity (Positive Brudzinskis & Kernig's signs) • Bulging Fontanels/poor feeding/projectile vomiting • High-pitched cry or lethargy

34. Kernig Sign: Raise child’s leg with knees flexed, then extend leg at the knee. If child becomes resistance or in pain: +ve sign. • Brudzinski Sign: Flex the head while Child in a supine position. If involuntary flexion of knees occur it is +ve Brudzinski sign

35. * Complications: 1. Deafness 2. Blindnesss 3. Facial paralysis 4. Hydrocephulus 5. Petechial rash in meningococcal infection Causes: A-BACTERIAL 1. Neisseria 2. Meningococci (Highly contagious) 3. Pneumococci (rare) 3. Group-B-beta Streptococcus 4. Hemophilus influenza (Most common) B-VIRAL

36. Management • Isolation precautions/quiet environment • Antibiotics agents (cephalosporins) • Dexamethasone (Steroid: anti-inflammatory) • Hydration/IV fluids • Antiepileptic drugs (phenobarbital, valproic acid, carbamazepine [tegretol]). • Safety environment • Observation of vital signs, neurologic signs, urinary output • Vaccines against the most common form of meningitis are available.

37. Cerebral Palsy (CP) CP is a group of disorders affecting body movement, balance, and posture. It is abnormal development or damage in one or more parts of the brain that control movement. However, the exact cause is unknown. Factors/Groups at risk: A. Prenatal: 1. LBW (low birth weight) 2. birth injury 3. intrauterine anorexia 4. placenta disorder 5. drug administration or nutrition disorder during pregnancy . B. Perinatal: breech presentation C. Postnatal: Infection

38. Types of C.P: 1. Spastic type (pyramidal): Increased muscle tone (hypertonic muscle, abnormal reflex, Arch their back, and scisors gait )-70-80% of cases. 2. Dyskinetic (extra-pyramidal): a- Athetoid type (abnormal involuntary uncontrolled and slow movements, make every thing slow, difficult swallow and diet ) b- Ataxic type (wide based gait - fine coordination motion disorder- failed to perform finger-to-noise: affects balance and coordination, difficulty with quick movements) 3. Mixed type (combination of spasticity & athetosis)

39. Infants with cerebral palsy are usually slow to reach developmental milestones such as rolling over, sitting, crawling, and walking. • Problems often linked to cerebral palsy: Mental retardation, seizures, learning disabilities, incontinence problems, skeletal deformities, eating difficulties, and hearing and vision problems

40. Assessment :cognitive disorder, recurrent seizures, sensory and motor disorders * Management: 1. Medication to decreased spasticity (Dantrolene; a muscle relaxant) 2. Physical therapy/Passive & active muscle exercises 3. Self-care daily (dressing, bathing, toileting, & feeding) 4. Speech therapy

41. Seizures: are periods of abnormal electrical discharges in the brain that causes involuntary movements as well as, behavioral & sensory alteration • Acute/Non-recurring (provoked by stimuli) (i) with fever: febrile convulsion, infections e.g. meningitis, encephalitis. (MMR vaccine).(ii) without fever: poisoning including medicinal overdose, metabolic disturbance e.g. hypoglycaemia, hypocalcaemia and electrolyte imbalance, head injury, brain tumour, emotional stress, anxiety. • Chronic/Recurring :(i) without fever: epilepsy (a chronic disorder characterized by recurrent, unprovoked (idiopathic) seizures secondary to CNS disorder). • Status Epilepticus: More than thirty minutes of continuous seizure activity, or recurrent seizures without intercurrent recovery of consciousness

42. Types of Seizure in Children • Partial or focal seizures: electrical activity in one hemisphere or area of the cerebral cortex. results in localized symptoms. • Generalized/Tonic-clonic: result from a diffuse electrical activity that begin in the hemispheres & spread throughout the cortex into the brainstem. Hence the movements & spasm are bilateral & symmetric. * Seizures increase in the metabolic rate, leading to cyanosis, paleness & hypoglycemia (length of the seizure is vital)

43. Stages of seizures: 1-the Aura: an olfactory or visual sensory sensation as an early warning sign of seizure. 2-tonic phase: muscles are contracted while patient is unconscious. 3-clonic phase: involves periods of contractions & relaxations. 4-the postictal period: after the seizure where the patient's LOC is decreased.

44. Management • Treat underlying cause • Antiepileptic medication (Phenytoin or Carbamazepine tablets) -Check blood medication level -The doses need to be increased as child grows -CBC, LFT, KFT are monitored frequently -If child on anticonvulsants for 2 years & with no risk factor gradual decrease of dose until discontinue is allowed

45. Safety measures during an attack: -ease child to the floor immediately -place child on side -suctioning -V/S Other measures: • Side rails raised & padded (precaution) • Monitor for electrolytes, glucose, blood gases, & abnormal blood pressure. • Family support & teaching

46. Febrile Seizure • It is the most common seizure disorder during childhood. Usually generalized seizures occur in children with high grade fever >39C but without evidence of intracranial infection. It involves tonic-clonic movements and lasts a few seconds to 15-min. Simple febrile seizures are the most common form. • Age dependent and are rare before 9 months and after 5 yrs of age. • A strong family history of febrile convulsions.

47. Treatment of febrile seizures • No anticonvulsant therapy is administered. • A careful search for the cause of the fever. • Use of antipyretics. • If severe, control seizure with IV or rectal diazepam (anti anxiety, CNS depressant) • Reassurance of the parents. If febrile seizure lasts more than 5 minutes, parents should seek medical help immediately

48. Nursing DX for seziures • Ineffective breathing patterns. • Ineffective airway clearness. Intervention: Maintain airway patency by positioning child on the side to drain secretions, O2 therapy • Risk for trauma Interventions: Ensure safety and protect from injury by padding side rails, stay with patient until seizure stops • Anxiety ; ensure parents and teach them

49. Phenylketonuria (PKU) • A disease of protein metabolism inherited as an autosomal – recessive trait, characterized by the inability to metabolize the essential amino acid phenylalanine • The hepatic enzyme which controls the conversion of phenylalanine to tyrosine is absent in PKU patients • the accumulation of phenylalanine in the blood hence urinary excretion of phenyl acids termed “phenylketonuria”

50. Accumulation of phenylalanine affect the normal development of the brain and CNS, and mental retardation occurs. • Clinical manifestations: Failure to thrive, frequent vominting, irritability, anxiety reactions, screaming episodes, disorientation, Failure to respond to strong stimuli, and convulsion • Dx: diagnosing then treating the disorder is vital to prevent mental retardation. Serum phenylalanine levels greater than 4 mg/dl is abnormal (after birth a heel stick is conducted).