Neurological

1. Neurological

2. Common Neurological Disorders in Children • Hydrocephalus • Neural Tubes Defects • Bacterial Meningitis • Guillain-Barre Syndrome • Reye’s Syndrome • Seizures

3. Structural Defects

4. Hydrocephalus • “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

5. Hydrocephalus

6. Symptoms in the infant Early Signs 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) • Projectile vomiting not associated with feeding • Scalp veins become prominent • Shrill, high pitched cry • Increasing irritability

7. Symptoms in the Child • No enlargement of head (skull is closed) • Begins with generalized neuro symptoms • HA in morning • Nausea • Vomiting • Followed by signs of increased ICP

8. 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

9. Post-op Nursing Care Shunt Placement • 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

10. 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

11. Discharge Management Post 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

12. Neural Tube Disorders • 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

13. Neural Tube Disorders Types: • Spina Bifida • Occulta • Cystica • Meningocele • Myelomeningocele

14. Spina Bifida • 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

15. 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

16. Spina Bifida Cystica • Meningocele • External sac that contains meninges and CSF • Protrudes through defect in vertebral column

17. Meningocele • Not associated with neurologic deficit – good prognosis • Hydrocephalus may be an associated finding, or aggravated after repair

18. 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

19. 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

20. 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

21. 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)

22. 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 living • Major problems: incontinence, constipation, obesity or malnutrition

23. Neurologic Infections

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

25. Bacterial Meningitis • Haemophilusinfluenzaetype 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 pneumoniaein child < 24months as not fully vaccinated with PCV vaccine • Meningococcal predominantly in unvaccinated school-age children & adolescents

26. Symptoms • Abrupt onset of fever • Chills • Increasing irritability • Headache • Nuchal Rigidity • Poor feeding • Weak Cry • Bulging fontanel Opisthotonic position

27. Symtoms Kerning’s Sign Brudzinski’s Sign

28. Nursing Management • 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

29. 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!

30. Complications • Life Threatening Condition • If Survival • Hearing loss • Blindness • Paresis • Intellectual impairment

31. 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

32. Initial Symptoms • 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

33. Treatment • Wait for disease to stabilize • Intravenous immune globulinIVIG • Physical Therapy • Rarely fatal, often residual paralysis

34. Nursing Care • 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

35. Reye’s Syndrome • 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)

36. 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

37. Reye’s SyndromeNursing Care If Survival in PICU Monitor: • Neurological status • Respiratory effort • Hypoglycemia • Cerebral edema

38. Seizures

39. Seizures • 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

40. 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

41. Seizure Terms • 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

42. Partial Seizures Simple Partial Seizures Complex Partial Seizures

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

44. Complex Partial Seizures • Seizure is longer, 30 seconds-5 minutes • Consciousness is impaired immediately • May have slight aura Seizure Activity • Sudden change in posture • Abnormal motor activity, twitching, loss of tone, tingling or numbness • Automatisms-lip smacking, chewing, sucking • Circumoral pallor • Afterward: drowsiness

45. Generalized Seizures Infantile spasms Absence Tonic Clonic Febrile

46. 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, extremities • Eye rolling • May have permanent cognitive & developmental delays

47. 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 arm • Mistaken for daydreaming or behavior problems • Interferes with learning • 1/3 of children will grow out of them by adolescence

48. Tonic Clonic4 stages of Seizure 1. Prodromal: • Drowsiness, dizziness, malaise, lack of coordination, “not himself” 2. Aura • May precede seizure, reflects portion of brain where seizure originates

49. Tonic-clonic stage 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

50. Acute Febrile Seizure • 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