Neurological and Sensory Conditions in Children

1. Chapter 29 Caring for the Child with a Neurological or Sensory Condition

2. A & P Review • Nervous system • Central nervous system • Brain and spinal cord • Peripheral nervous system • Sensory-somatic • Autonomic

3. Altered States of Consciousness • Arousal or level of consciousness: awareness of the environment • Content of thought: all cognitive functions that ensure awareness of affective states, self, and environment

4. The Unconscious Child • Unconsciousness is a state in which a child’s cerebral function is depressed and ranges from stupor to coma

5. Caring for the Unconscious Child • Evaluating neurological status • The pediatric Glascow Coma Scale • Eye opening, verbal response, and motor response

6. Caring for the Unconscious Child • Monitor vital signs • Manage the airway • Manage bladder and bowel elimination • Maintain hydration & nutrition • Provide proper hygiene • Position and perform exercise

7. Persistent Vegetative State • A complete unawareness of the environment accompanied by sleep–wake cycles. • The diagnosis is established if it is present for 1 month after acute or nontraumatic brain injury or has lasted for 1 month in children with degenerative or metabolic disorders or developmental malformations • Family support is needed

8. Increased Intracranial Pressure • Intracranial pressure (ICP) is the pressure of the cerebral spinal fluid (CSF) in the subarachnoid space between the skull and the brain. A child can have increased ICP as a result of many internal or external factors. • Signs and symptoms • See Table 29-2

9. Increased Intracranial Pressure • Nursing care • Close monitoring (neurologic status) • Maintenance of a patent airway • Monitor vital signs closely (hyperthermia) • Administer IV fluids • Monitor fluid balance (I & O) • Protect child from injury • Administer antiseizure medications • Provide emotional support • Administer medications to decrease cerebral edema • Analgesia and sedation • A craniotomy is recommended when all other measures have been unsuccessful

10. Seizure Disorders • Signs and symptoms • See Table 29-3 • Nursing care • Complete a detailed history • Ensure airway management • Maintain anticonvulsant therapy • Implement seizure precautions (padded side rails, oxygen, suction equipment, IV access, and anticonvulsant medications) • Provide continuous cardiac, respiratory, and oxygen monitoring • Instruct caregivers instructed in CPR • Keep school nurses and teachers informed about the condition • Encourage medical alert identification bracelet

11. Inflammatory Neurological Conditions

12. Meningitis • Signs and symptoms • Mildly ill with general vague or subtle symptoms (lethargy, malaise, irritability, vomiting, fever, and diarrhea) • Kernig and/or Brudzinski sign • Nursing care • Assess neurological status, anterior fontanel in infants, and seizure activity • Provide comfort care • Educate family and child about disease and treatment options • Explain long-term parenteral access and IV antibiotics

13. Encephalitis • Signs and symptoms • Disorientation, confusion, headache, high fever, photophobia, lethargy, aphasia, hallucinations, seizures, nuchal rigidity, and coma • Nursing care • Viral is treated with antiviral medication • Bacterial is treated with a narrow-spectrum antibiotic • Other medications include antipyretics, anticonvulsants, analgesics, and anti-inflammatories • Provide intravenous fluids and nutrition • Implement seizure precautions • Monitor fluid & balance • Do not suction or give percussion

14. Brain Abscess • Signs and symptoms • Localized headache, fever, drowsiness, stupor, confusion, general or focal seizures, focal motor or sensory impairments, ataxia, nausea and vomiting, papilledema, and hemiparesis • Nursing care • Assess neurological status, assess response to treatment, administer medications, and provide supportive care • Monitor serum labs • Surgery required if no response to antimicrobial therapy (postoperative care) or does not meet criteria for medical therapy

15. Reye Syndrome • Signs and symptoms • Lethargy, vomiting, drowsiness, liver dysfunction • Nursing care • Conduct neurological assessment • Administer IV fluids • Administer corticosteroids and/or diuretics • Monitor oxygen saturation (supplemental oxygen) • Insert arterial line (blood gases) • Take seizure precautions • Limit invasive procedures • Provide emotional support

16. Guillain-Barré Syndrome • Signs and symptoms • Three phases: acute, second, recovery • Nursing care • Plasma exchange and IV immunoglobulin therapy • Give corticosteroids • Monitor progression • Insert indwelling urinary catheter • Assess pain level • Prevent contractures and loss of function (passive ROM) • Provide skin care • Suggest age-appropriate activities

17. Developmental Neurological Conditions

18. Spina BifidaNeural tube defects (NTDs) • Signs and symptoms • Vary depending on the level of the lesion and defect • Spina bifida occulta • Meningocele • Myelomeningocele • Types • Meningocele • Myelomeningocele • Spina bifida occulta

19. Spina Bifida • Nursing care • Place newborn in prone position (prevent injury to sack) • Provide postoperative care for laminectomy & closure of defect • Evaluate orthopedic function • Prevent joint contractures • Assess bladder and bowel function • Provide skin care • Assess neurological status • Measure head circumference and assess fontanel • Manage pain

20. Hydrocephalus • Signs and symptoms • Increased ICP • Macewen sign • Nursing care • Understand shunt function and complications • Obtain history and physical (life-threatening conditions) • Discuss pharmacological measures or surgical procedure • Perform nursing actions related to ICP • Measure head circumference • Give preoperative and postoperative antibiotics • Assess neurological status • Assess for shunt malfunction (eye assessment) • Assess abdominal status (pain, bowel sounds, and circumference) • Elevate HOB 30°

21. Cerebral Palsy • Signs and symptoms • Vary individually depending on the area of the brain involved and the extent of damage • Four categories • Spastic • Ataxic • Athetoid or dyskinetic • Mixed

22. Cerebral Palsy • Nursing care • Use splints and braces • Promote self-care • Administer medications (reduce muscle spasms, spasticity, anxiety, and seizure) • Surgery (selective dorsal rhizotomy) • Address feeding problems • Provide intellectual stimulation • Ensure safe environment

23. Neurological Injuries

24. Near Drowning(Submersion) • Signs and symptoms • Cerebral edema, alteration in LOC, respiratory distress, cardiovascular complications, hypovolema • Nursing care • Assess and maintain airway • Provide life support measures • Suction secretions • Insert NG tube • Administer oxygen • Assess other injures (head or spinal trauma)

25. Head InjuryTraumatic Brain Injury (TBI) • Signs and symptoms • Obvious signs: blood on the scalp, depression of the skull, and an obvious penetrating wound • Other signs and symptoms: loss of consciousness, alteration LOC, seizures and combativeness • Nursing care • Provide immediate care to prevent life-threatening complications • Maintain airway patency and oxygen administration • Insert IV and administer hypertonic fluid • Assess neurological status • Assess ICP

26. Shaken Baby Syndrome • Signs and symptoms • Seizure activity, apnea, budging fontanels, coma, hemorrhage, bradycardia & cardiovascular collapse • Nursing care • Provide respiratory and cardiovascular support • Assess for ICP • Insert NG tube • Maintain seizure precautions • Maintain adequate fluid and nutritional intake • Assess and document visible injuries • Discuss short- or long-term care • Assess parental concerns

27. Spinal Cord Injury • Signs and symptoms • Numbness, tingling, or loss of function • Nursing care • Maintain airway management and respiratory function • Provide cardiovascular and circulatory support • Give steroid therapy • Monitor fluid intake and output • Maintain gastrointestinal function • Provide nutritional support • Provide emotional and social support • Be attuned to an adolescent’s unique needs • Explain lifelong care and support, circulation support, disability identification, and exposure of known and unknown physical limitations

28. Nontraumatic Neurological Conditions

29. Headaches • Types • Primary headaches • Secondary headaches • Tension • Migraine • Cluster

30. Headaches • Signs and symptoms • Primary (triggers — i.e., stress) • Secondary (organic disorder — i.e., trauma) • Subtypes (tension, migraine, cluster) • Nursing care • Provide pharmacologic and nonpharmacologic care • Discuss prophylactic measures • Give intramuscular or intranasal medications • Promote rest and stress reduction strategies

31. Sensory Conditions

32. Eye Disorders • Hyperopia (farsightedness) • Myopia (nearsightedness) • Correction • Concave lenses or contact lenses • Laser assisted surgery

33. Astigmatism • Irregular curvature or uneven contour of the eye • Correction • Corrective lenses • Surgery • Complaints of headache, blurry vision, or dizziness; ophthalmologist referral

34. Amblyopia • Signs and symptoms • Strabismus or anisometropia are the most common causes • Correction • Occlusion therapy (patching of the normal eye) is done to restore strength and function of the “lazy eye”

35. Strabismus • Nonparallelism in the different fields of gaze causing visual lines to cross even when focused on the same object • Correction • Ocular patching of the stronger eye, glasses, and pharmacotherapy • Early identification and recognition

36. Color Blindness • X-linked recessive inheritable color vision deficiency • Color blindness is detected using colored charts called the Ishihara Test plates • Child can learn to compensate with support from family members, teachers, and friends

37. Nystagmus • Rapid irregular involuntary eye movement caused by a disorder of the central nervous system • Correction • Extraocular surgery

38. Cataracts • Signs and symptoms • Excessive tearing, extraocular movements, photophobia, lens appears cloudy, or there is a white or dulled red reflex • Correction • Prevent loss of visual acuity • Laser procedure • Postoperative (monitor nausea, emesis, pain, hemorrhage and signs of infection) • Postoperative eye drops • Follow-up care for visual acuity • Educate family • Early identification and recognition

39. Glaucoma • Signs and symptoms • Bupthalmos (enlarged eye globe), epiphora (excessive tearing), and photophobia (sensitivity to light) • Correction • Preoperative maintain quiet environment • Antiglaucoma medications • Analgesia and anxiety reduction strategies • Pre- and postoperative care (teach parents)

40. Retinoblastoma • Signs and symptoms • Absence or abnormality of the red reflex • A whitish or yellow color of the pupil called leukocoria • Correction • Laser, radiation, cryotherapy, or enucleation

41. Eye Injuries

42. Foreign Bodies • Penetration • Immediate transport to ER for removal • Corneal abrasion • Treatment • Topical antibiotic solutions or ointments, analgesics, eye patch

43. Hyphema • Hemorrhage into the anterior chamber of the eye • Treatment • Rest, possible evacuation • Monitor increased intraocular pressure • Promote decreased activity • HOB 30° • Patch both eyes

44. Chemical burns • Usually occur as a result of an accident • Treatment • Rapid eye flushing for 15 to 30 minutes followed by pH analysis of the chemical agent • Eye patching

45. Hearing Loss

46. Hearing Loss • Causes • 1/3 of all cases are due to genetic causes • 1/3 of all cases are due to non-genetic influences • 1/3 of all cases are due to unknown causes

47. Hearing Loss • Diagnostic testing • Universal infant hearing screening before 1 month of age is recommended • Treatment • Based on underlying pathologic conditions, presence of organic diseases, the severity of hearing loss, the degree of frequency loss, and any CNS abnormalities • Amplification aids (hearing aid) • Nursing care • Provide emotional, educational, and collaborative support for the child and family

48. Language Disorders • Communication • A process of complex interaction involving the exchange of information, feelings, ideas, and interactions • Receptive language • Expressive language • Nursing care • Recognize speech and language developmental delays