NeurologicalStressors and

Adaptation

Common Neurological Disorders in Children

Neural Tubes DefectsHydrocephalusBacterial MeningitisGuillain-Barre SyndromeReye’s SyndromeSeizures

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

• Surgical shunting may be necessary

Nursing Interventions• Surgical repair usually within first 24 hours

• 90% develop hydrocephalus• MUST observe for early signs of infection: elevated temp, irritability, lethargy, nuchal rigidity

• MUST observe for signs of increasing ICP (may indicate hydrocephalus)

HabilitationEmphasizes 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

Hydrocephalus

Ventricles of the brain are enlarged as a result of an imbalance between the production and absorption of CSFOften occurs in conjunction with myelomeningocele which blocks the flow of CSFCan lead to irreversible neurological damage

INFANT Hydrocephalus Early signs & symptomsProjectile 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 ChildNo enlargement of head (skull is closed)Begins with generalized neuro symptomsFollowed by signs of increased ICP

Relief of hydrocephalus

VP shunt placement to bypass the obstruction Needs replaced PRN

Pre-op for Shunt Placement

Observe for increasing ICPDaily head circumferencesMaintaining adequate nutrition with flexible feeding schedule offering small feedings at shorter intervalsSedate child prn for procedures (MRI, CT)Support head when feeding or moving

Post-op Nursing Care Shunt Placement

Keep child flat unless ICP is present the bed slightly elevatedPain managementObserve for signs of increasing ICP – neurologic assessmentObserve for abdominal distentionStrict I & O AntibioticsMeticulous skin careSupport family

Discharge Management Post Shunt Placement

Treatment of shunt complications: meningitis, septicemia, bacterial endocarditis, wound infection, shunt nephritis, ventriculitisManagement of problems r/t psychomotor developmentLifelong problem, parents need to know signs of shunt malformation

Meningitis

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

Bacterial Meningitis Follows 2-3 days of upper respiratory infection (seasonal)

May be caused by Strep pneumoniae & Neisseria meningitis in child < 24months

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

Bacterial MeningitisSigns & SymptomsAbrupt onset of feverChillsIncreasing irritabilityHeadacheConvulsionsBlurred visionCranial nerve paralysis

Opisthotonic 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 Monitor for increasing ICP (Dexamethosone, Mannitol)

SequelaeHearing lossBlindnessParesisIntellectual impairment

EncephalitisAcute inflammation of the brainSymptoms do not include nuchal rigidity or positive kernig or brudzinskiSymptoms depend on the causative organism

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

• 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

Nursing careAssess degree of paralysisPrevent complications (immobility)Watch for difficulty swallowing, respiratory involvementWait for disease to stabilize: no abx, may get IVIG otherwise tx is supportive

(PT important for recovery)

Reye’s Syndrome A life threatening acute encephalitis w/ fatty infiltration of liver, heart, lungs, pancreas & skeletal muscleOccurs after viral infection if tx’d w/ aspirinEducation efforts has helped to reduce incidence (use tylenol not ASA)

Reye’s Syndrome

Dx:Based on symptoms & labsStaged 1-5

Reye’s SyndromeBegins 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, PTTBunAmylaseWBC’s

Decreased:Serum glucose

Reye’s SyndromeNursing CareMonitor:

Neurological statusRespiratory effortHypoglycemiaBrain edema

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) epilepsyEpilepsy secondary to trauma, hemorrhage, infections, congenital defects

Type and Cause of Seizures is predicted by

age:Newborn Infant and ToddlerChildren age 3 and older

Seizures: 2 categories

PartialSimpleComplex

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

GeneralizedNewbornInfantile spasmsAbsenceTonic Clonic

Entire brainUsually have loss of consciousnessMay have aura

Simple Partial SeizuresAge: anyNo loss of consciousness, no auraHas either:

Abnormal motor activity• One extremity, uncontrolled movement, may progress

into generalized seizureAbnormal sensory activity

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

TX: Variety of anticonvulsants

Complex Partial SeizuresAge: Children age 3 and olderConsciousness is impairedIdiopathicCT, MRI, EEG are normal

May have slight auraSudden change in postureAutomatismsSlump to ground, unconsciousCircumoral pallor

Afterward: drowsiness, no postictal state

Tx: Tegretol, Dilantin

Generalized Seizures

Newborn PeriodAge: Newborn to age 3 monthsSudden twitching of head, arms, eyes, slight cyanosis, respirations may be affectedAfter seizure may be limp

Causes:Trauma at birthMetabolic disorderInfectionKernicterus

TX: Phenobarbital

Generalized Seizures

“Infantile Spasms”Age: 3 months to 2 years• Altered consciousness

Rapid movement of trunk followed by relaxationChild falls forward or to groundOccur singly or in clustersMay have permanent cognitive & developmental delays

TX: variety of anticonvulsants

Generalized SeizuresAcute Febrile seizure• Age: Any

Due to increased temperature > 102 F (but may occur as low as 100 F)Tonic-clonic pattern15-20 seconds

Tx:Protect from harmR/O infection (meningitis)

Generalized SeizuresAbsence Seizure

• Age: 3 years• Brief loss of consciousness• Staring spell

Rhythmic blinking & twitching of mouth or arm mistaken for daydreaming or behavior problemsLasts 5-10 seconds, multiple times a day

TX:DepakeneEncourage normal school activities1/3 of children will grow out of them by adolescence

Generalized SeizuresTonic Clonic

Age: any4 stages1. 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

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

Tx: Dilantin, Depakene, Tegretol

Chronic Seizures in children 3 and older

Epilepsy• Chronic seizure disorder with

recurrent seizures • Symptoms depend on type of

seizure• No association with illness,

injury• seizure may be triggered by

something

Epilepsy Management

Anti-seizure meds 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 EpilepticusContinuous seizure activity lasting > 30 minutes or a series of seizures from which the child does not regain a premorbid level of consciousness

Nursing Responsibilities: A, B, C’s IV access Observe and record Protect Medications -IV benzodiazepine (Ativan,

Valium), then seizure meds

Dilantin (phenytoin)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

A 10-year old client presents with weakness in legs and history of the flu. The medical 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 hoarseness4. 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, child, 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. Increased intracranial pressure2. 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