Pediatric Nursing

Module 6Caring for Children with Alterations in Neurosensory Functions

Neurological Assessment Assessment

indirect measurements children under 2 years

normal growth and development parameters parents evaluation of their child developmental milestones history

prenatal birth history post natal

Neurological Assessment

Behavior personality, affect, level of activity, social

interaction, attention span Motor function

muscle - size, tone, strength abnormal movements

Sensory function discrimination of touch with eyes closed

Neurological Assessment Cranial Nerves

Olfactory - smell Optic - light perception

visual acuity peripheral vision

Ocular motor - 6 cardinal positions of gaze PERRLA

Trochlear - have child look down and in

Trigeminal nerves - bite down and try to open jaw, sensation to face

Neurological Assessment Abducens- look toward

temporal side Facial - make a funny face or

smile Acoustic - hearing and balance Glossopharyngeal - gag reflex,

taste Vagus - uvula is midline,

swallow Accessory - shrug shoulders

against mild applied pressure

Hypoglossal - move tongue in all directions

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Video - Neurological exam in children

Increased Intracranial Pressure Causes

tumors accumulation of fluid

within the ventricular system

bleeding edema in cerebral

tissues

early signs and symptoms are often subtle and assume many patterns

Assess for signs of Increased Intracranial Pressure

Level of consciousness (LOC) earliest indicator of changes in

neurological status1. Alertness

arousal-waking state ability to respond to stimuli

2. Cognitive abilities process stimuli produce verbal and motor

responses

Increased Intracranial PressureSigns/symptoms

Lack of painful stimuli is abnormal and is reported immediately

as ICP increases LOC decreases 3. Vital Signs

pulse variable, may be rapid or slow, bounding or

feeble B/P

normal or elevated with a widening pulse pressure, at shock level

Respiration's varies

Increased Intracranial PressureSigns/symptoms

Temperature elevated especially with infections and

intracranial bleeding subnormal in a coma of toxic origin

Pupils size and reactivity bilateral vs unilateral sudden fixed and dilated pupils is a

neurosurgical emergency pressure from herniation of the brain

through the tentorium

Neuromuscular - Signs/symptoms

Neuromuscular Movement strength, spontaneous movements asymmetric or absent movements tone

may be increased or decreased tremors, twitching, spasms purposeless flapping hyperactive or flaccid

Increased Intracranial Pressure Signs/symptoms

Posturing decorticate

adduction and flexion

decerebrate rigid extension and

pronation

Diagnosis Procedures

Lumbar puncture measure pressure and sample

for analysis Subdural tap

r/o subdural effusions, relieves ICP

EEG measures electoral activity detects abnormalities

Diagnosis Procedures Computer Tomography (CT)

visualizes horizontal and vertical cross section of the brain

distinguishes density MRI

permits tissue discrimination unavailable with other techniques

Transillumination localized glowing seen in abnormal

fluid

Diagnosis Procedures

Labs CSF blood glucose electrolytes

Ca, Mg, Na

clotting studies liver function tests blood cultures drug titre

Cerebral TraumaHead Injury

Etiology falls, MVA, bicycle injuries head is larger, heavier children curious incomplete motor development

Concussion Contusion/laceration Fracture

Shaken Baby Syndrome

coup countrecoup

Fatal bacterial meningitis

Meningitis Inflammation of the

meninges Spread

vascular dissemination OM or URTI

exudate covers the brain brain becomes

hyperemic and edematous

Meningitis Causative Organism

H. Influenza, type B S. Pneumoniea N. Meningitis

Meningococcus Signs and Symptoms

FUO lethargy

MeningitisSigns/symptoms

irritable vomiting and/or diarrhea signs of meningeal irritation guarding of the neck

nuchal rigidity cries when moved

poor feeding

MeningitisDiagnosis Labs

CSF culture, glucose, protein, cell count, gram

stain Blood Culture

r/o sepsis Urine Culture

r/o UTI Chemistry panel

electrolytes, glucose, BUN, creatinine

MeningitisTreatment

Antibiotics administer within 1 hour of diagnosis type is based on age and causative

organism neonate - ampicillin / claforan 3 months to 3 years - ampicillin /

ceftriaxone older children - penicillin / chloramphemicol

MeningitisTreatment

Fluid Management fine balance between dehydration and

cerebral edema child may be dehydrated due to v/d, poor

po, fever 2/3 maintenance of IV replacement fluid restriction

MeningitisNursing Care

PC: Neurological dysfunction cerebral hypoxia seizures increased ICP

PC: Seizure High Risk for spread of infection

needs resp. isolation for first 24 hrs of antibiotic therapy

MeningitisNursing Care

Fluid Volume Deficit: less than body requirements r/t dehydration NPO/fluid restriction I & O daily weights Labs

specific gravity and electrolytes IV fluid - careful, conservative

replacement

MeningitisNursing Care

PC: Neurological damage seizures sequelae to meningitis

seizures hydrocephalus visual/hearing deficits

Reye Syndrome Toxic encephalopathy with additional organ

involvement Etiology

follows viral illness, ASA Signs and Symptoms

fever decrease LOC hepatic dysfunction

Prognosis good

Febrile Convulsions

Age most common between 6 months and 3 years

Occurrence Seizure accompanied by fever without CNS

infection Occurs during the temperature rise

Treatment fever - tylenol seizure - ativan, valium

Tonic clonic seizure Tonic – stiff Clonic - jerking

Rescue position

Assessment seizure precautions emergency

treatment rescue position

Nursing Care protect from injury open airway accurately observe

and record happenings

Hydrocephalus

Hydrocephaly

Abnormal condition characterized by an increase volume of normal cerebrospinal fluid under increased pressure with in the intracranial cavity Communicating

obstruction is located in the subaranoid cistern or within the subarachnoid space

Non-communicating blockage is within the ventricles

Hydrocephaly - Pathology 3 possible mechanisms

leading to hydocephalus

1. Over production of CSF

2. Defective absorption of CSF

3. Obstruction of CSF 3 major causes

inflammation congenital malformations tumors

HydrocephalusSigns/symptoms

Signs of increased fluid pressure tense or bulging anterior

fontanel scalp becomes thin and shiny vein dilate cranial suture lines begin to

separate Other clinical symptoms

vomiting wide bridge between eyes bulging eyes - sunset eyes

HydrocephalusSigns/symptoms

Severe Form head size increases rapidly infant’s cry is shrill, high pitched hyperirritability, restlessness

Older Children no head enlargement ataxia papilledema Alter mental status spasticity strabismus H/A

HydrocephalusTreatment

Surgical VP (ventriculo-peritoneal) Shunt

Nursing Care Pre-op

assessments daily head circumference size and fullness of anterior

fontanel behavior nutrition - vomiting

Hydrocephalus - Nursing Care

fluid and electrolyte needs positioning

prevent pressure ulcers support the neck good skin care

neuro assessments LOC irritable child/infant vital signs observe for seizures

Hydrocephalus

Nursing Care Post-op

monitor feeding and behavior patterns assess for increasing ICP and cerebral

irritability HOB flat or set elevation Shunt observation

infection - along the line or cerebral abdominal girth valve function, blockage, separation

emotional needs - hold and cuddle teaching

Cerebral Palsy Non-specific disorder

characterized by early onset of movement and posture impairments abnormal muscle tone and

coordination Spastic

hypertonicity, stiff Dyskinectic

slow, worm-like movement

Spina bifia - myelomeningocele Failure of the neural tube to

close during early development

Treatment early surgical closure

Associated Problems hydrocephalus paralysis bone deformity

Andrew, age 10 was a passenger in a MVA 3 weeks ago, he sustained a closed head injury from the impact. He is unconscious in the E.R.

What are is needs in the Emergency Room?

What are his priority nursing interventions?

He was admitted to the PICU, now transferred to your Pediatric Unit. He tracks his parents movement, he is receiving 02 via trach collar, has G-tube with enteral feedings, is incontinent of urine and stool, is able to nod his head appropriately.

Why do you think Andrew has a trach?

Why do you think Andrew has a G-tube?

What risk factors predispose Andrew to infection?

Why is he on these medications? ranitidine 70mg bid - zantac metoclopramide 3.5 mg qid - reglan phenytoin sodium 70mg bid - dilantin

How can you intervene to help met Andrew’s growth and development needs?