Pediatric Nursing (Neurology)

HYDROCEPHALUS IN CHILDREN

Ketan Thummar3rd B.Sc Nursing

RN:40

DEFINITIONDiverse group of conditions characterised by

excessive CSF in the brain. Thus:

1. Impaired flow2. Decreased reabsorbtion3. Increased production

FLOW OF CSF

ETIOLOGYCOMMUNICATING (non obstructive)1. AQUEDUCTAL STENOSIS: genetic(sex

linked recessive), neurofibromatosis, mumps2. AQUEDUCTAL GLIOSIS: meningitis,

intraventicular hemorrhage3. AQUEDUCTAL COMPRESSION:

malformations of the great vein of galen4.Dandy walker 5.Posterior fossa tumors

ETIOLOGYNON COMMUNICATING( obstructive)1. Meningitis with thick purulent exudates- s.

Pneumoniae, mycobacterium tuberculosis.2. Subarachnoid hemorrhage3. Leukemic infiltrates

PATHOPHYSIOLOGYAccumulation of fluid leads to increased

pressure in the proximal part of pathway and progessive dilatation.

Pressure effect on the surrounding nervous pathways and delicate portions of brain: pyramidal tracts, cortex, tectum

PATHOPHYSIOLOGY

CLINICAL FEATURESSYMPTOMS:

IrritabilityBig headPoor feedLethargyVomitingIn older patients:

Headache Changes in personality Academic deterioration

CLINICAL FEATURESSIGNS:

Anterior fontanel wide open and bulging, increased head circ.

Dilated scalp veinsSetting sun signBrisk tendon reflexes, spasticityClonus, babinskyMacewen sign “cracked pot”Prominent occiput (dandy-walker)

Child with hydrocephalus

IMAGING STUDIESX-ray plain films:

Separation of suturesErosion of posterior clinoidsIncreased convolutional markings (beaten

silver appeareance)UltrasoundCT SCANMRI

THERAPYMULTIDISCIPLINARYMedical:

AcetazolamideFurosemide

Surgical: main stayV-p shunt placementExtraventricular drainage

VENTRICULOPERITONEAL SHUNT

©2007, National League for Nursing

Patient Report: Assessments

144-36-88/60-37.6 C (99 F)Pain, irritable

Ketan Thummar-Hydrochephalus in children

Vital Signs

Neurological/behavioral Pupils sluggish L>RIrritable, cryingVS: WNL


History:• Sunsetting eyes• Projectile vomiting• Irritability• Full fontanel• Slightly separated

sutures• Floppy• Lethargic

Labs: • LP - elevated pressure• No RBCs or WBC’s• CT scan/serial

transilluminations demonstrate fluid/ no signs of trauma, swelling, or bleeding


Hydration Skin turgor: Skin suppleWeight: WNLI&O: diaper dryVS: WNL


History: Last void 8 hours ago Vomiting: 30-60 cc q 1h

Labs: Elevated specific gravity Normal blood glucose


Nutrition Well developed, floppyLethargicWeight: Weight WNLI&O: Intake = OutputVs: WNL

History: Last void 8 hours agoVomiting



Family Parental anxietyLack of primary, well child

carePoor eye contactMother’s comments


History:Family signs of stress

Labs:No signs of trauma


Developmental Patient has met age-appropriate milestonesPatient is alert, crying, irritable

Patient able to roll and sit with support


Developmental Milestones • Overall development

Gross and fine motor Language Cognitive Social skills

• Social and Emotional Development • Speech and Language Development


Patient Priority: Safety/Developmental Care

Provide developmentally-appropriate safety measures

SiderailsName bandAllergy bracelet Provide developmentally-appropriate

toys and stimulation

Nursing Actions


Patient Priority: Hydration

Principles of IV therapyIV therapy - replace for

losses (bolus)Restrict fluids as

indicated for IICPAssess and maintain IV

site

Nursing Actions


Patient Priority: Care of the patient related to surgery

Consents, teaching, preparation, sedationAssessments: prep for the operating roomPost-operative care:

Incision assessmentAdvancing diet and

activity as toleratedPumping of shunt

as orderedAssess for infectionsPulmonary care

Nursing Actions


Patient Priority: Family-centered care

Ensure patient safetyFamily-oriented teaching and explanationsInclude family in careAdapt family orientation for specific family

needsFamily support, counseling, and referral

Nursing Actions


Patient Priority: Pain assessment and

management/meeting comfort needs

Pain assessment across the lifespan - Using behavioral signs/vital signs/parental

reportNon-pharmacological measures -

Positioning, music, contact, comfort measures

Pharmacological measures - Fentanyl (Duragesic) or acetaminophen with codeine (Tylenol #3 )

Assessing response to pain interventionsDocumentation

Nursing Actions


Complications:Signs of increased intracranial pressure (IICP)The night before surgery the patientdemonstrates signs of IICP


Monitor for Symptoms: • Increased systolic

blood pressure • Decreased HR and RR• Irritability• Sluggish pupils• Vomiting• Decreased level of

consciousness

Nursing Actions:• Providae oxygen• Encourage ventilation to blow off CO2• Diuretics to decrease ICP -

mannitol (Osmitrol)• Surgery• Monitor

Complications: Hypothermia Following surgery, during frequent vital sign while in the PACU, the nurse assesses the child’s temperature. The electronic thermometer reads 35.8 C (96.5 F).

Monitor for Symptoms: • Body temperature• Signs of vasoconstriction• Decreased level of

consciousness

Nursing Actions: • Warming blankets• Warmed blankets• Warmed intravenous

fluids• Frequent assessments

Ketan Thummar-Hydrocephalus in children

Complications: Seizures Patient has a seizure upon transfer to the patient care unit. The child becomes mildly cyanotic around the lips, has rapid eye movements, demonstrates tonic/clonic movements of upper and lower extremities.

Ketan Thummar-Hydrocephalus in children

Monitor for Symptoms: Aura, seizure activity (tonic/clonic movement, random muscle movement,eye movement, cyanosis)

Nursing Actions: Maintain patent airway, seizure precautions, padded siderail, loosen clothing, oxygen, suction at bedside, safety, monitor timing and characteristics of seizure activity, Anticonvulsants: phenytoin (Dilantin); status epilepticus diazepam (Valium)

Complications: Infection Ketan Thummar-Hydrochephalus in children

Two days after the insertion of the VP shunt, the patient develops signs of a shunt infection. Temperature at 1600 39.4 C (103 F).Child demonstrating behaviors consistent with IICP.

Monitor for Symptoms:

• Temperature• Pain and tenderness• Irritability• Incisional changes,

abdominal distension/ pain assess for meningitis(nuchal pain, etc.)

Nursing Actions: • Culture wound (+S. Aureus) • CSF (from LP) • Provide antipyretics acetaminophen [Tylenol]or ibuprofen [Advil]• Administer antibiotics cefuroxine [Ceftin]) • Comfort

Complications: Family StressDuring the post-operative period, the unit nurses notethe interactions are strained between the mother andfather. The father interacts little with the infant but visitsfrequently. Both parents express concern about cost ofhospitalization and missed work.

Monitor for Symptoms:

• Body language

• Family aspects (family communication, boundaries, dynamics, and decision-making)

• History

• Stress levels

• Assess for cardinal signs of abuse

Nursing Actions:

• Family support, counseling, and referral

• Role as mandatory reporters

• Referral to resources/social service consult


PROGNOSISIncreased risk for developmental disabilitiesMean IQ is reduced compared to general

populationAbnormalities in memory Some patients show aggressive or delinquent

behavior.

PROGNOSISVisual problems:

StrabismusVisuospatial abnormalitiesDecreased visual acuityVisual field defects

Patients require long term follow up (multidisciplinary)

Ketan Thummar

3rd BSc.(N)RN:40

DefinitionMeningitis is the inflammation of the

membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia matter.

IncidenceMeningitis can occur at all ages but it is

commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age.

It is more common in males than females.

TransmissionThe bacteria are transmitted from person to

person through droplets of respiratory or throat secretions.

Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc.)

The incubation period ranges between 2 -10 days.

Routes of InfectionNasopharynxBlood streamDirect spread (skull fracture, meningo and

encephalocele)Middle ear infectionInfected Ventriculoperitoneal shunts.Congenital defectsSinusitis

Signs & SymptomsThe symptoms of meningitis vary and depend on the age

of the child and cause of the infection. Common symptoms are:

Flu-like symptomsfever lethargy Altered consciousnessirritability headache photophobia stiff neck Brudzinski signKernig sign skin rashes seizures

SymptomsOther symptoms of meningitis in

Neonates/infants can include:Apneajaundiceneck rigidity Abnormal temperature

(hypo/hyperthermia)poor feeding /weak sucking a high-pitched cry bulging fontanellesPoor reflexes

TypesBacterialViral (aseptic)FungalParasiticNon-infectious

Pyogenic Meningitis ETIOLOGY ‘Meningococcal’ meningitis- N. meningitidis. A, B, C and

W135) are recognized to cause epidemics

The commonest organisms according to age groups are:

0-2 months0-2 months E.ColiE.Coli, Group B streptococci, S.Aureus, Listeria , Group B streptococci, S.Aureus, Listeria MonotocytogenesMonotocytogenes

2 months- 2yrs 2 months- 2yrs H.Influenzae type bH.Influenzae type b, S.Pneumoniae, , S.Pneumoniae,

N.Meningitides.N.Meningitides. 2 yrs – 15+yrs2 yrs – 15+yrs N.MeningitidesN.Meningitides (serotypes A,B,C, Y & W135) (serotypes A,B,C, Y & W135)

S.PneumoniaeS.Pneumoniae (serotypes 1,3, 6,7) (serotypes 1,3, 6,7)

H.InfluenzaeH.Influenzae

Bacterial MeningitisPathogenesis: Entry of organism through blood brain

barrierrelease of cell wall & membrane products Outpouring of polymorphs & fibrincytokines & chemokines Inflammatory mediatorsInflamed meninges covered with exudate

(most marked in pneumoccocal meningitis).

PathogenesisMeningeal irritation signs: inflammation of the spinal

nerves & roots.

Hydrocephalus: Adhesive thickening of the arachinoid in basal cistern or fibrosis of aqueduct or Foramina of Lushka or Magendie

Cerebral atrophy: thrombosis of small cortical veins resulting in necrosis of the cerebral cortex.

Seizures: depolarisation of neuronal membranes as a result of cellular electrolyte imbalance.

Hypoglycorhachia: decreased transport of glucose across inflammed choroid plexus & increased usage by host.

Viral meningitis

Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following:

Enterovirus (polio virus, Echovirus, Coxsackievirus )

Herpesvirus (Hsv-1,2, Varicella.Z,EBV )Paramyxovirus (Mumps, Measles)Togavirus (Rubella)Rhabdovirus (Rabies)Retrovirus (HIV)

Fungal MeningitisIt’s rare in healthy people, but is a higher

risk in those who have AIDS, other forms of immunodeficiency or immunosuppression.

The most common agents are Cryptococcus neoformans, Candida, H capsulatum.

Parasitic MeningitisInfection with free-living amoebas is an

infrequent but often life-threatening human illness.

It’s more common in underdeveloped countries and usually is caused by parasites found in contaminated water, food, and soil.

The most common causative agents are:Free-living amoebas (ie, Acanthamoeba,

Balamuthia, Naegleria)Helminthic eosinophilic meningitis

Non-infectious meningitisRarely, meningitis can be caused by exposure to

certain medications, such as the following:

Immune globulin

Levamisole

Metronidazole

Mumps and rubella vaccines

Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen)

Tuberculous meningitisIt’s a complication of Childhood tuberculosis & common cause of prolonged morbidity, handicap & death.

Children below 5 years are specially prone.

CLINICAL FEATURES

Always sec. to primary tuberculosis.First Phase: Vague symptoms. Child doesn’t play, is irritable, restless or

drowsy.Anorexia & vomiting may be presentOlder child may complain of headache.Possibly preceding history of Measles or another

illness with incompletely recovery

SECOND PHASE: Child is drowsy with neck stiffness, &

rigidity.Kernig & Brudzinski sign may become

positive, anterior fontanels bulgesTwitching of muscles, convulsions,

raised temperature.strabismus, nystagmus, and

papilloedema may be present.Fundoscopy: Choroidal TB may be seen

TERMINAL PHASE

Child is characteristically comatose with opisthotonus, & multiple focal paresis.

Cranial nerve palsies are present.

High grade fever often occurs terminally.

Diagnostic TestsLumbar Puncture: pressure usually raised, 10-500 PMNs early but later lymphocytes

predominateProtein- 100-500,raisedGlucose less than 50mg/dl in most casesCulture for tubercle bacilli.Presence of tuberculous focus elsewhere

in the body is strong supportive diagnosis.Chest X-Ray.Tuberculin skin test.

TreatmentAntituberculous Therapy:Includes simultaneous administration of 4 drugs

(Isoniazid, rifampicin,streptomycin , pyrazinamide) for first 3 months, followed by 2 drugs for another 15 months usually Rifampicin & INH.

Total period: 18 months.

TreatmentSTEROIDS: to reduce cerebral edema and to

prevent subsequent fibrosis & subsequent obstruction to CSF

2mg/kg/24 hours of prednisolone for 6-8 weeks at the start of treatment starting 3 days after initiation of anti tuberculous therapy.

Examination General physical- Check for Consciousness level according

to GCS scoring, jaundice or irritability.

Resuscitation: incase of septic shock, or DIC.

Vitals: temperature , HR, B.P., R/R.

Signs of Increased ICP- Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema

Fundus: papilloedema

CN palsies: (esp. occulomotor, facial, and auditory)

Examination Meningismus - check for nuchal rigidity with

passive neck flexion (gives 'involuntary resistance).

Brudzinski sign (hip & knee flexion with neck movement)

Kernig sign (extend knee with hip flexed)

Hemiparesis.

Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia).

InvestigationsCBCBlood cultureGram stainingLP- D/r, C/s (color, leukocyte count, differential,

glucose, protein)ElectrolytesPCRCoagulation profile liver and kidney function Chest X-rayCT/ MRIBlood gasesEEGECG

Diagnostic TestsCSF picture is quite diagnostic of the kind

of meningitis present.

Diagnostic TestsLatex particle agglutination: detects presence

of bacterial antigen in the spinal fluid. useful for detection of H.influenzae type b, S.Pnemoniae, N.Meningitidis, E.Coli

Concurrent immuno-electrophoresis (CIE)-used for rapid detection of H.influenza, S.pneumoniae & N.meningitides.

Smears: taken from purpuric spots may show meningococci in Meningococcaemia

DNA sequences : are helpful in identifying bacteria

TreatmentSupportive therapy:Maintain fluid & electrolyte balance as

requiredTransfuse whole blood,or platelets as

required.Maintain temperature control

TreatmentSteroids:Dexamethasone useful for H.influenzae type

b, First dose should be given 1 hr prior to starting antibiotics.

Antibiotics IV.Duration:1-3 weeks depending on age &

type of organisms.

Treatment

Initial till results of C/S are known

Probable/Proved Meningococci

Ampicillin 300mg/kg/day+

Chloramphenicol 75-100mg.kg/day

Penicillins 2-5 lac units

/kg/day

TreatmentProbable

H.Influenzae

Probable E.Coli

Ampicillin + chloramphenicol or

3rd generation cephalosporin

(cefotaxime 200mg/kg/day)

Ampicillin + gentamycin

200mg/kg+2.5-4 mg/kg IV 12hrly

TreatmentProbable group

B streptococciPenicillin

50,000i.u/kgI.V/4 hourly.

Other Drugs availableAnti-microbialsCeftriaxoneCefotaximePenicillin G VancomycinAmpicillinGentamicin

Anti-ViralsAcyclovir Ganciclovir

(>3mths)

Anti-fungalsAmphotericin BFluconazole

PreventionThe vaccines against Hib, measles, mumps, polio,

meningococcus, and pneumococcus can protect against meningitis

Hib vaccine: all infants should receive at 2,4,6 months of age & booster 1 year later.

After 1 year 1 dose is given till the age of 5 years.

Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs)

PreventionHigh-risk children should also be immunized

routinely.

Vaccination before travelling to an endemic area

Chemoprophylaxis for susceptible individuals or close contacts:

H influenzae type b : Rifampin(20 mg/kg/d) for 4 days

N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto 10weeks

Ceftriaxone (250 mg IM) single dose or Ciprofloxacin(500-750 mg) single dose.

ComplicationsBacterial meningitis may result inCranial nerve palsies Subdural empyema Brain abscess Hearing loss Obstructive hydrocephalus Brain parenchymal damage: Learning disability,

seizures, Mental retardation.Septic shockAtaxiaStrokeSIADH (Na+ <130 mE/l), puffiness of face, dec

UO.

Treatment of Complications:Convulsions: Diazepam I.V, Can be

repeated q4 hours as required.

Cerebral edema: *I.V Mannitol 1g/kg in 20-30 mins 6-8 hourly given for first few days.

IV Dexamethasone can then be used 6

hourly.

Subdural effusion: Aspirate subdural effusion if large.

Shock: Treat with IV Fluids, maintanence of BP.

SIADH: Increase body weight, decreased serum osmolality, hyponatremia.

Prevented by fluid restriction to 800-1000ml/m2/24 hours.

Hyperpyrexia: Tepid sponging, correction of dehydration.

Nursing careObtain a history of recent infections such

as upper respiratory infection, and exposure to causative agents

Assess neurologic status and vital signs,signs of meningeal irritation

Assess sensorineural hearing loss (vision and cranial nerve damage.

(eg, facial nerve d diminished cognitive function.

Cont;Reducing Fever Administer antimicrobial agents on time

to maintain optimal blood levels. Monitor temperature frequently or

continuously, and administer antipyretics as ordered.

Institute other cooling measures, such as a hypothermia blanket, as indicated.

Cont;Maintaining fluid balancePrevent IV fluid overload, which may

worsen cerebral edema.Monitor intake and output closely.Monitor CVP frequently.

Cont;Enhancing Cerebral Perfusion Assess LOC, vital signs, and neurologic parameters

frequently. Observe for signs and symptoms of ICP (eg, decreased LOC, dilated pupils, widening pulse pressure).

Maintain a quiet, calm environment to prevent agitation, which may cause an increased ICP.

Prepare patient for a lumbar puncture for CSF evaluation, and repeat spinal tap, if indicated. Lumbar puncture typically precedes neuroimaging

Notify the health care provider of signs of deterioration: increasing temperature. decreasing LOC. seizure activity, or altered respirations.

Cont;Redusing PainAdminister analgesics as ordered; monitor for

response and adverse reactions. Avoid opioids which may mask a decreasing LOC.

Darken the room if photophobia is present. Assist with position of comfort for neck

stiffness, and turn patient slowly and carefully with head and neck in alignment.

Elevate the head of the bed to decrease ICP and reduce pain.

Cont;Promoting Return to Optimal Level of

FunctioningImplement rehabilitation interventions after

admission (eg, turning, positioning). Progress from passive to active exercises based

on the patient's neurologic status.Patient Education and Health Maintenance Advice close contacts of the patient with

meningitis that prophylactic treatment may be indicated: they should check with their health care providers or the local public health department.

Cont;To help prevent the development of

meningitis, teach patients with chronic sinusitis or other chronic infections the importance of proper medical treatment.

Encourage the patient to follow medication regimen as directed to fully eradicate the infectious agent.

Encourage follow-up and prompt attention to infections in future.

Cont;Inform patient who have children

about the importance of vaccination with measles, mumps, rubella vaccine, H. influenzae type B vaccine, pneumocococcal vaccine as a preventive measure. Vaccination is recommended for children younger than school age.

PrognosisIt depends on the age of the patient, the duration

of the illness, complications, micro-organism & immune status.

Patients with viral meningitis usually have a good prognosis for recovery.

The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency.

Patients presenting with an impaired level of consciousness are at increased risk for developing neurologic sequelae or dying.

PrognosisA seizure during an episode of meningitis

also is a risk factor for mortality or neurologic sequelae.

Acute bacterial meningitis is a medical emergency and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality.

The prognosis of meningitis caused by opportunistic pathogens depends on the underlying immune function of the host as may require lifelong suppressive therapy.

DEFINITIONConvulsion is involuntary contraction or

series of contraction of voluntary muscle.

It occur due to disturbance of brain function resulting from abnormal excessive electrical discharge from brain.

It may be associated with alteration of level of consciousness.

Convulsion is also termed as SEIZURE.

CAUSES OF CONVULSIONNEONATAL PERIOD :•asphyxia & injury•Hypoglycemia & hypocalcemia•Narcotic & anesthetic drug•Septicemia, meningitis Birth, tetanus ,

kernicterus•Congenital malformation• Intra uterine infection

SIGNS & SYMPTOMSTwiching of limbTongue biteDischarge from the mouthPale facesucking movementTremors

Infant & young childrenFebrile convulsionCNS infectionAccidental & non accidental injury

Metabolic disturbance Drug & poison

Febrile convulsionIt refers to the seizures associated with fever but excluding those related to CNS infection.

It is related to increase in body temperature rather than degree of temperature rise.

TypesTypical febrile convulsion :-

• it is usually found in children between 6 month & 5 years of age.

• The fits occur within 24 hours of the onset of fever.

• Higher incidence occur in twins & genetic predisposition or immature neuronal membrane.

ATYPICAL FEBRILE CONVULSIONThere may have abnormal EEG for 2 weeks after attack.

The children may have focal convulsion of more than 20 minutes duration even without significant fever.

MEDICAL MANAGEMENTAnticonvulsive drug : Diazepam 0.3mg/kg iv Phemobarbital 5mg/kg

Antipyratic drug : Paracetamol Mefanamic acid

NURSING MANAGEMENT

Tapid sponge bath.Clearing the airway % oxygen therapy.

Provide Rest , comfortable position .

Explanation & emotional support.Maintain nutritional status.

EPILEPSYEpilepsy is recurrent episodic paroxysmal transient disturbance of brain function due to abnormal electrical activity of neurons.

It is manifested as abnormal motor sensory or psychomotor phenomena & loss of consciousness.

1 GENERALIZED SEIZURES

Tonic – clonic seizures absence seizures : - typical : -

atypical Atopic seizures Myoclonic seizures

TONIC-CLONIC SEIZURESPHASES

A. AN AURAB. TONIC SPASM PHASEC. CLONIC PHASED.POSTICTAL OR POST

CONVULSIVE PHASE

CLINICAL MENIFESTATIONAn Aura:1. Dizzines2. Convulsion Tonic spasm phase1.Body become stiff2.Pale face3.Eye fixe one position

4.Unconciouness5.Discharge from the mouth6.Breathing difficulty & cynosis7.Muscular spasm8.Pulse mazy be weak CLONIC PHASE1. Jerky movement2. Contraction of muscle3. Tongue bite

4. Involunantry pass stool & urine5. Jerky movement6. Contraction of muscle7 Tongue bite8. Involunantry pass stool & urinePOSTICAL STAGE

1. Become sleepy2. Confused3. Headache

ABSENCE SEIZURE(PETIT MAL)

1.Staring appearance2.Discontinue activity suddenly3.Duration: 5 to 10 sec4.Fatigue5.Stress situation

STATUS EPILEPTICUS1.Ataxia2.Aphasia3.Cardiopulmonary arrest4.Aspiration of vomitus5.Duration: 30 min

MYOCLONIC SEIZURE

1.Mental retardation2.Cerebral abnormality3.Contraction of muscles of

trunk, neck, extremities4.Duration: less than 1min

PARTIAL SEIZURES

SIMPLE PARTIAL SEIZURES with motor sing with somato-sensory or special sensory

with autonomic manifestationCOMPLEX PARTIAL SEIZURES Impaired consciousness

MEDICAL MANAGEMENT

Phenoberbital : 3 to 5mg/kg/dayDiphenylhydantoin : 10 to 20mg/kg/dayCarbamazepin : 10 to 20mg/kg/daySodium valproate : 15 to 20mg/kg/dayEthosuximide : 10 to 20mg/kg/day

NURSING MANAGEMENTEnsuring safety during seizures

protect child from injury

side rail of bed

oxygen therapy should be given

close observation & monitoring child

condition for vital sign & airway

Preventive respiratory arrest & aspiration

loosen the clothing around neck & placing the child flat

Do not give anything between teeth

or in mouth when teeth are clenched

during convulsion

Clear airway, remove secretion &

turn head to one side during seizuere.

Providing health teachingContinuation of medication, care during

convulsion & diet therapy, restricted activities.

DIET THERAPYKetogenic diet should be given.Protien & fat amount should be calculated.Child should not be given IV fluid with

dextrose.Strict fluid restriction

HEAD INJURY (CARCINO CEREBRAL TRAUMA)

Head injury includes any injury including scalp, skull, meninges or any portion of the brain caused by external forces.

It is one of the important cause of childhood mortality & morbidity.

One third of all head injury cases are children.

CAUSESNEONATES - birth injury

instrumental delivery

TODDLER - fall from height hits on head by hard object

OLDER - automobile accident CHILDREN road traffic accident sports injury

TYPES OF INJURY1. Fracture of skull2. Intracranial hemorrhage3. Concussion of brain4. Cerebral contusion5. Extradural hematoma6. Acute subdural hematoma7. Brain swelling

Diagnostic testPhysical & neurological examination

Examination of blood, urin , CSFEEGX-RAY of skullCT SCANMRI

Fracture of the skull

A typical “ping-pong” fracture may occur due to elasticity of bone.

The fracture may be fissured or depressed type.

Older children may have comminuted fracture with dural tear & laceration with brain damage.

INTRACRANIAL HEMORRHAGE

Excessive moulding of skull bone

Rupture of delicate surface veins leads to acute subdural hemorrhage

About 20 to 25 % neonatal death due to intracranial hemorrhage

CONCUSSION OF BRAIN

Concussion is reversible neurological dysfunction

Transient loss of consciousness & loss of memory

Injury at occipital area & shearing srain at brain stem

CEREBRAL CONTUSIONIt is bruising or petechial hemorrhage in brain tissue

It consist of hemorrhagic brain necrosis & infraction

Contusion at frontal & temporal lobe are common

EXTRADURAL HEMATOMAIt occurs mostly in temporal or frontal lobe.

Blood may be collected due to bleeding from fracture line.

ACUTE SUBDURAL HEMATOMAIt results from any severe injury.It is an accumulation of fluid, blood within

potential subdural space between dura & arachnoid.

When sutures are not fused, the hematoma can grow slowly.

BRAIN SWELLINGIt may be occur due to vascular congestion, may be due to neurogenic vasoparalysis & increase blood flow.

SIGNS & SYMPTOMSLoss of consciousnessRespiratory obstructionIncrease icpHeadache VommitingConvulsionLoss of memoryBladder bowel dysfunction

DIAGNOSTIC STUDYPhysical examinationGlasgow coma scaleNeurological examinationCT SCANX – RAYEEGABGLumber puncture

NURSING MANAGEMENTMaintain the airwayEstablishment of breathingAssessment of neurological status

Maintain nutritional statusPrevent infection & related complication

Health & Medicine

Pediatric Nursing (Neurology)