Review the differences in the neurologic and nervous system differences in children.
- Cranial bones are not completely ossified.
–> Allows for brain growth
–> Increases risk for brain and spinal cord injury - The posterior fontanel closes at 2 to 4 months.
- The anterior fontanel closes by 12 to 18 months.
- The skull and brain grow and develop rapidly during early childhood. Infants and young children are at higher risk for injury to the brain and spinal cord because of developing anatomic structures.
ASSESSMENT: Level of Consciousness
- Level of consciousness
–> Most important indicator of neurologic dysfunction - Consciousness
–> Receptiveness to stimuli - Alertness
–> Arousal, ability to react - Cognitive power
–> Ability to process data and respond
ASSESSMENT: Altered Levels of Consciousness & Other Neurologic Conditions
- Altered levels of consciousness – what can cause this?
- Levels of consciousness assessment
–> Confusion
–> Delirium
–> Obtunded
–> Stupor
–> Coma - Decorticate and decerebrate posturing (late sign)
- Increased intracranial pressure – Early vs. late signs?
–> Scales for responsiveness (AVPU, GCS)
–> Glasgow coma scale
–> Fixed dilated pupils (late sign)
Posturing Associated with Severe Brain Injury
- Flexor posturing (decorticate), characterized by rigid flexion, is associated with lesions above the brainstem in the corticospinal tracts.
- Extensor posturing (decerebrate), distinguished by rigid extension, is associated with lesions of the brainstem.
Glasgow Coma Scale for Assessment of Coma in Infants and Children
GCS <8 = Intubate!
*Add the score from each category to get the total. The maximum score is 15, indicating the best level of neurologic functioning. The minimum is 3, indicating total neurologic unresponsiveness.
Pupil Findings in Various Neurologic Conditions with Altered Consciousness
A, A unilateral dilated and reactive pupil is associated with an intracranial mass.
B, A fixed and dilated pupil may be a sign of impending brainstem herniation.
**C, Bilateral fixed and dilated pupils (“blown pupils”) are associated with brainstem herniation from increased intracranial pressure and DO NOT respond to light.
Mild, Moderate, and Severe Brain Injury
- Traumatic brain injuries
*** Falls are a major cause - See Growth & Development, p. 777**
- Primary vs. secondary injury
- Cushing triad
–> HTN (increased systolic pressure with wide pulse pressure), bradycardia, irregular respirations - Nursing management of mild vs. severe brain injury
–> Emergency care
–> Long-term care
Clinical Manifestations of Traumatic Brain Injury by Severity
HypoXIC-ISCHEMIC BRAIN INJURY (SUBMERSION/Drowning)
- Increased submersion time = poor outcomes
–> 5 to 10 minutes & resuscitated at the scene = few symptoms, often full recovery without neurologic impairment.
–> >10 minutes before BLS or pulseless > 25 minutes = poor prognosis. - Prevention is Key!: Education, Legislation, Environmental safety
–> Never leave infants and young children unsupervised near water—bathtubs included. Keep buckets empty.
–> Fencing, alarms around swimming pools
–> Pool and hot tub drain covers
–> Pool owners should know cardiopulmonary resuscitation (CPR).
–> Educate adolescents about mixing alcohol and swimming.
Seizures: NURSING MANAGEMENT
- Maintain airway – Do not put anything in mouth!
–> Roll to side if vomiting or increased secretions - Ensure safety.
–> Bed low, Remove items from area/body, Rails up & padded on admission if seizure hx - Administer medications.
- Provide emotional support.
- Questions to Ask, Table 27-10, p. 752
- Provide education.
–> Triggers
–> Patient & family teaching - Prolonged seizure vs. Status epilepticus
–> > 5 minutes vs. > 15 minutes despite intervention or clusters without full recovery
–> Priority: Administer rescue benzo if seizure > 5 minutes
Status Epilepticus
- An acute seizure or seizure cluster that lasts over 30 minutes
- Electrolytes, glucose, blood gases, temperature, and blood pressure need monitoring if a seizure occurs for longer than 15 minutes
- Nurses need to administer medications as ordered
–> Benzodiazepines
–> Antiepileptics - Collaborative care
Meningitis
- An inflammation of the meninges covering the brain and spinal cord
Bacterial Meningitis - More virulent than viral
–> Can be fatal – Infants at greatest risk - May occur secondary to other bacterial infections
–> Otitis media, Sinusitis
Viral Meningitis - Symptoms are the same as those of bacterial meningitis, but child does not seem quite as ill.
- Child is treated with antibiotics on an emergency basis until bacterial meningitis can be ruled out.
- Usually full recovery
Opisthotonic Position
The Child with Bacterial Meningitis May Assume an Opisthotonic Position, with the Neck and the Head Hyperextended, to Relieve Discomfort
REYE SYNDROME
- Acute encephalopathy
–> Cerebral edema, neurological & liver dysfunction – progression to coma, loss of DTRs, & respiratory arrest (high mortality rate) - Symptoms – depend on causative organism
–> Fever (or symptoms or a resolving viral illness)
–> Irritability
–> Headache
–> Bulging fontanelle
–> Altered mental status
–> Paralysis
–> Possible Kernig or Brudzinski sign - Treatment: supportive care in the ICU; efforts to prevent secondary cerebral edema & metabolic injury R/T ↑ ammonia & short chain fatty acid levels; intubate/ventilate once comatose
- Prevention: Don’t given aspirin for flu-like symptoms or varicella
–> Give ibuprofen or acetaminophen
Spina Bifida
- Sometimes called meningomyelocele, myelomeningocele or myelodysplasia
–> Reduce risk of NTD: Folic acid 400 mcg/day – all women child-bearing age
–> A defect in one or more vertebrae that allows the spinal cord contents to protrude; most commonly occurs at the lumbar or sacral portion. - Impaired physical mobility
–> Related to neuromuscular impairment - Impaired urinary/gastrointestinal elimination
–> Related to sensory impairment (neurogenic bladder/bowel) - Impaired skin integrity, Risk for
–> Related to motor & sensory deficits - Latex allergy response, Risk for
–> Related to multiple surgical procedures
SPINA BIFIDA: NURSING MANAGEMENT
PRE-OPERATIVE
* Newborn transferred to specialty center or neonatal intensive care until surgery.
* Monitor the sac for leakage of cerebrospinal fluid (C S F).
* Assess extremities for deformities.
* Frequently assess vital signs and for signs of infection.
POST-OPERATIVE
* Manage the infant’s postoperative pain.
* Assess intake and output.
* Measure head circumference daily.
* Place infant in prone or side-lying position sleep.
* Keep diaper away from incision site.
* Assess for infection, motor deficits, and bladder and bowel involvement.
* Perform urinary catheterization regularly only if needed.
* ROM exercises as soon as possible.
* Provide emotional support and education.
SPINA BIFIDA: Health Promotion (General)
- Provide all recommended immunizations & routine screening.
–> If the child has a seizure disorder, alert parents of seizure risk after immunizations.
–> Screen for scoliosis annually beginning at birth. - Obtain a urinalysis with culture in the newborn period and when signs of infection are noted.
- Growth and Development Surveillance
–> Monitor the growth of the child (length or height, weight, head circumference).
–> Monitor head circumference growth carefully because of hydrocephalus risk.
–> Assess developmental status regularly. Motor skills are often delayed.
–> Enroll in early intervention program to promote the child’s development.
–> Promote gradual independence in mobility and self-care.
SPINA BIFIDA: Health Promotion (nutrition & elimination)
Nutrition
* Teach families appropriate caloric intake and portion control for the child at each age to reduce the risk for obesity.
* Provide guidance about increased fluids and fiber in the diet to reduce the risk for constipation and urinary tract infections.
* Alert parents that allergies to foods such as bananas, avocados, papaya, kiwi, and other foods may occur because of the risk of latex allergy.
Elimination
* Teach families the importance of performing intermittent catheterization on a regular schedule.
* Teach the child to perform self-catheterization and care for the catheter in preparation for school entry.
* Teach families to initiate bowel training so that a bowel regimen is established.
SPINA BIFIDA: Health Promotion (Sleep & rest, relationships)
Sleep and Rest
* Position the child to prevent contractures.
* Change the child’s position during the night to reduce pressure over skin surfaces.
* Teach parents to be alert for apnea spells or snoring that could be related to a Chiari type II malformation.
Relationships
* Encourage interaction with peers.
* Be alert for psychosocial adjustment problems, especially during the adolescent years.
Hydrocephalus: CLINICAL FINDINGS
- Infants: ↑ FOC; split cranial sutures; high-pitched cry; bulging fontanel(s); irritability when awake; seizures
- Toddlers & Older Children: setting-sun eyes; papilledema; seizures; irritability; ↓ LOC, ↑ BP, widening pulse pressure
- Older Child: unbalanced & uncoordinated
- All Children: vomiting; lethargy; Cheyne-Stokes respirations
Hydrocephalus: TREATMENT
- Medications: decrease CSF production (temporary measure; only helps slow progression)
- Acetazolamide
- Isosorbide
- Furosemide
- Shunt – ventricles → peritoneum or atrium (VP or VA)
Hydrocephalus: NURSING MANAGEMENT & TEACHING
- Assess all infants for hydrocephalus.
–> Measure head circumference regularly and compare to growth curve.
–> Note any signs of increased intracranial pressure. - Pre-op: monitor for ↑ ICP
Post-op: - Place flat & on nonoperative side (off shunt)
- If held, don’t allow head to be elevated
- Monitor for signs of infection & notify MD of the following:
–> Fever; change in LOC; excessive redness at incision site or along shunt tract; ↑ WBC with leukocytes or left shift - Teach signs of shunt malfunction
Cerebral Palsy
- Most common chronic disorder of childhood; most common cause of disabilities in children
- Group of permanent disorders of movement and posture
- Nonprogressive in nature
- May have additional sensory, cognition, communication, and behavior problems
* Spastic: most common (70%); muscles stiff & tight; limited movement; mild to severe
Clinical presentation of CP
hypotonia, head lag
