hydrocephalus neural tubes defects bacterial meningitis guillain-barre syndrome reye’s...
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Hydrocephalus Neural Tubes Defects Bacterial Meningitis Guillain-Barre Syndrome Reye’s Syndrome Seizures
Common Neurological Disorders in Children
“Water on the Brain” Imbalance between the production and
absorption of CSF. Often from congenital CNS malformations Results in rapid head enlargement in infants
Can lead to irreversible neurological damage
Hydrocephalus
Hydrocephalus
Symptoms in the infant
Early Signs Projectile vomiting
not associated with feeding
Scalp veins become prominent
Shrill, high pitched cry
Increasing irritability
Late Signs Bulging anterior
fontanel
Head circumference that increases at an abnormal rate
Enlargement of the forehead
Depressed eyes rotated downward “sunset eyes” (pupils sink downward)
No enlargement of head (skull is closed)
Begins with generalized neuro symptoms HA in morning Nausea Vomiting
Followed by signs of increased ICP
Symptoms in the Child
Relief of hydrocephalus
Create a new pathway to divert excess CSF.
A catheter or shunt is placed in the ventricle and passes the CSF to the peritoneal cavity
Needs to be replaced PRN
Keep child flat unless ICP is present
the bed slightly elevated Slowly increase HOB over few days Support head when moving child Pain management Vital Signs
Post-op Nursing Care Shunt Placement
Observe for signs of increasing ICP –
neurologic assessment Observe for abdominal distention Strict I & O Antibiotics Meticulous skin care Support family
Post-op Nursing Care Shunt Placement
Teach parents to monitor for shunt
complications: Headache, progressive or worsening Drowsiness or inappropriate sleepiness during the
day, irritability Nausea, vomiting Personality changes or changes in school
performance Fever Redness or swelling along the shunt tract
Discharge Management Post Shunt Placement
Defects of closure of neural tube
during fetal development Congenital (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
Neural Tube Disorders
Types: Spina Bifida
Occulta Cystica
Meningocele Myelomeningocele
Neural Tube Disorders
Most common CNS defect Caused by failure of neural tube to
close at some point along spinal column
Types: spina bifida occulta spina bifida cystica
Spina Bifida
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
Myelomeningocele Same 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
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
Nursing Interventions
Surgical repair usually within first
24 hours observe for early signs of infection:
elevated temp, irritability, lethargy, nuchal rigidity
observe for signs of increasing ICP (may indicate hydrocephalus)
Nursing Interventions
Emphasizes constructive use of ‘normal’ parts
of body & minimizes the disabilities making the child as self-helpful as is possible in the activities of daily living
Major problems: incontinence, constipation, obesity or malnutrition
Habilitation
Meningitis
Acute inflammation of the cerebral meninges as a result of a bacterial or viral infection
Haemophilus influenzae type b was the most
common cause of bacterial meningitis in children prior to the use of the Hib conjugate vaccine
Still may be caused by Strep pneumoniae in child < 24months as not fully vaccinated with PCV vaccine
Meningococcal predominantly in unvaccinated school-age children & adolescents
Bacterial Meningitis
Symptoms
Abrupt onset of fever
Chills Increasing
irritability Headache Nuchal Rigidity Poor feeding Weak Cry Bulging fontanel
Opisthotonic position
Symtoms
Kerning’s Sign Brudzinski’s Sign
Lumbar puncture Administer IV antibiotics Respiratory isolation Promote hydration- monitor I + O Frequently assess vital signs, LOC, neurologic
assessment to identify changes in the child’s condition
Measure head circumference frequently- risk for hydrocephalus
Prepare for seizures
Nursing Management
Promote comfort
• reduced stimulation (dim lights, quiet room)
Side-lying position Identify parents’ concerns, provide support
Prevention is a major role for nurses Encourage parents to get their infants
and children fully immunized!
Nursing Management
Life Threatening Condition If Survival
Hearing loss Blindness Paresis Intellectual impairment
Complications
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 though demyleination
Ascending paralysis from lower extremities
Guillain-Barre Syndrome
Peripheral neuritis occurs several days
after primary infection Muscle tenderness Tendon reflexes decreased or absent Paresthesia & cramps Proximal symmetric muscle weakness Urinary incontinence or retention Decreased swallowing & respiratory
efforts-may lead to respiratory failure
Initial Symptoms
Wait for disease to stabilize Intravenous immune globulin IVIG Physical Therapy Rarely fatal, often residual paralysis
Treatment
Monitoring respiratory status Managing autonomic nervous system
dysfunction Preventing complications associated with
immobility Providing emotional support Teaching the parents how to care for the child
after discharge
Nursing Care
A life threatening acute encephalitis
Occurs after viral infection if given aspirin
Education efforts has helped to reduce incidence (use Tylenol or Ibuprofen not ASA)
Reye’s Syndrome
Begins with mild viral infection that worsens w/i 24-48 hours
Lethargy
Vomiting
Followed by Agitation Anorexia Combativeness Confusion leading to stupor, coma, seizures, respiratory
arrest
Reye’s Syndrome
If Survival in PICUMonitor: Neurological status Respiratory effort Hypoglycemia Cerebral edema
Reye’s SyndromeNursing
Care
Involuntary contraction of muscle caused by
abnormal electrical brain impulses They are episodic and abrupt Often 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)
Some seizures in children are acute, not believed to re-occur
Re-ocurring seizures will be diagnosed as epilepsy
Seizures
Seizures: 2 categories
Partial Simple Complex
Only 1 area of brain involved
Symptoms are associated with the area affected
No LOC or consciousness is impaired
Generalized Infantile spasms Febrile Absence Tonic Clonic
Entire brain Usually have loss of
consciousness May have aura Postical State
Aura
sensation experienced before the seizure activity it often manifests as the perception of a strange
light, an unpleasant smell or confusing thoughts or experiences
Postictal altered state of consciousness that a person enters
after the seizure, lasts between 5 and 30 minutes emergence from this period is often accompanied by
amnesia or other memory defects
Seizure Terms
Simple Partial SeizuresSimple Partial Seizures
Complex Partial SeizuresComplex Partial Seizures
• Seizure is short, lasts < 30 seconds• No loss of consciousness, aura, or postical stateSeizure Activity is either:
Abnormal motor activity• One extremity or part of extremity, uncontrolled
movement
Abnormal sensory activity Numbness, tingling, paresthesia or pain starting in 1
area of body, may spread to other parts of body May include abnormal auditory, olfactory and visual
sensations
Simple Partial Seizures
Seizure is longer, 30 seconds-5 minutes Consciousness is impaired immediately May have slight auraSeizure Activity
Sudden change in posture Abnormal motor activity, twitching, loss of tone,
tingling or numbness Automatisms-lip smacking, chewing, sucking Circumoral pallor
Afterward: drowsiness
Complex Partial Seizures
Infantile spasmsAbsence
Tonic ClonicFebrile
Age: 4 months to 2 years Occur in clusters 5-150/day, worse at night Altered consciousness Abrupt flexion/extension of neck, trunk,
extremities Eye rolling May have permanent cognitive &
developmental delays
Infantile Spasms
Lasts 5-10 seconds, multiple times a day 50-100 per day
Seizure is a brief loss of consciousness Appears to look like a staring spell Rhythmic blinking & twitching of mouth or arm Mistaken for daydreaming or behavior
problems Interferes with learning 1/3 of children will grow out of them by
adolescence
Absence Seizure
1. Prodromal: Drowsiness, dizziness, malaise, lack of
coordination, “not himself”
2. Aura May precede seizure, reflects portion of
brain where seizure originates
Tonic Clonic4 stages of Seizure
3. Tonic-Clonic
Tonic: 20 seconds, all muscles cx (rigid), child falls to ground, LOC, respiratory muscles affected, grunting, airway compromised
Clonic: 20-30 seconds, jerky muscle contract & relax rapidly, froth or bloody sputum, urinary or bowel incontinence
4. Postictal Appears to relax, semi-conscious, sound sleep for hrs, no recollection of event
Tonic-clonic stage
Due to increased temperature > 102 F (but may occur as low as 100 F) Higher fever=higher risk Occur between 6 months and 5 years, with a
peak incidence between 18 and 24 months of age
Tonic-clonic pattern Lasts 15-20 seconds
Acute Febrile Seizure
Chronic disorder with recurrent seizures in
children 3 and older
Symptoms depend on type of seizure No association with illness, injury Seizure may be triggered by something
Epilepsy
Anticonvulsants-monotherapy is desired
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
Epilepsy Management
Changes in dark-light patterns Sudden loud noises, specific voices Sudden or startling movements Extreme changes in temperature Dehydration, fatigue Hyperventilation Hypoglycemia Caffeine, insufficient protein in diet
Triggers
Ensure IV access and Patency Check MD orders for Seizure Medication Check that medication is on the Unit Check Suction at bedside, ambu bag, mask
and 02 tubing, SaO2 is available and working! Are Side Rails Padded? ID band- correct? Indicate Seizure Risk? Know how to initiate emergency or rapid
response
If A Patient is Admitted for Seizure Activity or has PMH
of Seizures
1. Maintain Patent AirwayPlace nothing in the child’s mouth during a seizure
Loose teeth may be knocked out and aspirated. Position side so secretions can drainPulse oximetry reading (SpO2) Oxygen for < 95%- use maskSuction prn
Nursing Management during Seizures
Ensure Safety•If OOB gently assist to floor•Bed in lowest position •Stay near child•Protect head from injury
Nursing Management during Seizures
Administer MediationInitial order is intravenous medicationsIV push slowly Benzodiazopene IV push slowly to avoid apneaDiazepam (Valium) or lorazepam (Ativan)Followed by anticonvulsant
Nursing Management during Seizures
Observe and Record
Type of seizure activity Vital Signs Time seizure started and stopped
Nursing Management during Seizures
Toxicity: nystagmus, ataxia, decresed mental
capacity
Low levels: seizure activity
Side Effects gingival hyperplagia (discuss oral hygiene), drowsiness, thrombpcytopenia, leukopenia, increased liver enzymes
Nursing responsibility: Monitor CBC, LFT, therapeutic drug levels
Dilantin
A 10-year old is 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 hoarseness and cough4. 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, chills, 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. Hydrocephelus2. 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
The nurse is taking a history of a child
admitted for EEG testing to determine seizure activity. The parent reports that the child has “odd” behavior, including periods of lip smacking, and muscle twitching. The nurse suspects:
1. Simple Partial Seizures2. Complex Partial Seizures3. Absence Seizures4. Tonic-Clonic Seizures