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Neurologic AlterationChapter 28

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Glascow Coma Scale

Modified for infants and children

Used to assess level of

consciousness

Measures verbal and motor

responses based on child’s age

Three parts – eye opening, verbal

response – smiling, crying and

interaction, and motor response

Increased Intracranial Pressure

Pressure exerted by the blood, brain, CSF, and any other space occupying fluid or mass

Can result from tumor or mass

Brain can swell as result of trauma, infection or hypoxic episode

Overproduction of fluid, malabsorption of fluid, or communication problem in system can disrupt CSF dynamics

Signs & Symptoms of increased ICP

Infant

- poor feeding or vomiting

- irritability or restlessness

- lethargy

- bulging fontanel, distended scalp veins

- high pitched cry

- increased head circumference

- separation of cranial sutures

- eyes deviated downward (“setting sun” sign)

- increased or decreased response to pain

Increased ICP S&S

Child

- headache

- diplopia

- mood swings

- slurred speech

- papilledema (after 48 hours)

- altered level of consciousness

- nausea and vomiting, esp in morning

Increased ICP

Changes in child’s normal behavior – “he’s not acting like himself”

Changes in pupils – dilation with sluggish or absent constriction in response to light

Changes in motor function – decreased purposeful movements, abnormal posturing

flexion posturing (decorticate) – flexion of upper extremities with extension of lower

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Increasing ICP

extension posturing (decerebrate) –

extension of upper extremities with

internal rotation of upper arm and wrist,

lower extremities extend with some

internal rotation of knees and feet

* Progression from flexion to extension

posturing indicates deteriorating

neurological functioning – notify MD

Increasing ICP

Vital signs – increased temperature

Late sign Cushing’s response – increased BP, widened pulse pressure, decreased HR, and decreased or irregular RR

As ICP rises baseline respiratory pattern may change

- Cheyne Stokes respirations

- central neurogenic hyperventilation

- apneustic breathing

Diagnostic tests – CT, MRI, lumbar

puncture, electrolytes, ABG’s, CBC, EEG

Management – treat underlying cause,

reduce volume CSF, preserve metabolic

function and avoid situations that increase

ICP

Nursing Care of Child with Nervous

System Disorder

Assessment – LOC, mood and behavior,

compare with normal developmental

milestones, observe interaction with

family and environment, note lethargy,

drowsiness, hyperactivity, tremors or

jitteriness

Nursing Care of Child with Nervous

System Disorder

Interventions

- Neuro assessment with LOC, Vital signs

- Have emergency equip avail. ^ ICP can cause

apnea which may lead to arrest

- monitor factors that increase cerebral edema

or ICP (hypoxia, fever, seizures, hypotension,

hypercapnia)

- maintain HOB @ 30-45 degrees (facilitates

venous outflow drainage of the brain by gravity)

Nursing Care of Child with Nervous

System Disorder

- Avoid prone position, neck or hip flexion, or lying flat. All ^ ICP

- organize care around periods of low ICP –bathing, suctioning, repositioning all ^ICP

- monitor pupil size and reactivity hourly or as ordered

- monitor head circumference, anterior fontanel and sutures if age appropriate

- observe for irritability, lethargy, feeding intolerance & decreasing GCS score

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Nursing Care of Child with Nervous

System Disorder

Nursing diagnosis – Imbalanced nutrition: less than body requirements r/t restricted intake, neurological impairment, swallowing or chewing difficulty, risk for aspiration, nausea or vomiting

Interventions – determine LOC before giving liquids, daily weight, strict I&O, monitor skin turgor. Position upright after feeding. Check NGT placement bf tube feeding, flex feeding schedule if no NGT with small feedings of favorite foods.

Nursing Care of Child with Nervous

System Disorder

Nursing diagnosis – Risk for impaired skin integrity r/t neuromuscular impairment, decreased LOC, inadequate physical activity, immobility, or improper fluid or nutritional intake

Interventions – special mattress, observe skin condition and reposition q 2 hrs, passive ROM if appropriate, if braces or splints used assess skin before and after application, daily skin care regimen

Spina Bifida

Midline defect involving failure of the

osseous spine to close

Two types:

◦ Spina Bifida Occulta

◦ Spina Bifida Cystica

Spina Bifida Occulta

Defect that is not visible externally

Common the lumbosacral area (L5 and

S1)

Signs

◦ skin depression or dimple

◦ hemangioma

◦ dark tufts of hair

◦ soft, subcutaneous lipomas

Spina Bifida Cystica

Visible defect with an external saclike

protrusion

Two forms

◦Meningocele

◦Myelomeningocele

Meningocele

Encases the meninges and spinal fluid

but no neural elements

Not associated with neurologic

defects

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Myelomeningocele

Involves the meninges, spinal fluid and

nerves

Usually the sac is covered with a fine

membrane which tears easily

Location and magnitude of the defect

determine the nature and extent of

neurological impairment

Other associations: hydrocephalus

Initial Nursing care –Pre-op

Place the infant in a radiant warmer so that body temperature can be maintained without clothing

Apply a sterile, moist dressing over the sac

◦ Changed every 2-4 hours

◦ Cleanse the sac if soiled but do not puncture it

Keep the infant prone to reduce tension on the sac

Leave diaper under baby and do not fasten

—Other Considerations—

Post-op

◦ Monitor VS

◦ Assess Pain

◦ Weight

◦ I&O

◦ Observe for Infection

◦ Provide Nourishment

Support the family and teach them how to care

for the infant

GU Functions

Neurogenic bladder is most common

The goal in infancy is to preserve renal function

In older children the goal is to preserve renal function and optimum urinary continence

May have urinary tract infections, vesicoureteralreflux, or renal insufficiency

Residual urine

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FYI

Latex Allergies are more common in SB

children because of the increased

exposure during surgery and numerous

catheterizations to latex

Hydrocephalus

Result of imbalance b/t production and

absorption of CSF

Results in enlargement of skull if sutures are

open; S&S of ^ICP if sutures closed

Tx aimed at preventing further CSF

accumulation and reducing disability and death

Obj. bypass blockage &drain fluid from

ventricles to area where can be reabsorbed into

circulation

Hydrocephalus

VP (ventriculoperitoneal) shunt – tube

leading from the ventricles out of skull,

under the skin to the peritoneal cavity

VA (ventriculoatrial) shunt – drains fluid

from ventricles to the right atrium of

heart

Shunts need to be revised as child grows

Long term follow up essential

Hydrocephalus S&S Infant

Early

- rapid head growth

- full bulging anterior

fontanel

- irritability

- poor feeding

- distended prominent scalp

veins

- widely separated cranial

sutures

Late

- setting sun sign

- frontal bone enlargement

- vomiting, diff feeding

- ^BP, decreased HR

- altered resp pattern

- shrill, hi pitched cry

- sluggish or unequal pupil

resp. to light

Hydrocephalus S&S Child

Early

- strabismus, diplopia

- Frontal HA in am relieved by sitting upright or vomiting

- N&V, papilledema

- Restlessness

- Behavior changes

- Irritability, ataxia

- Confusion, lethargy

- Sluggish + unequal pupil response to light

Late

- Seizures

- Increased BP

- Decreased HR

- Alteration in resp pattern

- Blindness from herniation of optic disc

- Decerebrate rigidity

Hydrocephalus

Nursing considerations

Vital signs every 1 to 2 hours or as needed

Monitor for swelling or redness along the shunt tract

Observe head, abdominal, and chest dressings for drainage

Position the child off the shunt site

Intravenous antibiotics as ordered

Dressing changes as ordered

Slide 30

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Cerebral Palsy

Chronic non-progressive disorder of posture and movement

Characterized by difficulty in controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system

Motor system damage can occur prenatally, perinatally, or postnatally

Clinical Manifestations of CP

PHYSICAL SIGNS

Poor head control after 3 months of age

Stiff or rigid arms or legs

Pushing away or arching back

Floppy or limp body posture

Cannot sit up without support by 8 months (failure to meet developmental norms)

Uses only one side of body or only the arms to crawl

Clenched fists after 3 months (absence or presence of reflexes that extend beyond the expected age)

Clinical manifestations of CP

BEHAVIORAL SIGNS

Extreme irritability or crying

Failure to smile by 3 months

Feeding difficulties

Persistent gagging or choking when fed

Persistence of extrusion reflex after 6

months

Nursing Considerations - CP

Many individuals have a need for

increased calorie intake because of

spasticity or increased motor functioning

Seizure precautions

A safe environment if child has poor

coordination

Child may need to use a communication

board or computer-assisted

communication

CEREBRAL PALSY

Self-care is a goal for all children; extensive collaboration with occupational therapist for strategies and devices to assist in this area may be necessary

Use of adaptive feeding devices and positioning during feedings may be necessary if a risk of aspiration is present

Collaboration with multidisciplinary team for speech, nutrition, occupational and physical therapy; child and family form center of the team

Provide adequate nutrition and rest

Management of CP

Often not diagnosed before the child is 2

Baclofen a skeletal muscle relaxant can be used intrathecally via pump for severe spasticity

Botox is also used in treatment of CP

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Seizures

Brief paroxysmal behavior caused by excessive abnormal discharge of neurons

Epilepsy – recurrent seizure activity not in association with acute illness

Partial seizures – occur in one part of brain and may or may not alter consciousness

Generalized – occur over entire brain and alter consciousness

Partial Seizures

Simple partial seizures – no change in

LOC. Consist of motor, autonomic,

or sensory symptoms

Complex partial seizures – impaired

consciousness, staring, chewing, lip

smacking, unusual hand movements,

etc.

Generalized Seizures

Absence (petit-mal) seizures – very brief

episodes of altered consciousness (5-10

secs)

Myoclonic seizures – brief random

contractions of a muscle group, can occur

on both sides of body, singly or in clusters

Tonic-clonic (grand mal) seizures – abrupt arrest of activity, impairment of consciousness, aura precedes, seizure followed by variable period of confusion, lethargy, and sleep (post ictal phase)

Febrile seizure – assoc. with fever no underlying neurological problem, familial disposition, males more than females, usually bt 6mo-3 yrs, temp usually >101.8

Nursing Care & Observations During A

Seizure

Look at time at onset

Protect child from injury – loosen clothing, turn

to side DO NOT RESTRAIN

Observe how began, how progressed, how

ended

Describe any preceding or accompanying

sensory or motor manifestations

After over allow child to rest

Medications

Teach parents and child regarding

anticonvulsants

Blood levels monitored to maintain

therapeutic levels

Dilantin – oral care important (causes

gum problems)

Depakene – watch for bleeding bruising

(affects platelets)

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Medications cont.

Advise parents and patient not to

suddenly dc meds - seizures or status

epilepticus can occur

Some states require drivers to be seizure

free for 6-12 months to obtain drivers

license

Birth control pills less effective with

antiepileptics - need additional method

Alcohol, marijuana, street drugs lower

seizure threshold

FYI

In neonates, if movement can be

initiated by gentle stimulus (such as

touch) it is probably a tremor. If it

can’t be stopped or controlled with

gentle restraint or passive flexion, it

is probably a seizure.

Status Epilepticus

Pediatric emergency

Prolonged seizure activity of either 1 seizure lasting 30 min or more or recurrent seizures lasting more than 30mins. With no return to normal LOC between seizures

Treatment ; maintain optimal resp and hemodynamic function, identify and treat cause

IV valium or ativan – can give PO or PR

Meningitis inflammation of the meninges

etiology: bacterial; viral ; tuberculous

Infant & child S&S

- fever

- Poor feeding

- Vomiting

- Irritability

- Seizures

- High pitched cry

- Bulging fontanel

- Lethargy

Children/adolescents S&S

- Severe HA

- Photophobia

- Nuchal rigidity

- Fever, vomiting/diarrhea

- Altered LOC

- Decreased appetite

- Agitation/drowsiness

- Late – seizures, chg LOC

- rash

Meningitis

Diagnosis: lumbar puncture

◦ blood cultures

Management:

◦ Viral-symptomatic care

◦ bacterial: isolation

◦ drugs: antibiotics; anytipyretics,

anticonvulsants, corticosteroids

◦ treat complications

Meningitis: Nursing considerations

Monitor cardiorespiratory status

Have emergency airway equipment in

room or at bedside

Monitor level of consciousness

Provide an environment that will minimize

intracranial pressure

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Meningitis: Nursing considerations

Monitor for cerebral edema

(check head circumference)

Monitor intravenous fluids to prevent

fluid overload

Administer antipyretics as ordered

Monitor for complications of meningitis

(seizures, hearing loss, visual alterations)

Bacterial Meningitis

Medical emergency

Isolation – droplet transmission

precautions for at least 24 hrs after

antibiotics started

Antibiotics begun before causative agent

identified (cultures can take 3 days)

Untreated can be fatal

Prophylaxis for ill child’s close contacts

Encephalitis

Encephalitis: inflammation of the brain

Inflammation caused by infection or toxin

results in cerebral edema and neurologic

dysfunction

Diagnosis lumbar puncture and CSF

culture

EncephalitisNursing considerations

Monitor child’s vital signs, respiratory status, oxygenation, and urine output

Take seizure precautions and have resuscitation materials at bedside

Manage complications related to immobility

Educate family regarding discharge

Provide supportive measures (facilitate grieving if poor prognosis)

Reye’s syndrome

Preceding viral infection leads to liver cell

damage with rising serum ammonia levels

Thought to be related to administration

of ASA to children with viral disease

Care similar to that for ^ ICP, with

potential addition of mechanical resp

support

Reye syndrome

Toxic serum ammonia levels result in

cerebral dysfunction, fluid-electrolyte and

acid-base imbalance, and coagulopathies

Average age of onset 6-7 years

Can result in death

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Reye Syndrome characterized by 5 stages

Vomiting and lethargy

Combativeness and confusion

Coma, decorticate posturing

Decerebrate posturing

Seizures, loss of deep tendon reflexes,

respiratory arrest

Reye SyndromeDiagnostic evaluation

History reveals recovery from a recent viral

disease; sudden onset of vomiting and

mental confusion

Liver enzymes (elevated)

Blood glucose (below normal)

Ammonia levels (elevated)

Prolonged partial thromboplastin time

Reye SyndromeTherapeutic management

Monitoring neurologic status, intracranial pressure, hydration, acid-base balance, and cardiorespiratory status

Medications may include the following:

◦ Corticosteroids

◦ Mannitol

◦ Barbiturates (if cerebral edema is severe)

◦ Phenytoin (to control seizures)

◦ Vitamin K (to aid coagulation)

Reye SyndromeNursing considerations

Care is focused on support and monitoring of the

child’s physical status

Monitor cerebral edema

Monitor intake and output

Monitor vital signs

Perform ongoing neurologic assessments

Monitor laboratory values

Prevent complications of immobility

Provide emotional support to family