pediatric nursing module 6 caring for children with alterations in neurosensory functions
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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?