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Overview
Neurological Assessment
Hydrocephalus
Acute Head Injury Seizure Disorder
Meningomyelocele
Neurological Assessment/History
It all begins with the history...
Neurological Assessment/History
Prenatal Factors:
Maternal Age Maternal Health Adequacy of Prenatal Care Exposure to Teratogens
Family Support
Resources during Pregnanacy
Neurological Assessment/History
Perinatal Factors
position of fetus progression of labor premature ROM/fever anesthesia/medications
placental function
monitoring abnormalities
Neurological Assessment/History
Postnatal Factors
APGAR scores meconium hypoxia (ABGs) assisted ventilation
hyperbilirubinemia
infections seizures
Neurological Assessment/History
Childhood Problems
Growth Parameters Illnesses/Operations Immunizations Exposure to Illness
Injuries
Seizures
Assess individual trend on curve Height, Weight, Head Circumference is monitored Be alert to growth deceleration
Neurological Assessment/History
Developmental History
Age milestones achieved School performance Need for early intervention
Plateau or regression
Neurological Assessment/History
Family History
hypotonia
cerebral palsy epilepsy mental retardation developmental delay
systemic problems
Head Circumference
Fontanelle Assessment
Assess for overriding, nonmobile sutures AF = closes 14-18 months PF = closes 6-8weeks Fontanelles bulge with crying and activity
Motor
Sensory
Cerebellar
Reflexes
ability to calm
As child develops can begin to assess orientation around age 3-4 Full orientation assessment begins at ages 7-8 The adolescent should respond to all components of the orientation exam
VI: Abducens:
lateral gaze
Strabismus:
may be normal up to 6 months
The posterior fossa surgical approach places the child at risk for IX and X cranial nerve damage
Motor Exam
Note Tone and Strength Assess Progression of Motor Milestones
Motor Milestones/Gross
Lifts head to chin, hands to midline: 2 months
Motor Milestones/Fine
Neat pincer grasp: 9 months
Tower of 4 cubes: 15-20 months Copy circle: 3 years
Sensory Exam
Pain is felt by all age groups and is subjective Can begin to test vibration in the preschooler Other sensory function can not be tested until school age years. Assess for symmetry of sensation
Cerebellar Exam
Can not perform specific testing until age 3 Preschooler: unipedal hopping, stand on one foot
Reflexes
All deep tendon reflexes are tested as in adults Bicpes, brachioradialis, maxillary, patellar present at birth
Developmental Reflexes
Tongue Protrusion: present from birth to 3 months
Developmental Reflexes
Moro: Symmetric abduction and flexion of upper extremities when allowed to fall back or with loud noise Present from birth to 6 months
Developmental Reflexes
Plantar Grasp Place finger under toes and infant grasps finger with toes
Dissipates by 9 months
Developmental Reflexes
Palmar Grasp infant will grasp object when placed in palm Present from birth to 6 months
Developmental Reflexes
Babinski
Present until 18 months Indicates myelinization of motor tracts Note: myelinization begins at birth and is a process that occurs over time
Blood:
10%
CSF:
10%
Normal ICP
0-15mm Hg
Clinical Manifestations
Infant:
tense, bulging fontanelle separated cranial sutures
Clinical Manifestations
Children:
headache altered level of consciousness
vomiting (projectile)
visual changes pupillary signs
seizures
motor dysfunction
Late Signs
Depressed level of consciousness unilateral/bilateral dilated pupils sluggish or non-reactive pupils respiratory abnormalities decerebrate or decorticate posturing
Medical Management
Maintain oxygenation saturation at 100% CO2 = 30-35 Control Ventilation
Medical Management
Avoid hypotension: hypotension >30 minutes doubles mortality Intravascular volume and hypertensive therapy may be used to maintain CPP Diuretics Mannitol, loop diuretics, hypertonic saline Analgesics/Sedation: narcotics, propofol, barbiturate coma
Medical Management
Glucocorticoids used for focal edema as in tumor
Maintain normal blood sugar: hypoglycemia increases secondary injury and worsens edema hyperglycemia increases cerebral edema, morbidity, and mortality Surgery: ICP monitor/CSF drainage
hemicraniotomy or lobectomy
Nursing Interventions
Positon head in neutral position to promote venous outflow
Nursing Interventions
Maintain normal to hypothermia Every 1 degree of temperature elevation increases cerebral metabolism by 5-10%
AVOID SHIVERING
Use acetominophen aggressively Control the environment (low lights, decrease sound, move patient to quiet area of unit, direct staff and visitors to minimize noise)
Bacterial Meningitis
Epidemiology
1993: 2 cases per 100,000 children <5 years Approximately 5 cases per 100,000 peopled are diagnosed annually in developed countries
The median age has increased from 15 months to 25 years in developed countries
Most common in fall and winter
Etiology
3 pathogens account for > 80% of bacterial meningitis Streptococcus pneumonia = pneumococcal meningitis Neisseria meningitidis = meningococcal meningitis
Symptomatology
Classic Triad: severe headache, fever, nuchal rigidity Insidious nonspecific illness that starts with fever, malaise, irritability, and vomiting that progresses rapidly over 2-4 days Notable petechial rash in 50% of meningococcal cases Illness often becomes fulminating in < 24 hours and is often associated with a poor outcome
Symptomatology
As the meninges become affected the patient develops:
photophobia
nuchal rigidity headache increased ICP
Symptomatology/Infant
Management
Prevention through vaccination Early identification and rapid treatment with antibiotic therapy
Management of ICP
serial head circumference measurements in the infant
Aseptic Meningitis
Also called nonbacterial or viral meningitis
Most common type of meningitis
Etiology
enteroviruses arboviruses herpesviruses 85%-90% caused by enterovirus
Symptomatology
Usually milder than those of bacterial meningitis and resemble influenza duration of symptoms usually 1-2 weeks after onset headache, nuchal rigidity, photophobia, malaise, and nausea
Management
Provide supportive care May give Acyclovir if HSV suspected Patient education Patient is expected to recover without neurological sequelae If symptoms become severe the nursing care is consistent with that of patients with bacterial meningitis
Reye Syndrome
Toxic encephalopathy associated with hepatic dysfunction
Symptomatology
Fever Profoundly impaired consciousness Disordered hepatic function increased ammonia levels Advances to coma and brainstem dysfunction
Management
Early diagnosis and aggressive therapy Manage increased ICP Do not use aspirin for fever management Family education Psychosocial support
Seizure Disorder
Seizure: clinical presentation of the central nervous system characterized by abnormal electrical firing of neurons
Epilepsy:
recurrent, unprovoked seizures caused by biochemical, anatomic, and/or physiological changes
Epidemiology
Approximately 10% of Americans will experience a single unprovoked seizure in their lifetime 5% of children can be expected to experience a single seizure before the age of 20 Incidence from birth to 16 years is 40/100,000 Comorbidities:
Symptomatology
Classification of Epileptic Seizures A. Partial (Focal, Local) 1. Simple partial (consciousness is not impaired) 2. Complex partial (consciousness impaired 3. Partial seizures evolving to secondarily generalized B. Generalized 1. Absence (petit mal) 2. myoclonic 3. Tonic 4. Atonic 5. Clonic 6. Tonic-clonic (grand mal) C. Unclassified epileptic seizures (related to incomplete data)
SEIZURE CLASSIFICATION
Pathophysiology
Epileptogenesis originates from an imbalance between cerebral excitation and inhibition. In a seizure, abnormal neuronal pathways are established that lead to abnormal electrical firing - Core Curriculum 2003
3. N-methyl-D-asparate (NMDA)
GABA = inhibition
facilitates activity of chloride channels making the cell membrane more negatively charged
Glutamate = Excitation
Etiology/Triggers
60-80% of new pediatric cases are idiopathic structural defect metabolic abnormality toxic ingestion cerebral insult
hypoxia
sleep deprivation febrile illness
Medication Therapy
All anticonvulsants affect cognitive function NEVER withdraw medication abruptly Wean medication over a prolonged period Be aware of blood level before administering the dose Review side effect panel closely
Nursing Interventions
Assist with developing an individualized medication administration plan Monitor drug levels
Febrile Seizures
Most common form of childhood seizures Most common between ages of 6mos - 3 years The fever usually exceeds 101.8 before the seizure Usually occurs during the temperature rise Lasts less than 5 minutes 95% will not develop epilepsy or have brain damage
Etiology
3 major causes:
falls
motor vehicle injuries
bicycle injuries
Types of Injury
Concussion
Contusion and Laceration
Fractures
Epidural Hemorrhage
Subdural Hemorrhage
Concussion
Most common injury a traumatically induced alteration of consciousness LOC is not required pathogenesis unclear;may be a result of shearing forces
Contusion/Laceration
Visible bruising and tearing of cerebral tissue
Skull Fractures
A great deal of force is required to break the skull of an infant Linear: most common type, uncommon before 2-3 years of age Depressed: malleable bone may become dented Basilar fractures: very serious, often involves deep brain structures, portal for infection
Epidural Hemorrhage
blood accumulates between the dura and the skull generally arterial uncommon in children under 4 years of age the classic clinical picture is rarely evident the symptom free period can often last longer than 48 hours symptoms: irritability, headache, vomiting
Subdural Hemorrhage
bleeding between dura and the cerebrum 10 times more common than epidural hematoma
Menu
Menu
moderate concussion without LOC can be managed at home by checking child q 2 hours for 1-2 days
NPO, IVF, daily weights, manage pain review management of increased ICP psychosocial support consider mandatory abuse reporting
Myelomeningocele
Spina Bifida derived from embryonic neural tube 1996: 0.32/1000 live births failure of neural tube closure symptoms are related to the level and severity of the defect
Preoperative Care
deliver via C-section
Postoperative Care
I. Potential for UTI and urinary retention a. assess urine quantity, color, odor b. strict I and O c. straight cath (teach parents and staff) d. administer antibiotics e. document postvoid residuals
Postoperative Care
II. Potential for impaired skin integrity a. Change diapers as soon as soiled
Postoperative Care
III. Potential for Latex Allergy a. Reduce Latex exposure
Postoperative Care
IV. Potential for injury related to neuromuscular impairment
a. bracing, PT, botox injections
Hydrocephalus
Symptom of underlying brain disorder caused by an imbalance in the production and absorption of CSF Congenital hydrocephalus: 4/1000 live births
Etiology
Impaired absorption of CSF (communicating)
a. Congenital b. Subarachnoid hemorrhage
c. Infection
Obstruction to flow of CSF (noncommunicating) a. Blockage at or above 4th ventricle b. Most common blockage in aqueduct of Sylvius c. Tumor
Symptomotology
Infants:
large head circumference (plot on growth curve) irritability
extreme lethargy
dilated scalp veins split sutures, tense or bulging fontanelle seizures sunset eyes
Symptomotology
Toddler/Young Child macrocephaly poor appetite failure to thrive double vision/vision changes loss of previous developmental ability vomiting seizures
Symptomotology
Adolescents headache vomiting vision changes/double vision decline in cognitive/school performance
Management
Major treatment is surgical Shunt placement to relieve pressure
Shunt Management
Position on unoperated side immediately post-op
assess for signs of subdural hematoma manage pain
strict I and O
astute abdominal assessment monitor incision site prevent infection routine postoperative care (IS, SCDs etc.,)
Management
Promote skin integrity Frequent suctioning, pulmonary toilet Prevent feeding aspiration Attend to potential for injury Normal verbal, tactile, auditory stimulation Promote social interaction Intense family psychosocial support
Muscular Dystrophy
Largest single group of muscular diseases in children All have a genetic origin
Management
Major emphasis is on assisting the child and family in coping with the progressive, incapacitating, and fatal nature of the disease
Promote independence
Modify clothing Education regarding assistive devices