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Neurological Alterations NUR 264 - Pediatrics Angela Jackson, RN, MSN Developmental Differences The nervous system grows more rapidly before birth and during infancy Dramatic increase in the number of neurons at 15 to 20 weeks gestation Additional increase in rate of growth beginning at 30 weeks gestation and continuing until 1 year of age Developmental Differences Infants have open fontanels that allow brain growth 6-8 weeks posterior fontanel closes 12-18 months anterior fontanel closes 12 years – sutures unable to be separated by increased intracranial pressure Developmental Differences The brain constitutes 12% of body weight at birth, doubles its weight in the first year, and triples its weight by age 5 or 6 Cerebral blood flow and oxygen consumption in childhood, up to age six, is almost twice that of adults Neurons become fully myelinated in the first year and primitive motor reflexes are replaced by purposeful movement. Neural Tube Defects: Spina Bifida Spina bifida is a neural tube defect where there is an incomplete closure of the vertebrae and neural tube Occurs more commonly in families with English and Irish ancestry Occurs more commonly in females Chance of having an infant with the defect is higher if other family members have the defect Spina bifida: Pathophysiology May occur anywhere along the spine May be due to failure of the neural tube to close completely during the fourth week of gestation, or to a fissure resulting from increased cerebrospinal fluid pressure Cause is unknown Spina bifida: Clinical Manifestations Ancephaly Cranioschisis: neural tissue protrudes through the skull Exancephaly: the brain is totally exposed or herniated through a skull defect Encephalocele: protrusion of the brain and meninges into a fluid-filled sac through a skull defect Spina bifida occulta: failure of the posterior vertebral arches to fuse. No herniation of the spinal cord or meninges Spina bifida cystica: a defect in the closure of the posterior vertebral arch resulting in meningocele or meningomyelocele Spina bifida: Clinical Manifestations Meningocele: a saclike herniation through the bony malformation containing the meninges and cerebrospinal fluid. Spina bifida: Clinical Manifestations Meningomyelocele: a sac-like extrusion through the bony defect, containing the meninges, cerebrospinal fluid, a portion of the spinal cord and/or nerve roots Spina bifida: Clinical Manifestations Complete or partial paralysis Bowel and bladder dysfunction Flexion or extension contractures Club foot Hydrocephalus Kyphosis Scoliosis Tethered spinal cord resulting in back pain, increased spasticity and decreased urinary control Spina bifida: Diagnosis Prenatally: Maternal serum alpha-fetoprotein Amniocentesis Ultrasound After birth: Physical CT scan MRI exam Spina bifida: Treatment Multidisciplinary approach Neurosurgery Plastic surgery Orthopedics Urology Pediatric Medicine Nursing OT/ PT Social Work Spina bifida: Nursing Management Protection of sac Monitor neurological status Perform neuro checks Assess for infection Keep infant in prone position Keep sac covered with sterile normal saline dressing Fever Irritability Nuchal rigidity Monitor for hydrocephalus Signs and symptoms of increased intracranial pressure Spina bifida: Nursing Management Maintain skin integrity Sheepskin, lamb’s wool Gentle massage Frequent linen change or egg crate mattress Monitor bladder and bowel function Monitor for urine retention and constipation May need regular catheterization Provide family teaching and support Community resources Support groups Hydrocephalus Caused by increased production, impaired absorption or a block in the flow of CSF the result in excessive amount of CSF within the cerebral ventricles Hydrocephalus: Types Communicating: Dysfunction of the absorption of CSF Noncommunicating: Obstruction of CSF flow Hydrocephalus: Clinical Manifestations Increased head circumference Increased ICP: Tense bulging fontanel Separation of cranial sutures Irritability High-pitched cry Macewen’s sign (hollow sound produce on percussion of the skull) Changes in feeding Sunsetting sign Headache Nausea Vomiting Hydrocephalus: Diagnosis Increased head circumference Ultrasound CT/MRI Shunt Series Hydrocephalus: Treatment Shunt insertion VP (Ventriculo-peritoneal) most common VA (Ventriculo-atrial) Shunt Malfunction Mechanical difficulties usually occur within 6 months of insertion Kinking Plugging Migrating Separation of the tubing Infection can occur at any time Rapid decompression can cause tearing of the vessels leading to subdural hematoma. After surgery the infant should be placed flat, on the unoperated side. This prevents rapid CSF drainage and pressure on the valve Hydrocephalus: Nursing Management Measure head circumference daily Assess fontanel Monitor for signs and symptoms of increased ICP Monitor LOC Monitor feeding behavior Monitor skin integrity Monitor for neck strain Seizures Brief malfunction of the brains electrical system Causes is unknown, but may be based on many factors Neonate: birth injury, congenital defect Infant, young children: acute infections, toxins, trauma, neoplasms Older children: epilepsy, chronic disease of central nervous system Seizures: Clinical Manifestations Clonic movement Slow, regular body jerking Tonic posture Body stiffening Tonic/Clonic (Grand Mal) combination of rhythmic body jerking and body stiffening Postictal state follows (child may sleep, or if awake, is confused or combative) Generalized Involvement of entire body Partial Involvement of part of the body Seizures: Clinical Manifestations Automatisms Repeated, nonpurposeful actions such as lipsmacking, chewing, sucking or uttering the same word over and over Absence seizures Transient loss of consciousness. May stare into space, eyes may roll upward Seizures: Diagnosis History and physical CBC, electrolytes, lumbar puncture, tox screen CT/MRI EEG PET scan Seizures: Treatment Medications: Dilantin Tegretol Depakote Phenobarbital Diet Ketogenic diet: high in fat, severely restricted in carbohydrates which induces and maintains a state of ketosis which has an anticonvulsant effect – on diet for 2 years Other treatment Surgical excision of lesion Hemispherectomy Vagal nerve stimulator Seizures: Nursing Management During seizure: Ensure adequate airway Position on side Protect from injury Note length, type, location of seizure activity Instruct family on medication administration, safety, CPR Meningitis Inflammation of the meninges that develops as a result of infection from either bacterial or viral agents 90% of all cases are in children under five years of age Mortality rate is high Males are affected more often than females Usually secondary response to a primary infection such as otitis media, sinusitis, pharyngitis, cellulitis, pneumonia, septic arthritis, or dental caries Meningitis: Clinical Manifestations Irritability Lethargy Poor feeding (infants) Seizures Bulging fontanel Fever Nuchal rigidity Photophobia Headache Vomiting, diarrhea Opisthotonic position Meningitis: Clinical Manifestations Kernig’s Sign: Resistance to straightening of the knee when the hip is flexed Brudenski’s Sign: Flexion of the hip and knee when the neck is flexed Meningitis: Diagnosis History and physical Lumbar puncture CBC, CSF culture, serum electrolytes, osmolarity PT, PTT UA Comparison of Cerebrospinal Fluid in Viral - vs. - Bacterial Meningitis Normal Viral Meningitis Bacterial Meningitis Pressure 5-15mm Hg Normal or Elevated slightly elevated Appearance Clear Clear Leukocytes 0-5 Slightly elevated Elevated Protein (mg/dL) 10-30 Slightly elevated Elevated Sugar (mg/dL) 40-80 Normal or decreased Cloudy Decreased Meningitis: Treatment Isolation for bacterial meningitis Antibiotics (Ampicillin, Gentamicin or Rocephin) Decadron (give before antibiotic) [decreased the inflammatory response to lysis of the bacterial cell walls] Meningitis: Nursing Management Maintain isolation Close monitoring of vital signs Frequent neuro checks Monitor for seizure activity Administer antibiotics and other meds Comfort measures Cerebral Palsy Non-progressive motor dysfunction caused by damage to the motor areas of the brain Most common cause of CP is premature or very low birth weight Congenital malformation of or injury to the brain, or anoxia of the brain, at any time before, during or after birth may contribute to the development of CP CP: Clinical Manifestations Hypotonia Hypertonia Athetosis (Constant involuntary writhing motions) Ataxia Hemiplegia Diplegia Quadriplegia Warning Signs (pg. 1191) CP: Diagnosis Based on clinical findings Definitive diagnosis may not be possible until the child is between 18 months and two years of age Requires careful and continuous evaluation CP: Treatment There is no cure for CP PT/OT Braces and walkers Wheelchairs Speech therapy Surgical intervention Achilles tendon lengthening to increase ROM of the ankle Hamstring release to correct knee flexion Medications Muscle relaxers to decrease contractures Antianxiety drugs to reduce athetosis CP: Nursing Management Maintain body in optimal alignment Provide skin care Provide adequate nutrition Promote developmental and functional capabilities Protect from injury Provide support for the family Questions??