Transcript Slide 1
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??