ALTERATIONS IN PEDIATRIC NEUROLOGIC FUNCTIONS Flashcards
BASIC STRUCTURES OF THE NEUROLOGIC SYSTEM
- brain
- spinal cord
- nerves
DEVELOPMENTAL CONSIDERATIONS
- nervous system complete but immature at birth
- infant born with all nerves he or she will have
- myelination of nerves incomplete until age 4 yrs
- progresses in a cephalocaudal direction
- responisible for progressive development of fine and gross motor skills
- need fat in diet for myelin
PEDIATRIC DIFFERENCES AND RISKS
- head is “top heavy”
- neck muscles weak
- thin cranial bones
- excessive spinal mobility
- immature muscles and ligaments or cervical spine
PEDIATRIC DIFFERENCES: FONTANELS
How are fontanels useful in assessment?
- bulging
- sunken
- pulsating
- flat and soft
- closes early
LEVEL OF CONSCIOUSNESS(LOC)
- most important indicator of neurologic dysfunction
- conscious= awareness of stimuli
ALTERED LEVELS OF CONSCIOUSNESS
- confusion
- delirium
- lethargy
- stupor
- coma
DETERIORATION OF LOC: A SEQUENTIAL PATTERN
- awake and alert- responds appropriately
- slight disorientation to time, place,or person (confusion)
- restless,fussy,or irritable (delirium)
- profound slumber, responds to loud commands, painful stimuli(lethargy)
- non- purposeful response to moderate stimulation -decorticate or decerebrate posturing (stupor)
- No response (coma)
CAUSES OF ALTERED LOC
-infection of brain and meninges #1 cause in children
-other causes
trauma
hypoxia
poisoning
seizures
DKA
electrolyte or acid base imbalance
congenital structural defects
PEDIATRIC GLASGOW COMA SCALE
- three part assessment
- eyes
- verbal response
- motor response
- score of 15= unaltered LOC
- score of 3= extremely decreased LOC (worst possible score on the scale)
ALTERED LOC
any of causes of altered LOC can result in:
- increased intracranial pressure(ICP): force exerted by brain tissue, CSF, blood
- decreased cerebral perfusion pressure (CPP): amount of pressure needed to perfuse brain
- increase ICP can lead to decreased CPP
PEDIATRIC NEURO ASSESSMENT GUIDLINES
LOC Vitals Pain Cognition Head Eyes Neck Posture/movements reflexes cranial nerves
BACTERIAL MENINGITIS
- inflammation of the meninges
- newborns and infants at greatest risk
- higher morbidity and mortality than viral meningitis
ETIOLOGY MENINGITIS
NEWBORNS TO AGE ONE MONTH:
- group B streptococcus
- E.coli
- listeria monocytogenes
OVER 1 MONTH OF AGE :
- streptococcus pneumonaie most common
- Neisseria meningitis
- haemophilus influenza type B
-decreased incidence following Hib, pneumoccacal and meningoccal vaccine
PATHOPHYSIOLOGY
- often secondary to OM,sinusitis, pharyngitis, cellulitis , pneumonia or brain trauma
- bacteria enter bloodstream “bacteremia”
- bacteria cross “ blood brain barrier” and enter CNS
- inflammation occurs- WBC’s accumulate and cover brain with purulent exudate
- brain swells, can lead to increased ICP and hydrocephalus
CLINICAL MANIFESTATIONS OF MENINGITIS
classic triad
- fever
- nuchal rigidity
- headache or change in mental status
CLINICAL MANIFESTATIONS NEONATES
Nonspecific
- fever or hypothermia
- poor feeding/poor suck
- vomiting or diarrhea
- fontanel bulging
- irritable or lethargic, weak cry
- poor tone
- seizures
INFANTS AND YOUNG CHILDREN
- fever
- vomiting
- nuchal rigidity
- opisthotones
- bulging fontanel
- irritable or lethargic
- difficult to console
- high pitched cry
- seizures
OLDER CHILDREN AND ADOLESCENTS
- classic signs: fever,headache,nuchial rigidity
- photophobia,opisthotonos
- positive kernig and brudzinski signs
- confusion,delirium,irritable,lethargic
- vomiting
- petechial rash
DIAGNOSIS
-based on history, clinical presentation and labs
- lumbar puncture(LP)- definitive diagnostic test
WBC’s increased,increased protein, low glucose
Gram stain and culture and sensitivity - CBC’s ,blood cultures, serum electrolytes and clotting factors, UA with C&S
- CT scan for increased ICP or suspected brain abscess
TREATMENT
-antibiotics administered as soon as blood ,LP,urine obtained , IV antibiotics for 7-21 days
ampicillin cefotaxime(claforan) ceftriaxone (rocephin) penicillin G vancomycin aminoglygocides
- may be changed when culture results available
- contacts may need prophylactic antibiotics- cipro,or rifampin
TREATMENT MENINGITIS
- NPO -IVF (2/3 maintenance initially)
- treat increased ICP with mannitol and furosemide
- treat seizures
- treat shock to maintain CPP
- treat fever/isolation
NURSING MANAGEMENT
-monitor VS, LOC, pupils, neuroo status , I and O’s, labs,ICP, CPP
- assist with LP
position after LP:supine to prevent headache
-seizure precautions
NURSING MANAGMENT
- antibiotics ,antipyretics
- measure head circumference
- promote comfort and quiet environment with minimal stimulation -reduce noise,light
- isolate for first 24-48 hours
SEQUELAE (complications)
most common - 8th cranial nerve -hearing loss
- seizures
- hydrocephalus
- developmental delay
- learning problems severe -septic shock,stroke, death
- EBP: study indicates that heparin and aspirin may discourage stroke in pediatric
PREVENTATVE MEASURES
- HIB vaccine
- pneumococcal vaccine
- meningococcal vaccine
MICROCEPHALY
- small brain
- head below 3rd percentile
- due to :
fetal insult such as rubella,zika,
genetic disorder
chromosomal
insult during infancy
-assoiciated with DD
HYDROCEPHALUS
- water on the brain -imbalance B/W production and absorption of CSF
- body produces 500mls CSF/day
- CSF cushions brain from injury ,delivers nutrients , remove waste and maintains normal ICP
circulates throughout ventricular system
absorbed within the subrarachnoid spaces
HYDROCEHALUS
- non-communicating - most common
- caused by obstruction to flow of CSF thrpugh ventricular system -ventricles enlarge
- infection
- hemorrhage
- tumor
- congenital defect
ETIOLOGY /PATHO
- congenital or acquired
- congenital- present at birth ,may not be apparent ,may be assocoaited eith other CNS abnormalities (spina bifida)
- acquired may result of illness (tumor) or trauma
CLINICAL MANIFESTATIONS
vary with age of the child
Infant- rapidly increasing head circumfrance , decreased LOC, vomiting,irritablity, sunset eyes , bulging fontanel, distended scalp veins,bossing of frontal skull
older child- signs of increased intracranial pressure,headache in AM with vomiting, ataxia, strabismus
DIAGNOSIS
prenatally-ultrasound clinical manifestations after birth head circumference CT scan MRI U/S of head of infant- open fontanel
CLINICAL THERAPY
- removal of obstruction
- creating a new CSF pathway to divert excess CSF (VP shunt)
- treatment of complications
- manage problems related to pdychomotor development
VP SHUNT COMPLICATIONS
- infection
- malfunction- blockage or kinking of tube
- increased ICP
- worsening neurological status/altered LOC
HYDROCEPHALUS : NURSING CARE
- measure head circumference (infants)
- observe for signs of increased ICP -may indicate shunt malfunction
- positioning usually supine: head of bed is raised gradually (post-op)
- provide emotional support to child, parents
- teaching about medications,signs of shunt malfunction
NEURAL TUBE DEFECTS
- neural tube is structure in embryo that becomes CNS brain and spinal cord
- neural tube fused by 28th day of gestation
- if neural tube does not fuse properly , a NTD forms at open location
NTD’S
SPINA BIFIDA OCCUITA
spinal cord not completely fused, but does not protrude -tuft of hair or sacral dimple seen
SPINA BIFIDA CYSTICA (two types)
1. meningocele- fluid filled sac protrudes from back,but spinal cord in normal position
- meningomyelocele- fluid filled sac with spinal cord
ETIOLOGY /PATHO
causes
-50% or more =folic acid deficiency
other cases =multifactorial -environmental,chemical,medications,genetic,maternal obesity
PRENATAL DIAGNOSIS
- amniocentesis- elevated alpha-fetoprotein in amniotic fluid -16 to 18 weeks gestation
- uterine ultrasound
PREVENTION
-Folic acid supplementation -0.4mg/day
if history of NTD -4 mg /day
in 1998 FDA fortifies grain creals with folic acid
begin at preconception
SPINA BIFIDA OCCULTA
-mildest form of spina bifida
- usually no problem with nervous system
- skin indicators
sacral dimple
port wine nevus
sacral tufts of dark hair
sacral lipoma
SPINA BIFIDA CYSTICA
DEFINITION
visible defect with external saclike protrusion
Two Types:
- meningocele- sac contains meninges and spinal fluid but no neural elements
- spinal cord in normal position
- no neurologic deficits
MYELOMENINGOCELE
-sac contains meninges,spinal fluid, and nerves
- it defect below 2nd lumbar vertebra
- flaccid paralysis of lower extremeties
- sensory deficit
- orthopedic braces,walkers,crutches, and wheelchairs
- bladder and bowel sphincters may be affected
CLINICAL THERAPY
- prevent infection of sac
- assessment of neurologic and associated anomalies
- early closure in 24-48hrs after birth (prevent stretching of other nerve roots and further damage)
- hydrocephalus- VP shunt placement
- braces to support joint mobility
- neurogenic bladder- clean intermittent catheterization Q 3-4 hours
NURSING MANAGEMENT
- cover sac with sterile saline dressing
- place infant prone
- assess infant for motor,bladder,and bowel deficits
- monitor VS
- observe for signs of infection
- comfort infant
- create a latex safe environment
LATEX ALLERGY
- SB patients at high risk for latex allergy due to repeated exposure to latex products from multiple surgeries and repeated urinary cath.
- 73% of pt have allergy
- anaphylactic reactions possible
- recommended that SB patients avoid latex from birth
DISCHARGE TEACHING
-symptoms of increased ICP,hydrocephalus, shunt malformation , UTI
- splints, wedges
- ROM exercises
- clean intermittent cath every 3-4 hrs
- community based care-PT, OT,PCP,school nurse
- braces , walkers,whelchairs
- monitor adolescents for mental health issues
- teach to self -cath when old enough
CEREBRAL PALSY (CP)
-most common chronic disorder in childhood
disorder of impaired movement and posture
incidence 2 to 3 per 1000 live births
- non-progressive may have perpetual problem ,language deficits, and intellectual impairment
- most cases have abnormal muscle tone and lack of coordination with spasticity
ETIOLOGY/PATHO
- congenital- damage to the brain before or during birth
- hypoxia,infection,abnormal brain structure
- birth asphyxia,accounts for only 6-7% of cases
- preterm, twin, and LBW increase risk
- very low apgar score increase risk (0-3 at 5min)
- multifactorial , unknown
-infant /child develops CP from asphyxia- near drowning, choking poisoning ,head trauma
CLINICAL MANIFESTATIONS
Spastic
- most common clinical type -75% of cases
- persistent hypertonia and rigidity
- impairment of fine and gross motor skills
- contractures and abnormal curvature of the spine
- exaggerated DTRs ,positive Babinski
- classic gait- intoeing
POSSIBLE MOTOR SIGNS OF CP
- poor head control after age 3 months
- persistent premature reflexes
- stiff or rigid limbs
- arching back/pushing away
- floppy tone
- unable to sit without support at age 8 months
- clenched fists after age 3 months
POSSIBLE BEHAVIOR SIGNS OF CP
-excessive irritability
-no smiling by age 3 months
feeding difficulties
-persistent tongue thrusting
-frequent gagging or choking with feeds
DIAGNOSIS
-diagnosis is based o clinical findings
-failure to achieve milestone may be the first sign
-suspect CP if:
small for age
H/O prematurity
low apgar score
traumatic,inflammatory or anoxic event
CLINICAL THERAPY
- treatment focuses on helping the child to develop to his/her maximum potential
- referrals for PT,OT,speech therapy
- special education to improve motor function and ability
- braces,splints, serial casting- prevent contractures, increase ROM
- mobilizing devices- wheelchairs, scooters
CLINICAL THERAPY
- surgical intervention - lengthening of the Achilles tendon,dosal rhizotomy to decrease spasticity
- medications anti seizure,muscle relaxants
- prognosis depends on the severity amd presence of deficits
SEIZURE DISORDERS
- abnormal electrical discharges in brain
- one in 20 children will have seizures
- most children who have one wont experience a second
epilepsy -chronic disorder characterzed by recurrent unprovoked seizures, secondary to an underlying brain abnormality
ETIOLOGY /PATHO
-result from abnormal excessive electrical discharges from the brain
- may occur due to: infection brain trauma hypoxia brain tumor structural defect/electrolyte disturbance
-most common in children
TYPES OF SEIZURES
SIMPLE PARTIAL (FOCAL) -no aura, less than 30sec, no postictal confusion
COMPLEX PARTIAL
- aura,LOC, automatisms(smack lips), may progress to generalized, postical confusion
TYPES OF SEIZURES
ABSENCE
- no aura, lasts 5-10 sec ,hyperventilation ,staring, brief LOC, postical amnesia
TONIC CLONIC (GRAND MAL) -LOC,aura?, stiffness F/B rhythmic jerking, eyes roll back, postical confusion,
STATUS EPILEPTICUS
- continuous or recurrent seizure, 20min or longer
- may become hypoxic or hypoglycemic
- emergency :airway,suction,oxygen,monitoring,neuro assessments
- IV line for fluids and meds
- blood glucose administer glucose as indicated
- protect child from injury
- administer benzodiazepines ,diazepam ,lorazepam, or midazolam. phenytoin or phenobarbital if seizures continue
CLINICAL THERAPY
- through history and physical
- EEG
- antiepileptic drugs -monotherapy preferred
- serum drug level
- surgery if indicated
- trial of med withdrawl attempted for children who are seizure free for at least 2-5years
NURSING ASSSESSMENT
- monitoring of:
- seizure activity
- LOC
- vital signs/neuro checks
- signs of hypoxia
- safe environment
- family adaption and coping with uncertainty of when next seizure will occur
ANTIEPILEPSY DRUGS
- phenobarbital
- phenytoin(Dilantin)
- carbamazepine(tegretol)
- valproic acid (depacon,depakote)
- levetiracetam (keppra)
- gabapentin(neurotin)
- topiramate(topramax)
- benzodiazepines- diazepam , lorazepam
PLANNING FOR SAFETY
- do not leave alone in pool ,use shower instead of bathtub
- life vest when boating
- helmet if child has frequent seizures to protect the head
- wear a form of medical identification , such as medical alert bracelet
FEBRILE SEIZURES
- sensitivity of brain to fever
- run in families , benign
- 30-40% chance of having future febrile seizures
- peak incidence between 18-24 months
- generalized tonic-clonic movements with eyes rolling back, last 1-2min followed by brief postictal period
- acetaminophen or ibuprofen
