Neurological Alterations

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Neurological Alterations

• NUR 264 - Pediatrics
• Angela Jackson, RN, MSN

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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

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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

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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.

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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

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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

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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

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Spina bifida Clinical Manifestations

• Meningocele a sac-like herniation through the
  bony malformation containing the meninges and
  cerebrospinal fluid.

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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

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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

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Spina bifida Diagnosis

• Prenatally
• Maternal serum alpha-fetoprotein
• Amniocentesis
• Ultrasound
• After birth
• Physical exam
• CT scan
• MRI

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Spina bifida Treatment

• Multidisciplinary approach
• Neurosurgery
• Plastic surgery
• Orthopedics
• Urology
• Pediatric Medicine
• Nursing
• OT/ PT
• Social Work

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Spina bifida Nursing Management

• Protection of sac
• Keep infant in prone position
• Keep sac covered with sterile normal saline
  dressing
• Monitor neurological status
• Perform neuro checks
• Assess for infection
• Fever
• Irritability
• Nuchal rigidity
• Monitor for hydrocephalus
• Signs and symptoms of increased intracranial
  pressure

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Spina bifida Nursing Management

• Maintain skin integrity
• Sheepskin, lambs wool or egg crate mattress
• Gentle massage
• Frequent linen change
• Monitor bladder and bowel function
• Monitor for urine retention and constipation
• May need regular catheterization
• Provide family teaching and support
• Community resources
• Support groups

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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

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Hydrocephalus Types

• Communicating Dysfunction of the absorption of
  CSF
• Noncommunicating Obstruction of CSF flow

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Hydrocephalus Clinical Manifestations

• Increased head circumference
• Increased ICP
• Tense bulging fontanel
• Separation of cranial sutures
• Irritability
• High-pitched cry
• Macewens sign (hollow sound produce on
  percussion of the skull)
• Changes in feeding
• Sunsetting sign
• Headache
• Nausea
• Vomiting

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Hydrocephalus Diagnosis

• Increased head circumference
• Ultrasound
• CT/MRI
• Shunt Series

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Hydrocephalus Treatment

• Shunt insertion
• VP (Ventriculo-peritoneal) most common
• VA (Ventriculo-atrial)

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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

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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

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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

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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

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Seizures Clinical Manifestations

• Automatisms
• Repeated, nonpurposeful actions such as
  lip-smacking, chewing, sucking or uttering the
  same word over and over
• Absence seizures
• Transient loss of consciousness. May stare into
  space, eyes may roll upward

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Seizures Diagnosis

• History and physical
• CBC, electrolytes, lumbar puncture, tox screen
• CT/MRI
• EEG
• PET scan

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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

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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

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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

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Meningitis Clinical Manifestations

• Irritability
• Lethargy
• Poor feeding (infants)
• Seizures
• Bulging fontanel
• Fever

• Nuchal rigidity
• Photophobia
• Headache
• Vomiting, diarrhea
• Opisthotonic position

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Meningitis Clinical Manifestations

• Kernigs Sign Resistance to straightening of the
  knee when the hip is flexed
• Brudenskis Sign Flexion of the hip and knee
  when the neck is flexed

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Meningitis Diagnosis

• History and physical
• Lumbar puncture
• CBC, CSF culture, serum electrolytes, osmolarity
• PT, PTT
• UA

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Comparison of Cerebrospinal Fluid in Viral - vs.
- Bacterial Meningitis
Normal Viral Meningitis Bacterial Meningitis Bacterial Meningitis
Pressure 5-15mm Hg Normal or slightly elevated Elevated Elevated
Appearance Clear Clear Cloudy Cloudy
Leukocytes 0-5 Slightly elevated Elevated Elevated
Protein (mg/dL) 10-30 Slightly elevated Elevated Elevated
Sugar (mg/dL) 40-80 Normal or decreased Decreased
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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

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Meningitis Nursing Management

• Maintain isolation
• Close monitoring of vital signs
• Frequent neuro checks
• Monitor for seizure activity
• Administer antibiotics and other meds
• Comfort measures

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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

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CP Clinical Manifestations

• Hypotonia
• Hypertonia
• Athetosis (Constant involuntary writhing motions)
• Ataxia

• Hemiplegia
• Diplegia
• Quadriplegia
• Warning Signs (pg. 1191)

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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

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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

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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

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Questions??