Neurologic Alteration

Chapter 28
Page 733

Glascow Coma Scale

Modified for infants and children
Used

to assess level of
consciousness
Measures verbal and motor
responses based on childs age
Three parts eye opening, verbal
response smiling, crying and
interaction, and motor response

Increased Intracranial Pressure

Signs & Symptoms of increased ICP

Pressure exerted by the blood, brain, CSF,

and any other space occupying fluid or
mass
Can result from tumor or mass
Brain can swell as result of trauma,
infection or hypoxic episode
Overproduction of fluid, malabsorption of
fluid, or communication problem in
system can disrupt CSF dynamics

Increased ICP S&S

Increased ICP

Child
- headache
- diplopia
- mood swings
- slurred speech
- papilledema (after 48 hours)
- altered level of consciousness
- nausea and vomiting, esp in morning

Infant
- poor feeding or vomiting
- irritability or restlessness
- lethargy
- bulging fontanel, distended scalp veins
- high pitched cry
- increased head circumference
- separation of cranial sutures
- eyes deviated downward (setting sun sign)
- increased or decreased response to pain

Changes in childs normal behavior hes

not acting like himself
Changes in pupils dilation with sluggish
or absent constriction in response to light
Changes in motor function decreased
purposeful movements, abnormal
posturing
flexion posturing (decorticate) flexion
of upper extremities with extension of
lower

Increasing ICP

Increasing ICP

extension posturing (decerebrate)

extension of upper extremities with
internal rotation of upper arm and wrist,
lower extremities extend with some
internal rotation of knees and feet
* Progression from flexion to extension
posturing indicates deteriorating
neurological functioning notify MD

Vital signs increased temperature

Late sign Cushings response increased
BP, widened pulse pressure, decreased
HR, and decreased or irregular RR
As ICP rises baseline respiratory pattern
may change
- Cheyne Stokes respirations
- central neurogenic hyperventilation
- apneustic breathing

Nursing Care of Child with Nervous

System Disorder

Diagnostic tests CT, MRI, lumbar

puncture, electrolytes, ABGs, CBC, EEG
Management treat underlying cause,
reduce volume CSF, preserve metabolic
function and avoid situations that increase
ICP

Nursing Care of Child with Nervous

System Disorder

Nursing Care of Child with Nervous

System Disorder

Interventions
- Neuro assessment with LOC,Vital signs
- Have emergency equip avail. ^ ICP can cause
apnea which may lead to arrest
- monitor factors that increase cerebral edema
or ICP (hypoxia, fever, seizures, hypotension,
hypercapnia)
- maintain HOB @ 30-45 degrees (facilitates
venous outflow drainage of the brain by gravity)

Assessment LOC, mood and behavior,

compare with normal developmental
milestones, observe interaction with
family and environment, note lethargy,
drowsiness, hyperactivity, tremors or
jitteriness

- Avoid prone position, neck or hip flexion, or

lying flat. All ^ ICP
- organize care around periods of low ICP
bathing, suctioning, repositioning all ^ICP
- monitor pupil size and reactivity hourly or as
ordered
- monitor head circumference, anterior fontanel
and sutures if age appropriate
- observe for irritability, lethargy, feeding
intolerance & decreasing GCS score

Nursing Care of Child with Nervous

System Disorder

Nursing diagnosis Imbalanced nutrition: less

than body requirements r/t restricted intake,
neurological impairment, swallowing or chewing
difficulty, risk for aspiration, nausea or vomiting
Interventions determine LOC before giving
liquids, daily weight, strict I&O, monitor skin
turgor. Position upright after feeding. Check
NGT placement bf tube feeding, flex feeding
schedule if no NGT with small feedings of
favorite foods.

Nursing Care of Child with Nervous

System Disorder

Nursing diagnosis Risk for impaired skin

integrity r/t neuromuscular impairment,
decreased LOC, inadequate physical activity,
immobility, or improper fluid or nutritional
intake
Interventions special mattress, observe skin
condition and reposition q 2 hrs, passive ROM if
appropriate, if braces or splints used assess skin
before and after application, daily skin care
regimen

Spina Bifida

Spina Bifida Occulta

Midline defect involving failure of the

osseous spine to close
Two types:

Spina Bifida Occulta

Spina Bifida Cystica

Defect that is not visible externally

Common the lumbosacral area (L5 and
S1)
Signs
skin depression or dimple
hemangioma
dark tufts of hair
soft, subcutaneous lipomas

Spina Bifida Cystica

Meningocele

Visible defect with an external saclike

protrusion
Two forms
Meningocele
Myelomeningocele

Encases

the meninges and spinal fluid

but no neural elements

Not

associated with neurologic

defects

Myelomeningocele
Involves the meninges, spinal fluid and
nerves
Usually the sac is covered with a fine
membrane which tears easily
Location and magnitude of the defect
determine the nature and extent of
neurological impairment
Other associations: hydrocephalus

Initial Nursing care Pre-op

Other Considerations

Post-op

Monitor VS
Assess Pain
Weight
I&O
Observe for Infection
Provide Nourishment

Support the family and teach them how to care

for the infant

Place the infant in a radiant warmer so that

body temperature can be maintained without
clothing
Apply a sterile, moist dressing over the sac
Changed every 2-4 hours
Cleanse the sac if soiled but do not puncture
it
Keep the infant prone to reduce tension on the
sac
Leave diaper under baby and do not fasten

GU Functions
Neurogenic bladder is
most common
The goal in infancy is
to preserve renal
function
In older children the
goal is to preserve
renal function and
optimum urinary
continence

May have urinary tract

infections,
vesicoureteralreflux, or
renal insufficiency
Residual urine

FYI

Hydrocephalus

Latex Allergies are more common in SB

children because of the increased
exposure during surgery and numerous
catheterizations to latex

Hydrocephalus

Hydrocephalus S&S Infant

VP (ventriculoperitoneal) shunt tube

leading from the ventricles out of skull,
under the skin to the peritoneal cavity
VA (ventriculoatrial) shunt drains fluid
from ventricles to the right atrium of
heart
Shunts need to be revised as child grows
Long term follow up essential

Hydrocephalus S&S Child

Early
strabismus, diplopia
Frontal HA in am relieved
by sitting upright or
vomiting
N&V, papilledema
Restlessness
Behavior changes
Irritability, ataxia
Confusion, lethargy
Sluggish + unequal pupil
response to light

Result of imbalance b/t production and

absorption of CSF
Results in enlargement of skull if sutures are
open; S&S of ^ICP if sutures closed
Tx aimed at preventing further CSF
accumulation and reducing disability and death
Obj. bypass blockage &drain fluid from
ventricles to area where can be reabsorbed into
circulation

Late
Seizures
Increased BP
Decreased HR
Alteration in resp
pattern
Blindness from
herniation of optic disc
Decerebrate rigidity

Early

- rapid head growth

- full bulging anterior
fontanel
- irritability
- poor feeding
- distended prominent scalp
veins

- widely separated cranial

sutures

Late
- setting sun sign

frontal bone enlargement

vomiting, diff feeding
- ^BP, decreased HR
- altered resp pattern
- shrill, hi pitched cry
-

sluggish or unequal pupil

resp. to light

Hydrocephalus
Nursing considerations

Vital signs every

1 to 2 hours or as needed
Monitor for swelling or
redness along the shunt
tract
Observe head, abdominal,
and chest dressings for
drainage
Position the child off the
shunt site
Intravenous antibiotics
as ordered
Dressing changes
as ordered

Slide 30

Cerebral Palsy
Chronic non-progressive disorder of
posture and movement
Characterized by difficulty in controlling
the muscles because of an abnormality in
the extrapyramidal or pyramidal motor
system
Motor system damage can occur
prenatally, perinatally, or postnatally

Clinical Manifestations of CP
PHYSICAL SIGNS
Poor head control after 3 months of age
Stiff or rigid arms or legs
Pushing away or arching back
Floppy or limp body posture
Cannot sit up without support by 8 months
(failure to meet developmental norms)
Uses only one side of body or only the arms to crawl
Clenched fists after 3 months (absence or presence of
reflexes that extend beyond the expected age)

Clinical manifestations of CP

Nursing Considerations - CP

BEHAVIORAL SIGNS
Extreme irritability or crying
Failure to smile by 3 months
Feeding difficulties
Persistent gagging or choking when fed
Persistence of extrusion reflex after 6
months

CEREBRAL PALSY

Management of CP

Self-care is a goal for all children; extensive

collaboration with occupational therapist for
strategies and devices to assist in this area may
be necessary
Use of adaptive feeding devices and positioning
during feedings may be necessary if a risk of
aspiration is present
Collaboration with multidisciplinary team for
speech, nutrition, occupational and physical
therapy; child and family form center of the
team
Provide adequate nutrition and rest

Many individuals have a need for

increased calorie intake because of
spasticity or increased motor functioning
Seizure precautions
A safe environment if child has poor
coordination
Child may need to use a communication
board or computer-assisted
communication

Often not diagnosed before the child is 2

Baclofen a skeletal muscle relaxant can be
used intrathecally via pump for severe
spasticity
Botox is also used in treatment of CP

Seizures

Partial Seizures

Brief paroxysmal behavior caused by

excessive abnormal discharge of neurons
Epilepsy recurrent seizure activity not in
association with acute illness
Partial seizures occur in one part of
brain and may or may not alter
consciousness
Generalized occur over entire brain and
alter consciousness

Simple

partial seizures no change in

LOC. Consist of motor, autonomic,
or sensory symptoms
Complex partial seizures impaired
consciousness, staring, chewing, lip
smacking, unusual hand movements,
etc.

Generalized Seizures
Absence (petit-mal) seizures very brief
episodes of altered consciousness (5-10
secs)
Myoclonic seizures brief random
contractions of a muscle group, can occur
on both sides of body, singly or in clusters

Tonic-clonic (grand mal) seizures abrupt

arrest of activity, impairment of
consciousness, aura precedes, seizure
followed by variable period of confusion,
lethargy, and sleep (post ictal phase)
Febrile seizure assoc. with fever no
underlying neurological problem, familial
disposition, males more than females,
usually bt 6mo-3 yrs, temp usually >101.8

Nursing Care & Observations During A

Seizure

Medications

Look at time at onset

Protect child from injury loosen clothing, turn
to side DO NOT RESTRAIN
Observe how began, how progressed, how
ended
Describe any preceding or accompanying
sensory or motor manifestations
After over allow child to rest

Teach parents and child regarding

anticonvulsants
Blood levels monitored to maintain
therapeutic levels
Dilantin oral care important (causes
gum problems)
Depakene watch for bleeding bruising
(affects platelets)

Medications cont.

FYI

Advise parents and patient not to

suddenly dc meds - seizures or status
epilepticus can occur
Some states require drivers to be seizure
free for 6-12 months to obtain drivers
license
Birth control pills less effective with
antiepileptics - need additional method
Alcohol, marijuana, street drugs lower
seizure threshold

In

neonates, if movement can be

initiated by gentle stimulus (such as
touch) it is probably a tremor. If it
cant be stopped or controlled with
gentle restraint or passive flexion, it
is probably a seizure.

Meningitis inflammation of the meninges

Status Epilepticus
Pediatric emergency
Prolonged seizure activity of either 1
seizure lasting 30 min or more or
recurrent seizures lasting more than
30mins. With no return to normal LOC
between seizures
Treatment ; maintain optimal resp and
hemodynamic function, identify and treat
cause
IV valium or ativan can give PO or PR

Meningitis

Diagnosis: lumbar puncture

Management:
Viral-symptomatic care
bacterial: isolation
drugs: antibiotics; anytipyretics,
anticonvulsants, corticosteroids
treat complications

blood cultures

etiology: bacterial; viral ; tuberculous

Infant & child S&S

fever
Poor feeding
Vomiting
Irritability
Seizures
High pitched cry
Bulging fontanel
Lethargy

Children/adolescents S&S
Severe HA
Photophobia
Nuchal rigidity
Fever, vomiting/diarrhea
Altered LOC
Decreased appetite
Agitation/drowsiness
Late seizures, chg LOC
rash

Meningitis: Nursing considerations

Monitor cardiorespiratory status
Have emergency airway equipment in
room or at bedside
Monitor level of consciousness
Provide an environment that will minimize
intracranial pressure

Meningitis: Nursing considerations

Bacterial Meningitis

Monitor for cerebral edema

(check head circumference)
Monitor intravenous fluids to prevent
fluid overload
Administer antipyretics as ordered
Monitor for complications of meningitis
(seizures, hearing loss, visual alterations)

Medical emergency
Isolation droplet transmission
precautions for at least 24 hrs after
antibiotics started
Antibiotics begun before causative agent
identified (cultures can take 3 days)
Untreated can be fatal
Prophylaxis for ill childs close contacts

Encephalitis
Encephalitis: inflammation of the brain
Inflammation caused by infection or toxin
results in cerebral edema and neurologic
dysfunction
Diagnosis lumbar puncture and CSF
culture

Encephalitis
Nursing considerations
Monitor childs vital signs, respiratory
status, oxygenation, and urine output
Take seizure precautions and have
resuscitation materials at bedside
Manage complications related to
immobility
Educate family regarding discharge
Provide supportive measures (facilitate
grieving if poor prognosis)

Reyes syndrome

Reye syndrome

Preceding viral infection leads to liver cell

damage with rising serum ammonia levels
Thought to be related to administration
of ASA to children with viral disease
Care similar to that for ^ ICP, with
potential addition of mechanical resp
support

Toxic serum ammonia levels result in

cerebral dysfunction, fluid-electrolyte and
acid-base imbalance, and coagulopathies
Average age of onset 6-7 years
Can result in death

Reye Syndrome characterized by 5 stages

Reye Syndrome

Vomiting and lethargy

Combativeness and confusion
Coma, decorticate posturing
Decerebrate posturing
Seizures, loss of deep tendon reflexes,
respiratory arrest

Diagnostic evaluation
History reveals recovery from a recent viral
disease; sudden onset of vomiting and
mental confusion
Liver enzymes (elevated)
Blood glucose (below normal)
Ammonia levels (elevated)
Prolonged partial thromboplastin time

Reye Syndrome

Reye Syndrome

Therapeutic management
Monitoring neurologic status, intracranial
pressure, hydration, acid-base balance,
and cardiorespiratory status
Medications may include the following:

Corticosteroids
Mannitol
Barbiturates (if cerebral edema is severe)
Phenytoin (to control seizures)
Vitamin K (to aid coagulation)

Nursing considerations

Care is focused on support and monitoring of the

childs physical status
Monitor cerebral edema
Monitor intake and output
Monitor vital signs
Perform ongoing neurologic assessments
Monitor laboratory values
Prevent complications of immobility
Provide emotional support to family

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