ALTERATIONS IN NEUROLOGICAL FUNCTION IN PEDIATRICS

Christine Limann, RN, CPN

Pediatric Differences

-Head is larger in proportion to body

-Insufficient musculoskeletal support in neck

-Fontenelles not closed in young child

-Major cause of childhood deaths

-Who is more at risk?

Head Injuries

Concussion

Signs and Symptoms-Headache-Slowness in thinking, acting, speaking-Fatigue-Memory problems-Loss of balance

(Ball, Bindler, & Cowen, 2010)

Cerebral Contusion

Bruising of the brain secondary to blunt trauma.

Can be either coup or countercoup injuries.

May involve tearing of brain tissue and may lead to areas of necrosis or infarction.

(Ball, Bindler, & Cowen, 2010)

Head Trauma

Between dura and cerebellum

Result of head trauma such as falls, MVA, or shaken child syndrome

Symptoms may appear after 24-72 hours

Change in LOC, Headache, N/V, retinal hemorrhage, pupil on side of injury may be dilated

Prognosis poor

Between dura and skull

Almost never occurs in children less than 4 y/o. Blunt trauma such as MVA, assault, baseball injury

Delayed onset followed by rapid change in mental status

Headache, Fixed dialated pupils, s/s increased ICP

Prognosis good

Subdural Hematoma Epidural Hematoma

Shaken Baby

Physical abuse Countercoup injury Subdural Hematoma Retinal Hemorrhage Seizure Check baby for fractures

in the rest of their body

Countercoup injury

Injury by Severity

Concussion or mild brain injury 13-15 GCS

Moderate brain injury 9-12 GCS Loss of

consciousness Severe Brain Injury

8 or less GCS Coma Increased ICP

(Ball, Bindler, & Cowen, 2010)

Nursing Actions

What is the priority? Reportable changes

Decrease in coma scale Restlessness and irritability Pain Changes in pupils Changes in responses, reflexes, movements Drainage from nose/ears Increased thirst or urination Change in vital signs

Cushing’s Triad

Bradycardia

Widening

Pulse Pressu

re

Irregular

Respirations

Increased Systolic

Decreased Diastolic

(Ball, Bindler, & Cowen, 2010)

Intracranial Infections -Meningitis

More Dangerous Group B Streptococcus and

gram-negative enteric bacilli most likely cause in newborns

Neisseria Meningitidis 2 mo-12 yr Can also cause

meningococcemia

H influenzae B and Strep Pneumoniae are now less common because of vaccination

-Fever, vomiting, irritable, hemorrhagic rash, headache, nuchal rigidity, seizures

Treatment: Antibiotics

Does not appear as ill as the child with bacterial meningitis

Caused by enteroviruses, mumps, vericella

Irritable, fever, lethargy, headache, may have stick neck or back pain

Usually resolves in 3-10 days Treat with antibiotics until

bacterial meningitis is ruled out

Bacterial Meningitis

Viral Meningitis

Both Diagnosed by Lumbar Puncture-LP

Intracranial Infections-Reye’s Syndrome

Infection in the brain – acute encephalopathy

May cause permanent tissue damage to brain and liver

Associated with use of aspirin with viral illness such as chicken pox or influenza b

Symptoms: nausea/vomiting, mental changes, seizures, progressive unresponsiveness

Hydrocephalus – Cerebrospinal fluid build up

Communicating hydrocephalus – no blockage. Either a problem with over production of CSF or problem with absorption

Non-communicating- obstruction

Aqueduct of sylvius

Causes of Hydrocephalus

Myelomeningocele

Dandy-Walker Syndrome

Chiari Malformation

Aqueduct of sylvius stenosis

Intraventricular hemorrhage in premature infants

Post infectious meningitis

Brain tumors

Congenital malformation Non-Congenital

Hydrocephalus- clinical manifestations

Newborns and infants Bulging fontanels Increased head

circumference Sun set eyes Irritability High-pitched, catlike cry Visible scalp veins

Children Headache Visual disturbance Nausea/vomiting Pupils sluggish Decrease in

consciousness Seizures Cushing’s Triad

Widening pulse pressure

Bradycardia Irregular respirations(Ball, Bindler, & Cowen,

2010)

Hydrocephalus Treatment

Ventriculoperitoneal shunt (VP Shunt)

Seizures

Most common neurologic dysfunction in kids Caused by malfunctions of brain’s electrical

system Infections or high fever Chemical imbalance of the body that causes loss of

metabolism Congenital conditions or trauma Genetic factors and family history Brain tumors and neurological problems Habits of the mother like smoking, alcohol

consumption, drugs and certain medications

(Hockenbery & Wilson, 2010)

Types of Seizures

Absence – (3-12 years old)5-10 sec. Lip smacking, staring, twitching, brief loss of consciousness

Partial (focal) – Less than 30 sec., one extremity

Generalized (tonic-clonic or grand mal) Febrile Dependent Epilepsy – Chronic disorder

Febrile Seizures

Usually higher than 38.9 C or 101F

Usually short in duration. Instruct parents to call 911 if longer than 5 minutes

Use antipyretics and cooling measures(Mayoclinic.com, 2010)

Nursing actions with patients with seizures

Before Where there triggers such as

change in temperature, light? During

Maintain airway Role to side if possible Time changes started Part of the body involved and

movement Incontinence

After Do they remember what

happened?

(Ball, Bindler, & Cowen, 2010)

Treatment for Seizures

Common pharmacological choices Ativan -Lorazepan Diazepam – Diastat (can be given rectally) Phenobarbital or Phenytoin

Remind parents not to stop once the seizures are controlled until directed by a doctor.

Other types of treatment Vagal Nerve stimulator Ketogenic Diet

(Ball, Bindler, & Cowen, 2010)

Nursing Role:

Provide adequate Nutrition Promote safety and physical mobility

Maintain Skin Integrity Prevent Constipation

Cerebral Palsy

(Ball, Bindler, & Cowen, 2010)

Abnormal muscle tone, lack of coordination, spasticity. Symptoms very depending on age and type of CNS injury.

Spina Bifida

Surgery to close the repair usually occurs within 24-48 hours. Some cases can be repaired in utero. May need VP shunt.

Ongoing therapy Mobility-Braces,

wheelchair Neurogenic bowel and

bladder

References

Ball, J., Bindler, R., & Cowen, K. (2010).Child Health Nursing: Partnering with Children & Families 2nd Ed. Upper Saddle River, NJ. Pearson.

Hockenberry, M. & Wilson, D. (2010). Wong’s Nursing Care of Infants and Children 8th Edition. St. Louis, MO. Elsevier.

Mayoclinic.com (2010). Febrile Seizure. Retrieved from http://www.mayoclinic.com/health/febrile-seizure/DS00346/DSECTION=symptoms

Saewyc, E. (2007). Health Promotion of the Adolescent and Family. In Hockenberry, M. & Wilson, D. (Eds.) Wong’s Nursing Care of Infants and Children 8th Edition (pp. 811-848). St. Louis, MO. Elsevier.