NEUROLOGIC SYSTEM

CSF
Normal- colorless
- alkaline
- specific 1.004-1.008
- with traces of protein of CHON, glucose, lymphocytes and body salts
Decrease- Subarachnoid
Opening pressure 60-160 cm H2O Increased- infection, increased
ICP, hemorrhage
Granulocyte CSF infection
Cell count Lymphocyte Meningeal irritation, infflamation
Protein 15-45 mg/100 ml Increased- with RBC, meningitis,
subarachnoid hemorrhage
Glucose 60-80% Decreased- bacterial
meningitis,fungi, yeast TB,
protozoal infection
1. Cerebral Six Areas of Assessment
2. Cranial Nerves
3. Cerebellar function
4. Motor
5. Sensory function
6. Reflex function
INCREASED INTRACRANIAL PRESSURE
1-10 mmHg if greater than 15 Normal-
mmHg it is considered
abnormal

- increased CSF volume Causes:

- blood entering the CSF
- cerebral edema
- tumors
- infection
- birth trauma

Assessment:
headache, irritability, restlessness, sunset eyes, hydrocephalus,
tensed/bulging fontanels, diplopia, papilledema, unable to
comprehend to surroundings, time or place (first indication),
decreased deep tendon reflexes, Cerebral loss- decorticate
posturing
Intracranial Pressure Monitoring:
1. An intraventricular catheter inserted through the anterior fontanelle
2. A subarachnoid screw or bolt inserted through a burr hole in the skull
3. A fiberoptic sensor implanted into the epidural space (or the ant. Fontanelle)
4. A disposable fiberoptic transducer-tipped catheter inserted through a subarachnoid bolt into the
white matter of the brain
Mgt.
*coughing, sneezing and vomiting should be kept to a minimum
* Monitor rate of IVF administration
* Put in a semi-Fowlers
Medical mgt:
Corticosteroid (Dexamethasone)
Osmotic diuretic (Mannitol)
Ventricular tap- for immediate reduction of pressure
NEURAL TUBE DEFECTS
A. Surge Weber Syndrome *Port wine stain birthmark on the upper part of the face that extends
(encephalofacial inward to the meninges and choroid plexus
angiomatosis) * unilateral
 * ophthalmic branch is commonly involved
* sluggish blood flow anoxia to some portions of cerebral cortex

- hemiparesis (numbness on the opposite side of the lesion)

- intractable seizure
- may be cognitively challenged
- may develop blindness from glaucoma
Dx.
CT or MRI Reveals calcification of the cerebral cortex
EEG Railroad track

long term anticonvulsant Mgt

therapy
B. Neurofibromatosis (von - subcutaneous tumors
Recklinghausens Disease) - mutation or an inherited autosomal dominant trait carried on the
long arm of chromosome 17.
-irregular excessive skin pigmentation
Caf-au-lait (coffee with cream)
Acoustic nerve (VIII) hearing loss
Vision loss
Seizures
Cognitively challenges (result of cerebral deterioration)

CEREBRAL PALSY - a group of progressive disorders of upper motor neuron impairment

that result in motor dysfunction

1. LBW Associted factors:

2. premature birth
3. birth injury
4. occipitoposterior position

Cause:
1. Anoxia -(leading to cell destruction of the motor tracts)
2. Nutritional deficiencies, -drugs, and maternal infections (CMV, toxoplasmosis)
3. Infections meningitis, encephalitis

Head injuries can also lead to CP symptoms

TYPES OF CEREBRAL PALSY:

A. Spastic Type -Hemiplegia
-Quadriplegia (has impaired speech pseudobulbar palsy but may
bot be cognitively challenged)
-Diplegia/Paraplegia

B. Dyskinetic or Athetoid -wormlike

Type - child is limp and flaccid
- makes slow, writhing motions
-drools and with speech difficulty
* with emotional stress, the involuntary movements may become
irregular and jerking (Choreoid) with disordered muscle tone
(dyskinetic)
C. Ataxic Type - awkward, wide-based gait
-unable to perform the finger to nose test or to perform rapid,
repetitive movements

D. Mixed Type Assessment:

Sensory alterations such as strabismus, refractive disorders, visual
perception problems, visual field defects
Speech disorders- abnormal rhythm and articulation
 Attention deficit disorder or autism
Deafness (caused by kernicterus)
Cognitively Challenged
Recurrent seizures
NURSING DIAGNOSIS:
*Risk for disuse syndrome related to spasticity of muscle groups
Mgt.
Surgery to lengthen heel tendons
Baclofen (Lioresal) to improve motor function
Cerebellar pacemakers- reduce spasticity
Passive and active ROM to prevent contractures

*Risk for self-care deficit

-high roughage in the diet (does not have muscle group coordination for bowel evacuation)
*Risk for delayed growth and development related to activity restriction secondary to CP
*Risk for imbalance nutrition less than body requirements, related to difficulty sucking in infancy or
difficulty feeding self in an older child
*Impaired verbal communication related to neurologic impairment
INFECTION
A. Bacterial Meningitis -commonly occurs in children younger than 24 months
Causative Agent:
1. Neiserria meningitidis
2. Streptococcus pneumonia or group B Streptococcus
3. Pseudomonas (myelomeningocele)
1. upper respiratory infection It spreads through:
2. lymphatic drainage through
mastoid or sinus
3. lumbar puncture or skull
fracture

Hydrocephalus Obstruction of CSF flow can lead to _

Brain tissue edema can put pressure on the pituitary gland

causing increased secretion of ADH leading to SIADH secretion

* Irritability Assessment:
*Seizure or shock (first
noticeable sign of illness)
*Brudzinkis sign
* Kernigs sign
* Opisthotonus
* CN paralysis- CN III & VI-
not able to follow a light
through visual fields
* Bulging and tensed
fontanelles
*Papilledema (may develop)
septic arthritis H. influenza- may develop _
popular or purple petechial N. meningitidis-
skin rash

* poor sucking For newborns:

* weak cry
* lethargy

*increased WBC and CHON levels and lowered glucose in the CSF
* fulminating meningitis leads to leukopenia
Mgt.
Intrathecal injection
-H. influenza- Ampicillin
- 3rd generation cephalosporin such as cefotaxime or ceftriaxone (8-10 days)
- dexamethasone
- respiratory precautions for 24 hours after the start of antibiotic therapy
Dx.
*Pain related to meningeal irritation
*Risk for ineffective tissue perfusion (cerebral), related to increased ICP
B. Group B beta-Hemolytic - contracted either in utero or from secretions in the birth canal at
Streptococcal Meningitis birth

C. Encephalitis -an inflammation of brain tissue and possibly the meninges as well

Protozoa, Bacteria, Fungus Causes:

Virus ( Enterovirus,
Arbovirus)
May occur as a complication of common childhood disease such as :
measles, mumps, and chickenpox

Headache, High temperature Assessment:

Signs of meningeal irritation
Ataxia, muscle weakness or
paralysis, Diplopia,
Confusion, Irritability

Mgt.
* Primarily supportive
-antipyretic
-Take and record VS
- mechanical ventilation may be required in acute phase
Antivirals; acyclovir (Zovirax)
Anticonvulsants: carbamazepine (Tegretol), Phenobarbital or Phenytoin (Dilantin),
Dexamethasone,Mannitol
C. Reyes Syndrome - an acute encephalitis with accompanying infiltration of the liver,
heart, lungs, pancreas, and skeletal
Muscle
- this occurs after a viral infection- varicella, influenza treated with
acetylsalicylic acid (aspirin)

1-3 weeks after a viral Assessment:

infection, Lethargy, Agitation
Anorexia, Confusion,
Combativeness,
Hypothrombinemia,
Hypoglycemia, Elevated
blood ammonia levels, CSF
remains normal, Elevated liver
enzymes, Delayed PT,
Decreased blood glucose,
Elevated urea nitrogen,
Elevated serum amylase,
Elevated short chain fatty
acids, Elevated WBC
 Mgt.
* not infectious
Stage 1 & 2 - child responds to stimuli but may exhibit lethargy or delirium and
possibly combativeness
Stage 3-5 - unresponsiveness to stimuli and progressively deepening coma
Therapy is directed respiratory function, controlling hypoglycemia
and reducing brain edema
D. Guillain- Barre -involves both motor and sensory portions of the peripheral nerves
Syndrome (inflammatory - tendon reflexes are decreased or absent
polyradiculoneuropathy) - muscle paralysis and paresthesia starts in the legs and spread to
involve the arms, trunk, and head
- symmetric in nature
- patient may experience difficulty in swallowing, facial weakness

Dx. Elevated CSF protein level

- paralysis peaks at 3 weeks and is followed by gradual recovery

Mgt.
Prednisone- but controversial

Plasmapharesis or transfusionof immune serum globulin may shorten

the course of illness
Monitor cardiac and respiratory function
Indwelling urinary catheter may be used
Enteral or TPN to support CHO and CHON needs
Adequate analgesia if child has neuritis
E. Botulism

F. Facial Palsy (Bells Palsy) -facial paralysis of the seventh CN

- usually after a herpes or Lyme disease infection

Prednisone, Mgt.
Acyclovir (herpes related)
Recovery: 4 months
PAROXYSMAL DISORDERS
*Recurrent Seizures -an involuntary contraction of muscle caused by abnormal electrical
brain discharges
Idiopathic, Infection, Trauma, Causes:
Tumor growth

a.) Partial seizures - only one area of the brain is involved

b.) Generalized seizures - the disturbance involves the entire brain and loss of consciousness
usually occurs.

Seizures in the Newborn Period

- twitching of the head, arms, or eyes
- slight cyanosis
- possible respiratory difficulty or apnea

- trauma and anoxia Causes:

- metabolic disorders
-neonatal infection
- kernicterus
* EEG may be normal despite extensive disease

Seizures in Infant and Toddler Periods

-rapid movements of the trunk with sudden strong contractions of
most of the body
-unknown, trauma, PKU Causes:
- viruses such as herpes and
CMV
Note: Seizures also can be a late symptom of encephalopathy
caused by lead poisoning

*Seizures in Children older than 3 years of Age

Febrile seizures- 38.9-40 C

*Complex Partial - idiopathic type

(Psychomotor) Seizures -usually from focal or diffuse brain injury that has left residual
damage caused by laceration of the brain tissue, hemorrhage due to
blood dyscrasia, anoxia, infection or toxic condition such as lead
poisoning
- most difficult type to control
-may begin with a sudden change in posture, such as an arm
drooping suddenly to the side, automatisms ( lip smacking fumbling
hand movements)
- child may lose consciousness

Carbamazepine (Tegretol)- Mgt:

can lead to neutropenia
Valproic acid (Depakene)
Phenytoin (Dilantin)

*Partial (Focal Seizures) - originate from a specific part of the brain

- motor signs begin in the fingers and spreads to the wrist, arm, and
face in a clonic contraction

-numbness
- tingling sensation
-paresthesia
- pain originating in one area

*Absence seizures (petit mal -may occur up to 100 times a day

seizures) - an EEG usually shows a typical 3Hz wave and slow-wave
discharge

Mgt. ethosuximide (Zarontin) or valproic acid

*Tonic-Clonic Seizures (grand mal seizures)

Four stages:
1. Prodromal
2. Aura - may reflect the area of affectation
Smelling- unpleasant odors- activity in the medial portion of the
temporal lobe
Seeing flashes of light- occipital area
Repeated hallucinations- temporal lobe
Numbness of the extremity- opposite parietal lobe
Cheshire-cat grin- frontal lobe

3. Tonic - all muscles of the body contract and pt. falls to the ground,
extremities stiffen and face distorts
Lasts for 20 sec.
-hypoxia and cyanotic, saliva collects in the mouth
- guttural cry

Clonic- muscles of the body rapidly contract and relax producing

quick jerky movements
 -may be incontinent
- lasts for 20-30 sec

4. Postictal - will fall asleep for 1-4 hours and will only rouse to painful
stimulation

Mgt:
Daily administration of anticonvulsants- valproic acid
(Depakene), carbamazepine (tegretol),

Phenobarbital- should be tapered

Phenytoin- can cause painless gum hypertrophy

Ketogenic Diet- high in fat and low in CHO & CHON, high level of
ketones decrease myoclonic or tonic-clonic seizure activity

*Status Epilepticus - a seizure that lasts continuously for longer than 30 minutes or a
series of seizures from which the child does not return to his/her
previous LOC
-exhaustion
- respiratory failure
- permanent brain damage
- death

Drugs: benzodiazepine- diazepam (Valium), lorazepam (Ativan)

Followed by IV Phenobarbital or phenytoin

Breath holding

HEADACHES
Tension or stress headache
Sinus headache
Migraine Headache
ATAXIC DISORDERS
Ataxia -failure of muscular coordination or irregularity of muscle action

*Ataxia Telangiectasia - transmitted as an autosomal recessive trait attributable to a defect in

chromosome 11- a primary immunodefiency disorder that results in
progressive cerebellar degredation
-Choreoathetosis (rapid, purposeless movements)
-nystagmus
-an intention tremor
Scoliosis may develop

There is no effective treatment

*Friedrichs Ataxia -carried on the short arm of chromosome 9 as an autosomal recessive

trait, involves a variety of degenerative symptoms

-progressive cerebellar and spinal cord dysfunction

-high arched foot (pes cavus)
- hammer toes
-scoliosis
- (+) Babinski reflex
-absent deep tendon reflex in the ankle
-ataxia
Cause of neurologic injury- excess iron deposits in cells
* if ataxia remains untreated death occurs in young adulthood from
myocardial failure