The Child with a

Neurologic Disorder
 Standard Terms for
Level of Consciousness
• Full consciousness – Awake, alert, oriented,
interacts with environment
• Confused – Lacks ability to think clearly and rapidly
• Disoriented – Lacks ability to recognize place or
person
• Lethargic – awakens easily but exhibits limited
responsiveness
• Obtunded – Sleeps and, once aroused, has limited
interaction with environment
• Stupor – Requires stimulation to arouse
• Coma – Vigorous stimulation produces no response
 Glasgow
Coma
Scale
• Mild
(Score of 13-15)
• Moderate
(Score of 9-12)
• Severe
(Score of 3 – 8)
Assessment of mental status
• Infants & toddlers
• Behavior: irritability, restless, crying
• Passive for procedures
• Not responding to parents
• Alternating irritable with lethargy
• Difficult to arouse, sleeps unless
disturbed or unable to arouse
 Neuro Assessment
• LOC
• Pupils
• Head circumference
• Behavior
• Motor Function

• Decorticate – damage to
cerebral cortex
• Decerebrate – Damage
to midbrain or brain stem
 Developmental Manifestations
with Increased Intracranial Pressure (ICP)
• Poor feeding/vomiting Child
• Irritability/restlessness • Headache
• Lethargy • Diplopia
• Bulging fontanel • Mood swings
• High-pitched cry • Slurred speech
• Increased head • Altered level of
consciousness
circumference
• Nausea and vomiting,
• Eyes deviated downward especially in the morning
 Assessment for ICP
• Heart rate • Blood pressure
• Initial tachycardia • Increased systolic
• Bradycardia: late sign, brain damage pressure
• Respiration • Followed by widened
• Rate and quality changes pulse pressure
• Initially slowed followed by rapid and (increased SBP &
noisy decreased DBP)
• Late signs: impending • Cushing’s triad: late
herniation/death indicator of ICP
• Cheyne stokes • Bradycardia
• Increase Systolic BP
• Respiratory changes
 Diagnostic evaluation & management
• CT/MRI
• Lumbar puncture
• ICP monitoring/ ventriculostomy

• Keep HOB >30

• Normothermia
• Osmotic diuretic/ & anticonvulsant
• Hyperventilation controversial

• Avoid over-hydration
• Keep head midline
• Reduce agitation
 Prioritizing interventions
• Treat underlying disorder
• Continued reassessment of status
• Reduce intracranial volume (blood, CSF)
• Maintain normal oxygenation
• Hypercapnia (or hypoxia) leads to cerebral
dilatation & increased ICP.
• Hypocapnia leads to cerebral constriction &
decreased ICP
• Maintain BP for adequate
blood volume for CPP
(cerebral perfusion pressure)
 Hydrocephalus
• Imbalance of CSF • Management
• Clear liquid, rich in • Ventriculoperitoneal
glucose, cushions shunt
brain, supports weight • Permanent drain for
CSF
of brain in the skull
• revisions
• Symptoms?
 Complications
• Infection!!
• Shunt malfunction
• Peritoneal complication
 Cerebral Palsy
• Damage to the motor cortex, disorder posture/movement
• Non-progressive syndromes affecting the brain
(motor cortex, basal ganglia, cerebellum)
• Intelligence not necessarily affected
• May have other neuro disorders like
seizures, intellectual impairment,
hearing/visual impairment
• Types:
• Spastic
• Ataxic
• Dyskinesia
• Mixed
 Factors associated with CP
Prenatal/Perinatal Postnatal
• Maternal diabetes • Infections
• Brain malformation • Head Trauma
• Cytomegalovirus • Stroke
• LBW • Poisoning
• Premature
• Anoxia
 Interventions
• Goal is to maximize the child’s ability
• Adequate nutrition/assistive devices
• Change position frequently
• ROM exercises to prevent
contractures
• May need limb braces, wheelchair
• Meds to reduce spasticity, seizures,
GE reflux
• Oral hygiene if not able to
provide self care

• Multi-disciplinary team
 Head injury
• Concussion
• Transient reversible loss of awareness, responsiveness
• Repeated events can have long term sequelae
• Contusion
• Petechial hemorrhages along superficial parts of brain
• Can be present opposite site of injury via contracoup mechanism
• Closed vs. Open
• Skull fractures
• Often accompany brain injury due to damaged tissue
• Intracranial Hemorrhage
Epidural
• Subdural
• Always suspect cervical spine injury
• http://www.youtube.com/watch?v=LuxuKVKem78
 Interventions

• Assess airway • Other measures

• Neuro checks q 2 hours • Assess open
• LOC injuries
• Pupils • Drainage from
• Sensory/motor function nose/ears-may
be CSF
• Immobilize neck until C spine • No suctioning if
injury ruled out basilar skull
• Glasgow coma scale fracture-risk of
• Monitor s/s of ICP entering brain
• Vital signs
• Ice
• Clean wound
 Seizures
• Excessive discharge of neurons in the brain; results in
involuntary muscular activity and/or level of consciousness
changes
• Febrile: between 6 months and 5 years; occurs with rapid
rise in temp; often accompanies URI or OM in children with
febrile seizure disorder
• Generalized – involving both cerebral hemisphere’s,
consciousness is impaired
• Partial – limited area, involving one hemisphere, with or
with change in LOC
• Causes = Infection, trauma, lesions, malformations,
metabolic disorders, anoxia, stroke
 Videos
• Partial
• http://www.youtube.com/watch?v=lR2tenISiWs&fe
ature=related
• http://www.youtube.com/watch?v=zy4q2SNsEDI&
feature=related
Absence
http://www.youtube.com/watch?v=H3iLQi6wt94
http://www.youtube.com/watch?v=YAJ8A1IwI4s
Tonic/Clonic
http://www.youtube.com/watch?v=SAo-
UaE8YoY&feature=related
Diagnostic testing
• EEG: type, focus and seizure duration
• Neuro imaging: CT, MRI
• Auditory and visual evoked potentials
• Metabolic indicators: glucose, chem 7
• Infectious indicators: analysis of CSF,
CBC, blood cultures, etc.
• Serum anticonvulsant levels
 Febrile seizures
 Causes  Generalized seizure
• Infection lasting < 5 minutes;
occurs only once in
• Usually genetic 24 hour period
predisposition
 Prognosis good;
Precipitated by rapid rarely develop
rise in temperature epilepsy
>102F
 Most require no
 4% of children between treatment
age 6 mos. to 5 years
 Cooling measures
 Antipyretic
 Nursing Care During a Seizure
• As the seizure begins, note the time and begin to time the
seizure
• Protect the child from injury by loosening clothing at the neck
• Turn the child gently onto the side
• Do not restrain the child or insert any object into the mouth
• Observe where the seizure begins; note its progression and
ending
• When the seizure ends, allow the child to rest
• Record the child’s behavior before, during, and
after the seizure
 Medications
Acute episode Long term management
• Diazepam (Valium) or lorazepam
(Ativan) are given intravenously  Dilantin
• Given directly into the vein at a • gingival
rate no greater than 1 mg/min hyperplasia with
• Drugs must not be mixed and can long term use
be diluted only with normal saline  Tegretol
• Keep resuscitation equipment at  Valproic acid
the bedside  Topamax
• Monitor the child’s respirations  Keppra
 Lamictal
 Status Epilepticus
• Tonic clonic activity lasting longer than 10
minutes or repetitive seizures over a > 30 minute
period
• May lead to brain damage
• Head trauma
• Infection
• Electrolyte disorder
• Sudden cessation of anticonvulsants
 Meningitis
Etiology
 Inflammation of meninges
 CSF rich medium for
bacterial growth
 Edema, meningeal
irritation
 Age 1 month-5 years
greatest incidence & 18-
21
 Close contact (day care,
dorms, crowded living
environment
 Meninigitis
 Viral or Bacterial
• Otitis media, Sinusitis, Pharyngitis, URI
 Extension of infection to CSF
Haemophilus influenzae B – not common due to hib
 vaccine
Neisseria Meningitidis- Meningococcal meningitis
Strep pneumo - Pneumococcal meningitis most common most serious

Highly contagious
 transmitted primarily by droplet

 Diagnosis
 LP CSF

http://www.youtube.com/watch?v=h2-U1S74OH0
 Assessment
• Appears ill • Headache
• Febrile • GCS
• Signs of  ICP • Fontanels
• Nuchal rigidity • Seizures (late)
• Brudzinski sign-chin • Photophobia
to chest (neck rigidity) • N/V
• Kernig’s sign- leg flex • rash
to straight (cannot
extend fully)
 Prioritizing interventions
• Droplet Transmission Precautions
• Antibiotics immediately (cultures take 2-3 days)
• Pain meds
• Antipyretics
• IV hydration-LR, 0.9% NS and albumin
• Avoid hypertonic solutions  osmotic effect
• Avoid hypotonic solutions  ICP and increase cerebral edema
• I&O
• Quite environment; uninterrupted rest
Complications of meningitis
 Hearing loss
 Visual impairment
 Behavior changes
 Learning disabilities
 Developmental delay
 Mental retardation
 Cerebral palsy
 Seizure disorder
 Amputations
 Paralysis
 Death
 Spina Bifida
• Common neural tube defect (NTD), group of birth defects.
• Incomplete closure of vertebrae and neural tube.
• The neural tube develops into the brain and spinal cord.
• Occurs between days 24 and 28 of gestation.
• Defect of the spine in a developing fetus, affects the brain,
spinal cord, and surrounding muscles.
• Resulting in loss of movement and or sensation to the legs
and feet as well as bowel movement and bladder
dysfunction
 Spina Bifida
• Occulta- small defect or gap in one or more vertebrae of
the spine, most affected individuals have no problems.
• Meningocele- cyst consisting of membranes surrounding
the spinal cord pokes through the open part of the spine.
Surgically removed allowing for normal development.
• Myelomeningocele- cyst holds nerve roots of the spinal
cord and often the cord itself, sometimes it’s a fully
exposed. Has to be closed surgically. In spite of surgery
the problem of paralysis, bladder and bowel control still
remain.
 Intellectual & Developmental
Disorder
• Autism
• Onset by age 3
• Difficulty with language, social skills, behavior
• Poor eye contact/Lack of emotion
• Repetitive behaviors, Risk of injury
• Down Syndrome (trisomy 21)
• Severe intellectual impairment
• MANY medical conditions
• Failure to Thrive
• Caused by multiple factors
• Child’s weight falls below 5%, or percentile drops
more than 2 major percentile groups.
• Delay in dev. milestones/ decrease muscle mass
Practice Questions

?
 Cerebral Palsy can be best defined as:

• A. Congenital paralysis of voluntary muscles due to heredity

• B. Difficulty in controlling voluntary muscles due to brain
damage
• C. Permanent loss of sensation due to cerebral pressure
• D. Muscles weakness and incoordination caused by mental
retardation
• A. Congenital paralysis of voluntary
muscles due to heredity
• B. Difficulty in controlling voluntary
muscles due to brain damage
• C. Permanent loss of sensation due to
cerebral pressure
• D. Muscles weakness and incoordination
caused by mental retardation
A newborn undergoes surgery to remove a myelomeningocele. To
detect increased intracranial pressure (ICP) as early as possible, the
nurse should stay alert for which postoperative finding?

• A. Decreased urine output

• B. Increased heart rate
• C. Bulging fontanels
• D. Sunken eyeballs
• A. Decreased urine output
• B. Increased heart rate
• C. Bulging fontanels
• D. Sunken eyeballs
A toddler is having a tonic-clonic seizure.
What should the nurse do first?

• A. Restrain the child

• B. Place a tongue blade in the child’s
mouth
• C. Remove objects from the child’s
surroundings
• D. Check the child’s breathing
• A. Restrain the child
• B. Place a tongue blade in the child’s
mouth
• C. Remove objects from the child’s
surroundings
• D. Check the child’s breathing
 Case Study
Brent is a 9-yr-old child who was
involved in a MVA where he experienced a
closed head injury. He was hospitalized for 3
months, through rehab he regained cognitive
functioning, mobility, and most of his memory.
During his recovery he experienced several
seizures and was prescribed phenytoin
sodium 50mg PO t.i.d.
 Case Study
This afternoon, Brent has a seizure at school.
Brent’s teacher moved desks away from him, turned
him on his side, and sent another student for the
school nurse.
By the time the nurse arrived, Brent’s seizure
was over. Brent appears to be sleeping, but the
nurse can arouse him. His parents were called and
he was transferred to the hospital.
 Case Study
What are seizures?
Discuss the different types of seizures that children can
develop.
Discuss the relationship between Brent’s head injury and the
development of seizures.
What assessment data would be helpful in preparing Brent’s
plan of care.
What are priority nursing diagnosis related to Brent’s
condition?
What is phenytoin sodium and what does the
nurse need to know about it?
END