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Chapter 13 Neurologic and Sensory Disorders Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
The Nervous System Grows rapidly before birth and during the first year Central nervous system (CNS) –Cerebrum, cerebellum, brainstem, spinal cord –Myelinization is cephalocaudal and proximodistal –Primary focus of Chapter 13 Peripheral nervous system (PNS) –Cranial and spinal nerves Autonomic nervous system (ANS) –Sympathetic/parasympathetic systems Choroid plexus: primary site of CSF formation Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-2
Increased Intracranial Pressure Caused by volume increase of brain, CSF, or blood which exceeds cranial capacity Signs and symptoms –Cushing triad Increase in systolic blood pressure, widening pulse pressure, decrease in pulse, altered respiratory pattern –Possible temperature elevation from inflammation, systemic infection, damage to hypothalamus –More pronounced as consciousness deteriorates –As ICP increases, cerebral perfusion decreases Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-3
Intracranial Hemorrhage Description –Broken blood vessels within the skull cause bleeding in the brain; from trauma or anoxia –Complete recovery is likely if symptoms are mild –Death results if there is a massive hemorrhage Diagnosis –History of delivery, CT, MRI, increased CSF pressure, symptoms and course of the disease Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-4
Intracranial Hemorrhage Signs and symptoms –Inability to move normally, lethargy, poor sucking reflex, irregular respirations, cyanosis, twitching, forceful vomiting, high- pitched shrill cry, convulsions –Opisthotonic posture –Tense, pressurized fontanel –Pupil of one eye sometimes smaller than the other Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-5
Intracranial Hemorrhage Treatment and nursing care –Newborn placed in an isolette Allows temperature control, ease in administering oxygen, continuous observation –Head is elevated –Doctor may prescribe medication to control bleeding and convulsions –Nurse observes for signs of increased ICP and convulsions Nurse’s observation of convulsion aids the physician in determining the exact location of bleeding Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-6
Head Injuries Description –Falls, motor vehicle injuries, shaken baby syndrome, bicycle injuries, etc. –Infants and toddlers have soft skulls to absorb impact –By 2 years of age, both fontanels have completely closed; impact absorption decreases Complications –Hemorrhage, infections, cerebral edema (swelling of the brain), and compression of the brainstem –Increased ICP Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-7
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-8
Head Injuries Treatment and nursing care –ABCs (airway, breathing, circulation), assess for spinal cord injury, document baseline vital signs –Level of consciousness (LOC) –Record type and amount of any drainage from ears/nose –Fluids are carefully monitored to control cerebral edema –Feeding difficulties should be noted as the child’s diet is increased –Patients should be observed for signs of shock –Watch for decerebrate/decorticate posturing Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-9
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-10
Hydrocephalus Description –Increased CSF in the ventricles of the brain Causes increased head size, pressure changes in the brain –May occur along with a meningomyelocele or as a sequela of infections, including encephalitis, meningitis, or TORCH Toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex –Can also be caused by perinatal hemorrhage Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-11
Hydrocephalus Signs and symptoms –Depend on site of obstruction and the child’s age –Impairment of CSF absorption within subarachnoid space (communicating) –Obstruction of CSF flow within ventricles (noncommunicating) –Increase in head size –Bulging anterior fontanel –Separation of cranial sutures –Shiny scalp, dilated veins –Eyes may appear deviated downward “Setting sun” sign Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-12
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-13
Hydrocephalus Diagnosis and treatment –Head circumference is measured daily –Echoencephalography, CT, MRI locate enlarged ventricles and level of obstruction –Ventriculoperitoneal (VP) shunt or ventriculoatrial (VA) shunt –Prognosis has improved with modern drugs and surgical techniques Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-14
Shunts have a one way valve to prevent back pressure causing fluids to enter the brain. Shunts have a filter also. Shunt malfunctions are frequently caused by filter becoming plugged with protein. A surgical revision then needs to be done as quickly as possible to prevent increased pressure from forming. Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-15
Hydrocephalus Nursing care –The position of the infant must be changed frequently to prevent hypostatic pneumonia and pressure sores –In addition to routine postoperative care and observations, the nurse observes the patient for signs of increased intracranial pressure (ICP) and for infection at the operative site or along the shunt line –If the fontanels are sunken, the infant should be kept flat Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-16
Myelodysplasia and Spina Bifida Both categorized as neural tube defects (NTD) Myelodysplasia –CNS disorders characterized by abnormal development of the spinal cord and associated neural tube structures Spina bifida (divided spine) –Congenital embryonic NTD; imperfect closure of spinal vertebrae –Cause unknown; multifactorial –Development of a cystic mass in the midline of the spine Meningocele (only meninges in sac) Meningomyelocele (meninges and spinal cord/ nerves in sac) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-17
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-18
Myelodysplasia and Spina Bifida Treatment –Spina bifida: surgical closure to prevent meningeal infection Observe for hydrocephalus, place shunt if necessary Prognosis depends on lesion location, involvement of spinal cord, presence of other anomalies Habilitation Vesicostomy may be necessary (surgical opening of bladder to external skin surface) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-19
Myelodysplasia and Spina Bifida Nursing care –Objectives of extensive nursing care *Preventing infection of or injury to the sac *Correct positioning to prevent pressure on the sac and deformities from developing *Good skin care, particularly if incontinent of urine and feces Adequate nutrition Tender, loving care Accurate observations and charting Education of the parents Continued medical supervision Habilitation (* are pre-operative but may continue post-operatively) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-20
Bacterial Meningitis Description –Inflammation of the meninges –Infective organisms invade via teeth, sinuses, tonsils, lungs, directly through the ear (otitis media), from neurological procedures, or from a fracture of the skull Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-21
Bacterial Meningitis Signs and symptoms –Onset generally follows two courses Typically URI or gastrointestinal problem followed by irritability and lethargy Sudden rapid onset: shock, purpura, changes in level of consciousness, disseminated intravascular coagulation –Other nonspecific reactions: headache, drowsiness, delirium, irritability, restlessness, fever, vomiting, and stiffness of the neck and spine Petechiae: Small hemorrhages beneath the skin May have high-pitched cry, bulging tense fontanel –Convulsions are common Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-22
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-23
Bacterial Meningitis Treatment –Spinal tap at first indication of meningitis –Isolation is used until the patient has received at least 24 hours of antibiotic therapy –Antibiotics are given in combination and are adjusted on the basis of culture and sensitivity reporting –Dilantin may also be necessary if the child is having seizures Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-24
Bacterial Meningitis Nursing care –Frequent monitoring of the patient’s vital signs is necessary –Fever may be controlled with the use of antipyretics, sponge baths, and a hypothermia blanket –The patient’s intake and output are carefully observed and recorded –Syndrome of inappropriate antidiruetic hormone (SIADH) Determined by weight, serum electrolytes, serum and urine osmolarities Treated by fluid restriction Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-25
Encephalitis Description –An inflammation of the brain parenchyma Typically more severe than bacterial meningitis –Can be caused by arboviruses, enteroviruses, and herpes virus types 1 and 2 –Can be aftermath of upper respiratory tract infections, measles, an untoward reaction to vaccinations, lead poisoning Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-26
Encephalitis Signs and symptoms –Headache followed by drowsiness, may proceed to coma –Convulsions occur, particularly in infants –Fever, cramps, abdominal pain, vomiting, stiff neck, delirium, muscle twitching, and abnormal eye movements are other manifestations of the disease Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-27
Encephalitis Treatment and nursing care –Corticosteroids/immune globulin –Acyclovir for herpes virus encephalitis –Parenteral antibiotics until bacterial cause is ruled out –Sedatives, IV fluids, seizure control, monitoring for increased intracranial pressure –Antipyretics as ordered, seizure precautions instituted –Oxygen as needed, mouth and nose kept free of mucus Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-28
Question 12.2 Which is typically more severe? A.Encephalitis B.Bacterial meningitis Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-29
Seizure Disorders Febrile seizures –Occur in association with a rapid increase of temperature –Are a common pediatric neurological disorder and are generally transient in nature –They usually occur between the ages of 6 months and 5 years and are common in toddlerhood –Generally, the parents are educated on fever management and seizure precautions, although fever management (such as administering acetaminophen) does not typically reduce the risk for a seizure Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-30
Seizure Disorders Epilepsy –Recurrent paroxysmal attacks of unconsciousness or impaired consciousness May be followed by alternating contraction and relaxation of the muscles or disturbed feelings/behavior –Disorder of the CNS in which the neurons or nerve cells discharge in an abnormal way –Idiopathic epilepsy: unknown cause –Symptomatic epilepsy: cerebral abnormality is found Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-31
Epilepsy Signs and symptoms –Vary according to seizure type Convulsive seizures –Tonic phase, clonic phase, postictal state –Abrupt onset preceded by aura; dizziness, visual images, nausea, headache, or abdominal discomfort –Status epilepticus: series of convulsions, typically caused by withdrawal of anticonvulsants Nonconvulsive seizures –Could be lapse in consciousness, loss of muscle tone, distorted sensations, automatisms Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-32
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-33
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-34
Epilepsy Treatment and nursing care –First aid for a convulsive seizure includes protecting the child from harm, loosening clothing around the neck, turning on the side to maintain an airway, reassuring the child when consciousness returns –Seizure precautions in the hospital setting include padding side rails and having oropharyngeal suction, oxygen, and an oral airway at the bedside –Anticonvulsants –A ketogenic diet* is sometimes prescribed for children who do not respond well to anticonvulsant therapy –Surgery is considered with intractable seizures not responding to medication * see ‘1 st do no harm’ with Susan Sarandon Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-35
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc Meds used to suppress seizures; not abortive meds
Reye’s Syndrome Description –A pediatric disease characterized by a nonspecific encephalopathy with fatty degeneration of the viscera and altered ammonia metabolism –Triggered by a virus, particularly influenza or varicella –Patients noted to have taken aspirin before symptoms Signs and symptoms –Typically recovering from URI or chickenpox –Recuperation interrupted by general malaise –Sudden onset of persistent vomiting and lethargy –Diagnosis based on history, symptoms, laboratory data Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-37
Reye’s Syndrome Treatment and nursing care –Admission to ICU –Medications include osmotic diruetics, sedatives, barbiturates –Fluid management in conjunction with treatment of increased intracranial pressure (ICP) is crucial –Nursing care similar to increased ICP with greater awareness of respiratory status –Most survivors recover completely Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-38
Near-Drowning Signs and symptoms –Prognosis affected by length of submersion, physiologic response, exposure to hypothermia –Hypoxia is the primary problem (Hypoxic ischemic encephalopathy) –Pulmonary edema (osmotic fluid shift), pneumonia Treatment and nursing care –On-site CPR –Immediate transportation to a trauma facility –Intensive pulmonary care –Risk of cerebral edema and anoxia Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-39
Overview of Cognitive and Behavioral Disorders Developmental disability: any mentally/physically disabling condition that begins in childhood and is expected to continue throughout life Intellectual disability (mental retardation): significantly below-average score on a test of mental ability, limited function in daily life American Association on Intellectual and Developmental Disabilities (AAIDD) –Emphasizes both intelligence functioning and adaptive behavior as criteria for disability Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-40
Overview of Cognitive and Behavioral Disorders Signs and symptoms –Failure to suck –Feeding difﬁculties –Spasticity –Convulsions –Listlessness, irritability –Floppy, hypotonic muscles –Decreased alertness –Unresponsive to eye contact –Unusual clumsiness –Jaundice –Unusual-looking stools –Unusual odor to urine –Enlarged tongue –Asian appearance in white infants –Stubby ﬁngers or toes –Failure to achieve developmental milestones (smiling, rolling over, sitting, etc.) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-41
Overview of Cognitive and Behavioral Disorders Treatment and nursing care –Be mindful that pace of development is slower –Learn by habit formation; routine, repetition, relaxation –Any progress that has been made at home should not be allowed to slip during hospitalization –Like other children, set firm, consistent limits on behavior –Situations become more complicated as the child develops physically but still requires constant supervision –Nurses should familiarize families with community resources; i.e., The Arc Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-42
Attention Deficit/Hyperactivity Disorder Description –Refers to specific patterns of behavior that include inattention and impulsivity and might or might not involve hyperactivity Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-43
Attention Deficit/Hyperactivity Disorder Signs and symptoms –DSM-IV-TR criteria identifies three major patterns of ADHD Predominantly inattentive type Predominantly hyperactive-impulsive type Combined –For ADHD diagnosis, symptoms must Persist for at least 6 months Appear before the age of 7 years Be identified in more than one setting Cause significant impairment in psychosocial or educational adjustment and functioning Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-44
Attention Deficit/Hyperactivity Disorder Signs and symptoms (continued) –Inattentive to details, careless with schoolwork or other activities –Has difficulty organizing tasks –Is unable to sustain attention for periods of time that would be appropriate for age –Does not listen, follow instructions, or complete tasks –Avoids activities and games that require concentration –Is easily distracted and fidgety; has difficulty remaining seated and appears to have excessive energy –Is forgetful, loses things Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-45
Attention Deficit/Hyperactivity Disorder Treatment and nursing care –The specific medications used for the treatment of behavior problems in ambulatory patients are listed in Table 20-1 –Dietary modification (particularly eliminating food additives, such as preservatives and artificial flavors and colors) and the use of megavitamins –Behavior therapy Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-46
Down Syndrome Signs and symptoms –Close-set and upward-slanting eyes, small head, round face, flat nose, mouth breathing, and a protruding tongue that interferes with sucking –The hands of the baby are short and thick, and the little finger is curved –Simian crease –Undeveloped muscles (hypotonia) and loose joints enable the child to assume unusual positions Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-47
Down Syndrome Nursing care –Early infant stimulation enables children with Down syndrome to reach milestones as rapidly as possible –The nurse should become familiar with services located in and near the community –Allowing parents to become involved in care and planning for the infant from the start facilitates bonding Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-48
Autism A complex developmental disorder of the brain, most likely caused by abnormalities in brain structure or function Affects social interaction, language, and communication, as well as behavior Typically appears in the first 3 years of life Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-49
Autism Autistic children do not interact well with others; they prefer to be alone They may play with toys in an unusual manner and live in their “own little world” Often there is some degree of mental retardation Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.20-50
Deafness Description –Hearing loss falls into two major categories Sensorineural hearing loss results from damage to the structures of the inner ear or auditory nerve Conductive hearing loss occurs due to an interruption in the transmission of sound waves (from structural problems) from the external or middle ear –Some children have mixed hearing loss, which combines conductive and sensorineural causes Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-51
Deafness Signs and symptoms : Infant does not…. –Startle with sudden loud sounds –Turn his or her head toward a sound by 3 or 4 months –Begin babbling by 6 months of age –Respond by reacting to music around 8 months of age –Attempt to speak syllables such as “da” by around age 1 year Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-52
Deafness Treatment and nursing care –The auditory brainstem response (ABR) and the otoacoustic emissions (OAE) provide identification of infants with hearing losses –Audiometry—the measurement of hearing with an audiometer –Tympanogram—measures the movement of the eardrum in response to sound waves –Nurses should stress the importance of placing NO objects into the ear canal Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-53
Deafness Treatment and nursing care (continued) –Lip reading, sign language, writing, closed captioning (on television), computers, visual aids, music, and amplified sound are some means of communication –Flashing lights on the telephone and doorbell, hearing aid dogs, and telecommunications devices can facilitate communication –Hearing aids and cochlear implants can boost hearing Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-54
Amblyopia Description –A decrease in or loss of vision, usually in one eye –The vision loss is not caused by structural eye damage but results from the brain “turning off” confusing visual images –(brain turned off eye input so eye ‘ambles around’ because it is not used to see) Signs and symptoms –An observant parent might notice that the child sits closer to the television or appears to have difficulty seeing Treatment and nursing care –Glasses for significant refractive errors (hyperopia, myopia) and occlusion of the unaffected eye are used Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-55
Strabismus Description –Ocular misalignment; a condition in which the child is not able to direct both eyes toward the same object (muscles do not align eye to focus on object) –Most children with strabismus have esotropia, or an inward deviation of one or both eyes; some children have exotropia, which is outward turning Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-56
Strabismus Signs and symptoms –Malalignment during the uncover/cover tests Uncover test: Eye is covered, child looks at a light source; a quickly uncovered eye should not move Cover test: one eye is covered, movement of the other is observed while looking at a distant object Treatment and nursing care –Eye exercises and glasses –Occlusion therapy –Surgery is reserved for patients in whom nonsurgical methods are likely to be unsuccessful Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-57
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.13-58
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