1. Pediatric Nursing Unit Eleven The Child with Altered Neurologic Status

2. Differences in Children: Biological Differences: – At birth, brain is 25% of adult size. – By age 5, brain is 90% of adult size. – CSF is 5 ml in a neonate and 150 ml in adult. – Myelinization is complete by puberty. – Spinal cord terminates at L3 in infant.

3. Developmental Differences: – Handedness before age 1- year may be associated with focal lesion. – Reflexes present at birth disappear by 1 year. – Neurological assessment of the child is limited to their developmental level. Differences in Children:

4. Neurologic Assessment: Level of consciousness: – What stimuli is needed? – What is quality of the response? – What is length of response? – Confusion: Disorientation to time, place, or person.

5. Level of consciousness: – Delirium: Characterized by confusion, fear, agitation, hyperactivity, or anxiety. – Stupor: Response to vigorous stimuli only. – Coma: Severely diminished response. Neurologic Assessment:

6. Glasgow Coma Scale: (GCS) – Designed as a standardized assessment of the patient with disturbed consciousness. – The lower the score at time of admission the poorer the outcomes. – The PGCS was developed for children younger than 5 years of age as a more accurate tool to avoid errors that occur when the GCS is applied to children and infants with limited verbal skills. – A PGCS of 13-15 represents minor injury, 8-12 is moderate injury, and less than 8 is severe injury. Neurologic Assessment:

7. – Elements of PGCS are: Best eye response. Best verbal response. Best motor response Glasgow Coma Scale: (GCS) Neurologic Assessment:

8. Best eye response Score>1 Year0-1 Year 4Opens eyes spontaneously 3Opens eyes to a verbal commandOpens eyes to a shout 2Opens eyes in response to pain 1No response Glasgow Coma Scale: (GCS) Neurologic Assessment:

9. Best Motor Response Score>1 Year0-1 Year 6Obeys commandN/A 5Localizes pain 4Flexion withdrawal 3Flexion abnormal (decorticate) 2Extension (decerebrate) 1No response Glasgow Coma Scale: (GCS) Neurologic Assessment:

10. Best Verbal Response Score> 5 Years2-5 Years0-2 Years 5 Oriented and able to converse Uses appropriate words Cries appropriately 4 Disoriented and able to converse Uses inappropriate words Cries 3Uses inappropriate words Cries and/or screams Cries and/or screams inappropriately 2 Makes incomprehensible sounds Grunts 1No response Glasgow Coma Scale: (GCS) Neurologic Assessment:

11. Pupil Changes: – Pin point pupils suggest narcotic overdose. – Midpoint fixed pupils suggest structural damage in the midbrain. – Dilated or large pupils indicate severe anoxia or overdose. – One pupil fixed and dilated suggests herniation of the the temporal lobe. Neurologic Assessment:

12. Pupil Changes: Neurologic Assessment:

13. CT Scan. MRI. Lumbar Puncture: Neurologic Assessment:

14. Lumbar Puncture: – Analysis of CSF. – Insertion of spinal needle into subarachnoid space between the lower lumbar vertebrae. Neurologic Assessment:

15. Lumbar Puncture: Cerebral Spinal Fluid: Normal CSF: Clear, odorless. WBC’s 0 – 5. Protein 15 to 45. Glucose 50 – 80. Pressure 50 to 180. Abormal CSF: Turbid, cloudy. WBC’s 1000 – 2000. Protein 100 – 500. Glucose lower than blood sugar. Pressure 180 or greater Neurologic Assessment:

16. Intracranial Pressure: – The head is a closed box. – Total volume inside brain: V brain + V blood + V CSF + V other = Constant. – Brain volume can increase with: Edema. Blood flow. Bleed within the brain. Tumor. Neurologic Assessment:

17. Vital Signs: – Pulse rate decreases as ICP increases. – Respirations: rate, quality, and characteristic change: Initially slow as ICP rises rate becomes rapid and noisy leading to apnea. – Blood pressure rises slowly / late sign is widening pulse pressure Neurologic Assessment:

18. Convulsions: Convulsions are one of the most common complaints during infancy and child hood. More than 50% of all seizures in children occur in the age 6months to 3 years. Etiologic classification: – Acute non-recurrent convulsions: Febrile convulsions: – This is the most common cause of convulsions from 6 months to 6 years age. – It occurs during rise of temperature, in association with extra- cranial infections, most commonly with throat infections (tonsillitis), GIT infections, otitis media, pyelonephritis.

19. Etiologic classification: – Acute non-recurrent convulsions: Febrile convulsions: – It does not occur before 6 month age. – The attack is short in duration (less than 15 minutes), and is not recurrent. – Prognosis is good. – It may be the first attack of epilepsy if: » There are more than 3 recurrent attacks/year. » The attack lasts more than 15 minutes. » Persistent EEG changes between attacks. Convulsions:

20. Etiologic classification: – Acute non-recurrent convulsions: » Febrile convulsions: – Treatment: » Antipyretics and cold compresses. » Treatment of the cause. » Anticonvulsants. Intra-cranial infections: – Meningitis, encephalitis, cerebral abscess, sinus thrombophlebitis. Intra-cranial hemorrhage: – Complicated birth traumas, hemorrhagic blood disease, rupture or angiomatous malformation. Convulsions:

21. Etiologic classification: – Acute non-recurrent convulsions: Cerebro-vascular disorders: – Thrombosis, embolism. Intra-cranial space occupying lesion: – Tumour, abscess, cyst. Toxic: – Drugs: as Aminphylline, Strychine. – Bacterial: as Tetanus, Salmonella, Shigella. – Poisoning: as Lead, Salicylates. – Internal toxins: as Bilirubin, uremic toxins. Convulsions:

22. Etiologic classification: – Acute non-recurrent convulsions: Anoxic: – Asphyxia neonate, congenital cyanotic heart disease. Metabolic and nutritional: – Hypoglycemia, hypocalcaemia, hypomagnesaemia, hyponatremia, hypernatremia, vit B6 deficiency, vit B1 deficiency. Convulsions:

23. Etiologic classification: – Chronic or recurrent Seizures (Epilepsy): Epilepsy is a disorder of the cerebral cortex characterized by recurring paroxysms of abnormal neuronal discharge, that manifest as sudden change in motor, sensory, or psychic function, with associated characteristic EEG changes. Convulsions:

24. Etiologic classification: – Chronic or recurrent Seizures (Epilepsy): Grand mal: – A brief tonic phase of generalized contractions, is followed by a longer clonic phase of rhythmic convulsive movements. – Before the attack, a prodromal phase of discomfort for several hours may occur. Convulsions:

25. Etiologic classification: – Chronic or recurrent Seizures (Epilepsy): Petit mal: – It consists of staring episodes, or flickering of eye-lids lasting less than 30 seconds, which represent sudden, brief interruption of consciousness. – It can be precipitated by flashing lights or hyperventilation. – It usually occurs many times a day. Convulsions:

26. Etiologic classification: – Chronic or recurrent Seizures (Epilepsy): Psychomotor: – Changes in behaviour, with repetitive purposeless movements. – It is associated with loss of awareness or consciousness. It may be difficult to diagnose. Causes: – Idiopathic epilepsy: » No specific cause can be identified. Convulsions:

27. Etiologic classification: – Chronic or recurrent Seizures (Epilepsy): Causes: – Organic epilepsy: (Secondary or Symptomatic): » This is secondary to residual brain damage from previous focal or diffuse injury as post-anoxic, post-infectious, post-hemorrhage, post-toxic, post-traumatic, etc. » Also congenital developmental defects can sympyomatise by convulsions as: cerebral aplasia, hydrocephalus, vascular anomalies. Convulsions:

28. Investigations: – Blood: For glucose, BUN, serum Ca, creatinine, poisons as salicylates and lead, and for metabolic studies. – Urine: For evidence of glomerulonephritis, amino-aciduria, toxins. – Skull X-ray: For evidence of calcification, increased intracranial pressure. – Lumber puncture and CSF examination: For subarachnoid hemorrhage, meningitis, increased CSF pressure. – EEG: To diagnose idiopathic or focal epilepsy and organic brain damage. Convulsions:

29. Treatment: – First aid measures: Airway: assure patent airway, aspirate secretions, etc. Breathing: O2 inhalation. Drugs to control convulsions: phenobarbetone, phenytoin, diazepam,, and depakine. – Specific treatment of the cause in the secondary epilepsy. – Psycho-social rehabilitation of the patient and his family: To avoid exposure to dangerous situations as swimming, driving, etc. Convulsions:

30. Spina Bifida: Spina bifida is a congenital abnormality due to a defect in the formation of the skeletal arch enclosing the spinal cord. It occurs most frequently in the lumber region, but may be present anywhere along the spinal column or even in the skull.

31. Types of spina bifida: – Spina Bifida Occulta: The mildest case, there is nothing beyond the bony defect, or there may be hair or naevus over the spinal defect. Spina Bifida:

32. Types of spina bifida: – Meningocele: The spinal meninges herniated and the sac contains CSF. Spina Bifida:

33. Types of spina bifida: – Meningomyelocele: The most severe one, the sac contains nerve tissue as well as fluid. Spina Bifida:

34. Types of spina bifida: Spina Bifida:

35. Treatment: – Surgical intervention to those with mild to moderate neurological involvement. – The operation takes place within hours of birth, aims to cover the defect with skin. Nursing care: – Maintenance of a clear airway with careful positioning of the infant to protect the operative site. Spina Bifida:

36. Nursing care: – Oral feeding 4-6 hours after operation. – Prevention of infection and wound care. – Daily measurement of head circumference to detect the development of hydrocephalus. – The degree of handicap varies from child to child. Each child poses a different set of problems, such as urinary problems, bowel control, orthopedic handicaps, hydrocephalus, and social and psychological problems. Spina Bifida:

37. Hydrocephalus: Hydrocephalus is an excessive accumulation of cerebrospinal fluid within the skull, the skull circumference increases, and the substance of the brain become compressed.

38. It results from an imbalance between absorption and production of CSF caused by malformation, tumours, haemorrhage, infections, and trauma. Clinical picture of hydrocephalus: – Before closure of fontanels: Increased skull circumference. Palpable separated sutures. Widely opened fontanels. Sun set appearance of the eyes. Hydrocephalus:

39. Clinical picture of hydrocephalus: – After closure of the fontanels: Signs of increased intracranial pressure, which are: – Vomiting. – Headache. – Blurring of vision. – Papilledema. – Hyper-reflexia. Skull is not significantly enlarged. Hydrocephalus:

40. Diagnostic evaluation: – Blood examination, search for infection. – CSF examination. – Plain skull X-ray. – CT scan. Hydrocephalus:

41. Treatment: – Observation and evaluation: If the patient is well, with normal growth of skull; continue observation. – Medical treatment: In mild cases, diuretic may be given. Antibiotics. – Surgical treatment: Surgical removal of the cause of obstruction if possible, as cysts, tumours, or hematomas. Hydrocephalus:

42. Surgical treatment: – Shunting the CSF to bypass the obstruction. This is done using one way valve. The CSF is shunted to another location to be absorbed. – Once a successful shunt has been established; it should be maintained for life. Hydrocephalus:

43. Two major complications of shunt: – Obstruction: It may occur from either ends due to slipping, kinking, thrombus formation, or by tissue. It may be acute or chronic, leading to manifestations of increased ICP, in addition to deterioration of mental functions. – Infection: Commonly occur due to colonization of the shunt with Staph. Manifestations of chronic septicemia occur, leading to fever, rigors, splenomegaly, and lymphadenopathy. In addition, shunt malfunction occur. Hydrocephalus:

44. Nursing management: – Pre-operative: Assess for signs of increased intracranial pressure. Monitor vital signs. Carefully support head when feeding and turning to prevent head and skin breakdown. Observe seizure precautions. Prepare family for upcoming surgery. – Post-operative: Monitor and report signs of infection. Place the child on non operative side. Hydrocephalus:

45. Nursing management: – Post-operative: Monitor and report signs of infection. Place the child on non operative side. If ICP is elevated, the head of the bed should be elevated to 15-30 degree to enhance gravity flow through the shunt. Teach family how shunt work, malfunction, and increase ICP. Hydrocephalus:

46. Crebral palsy: It is a group of non progressive disorders that affect the motor centres of the brain causing problems with movement and coordination. Often it is associated with language and mental defects (retardation ). Dental decay, anemia and malnutrition are caused by poor mastication. Visual and hearing defects are also associated with cerebral palsy.

47. Causes: – Congenital.C.N.S problems as hydrocephalus. – Conditions of pregnancy or labor that interfere with O2 reaching fetal brain. – Head injuries, meningitis and encephalitis can cause cerebral palsy in older children. Crebral palsy:

48. Clinical manifestations: – Spatiality of muscles lead to: Paralysis of 1 limp or 2 or 3 or 4 limps. Difficulty in feeding and language due to spastic muscles of palate and jaw. – Abnormal movements. – Mental retardation may accompany motor retardation. – All these signs range between mild to severe. Crebral palsy:

49. Treatment and nursing care: – Physical & occupational therapy to assist with activities of daily living. – Special education and communication devices. – Sometimes surgery is necessary to correct deformities or improve function. – Nurse assists parents to accept the child and to be realistic about treatment. – Nurse assists for feeding problems & skin care. Crebral palsy:

50. Meningitis: Meningitis is an inflammation of the meninges, it is more common in children than in adults. Clinical manifestation: – Presentation: Headache and pain in back of neck. Vomiting and nausea. Fever. Irritability and restlessness. Photophobia. – Later signs: Increased drowsiness. Convulsions.

51. – + Kernigs = inability to extend legs: The test for Kernig sign is done by having the person lie supine (flat on the back), flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint. If the leg cannot be completely extended due to pain, this is Kernig sign. Meningitis:

52. – + Brudzinski sign = flexion of hips when neck is flexed: Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed. – Purple rash (check for blanching) Meningitis:

53. Diagnosis: – Established by lumber puncture and laboratory examination of the CSF. Treatment: – Appropriate antibiotics. Nursing management: – Frequent observation to monitor child's response to treatment: Vital signs. Head circumference for infants should be measured. Neurological status and behaviour. Intake and output to assess renal function. – Basic comfort care: Position semi-conscious or unconscious child on side and turn at regular intervals. Frequent suction to nasopharynx to prevent aspiration of secretions. Meningitis:

54. Nursing management: – Basic comfort care: Position semi-conscious or unconscious child on side and turn at regular intervals. Frequent suction to nasopharynx to prevent aspiration of secretions. – Droplet precautions: Isolation X 24 hours. If patient is a rule out meningitis the nurse should wear a mask when helping with diagnostic tests. Meningitis:

55. Head Trauma: Trauma is a leading cause of death in children older than 1 year in the United States, with head trauma representing 80% or more of the injuries. The mortality rate from head trauma is 29% in the pediatric population. Types of primary injury: – Scalp injury: It requires careful exploration for foreign bodies or underlying skull fractures. Bleeding associated with scalp lacerations could be significant enough to cause hypotension and shock in a small infant.

56. Types of primary injury: – Skull fracture: Skull fractures are linear, comminuted, depressed, and diastatic. In children, 90% of the fractures are linear and tend to be more diastatic. Depressed skull fracture is defined as displacement of the inner table of the skull by more than one thickness of the bone. Head Trauma:

57. Types of primary injury: – Basilar skull fracture: This is present in 6-14% of pediatric patients with head trauma and is suggested by a history of a blow to the back of the head. Children with basilar skull fracture usually have prolonged nausea, vomiting, and general malaise, most likely because of the vicinity of the fracture to the emesis and vestibular brainstem centers. Physical findings such as Battle sign, raccoon eyes, and CSF otorrhea and rhinorrhea are pathognomonic. Head Trauma:

59. Types of primary injury: – Concussion: A transient loss of consciousness, concussion occurs as the result of head trauma. – Contusion: Caused by a direct injury to the head, a contusion is an area of bruising or tearing of the brain tissue. – Epidural hematoma: Developing between the skull and the dura and secondary to the laceration of an artery or vein. Epidural hematomas of arterial origin peak in size 6-8 hours after the injury. Epidural hematomas of venous origin may grow over 24 or more hours. Head Trauma:

60. Types of primary injury: – Subdural hematoma: Located between the dura and the cortex. Subdural hematoma results from tearing of the bridging veins across the dura or laceration of the cortical arteries during acceleration- deceleration forces. It is usually associated with severe parenchymal injury, and the presentation is that of profound and progressive neurologic deterioration. – Penetrating injuries. Head Trauma:

61. Types of primary injury: – Intraventricular hemorrhage: This type of hemorrhage is usually the result of minor trauma and resolves spontaneously. Large hemorrhages could lead to obstructive hydrocephalus. [ CLOSE WINDOW ] – Subarachnoid hemorrhage: The most common form of hemorrhage associated with head trauma. Results from disruption of the small vessels on the cerebral cortex. Head Trauma:

62. Assessment of patient with head injury: – Primary survey: The primary survey is a focused physical examination directed at identifying and treating life-threatening conditions. – Circulation: – Cushing triad, bradycardia, hypertension, or alteration of respiration, if present, is a late manifestation indicative of herniation. – Several other causes may lead to hypotension. They include intracranial hemorrhage, internal hemorrhages, spinal cord injury, cardiac contusion, and dysrhythmias with secondary impaired cardiac output. Head Trauma:

63. Assessment of patient with head injury: – Airway: Airway inspection should be directed at identifying the presence of foreign bodies, loose teeth, facial lacerations and bone instability, deviation of trachea, and circumoral cyanosis indicative of hypoxia. Auscultation of airway may suggest the presence of upper airway obstruction, especially when a turbulent flow pattern is noted. Head Trauma:

64. Assessment of patient with head injury: – Breathing: Apnea and hypoventilation secondary to pulmonary or neurologic causes are common findings in patients with head trauma. When present, they require immediate intervention and endotracheal intubation. Head Trauma:

65. Assessment of patient with head injury: – Neurologic examination: Assessing responsiveness: – Is assessed with the alert, verbal, pain, unresponsive (AVPU) system and with the Glasgow Coma Scale (GCS) and its modified Pediatric Glasgow Coma Scale (PGCS). Pupillary examination: Pupillary size and response to light. Head Trauma:

66. Assessment of patient with head injury: – Secondary survey: The secondary survey of patients with head trauma is a detailed examination and assessment of the system with the goal of identifying all traumatic injuries and directing further treatment. Head: – Cervical deformity, swelling, pain with palpation, step-off, or malalignment could suggest an unstable injury of the cervical spine and should prompt immobilization of the cervical spine until further diagnostic tests are obtained. Head Trauma:

67. Assessment of patient with head injury: – Secondary survey: Head: – Lacerations and depressions, when present, require further exploration for foreign bodies and underlying bone and dural disruption. – Raccoon eyes or periorbital ecchymosis, CSF otorrhea and rhinorrhea are indicative of basilar skull fracture. – Bulging of the fontanel is a sign of increased intracranial pressure (ICP). Respiratory patterns: – Rate, depth, character… Head Trauma:

68. Assessment of patient with head injury: – Secondary survey: Neurologic examination: – PGCS. – Pupillary examination. – Reflexes. Motor and sensory function. Head Trauma:

69. Causes of head injury: – Motor vehicle accidents account for 27-37% of all pediatric head injuries. – Falls are the largest cause of injury in children younger than 4 years, contributing to 24% of all cases of head trauma. – Recreational activities. – Assault. – Firearm-related injuries Head Trauma:

70. Diagnosis: – Laboratory Studies: blood, urine, wound cultures. – Imaging Studies: CT scanning, MRI, Skull radiography, Ultrasonography (can be performed in neonates and small infants with open fontanel and could provide information regarding intracranial bleed or obstruction of the ventricular system). Head Trauma:

71. Treatment: – Cardiovascular management. – Airway management. – Breathing. – Increased ICP and cerebral perfusion management – Bleeding management. – Seizure management. – Surgical intervention. Head Trauma: