1. Care of Children Experiencing Alterations in Neurologic Function Marydelle Polk, Ph.D., ARNP-CS Florida Gulf Coast University

2. Objectives  Review and understand basic anatomy and physiology of the neurological system.  Review and use assessment skills to identify adaptive/non-adaptive behaviors that may be exhibited by the pediatric client.  Utilize lab/diagnostic data to enhance your nursing assessments.

3. Objectives…con’t.  Review the pathophysiological processes that occur with examples of neurologic deficits: * Cerebral Palsy * Epilepsy * Spina Bifida * Hydrocephalus

4. Objectives…con’t.  Identify common nursing diagnoses that can be drawn after an assessment of a pediatric client with alteration in neurologic function.  Identify and specifically describe nursing coventions for a pediatric client with alteration in neurologic function.  Describe means of evaluation of nursing coventions that correlate with medical orders and interventions for a pediatric client with alteration in neurologic function.

5. Article: McDonald, M.E. (1997). Use of the ketogenic diet in treating children with seizures. Pediatric Nursing, 23(5), 461- 464.

6. Hydrocephalus  A condition in which the normal circulation of the spinal fluid is interrupted, resulting in increased pressure on the brain, deformity, and progressive enlargement of the head.

7. Hydrocephalus  CSF formed in the chorcoid plexuses  to lateral ventricles  Foramen of Monro  3 rd ventricle  Aqueduct of Sylvius into 4 th ventricle  into the Cisterna Magna  to the cerebral and cerebellar subarachnoid spaces – and is absorbed.

10. Causes of Hydrocephalus  Impaired absorption of CSF via the SAS (communicating hydrocephalus)  Obstruction of CSF through the 3 rd and 4 th ventricles (noncommunicating hydrocephalus)

12. Remember…  Hydrocephalus is often a sequalae of other developmental defects – most common is Spina Bifida and/or myomeningocele

13. Clinical Manifestations  Head enlargement  Bulging fontanels w/o head enlargement  Dilated scalp veins  “Cracked-pot” percussion sound  Abnormal eye position (P  RLA)  Neurological changes

14. Diagnostic Tests  MRI  CT  EEG, echoencephalography,  Ventriculograms

15. Treatment Depends on the Cause of the Increased Pressure.  Removal of part of choroid plexus to  production of CSF.  Shunting of the fluid out of the brain to the heart or to the peritoneal cavity.

16. Surgical Management  Ventriculoperitoneal (VP) shunt  Ventriculoatrial (VA) shunt

17. Preoperative Care  Prevent pressure sores on head by changing child’s position, placing child’s head on sheepskin, or by holding the infant.  Provide good head support when the child is sitting in a Fowler’s position.

18. Preoperative Care  Promote optimal nutritional status.  Keep eyes free of irritation.

20. Major Complications  Malfunction -  ICP  Infection  Brain Abscess  Subdural hematoma

21. Nursing Diagnoses  Risk for head trauma r/t impaired cerebrospinal fluid absorption.  Risk for infection r/t presence of infective bacterial organisms

22. Nursing Coventions  Frequent occipitofrontal circumference (OFC)  Frequent LOC  Frequent fontanel checks  Close monitoring of VS, NVS, and feeding patterns  Keep flat after surgery unless  ICP  Monitor Intake and Output

23. Postoperative Nursing Care  Observe for shunt malfunction and valve patency: watch for progressive increase in head circumference and s/s of  ICP.  Observe for infection:  Position child flat on the un-operative side.

24. Postoperative Nursing Care  Prevent postoperative complications: turn q 3-4 hours, evaluate lung sounds, and assess for signs of infections.  Protect the operative site: avoid pressure on the site; ensure sterile dressing changes.

25. Spina Bifida  The failure of the posterior portion of the lamina of the bony spine to form, which causes an opening in the spinal column.

26. Actions are Dependent on Severity of Condition  Neurological Interventions  Urological Interventions  Orthopedic Interventions

27. Actions are Dependent on Severity of Condition  Neurological Interventions + Observe for s/s of hydrocephalus + Measure head circumference daily + Observe for s/s of  ICP

28. Actions are Dependent on Severity of Condition  Urological Interventions + If child is catheterized, use sterile technique + Keep a careful record of I/O + Observe for s/s of urinary tract infection

29. Actions are Dependent on Severity of Condition  Orthopedic Interventions + Provide opportunities for the child to exercise and develop unaffected areas. + Prevent contractures through proper positioning.

32. Epilepsy  A series of seizures that result from focal or diffuse discharges in the cortical neurons – symptoms of abnormal brain function

33. Epilepsy – Types  Partial Seizures + Simple Partial + Complex Partial  Generalized Seizures + Absence + Tonic-Clonic + Myoclonic

34. Epilepsy – Nursing Care  Prevent injury during a seizure  Observe and document seizure pattern  Administer and monitor medications  Administer post-seizure procedures

35. Epilepsy – Nursing Care  Prevent injury during a seizure.

36. Epilepsy – Nursing Care  Observe and document seizure pattern.

37. Epilepsy – Nursing Care  Administer and monitor medications.

38. Epilepsy – Nursing Care  Administer post-seizure procedures

39. Cerebral Palsy (CP)  A group of disorders used to describe a group of disorders characterized by motor and postural impairments – due to abnormal muscle tone. CP may also involve language, perceptual and intellectual deficits. It is the most common permanent physical disability of childhood, occurring in approximately 2/1000 live births.

40. Cerebral Palsy (CP)  Interventions – multi-faceted * Depends on the particular manifestations of the disease. * The child’s capacities.

41. Cerebral Palsy (CP)  Classification of CP * Spastic * Dyskinetic/athetoid * Ataxis * Mixed types

42. Cerebral Palsy (CP)  Major Focus of Interventions * Develop motor control * Develop communication skills * Provide adequate nutrition * Prevent orthopedic complications.