1. ALTERATIONS IN NEUROLOGICAL FUNCTION IN PEDIATRICS CH 37 Christine Limann Dyer, RN, CPN

2. Pediatric Differences -Head is larger in proportion to body -Insufficient musculoskeletal support in neck -Fontenelles not closed in young child

3. -Major cause of childhood deaths -Who is more at risk? Head Injuries

4. Concussion Signs and Symptoms -Headache -Slowness in thinking, acting, speaking -Fatigue -Memory problems -Loss of balance (Ball, Bindler, & Cowen, 2010)

5. Cerebral Contusion  Bruising of the brain secondary to blunt trauma.  Can be either coup or countercoup injuries.  May involve tearing of brain tissue and may lead to areas of necrosis or infarction. (Ball, Bindler, & Cowen, 2010)

6. Head Trauma  Between dura and cerebellum  Result of head trauma such as falls, MVA, or shaken child syndrome  Symptoms may appear after 24-72 hours  Change in LOC, Headache, N/V, retinal hemorrhage, pupil on side of injury may be dilated  Prognosis poor  Between dura and skull  Almost never occurs in children less than 4 y/o. Blunt trauma such as MVA, assault, baseball injury  Delayed onset followed by rapid change in mental status  Headache, Fixed dialated pupils, s/s increased ICP Prognosis good Subdural HematomaEpidural Hematoma

7. Shaken Baby  Physical abuse  Countercoup injury  Subdural Hematoma  Retinal Hemorrhage  Seizure  Check baby for fractures in the rest of their body Countercoup injury

8. Injury by Severity  Concussion or mild brain injury 13-15 GCS  Moderate brain injury 9-12 GCS  Loss of consciousness  Severe Brain Injury 8 or less GCS  Coma  Increased ICP (Ball, Bindler, & Cowen, 2010)

9. Nursing Actions  What is the priority?  Reportable changes  Decrease in coma scale  Restlessness and irritability  Pain  Changes in pupils  Changes in responses, reflexes, movements  Drainage from nose/ears  Increased thirst or urination  Change in vital signs

10. Drowning/Near-Drowning Drowning is the second leading cause of accidental death in children Death occurs from asphyxia while submerged Can occur with even small quantity of water (even as little as a pail of water) Near-drowning: survived at least 24 hours after submersion

11. Cushing’s Triad Bradycardia Widening Pulse Pressure Irregular Respirations Increased SystolicDecreased Diastolic (Ball, Bindler, & Cowen, 2010)

12. Intracranial Infections -Meningitis  More Dangerous  Group B Streptococcus and gram- negative enteric bacilli most likely cause in newborns  Neisseria Meningitidis 2 mo-12 yr  Can also cause meningococcemia  H influenzae B and Strep Pneumoniae are now less common because of vaccination  -Fever, vomiting, irritable, hemorrhagic rash, headache, nuchal rigidity, seizures  Treatment: Antibiotics  Does not appear as ill as the child with bacterial meningitis  Caused by enteroviruses, mumps, vericella  Irritable, fever, lethargy, headache, may have stick neck or back pain  Usually resolves in 3-10 days  Treat with antibiotics until bacterial meningitis is ruled out Bacterial Meningitis Viral Meningitis Both Diagnosed by Lumbar Puncture-LP

13. Intracranial Infections-Reye’s Syndrome  Infection in the brain – acute encephalopathy  May cause permanent tissue damage to brain and liver  Associated with use of aspirin with viral illness such as chicken pox or influenza b  Symptoms: nausea/vomiting, mental changes, seizures, progressive unresponsiveness

14. Hydrocephalus – Cerebrospinal fluid build up  Communicating hydrocephalus – no blockage. Either a problem with over production of CSF or problem with absorption  Non-communicating- obstruction Aqueduct of sylvius

15. Causes of Hydrocephalus  Myelomeningocele  Dandy-Walker Syndrome  Chiari Malformation  Aqueduct of sylvius stenosis  Intraventricular hemorrhage in premature infants  Post infectious meningitis  Brain tumors Congenital malformation Non-Congenital

16. Hydrocephalus- clinical manifestations  Newborns and infants  Bulging fontanels  Increased head circumference  Sun set eyes  Irritability  High-pitched, catlike cry  Visible scalp veins  Children  Headache  Visual disturbance  Nausea/vomiting  Pupils sluggish  Decrease in consciousness  Seizures  Cushing’s Triad Widening pulse pressure Bradycardia Irregular respirations (Ball, Bindler, & Cowen, 2010)

17. Hydrocephalus Treatment  Ventriculoperitoneal shunt (VP Shunt)

18. Seizures  Most common neurologic dysfunction in kids  Caused by malfunctions of brain’s electrical system  Infections or high fever  Chemical imbalance of the body that causes loss of metabolism  Congenital conditions or trauma  Genetic factors and family history  Brain tumors and neurological problems  Habits of the mother like smoking, alcohol consumption, drugs and certain medications (Hockenbery & Wilson, 2010)

19. Types of Seizures  Absence – (3-12 years old)5-10 sec. Lip smacking, staring, twitching, brief loss of consciousness  Partial (focal) – Less than 30 sec., one extremity  Generalized (tonic-clonic or grand mal)  Febrile Dependent  Epilepsy – Chronic disorder

20. Febrile Seizures  Usually higher than 38.9 C or 101F  Usually short in duration. Instruct parents to call 911 if longer than 5 minutes  Use antipyretics and cooling measures (Mayoclinic.com, 2010)

21. Nursing actions with patients with seizures  Before  Where there triggers such as change in temperature, light?  During  Maintain airway  Role to side if possible  Time changes started  Part of the body involved and movement  Incontinence  After  Do they remember what happened? (Ball, Bindler, & Cowen, 2010)

22. Treatment for Seizures  Common pharmacological choices  Ativan -Lorazepan  Diazepam – Diastat (can be given rectally)  Phenobarbital or Phenytoin  Remind parents not to stop once the seizures are controlled until directed by a doctor.  Other types of treatment  Vagal Nerve stimulator  Ketogenic Diet (Ball, Bindler, & Cowen, 2010)

23. Nursing Role: Provide adequate Nutrition Promote safety and physical mobility Maintain Skin Integrity Prevent Constipation Cerebral Palsy (Ball, Bindler, & Cowen, 2010) Abnormal muscle tone, lack of coordination, spasticity. Symptoms very depending on age and type of CNS injury.

24. Spina Bifida  Surgery to close the repair usually occurs within 24-48 hours. Some cases can be repaired in utero.  May need VP shunt.  Ongoing therapy  Mobility-Braces, wheelchair  Neurogenic bowel and bladder

26. References  Ball, J., Bindler, R., & Cowen, K. (2010).Child Health Nursing: Partnering with Children & Families 2 nd Ed. Upper Saddle River, NJ. Pearson.  Hockenberry, M. & Wilson, D. (2010). Wong’s Nursing Care of Infants and Children 8 th Edition. St. Louis, MO. Elsevier.  Mayoclinic.com (2010). Febrile Seizure. Retrieved from http://www.mayoclinic.com/health/febrile- seizure/DS00346/DSECTION=symptoms  Saewyc, E. (2007). Health Promotion of the Adolescent and Family. In Hockenberry, M. & Wilson, D. (Eds.) Wong’s Nursing Care of Infants and Children 8 th Edition (pp. 811- 848). St. Louis, MO. Elsevier.