Pediatric Neurologic

Disorders

Ma. Tosca Cybil A. Torres, RN, MAN

Hydrocephalus
An excess of CSF in the
ventricles or in the
subarachnoid space
Classification
1. Obstructive/ intraventricular
• caused by a block in the passage of fluid.
2. Communicating/ extraventricular
• fluid passes between the ventricles and
spinal cord
Assessment
1. Widened fontanelles 1. s/sx of increased ICP
2. Separates suture 2. Hyperactive reflexes
lines in the skull 3. Strabismus
3. Enlarged head 4. Optic atrophy
diameter 5. Irritable
4. Shiny scalp 6. Lethargic
5. Prominent scalp 7. Failure to thrive
veins
6. “Bossing” of forehead
7. Shrill cry
8. Sunset eyes
 Diagnostics
• Sonogram
• CT scan
• MRI
• Skull X-ray
• Transillumination
 Therapeutic Management
• Ventricular endoscopy
• Ventriculoperitoneal Shunt
 Nursing Diagnoses
• Risk for injury
• Risk of infection
• Risk for ineffective cerebral tissue perfusion
• Risk for impaired skin integrity
• Risk for imbalanced nutrition: less than body
requirements
• Impaired family processes
 Nursing interventions
• Assess infant’s neurologic status closely. Watch for
increasing irritability or lethargy.
• Measure and record head circumference every 4H. Assess
anterior fontanelle for tenseness and bulging.
• Position infant with the head if the bed elevated 15º to 30° and
maintain in neutral position.
• Monitor V/S q2H
• Administer O2 as ordered.
• Monitor I and O. Administer diuretics as ordered.
• Encourage mother to breast-feed. Position properly with head
supported. Avoid flexion or hyperextension.
• If vomiting occurs, encourage mother to attempt to refeed the
infant. If vomiting persists, anticipate the need for enteral or
parenteral nutrition.
 Nursing interventions
• Wash head daily with repositioning q 2H
• Encourage parents to verbalize feelings.
• Teach parents signs and symptoms of
increasing ICP.
 Post operative nursing care
• Elevate head of bed to 30°
• Infants are not turned to lie on the side of the
shunt
• Assess for signs of increasing ICP
• Assess for signs of infection
• Keep NGT in place.
• Introduce fluids gradually after NGT is removed.
• Observe for constipation
Neural Tube Defects
 Anencephaly

Absence of the
cerebral
hemispheres.
 Anencephaly
• Occurs when the upper end of the neural
tube fails to close in early uterine life
• Diagnosed by elevated AFP in maternal
serum or on amniocentesis
• Confirmed by sonogram.
 Anencephaly

100% mortality
rate.
 Microcephaly
• Disorder in which brain growth
is so slow that it fails more than
three standard deviations below
normal on growth charts.
• Causes:
• Intrauterine infection (rubella,
cytomegalovirus, toxoplasmosis)
• Severe malnutrition or anoxia in
infancy
 Spina bifida ("split spine")
• a developmental birth defect involving the neural
tube: incomplete closure of the embryonic neural
tube results in an incompletely formed spinal cord.

• the vertebrae overlying the open portion of the

spinal cord do not fully form and remain unfused
and open
 Spina bifida
Categories:
1. spina bifida occulta
2. spina bifida cystica (myelomeningocele)
3. meningocele

• The most common location of the malformations

is the lumbar and sacral areas of the spinal
cord
Assessment:
• varying degrees of paralysis
• absence of skin sensation
• poor or absent bowel and/or bladder
control
• curvature of the spine (scoliosis)
• most cases there are cognitive
problems
• hydrocephalus
Types
Spina bifida occulta
• Occulta is Latin for "hidden."
• no opening of the back, but the outer part of
some of the vertebrae are not completely
closed
• The skin at the site of the lesion may be
normal, or it may have some hair growing from
it; there may be a dimple in the skin, or a
birthmark
Spina bifida cystica (myelomeningocele)
• most serious and common form
• the unfused portion of the spinal column allows the spinal cord to
protrude through an opening in the overlying vertebrae

• meningeal membranes that cover the spinal cord may or may not form a
sac enclosing the spinal elements
 Meningocele
• least common form
• Meninges covering the spinal cord herniate through
the unformed vertebrae
• Protrusion may be covered with a layer or skin just
the clear dura
Encephalocele

Cranial meningocele or
myelomeningocele.
Most often occur in
the occipital area
 Medical-Surgical Treatment
• no cure for nerve damage
• Closure of the opening on the back
• if spina bifida is detected during
pregnancy, then open fetal surgery
can be performed
 Nursing diagnoses
• Risk for infection
• Risk for impaired cerebral tissue perfusion
• Risk for impaired skin integrity
• Impaired physical mobility
 Pre-operative care
• Place infant in supine
• If in side lying, place a towel or pillow in between the
infant’s legs
• Place a piece of plastic below the meningocele on the
child’s back like an apron and secure it with a tape
• Apply a sterile wet compress of saline, antiseptic, or
antibiotic gauze over the lesion
• Keep infant warm assess for seepage of any clear liquid
 Post operative care
• Place infant in prone until the skin incision
is healed
• Same careful precautions are observed.
• Assess for signs of increased ICP
Cerebral Palsy
 Cerebral Palsy
A group of nonprogressive
disorders of upper motor
neuron impairment that
result in motor dysfunction.
 Cerebral Palsy
• Cause is UNKNOWN.
• Associated with low birth weight, prebirth,
or birth injury
• Intrauterine anoxia and direct birth injury
may contribute to the development of CP
• Occurs in 2:1000 births
 Types of Cerebral Palsy
Spastic
S/Sx:
• Hypertonic muscles
• Abnormal clonus
• Exaggerated DTRs
• Abnormal reflexes (eg. Babinski)
• When held in ventral position, arching of back and abnormal
extension of arms and legs are observed
• Failure to demonstrate parachute reflex when lowered
suddenly
• Scissor’s gait
• Hemiplegia, tetraplegia or paraplegia
• astereognosis
 Types of Cerebral Palsy

Dyskinetic or Athetoid
S/Sx:
• Abnormal involuntary movement
• Athetoid means “wormlike”
• Early in life, child is limp and flaccid. Later, in
place of voluntary movements, the child makes
slow, writhing motions.
• Drooling
• Speech impairment
• Choreoid movements
• Disordered muscle tone (dyskinetic)
 Types of Cerebral Palsy
Ataxic
S/Sx:
• Awkward, wide based gait
• Unable to perform finger-to-nose exam or perform
rapid, repetitive movements or fine coordinated
motions.

Mixed
 Assessment
• History
• PE-all forms of CP may have sensory
alterations
• Strabismus
• visual perception problems
• Visual field defects
• Speech problems
• deafness
25% to 75% of children
with CP are cognitively
challenged.
50% have recurrent
seizures.
 Physical findings that suggest CP

• Delayed motor development

• Abnormal head circumference
• Abnormal postures
• Abnormal reflexes
• Abnormal muscle performance or tone
 Nursing Diagnoses
• Deficient Knowledge
• Risk for disuse syndrome
• Risk for delayed growth and development
• Risk for imbalanced nutrition: less than body
requirements
• Risk for self-care deficit
• Impaired verbal communication
 Nursing Intervention

Help parents
understand their
child’s condition
 Nursing Intervention

Assist in ambulation.
Prevent contractures.
Choose toys and activities
appropriate to the child’s
intellectual, developmental,
and motor levels, NOT
chronologic age.
Ensure adequate
nutrition.
Provide alternative form of
communication
SPINAL CORD INJURY
Causes:

• Trauma
• Tumor
• Ischemia
• Developmental disorders
• Neurodegenerative diseases
• Transverse myelitis
• Vascular malformations
 SPINAL CORD INJURY

Effects are less severe

the lower the injury.
 Manifestations
• C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.
C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity,
complete dependency for ADLs.
C-6 to C-7: Tetraplegia with some arm/hand movement allowing some
independence in ADLs.
C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing
independence.
T-2 to L-1: Paraplegia with intact arm function and varying function of
intercostal and abdominal muscles.
L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder
dysfunction.
 Diagnostic:
1. Clinical evaluation: absence of reflexes,
flaccidity, loss of sensation below injury level
2. Spinal x-ray: vertebral fractures, bony
overgrowth
3. CT scans/MRI: evidence of cord compression
and edema or tumor formation
SPINAL CORD
SYNDROME
 Central Cord Syndrome

• Central cord syndrome is a form of incomplete spinal cord injury

characterized by impairment in the arms and hands and, to a
lesser extent, in the legs.

• This is also referred to as inverse paraplegia, because the hands

and arms are paralyzed while the legs and lower extremities work
correctly.

• This condition is associated with ischemia, hemorrhage, or

necrosis involving the central portions of the spinal cord
 Anterior cord syndrome

• an incomplete spinal cord injury.

• Below the injury, motor function, pain sensation,
and temperature sensation is lost; touch,
proprioception and vibration sense remain
intact..
 Brown-Séquard Syndrome

• usually occurs when the spinal cord is

hemisectioned or injured on the lateral side. On
the ipsilateral side of the injur, there is a loss of
motor function, vibration, and light touch.
Contralaterally, there is a loss of pain,
temperature, and deep touch sensations.
 Assessment
ACTIVITY/REST

May exhibit: Paralysis of muscles (flaccid during

spinal shock) at/below level of lesion
Muscle/generalized weakness (cord contusion
and compression)
 Assessment
CIRCULATION
May report: Palpitations
Dizziness with position changes
May exhibit: Low BP, postural BP
changes, bradycardia
Cool, pale extremities
Absence of perspiration in affected area
 Assessment
ELIMINATION

May exhibit: Incontinence of bladder and

bowel
Urinary retention
Abdominal distension; loss of bowel
sounds
Melena, coffee-ground
emesis/hematemesis
 Assessment
EGO INTEGRITY

May report: Denial, disbelief, sadness,

anger
May exhibit: Fear, anxiety, irritability,
withdrawal
 Assessment
FOOD/FLUID

May exhibit: Abdominal distension; loss of

bowel sounds (paralytic ileus)
 Assessment
HYGIENE

May exhibit: Variable level of dependence

in ADLs
 Assessment
NEUROSENSORY

May report: Absence of sensation below area of injury, or opposite

side sensation
Numbness, tingling, burning, twitching of arms/legs
May exhibit: Flaccid paralysis (spasticity may develop as spinal shock
resolves, depending on area of cord involvement)
Loss of sensation (varying degrees may return after spinal shock
resolves)
Loss of muscle/vasomotor tone
Loss of/asymmetrical reflexes, including deep tendon reflexes
Changes in pupil reaction, ptosis of upper eyelid
Loss of sweating in affected area
 Assessment
PAIN/DISCOMFORT

May report: Pain/tenderness in muscles

Hyperesthesia immediately above level of
injury
May exhibit: Vertebral tenderness,
deformity
 Assessment
RESPIRATION

May report: Shortness of breath, “air hunger,”

inability to breathe
May exhibit: Shallow/labored respirations;
periods of apnea
Diminished breath sounds, rhonchi
Pallor, cyanosis
 Assessment
SAFETY
May exhibit: Temperature fluctuations (taking on
temperature of environment)
SEXUALITY
May report: Expressions of concern about return
to normal functioning
May exhibit: Uncontrolled erection (priapism)
Menstrual irregularities
 Nursing Diagnoses
• Ineffective breathing pattern
• High risk for disuse syndrome
• Impaired physical mobility
• Altered sensory perception
• Risk for infection
• Altered elimination
• Risk for impaired skin integrity
• Ineffective individual coping
• Powerlessness
 NURSING PRIORITIES

1. Maximize respiratory function.

2. Prevent further injury to spinal cord.
3. Promote mobility/independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of patient/SO.
6. Provide information about injury, prognosis and
expectations, treatment needs, possible and preventable
complications.
 Therapeutic management:
a. Surgery- laminectomy or fusion for decompression and
stabilization, wound debridement, placement of cervical tongs or
halo traction for stabilization, tracheotomy for mechanical
ventilation as needed

b. medications: massive corticosteroid therapy to improve outcome,

vasopressors for shock, prophylactic antibiotics for open wounds,
analgesics for pain, anticoagulants to prevent emboli and
thrombus formation, anti anxiety to reduce emotional stress.
 Therapeutic management
c. General:
a. initial:
1. spinal stabilization with backboard or cervical collar on initial
transport
2. MV if necessary
3. monitor cardiac status, blood gases, neuro V/S, I&O, V/S
4. maintain skeletal traction and body alignment
5. reposition and turn every 2hrs
6. passive ROM
7. monitor bowel and bladder function, skin integrity and avoid
extreme temperatures
 Therapeutic management
b. Long term
1. bowel training
2. bladder training
3. PT to diminish orthostatic hypotension, increase strength and
endurance, decrease muscle spasticity, prevent contractures
4. OT to aid adaptation of ADLs
5. respiratory therapy
6. recreational therapy
7. speech therapy
8. case mgt for needed resources
9. long term medical ff up
10. counseling of individual and family support adaptation
 Prevention and promotion:

1. Daily skin inspections

2. Diligent use of bowel and bladder programs to
prevent bowel obstruction and UTI
3. Influenza and pneumonia vaccines to prevent
respiratory complications
4. Early recognition and treatment of urinary tract
and respiratory problems
 DISCHARGE GOALS
1. Ventilatory effort adequate for individual needs.
2. Spinal injury stabilized.
3. Complications prevented/controlled.
4. Self-care needs met by self/with assistance, depending on
specific situation.
5. Beginning to cope with current situation and planning for
future.
6. Condition/prognosis, therapeutic regimen, and possible
complications understood.
7. Plan in place to meet needs after discharge.
Infection of the CNS
 Bacterial Meningitis

Infection of the cerebral

meninges
Causes:

• RTI
• Lumbar puncture
• Skull fracture
• Meningocele
• Myelomeningocele
 Assessment
• History
• S/Sx:
• Irritable
• Headache
• Seizure/shock
• Brudzinski’s sign
• Kernig’s sign
• Opisthotonos
• Cranial nerve paralysis (III & VI)
• Papilledema
Neonate

• Bulging and tense fontanelles

• Poor sucking
• Weak cry
• Lethargy
• Apnea
• Seizures
 Diagnostics
• Lumbar tap with CSF analysis
• Blood culture
• Ct scan
• MRI
• Ultrasound
 Therapeutic management
• Antibiotic therapy (IV/intrathecal)
• Corticosteroid
• Osmotic diuretic
 Nursing diagnoses
• Pain
• Risk for ineffective cerebral tissue
perfusion
• Altered sensory perception
 Nursing interventions
• Position in supine without pillows
• Place in isolation
• Ensure strict medication compliance
• Observe for signs and symptoms of increasing
ICP
• Monitor I and O with specific gravity of urine
• Assess senses
 Encephalitis

Inflammation of the brain tissue and

possibly the meninges as well
 Assessment
S/Sx
Symptoms begin gradually or suddenly
• Headache
• Fever
• Nuchal rigidity((+) brudzinski’s and Kernig’s sign)
• Ataxia
• Muscle weakness or paralysis
• Diplopia
• Confusion
• Irritability
 Therapeuic Management
• Treatment is primarily supportive
• Antipyretic
• Antibiotic therapy
• Corticosteroid
• Osmotic diuretic
 Reye’s Syndrome
• Acute encephalitis with accompanying fatty infiltration of the
liver, heart, lungs, pancreas, and skeletal muscle.
• Occurs in children 1-18 years of age
• Both sex are equally susceptible
• Cause Unknown but generally occurs after a viral infection
such as varicella and influenza
• If child was treated with salicylate such as acetylsalicylic acid
(aspirin) during the viral infection
Neurologic Diseases that result from
viral infections or neurotoxins
 Postpoliomyelitis Syndrome
• Complication of previous poliomyelitis virus (epidemic occurred in USA
during 1940’s and 1950’s); persons who recovered are re-experiencing
manifestation of acute illness in their advanced age
• Pathophysiology: Process is unknown
• Manifestations: Fatigue, muscle and joint weakness, loss of muscle
mass, respiratory difficulties, and pain
• Diagnosis: By history and physical examination
• Treatment: Involves physical therapy and pulmonary rehabilitation
• Nursing Care: Involves emotional support and interventions to deal with
dysfunction; ADL, safety are including in interventions
 Rabies
Rhabovirus infection of CNS transmitted by
infected saliva that enters the body through bite
or open wound
• Critical illness almost always fatal
• Source often is bite of infected domestic or wild
animal
• Incubation is 10 days to years
 Rabies
Manifestations occur in stages
• Prodromal: wound is painful, various paresthesias,
general signs of infection; increased sensitivity to light,
sound, and skin temperature changes
• Excitement stage: periods of excitement and quiet;
develops laryngospasm and is afraid to drink
(hydrophobia), convulsions, muscle spasms and death
usually due to respiratory failure
 Rabies
Collaborative Care
• Animal that bit person is held under observation
for 7 – 10 days to detect rabies
• Sick animal are killed and their brains are tests
for presence of rabies virus
• Blood of client may be tested for rabies
antibodies
 Rabies
Post-exposure treatment
• Rabies immune globulin (RIG) is administered for passive
immunization
• Client often has local and mild systemic reaction;
treatment is over 30 days
Treatment of client with rabies: involves intensive care
treatment
Health Promotion
• Vaccination of pets
• Avoid wild animals, especially those appearing ill
• Follow up care for any bites
 Tetanus (lockjaw)
Disorder of nervous system caused by neurotoxin from Clostridium
tetani, anaerobic bacillus present in the soil
• Contract disease from open wound contaminated with dirt, debris
• Has high mortality rate
Incubation is usually 8 – 12 days
Manifestations
• Stiffness of jaw and neck and dysphagia
• Spasms of jaw and facial muscles
• Develops generalized seizures and painful body muscle spasms
• Death occurs from respiratory and cardiac complications
 Tetanus (lockjaw)
Diagnosis is made on clinical manifestations
Clients with disease are treated in intensive care with
antibiotics, chlorpromazine (Thorazine) and diazepam
(Valium ) for muscles spasms
Health Promotion
• Active immunization with boosters given at time of
exposure
• Passive immunization is given to persons who are not
adequately immunized
 Botulism
Food poisoning caused by ingestion of food contaminated
with toxin from Clostridium botulinum, anaerobic
bacteria found in soil
• Contracted by eating contaminated foods usually
improperly canned or cooked
• Untreated death rate is high
Pathophysiology: Bacteria produce a toxin, which blocks
release of acetylcholine from nerve endings causing
respiratory failure by paralysis of muscles
 Botulism
Manifestations
• Visual disturbances
• Gastrointestinal symptoms
• Paralysis of all muscle groups
• Effecting respiration
Diagnosis
• Based on clinical picture
• Verified by laboratory analysis of client’s serum
and stool
• Testing the suspected food
 Botulism
Treatment
• Administration of antitoxin
• Supportive treatment including mechanical ventilation
and systemic support in intensive care unit
Health Promotion
• Teaching clients to process foods properly when home
canning
• Boiling foods for 10 minutes which destroys the toxin
• Not eating spoiled foods
End of Concept