Elective_neurologic Reporting 1

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NEUROLOGIC ALTERATIONS

1. SEIZURES

A seizure is an involuntary contraction of muscle caused by abnormal electrical braindischarges.

Etiology: Idiopathic

Secondaryo Birth trauma

o Infection

o Vascular abnormalities

o Trauma

o Tumors

Classification of Seizures:Partial (Focal) Seizures Simple partial seizures ( no altered level of consciousness)

Complex partial (psychomotor ) seizures (some impairment or alteration in thelevel of consciousness)

Generalized SeizuresTonic-clonic seizures (formerly grand-mal)

Tonic- sudden onset of muscle rigidity

Clonic- sudden onset of jerky movements.

Absence seizures (formerly petit mal)- involuntary blinking; with loss ofconsciousness

Atonic seizures (formerly drop attacks)- sudden loss of muscle tone

Myoclonic seizures

Infantile spasms- characterized by very rapid movements of the trunk with sudden

strong contractions of most of the body, including flexion and adduction of thelimbs; commonly seen in infants and toddlers.Others: Febrile seizures- seizures associated with high fever (102F to 104F / 38.9C to

40.0C) that is most common among preschool children, although they canoccur as early as 3 months or as late as 7 years of age. It shows an activetonic-clonic pattern, which lasts for 15-20 seconds.

Status epilepticus- a seizure that lasts continuously for longer than 30 minutes or aseries of seizures from which the child does not return to his/her previous levelof consciousness. This is an emergency situation requiring immediatetreatment. Otherwise, exhaustion, respiratory failure, permanent brain injury ordeath may occur.

Assessment:Thorough pregnancy history

Complete physical and neurologic examination

Lumbar puncture- for ruling out meningitis or bleeding into the CSF

CT scan/ MRI/ skull radiograph/ EEGNursing Management:1. Seizure precautions:

a. Side rails up and padded

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b. Side-lying/ supine with the head to the sidec. Suction secretionsd. Support the head and each extremitye. Sharps and stray objects- put them awayf.Stay with the patient-Monitor onset, duration, frequency, interval, and aura

of seizure.

2. For febrile seizures:a. Teach parents that after the seizure subsides, they should sponge the child

with tepid water to reduce the fever quickly.b. Advise them not to put the child in the bathtub; however, because it would

be easy for the child to slip under water should a seizure occur.c. Applying alcohol or cold water is not advisable. Extreme cooling causes

shock to an immature nervous system; in addition, alcohol can beabsorbed by the skin or the fumes can be inhaled in toxic amounts,compounding the childs problem.

d. Parents should not attempt to give oral medications such asacetaminophen, because the child will be in a drowsy, or postictal stateafter the seizure and might aspirate the medicine.

e. If attempts to put the childs temperature down is unsuccessful, adviseparents to put washcloths on the childs forehead, axillary and groin areas,and transport the child, lightly clothed, to a health care facility forimmediate evaluation.

f. Reassure parents that febrile seizures do not lead to brain damage and thatthe child is completely well afterward.

Pharmacotherapy:Infantile spasms

Parenteral adrenocorticotropic hormone (ACTH) and pyridoxine (Vit. B6)

Valproic acid/ topimarate (Topamax)Complex partial (psychomotor) seizures

Carbamazepine( tegretol)- can lead to neutropenia; WBC count shoud be monitored. Valproic acid (Depakene)

Phenytion (Dilantin)

Phenobarbital* If medications are not effective, surgery to remove the epileptogenic focus may beattempted.

2. STRUCTURAL ABNORMALITIES2.1. HYDROCEPHALUS- an excess of CSF in the ventricles or the subarachnoid space. It can causeenlargement of the skull.Types:

Communicating Hydrocephalus or Extraventricular Hydrocephalus-if fluid canreach the spinal cord

Obstructive Hydrocephalus or Intraventricular Hydrocephalus there is ablock to the passage of fluid.

Congenital Acquired

Causes:

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1. Overproduction of fluid by a choroid plexus in the first or second ventricle.(rare)

2. Obstruction of the passage of fluid in the narrow aqueduct of Sylvius (commoncause)

3. Interference with the absorption of CSF from the subarachnoid space if aportion of of the subarachnoid membrane is removed, as occurs with surgery

for meningocele, or after extensive subarachnoid hemorrhage, when portionsof the membrane absorption surface become obscured.

Assessment: Abnormal rate of head growth

Bulging fontanelle

Tense anterior fontanelle (often bulging and nonpulsatile)

Dilated scalp veins

Macewens sign (cracked pot)

Frontal bossing

Setting sun sign

Sluggish and unequal pupils Irritability and lethargy with varying LOC

Abnormal infantile reflexes

Possible cranial nerve damage

Diagnosis: Level II ultrasonography of the fetus will allow a prenatal diagnosis. (Transuterine

placement of ventriculoamniotic shunts during late pregnancy is still being

developed as a treatment modality).

CT scan will diagnose most cases postnatally.

MRI can be used if a complex lesion is suspected.Nursing Management:

Teach the family about the management required for the disorder

oTreatment is surgical by direct removal of an obstruction and insertion of

shunt to provide primary drainage of the CSF to an extracranialcompartment, usually peritoneum (ventriculoperitoneal shunt)

The major complications of shunts are infections and malfunction

Other complications include subdural hematoma caused by a toorapid reduction of CSF, peritonitis, abdominal abscess, perforationof organs, fistulas, hernias and ileus.

o A third ventriculostomy is a new nonshunting procedure used to treat

children with hydrocephalus.

Provide preoperative nursing careo Assess head circumference, fontanelles, cranial sutures, and LOC; check

also for irritability, altered feeding habits and a high-pitched cry.o Firmly support the head and neck when holding the child.

o Provide skin care for the head to prevent breakdown.

o Give small, frequent feedings to decrease the risk of vomiting.

o Encourage parental-newborn bonding.

Provide Postoperative nursing care (nursing interventions are the same as thosefor increased ICP)

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o Assess for signs of increased ICP and check the following; head

circumference (daily), anterior fontanelle for size and fullness andbehavior.

o Administer prescribed medications which may include antibiotics to

prevent infection and analgesics for pain.o Provide shunt care

Monitor for shunt infection and malfunction which may becharacterized by rapid onset of vomiting, severe headache,irritability, lethargy, fever, redness along the shunt tract, and fluidaround the shunt valve.

Prevent infection (usually from Staphylococcus epidermis orStaphylococcus aureus)

Monitor for shunt overdrainage (headache, dizziness and nausea).Overdrainage may lead to slit ventricle syndrome whereby theventricle become accustomed to a very small or slitlikeconfiguration, limiting the buffering ability to increased ICPvariations.

Teach home careo Encourage the child to participate in age-appropriate activities as

tolerated. Encourage the parents to provide as normal lifestyle aspossible. Remind both the child and parents that contact sports areprohibited.

o Explain how to recognize signs and symptoms of increased ICP. Subtle

signs include changes in school performance, intermittent headache,and mild behavior changes.

o Arrange for the child to have frequent developmental screenings and

routine medical checkups.

2.2. NEURAL TUBE DISORDERS

Spina Bifida- latin word for divided spine; often used as a collective term for allspinal cord disorders, but there are well-defined degrees of spina bifida involvement,and not all neural tube disorders involve the spinal cord. All of these disorders,however, occur because of lack of fusion of the posterior surface of the embryo inthe early intrauterine life. They can be compared with cleft lip or cleft palate- theseare also closure disorders.

Types:a. Anencephaly

absence of the cerebral hemisphere.

occurs when the upper end of the neural tube fails to close in early intrauterinelife. It is revealed by an elevated level of AFP in the maternal serum or onamniocentesis and confirmed by a sonogram.

it is also called asAprosencephaly with open cranium.

it is one of the most common forms of neural tube disorders.Etiology: environmental toxins (such as lead, chromium, mercury, and nickel)

lack of folic acid intake of the mother.

b.Microcephaly

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a disorder in which brain growth is so slow that it falls more than threestandard deviations below normal on growth charts.

Etiology: intrauterine infection( rubella, cytomegalovirus, toxoplasmosis)

severe malnutrition

anoxia in early infancy

Assessment: appearance of the baby's head is very small

high-pitched cry

poor feeding

seizures

increased movement of the arms and legs (spasticity)

developmental delays

mental retardation

c. Spina Bifida Occulta Occurs when the posterior laminae of the vertebra fail to fuse. This occurs

most commonly at the fifth lumbar or first sacral level but may occur at anypoint along the spinal canal.

May be noticeable as a dimpling at the point of poor fusion; abnormal tufts ofhair or discolored skin may be present.

d. Meningocele- If the meninges covering the spinal cord herniated throughunformed vertebrae, a meningocele occurs. The anomaly appears as a protrudingmass, usually approximately the size of an orange, at the center of the back. It

generally occurs in the lumbar region although it might be present anywherealong the spinal canal. The protrusion may be covered by a layer of skin or onlythe clear dura mater.

e. Myelomeningocele- The spinal cord and the meninges protrude through thevertebrae the same as with meningocele. The difference is that the spinalcord ends at the point, so motor and sensory functions is absent beyondthis point. The child will have flaccidity and lack of sensation of the lowerextremities and loss of bowel and bladder control. The infants leg are lax, and heor she does not move them; urine and stools continually dribble because of lack ofsphincter control. They have accompanying talipes disorders and development hipdysplasia. Hydrocephalus accompanies myelomeningocele due to the lack of

subarachnoid membrane for CSF absorption.

f. Encephalocele- Occurs when meningeal and cerebral tissue protrudes in a sacthrough a defect in the skull, with the occiput being the most common site. Whenpossible, the brain is placed back in the skull. Many infants have hydrocephalus. Inmild forms there is little or no residual neurologic impairment.

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NURSING MANAGEMENT:Teach the family about the management required for this disorder.

o No treatment is indicated for spina bifida occulta unless there is

neurologic damage. If a sinus is present, it may need to be closed.o Meningocele requires closure as soon after birth is possible. The child

should be monitored for hydrocephalus, meningitis, and spinal corddysfunction.

o Myelomeningocele requires a multidisciplinary approach. There is no cure.

Closure is performed within 24 hours to minimize infection and preventfurther damage to the spinal cord and roots; skin grafting may benecessary. Shunting is performed for hydrocephalus and antibiotics areinitiated to prevent infection. The child will need correction ofmusculoskeletal deformities and management of urologic and bowelcontrol problems.

During the newborn period, assess and monitor vital signs, measure headcircumference, and assess neurologic status, including signs of ICP.

Monitor the child throughout childhood to detect the true extent of the disorder.

Administer prescribed medications. Antibiotics, anti-convulsants,anticholinergics Prevent infection and injury.

o Preoperatively, apply a sterile dressing, constantly moistened with saline,

to the lesion. Use protective devices and handle the infant with care.o Preoperatively, and postoperatively, perform the following:

Maintain a sterile dressing.

Examine the dressing for leakage.

Avoid placing a diaper or other covering directly over the lesion(could cause fecal contamination).

Monitor the child for signs of local infection and meningitis.o

Position the infant in a prone or side-lying position to prevent contaminationby stool or urine.oPrevent hip subluxation by maintaining legs in abduction with pads between

the knees and the feet in a neutral position with a roll under the ankles.o Prevent skin breakdown by padding the bony prominences.

Prevent trauma from increased ICP because many children have associatedhydrocephalus.

oMonitor head circumference and observe for signs of increased ICP

oMinimize stress( increases ICP)

Prevent urinary complications.o Assess urologic status.

o Instruct the child and family on self-catheterization.

o Prevent urinary tract infectionsoMaintain urinary diversion of the child has this procedure.

Prevent trauma from latex allergy.o Screen for latex allergy.

o Administer antihistamines or steroids before surgery or procedures.

o Ensure that the child and family are aware of the childs allergy to latex and

that they will inform medical and school personnel.oMaintain a latex-free environment.

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Prevent injury due to neuromuscular impairment.o Carefully monitor the childs skin condition.

o Promote mobility and turn the child frequently.

o Use caution in positioning the child because a lack of sensation makes the

child unable to detect potential skin irritants.

Promote optimal bowel functioning.o Instruct the parents on colon training which consists of timing, diet,exercise, posture and rectal stimulation.

o Encourage a diet high in fiber and low in carbohydrates.

o Exercise the lower part of the body.

o Use the knee-chest position to put pressure on the abdomen and aid in

bowel evacuation.o Use rectal stimulation with digit or suppository.

Promote family coping.o Explain the essentials of infant care.

o Promote parent-infant relationship by encouraging parental participation

with feeding, cuddling and stimulation.o Emphasize infection prevention and recognition of early S/Sx of infection

and increased ICP.o Explain and demonstrate bladder and bowel management and skin care.

oDiscuss the effects of immobilization and how to deal with them.

oDiscuss the need for lifelong care.

o Encourage as much normalcy as possible.

o Carefully assess the familys ability to care for the child and refer them for

further assistance is needed.o Encourage parents to verbalize their fear.

Prevent the development of neural tube defects.

3. INFECTIONS3.1. Bacterial Meningitis- an infection of the cerebral meninges that occurs most often in children youngerthan 24 months of age.-caused frequently by Streptococcus pneumonia or group B Streptococcus. Inchildren younger than 2 months of age, group B Streptococcus and Escherichia coliare the common causes.Assessment:

2-3 days of URTI

Irritability because of headache

Seizures

Signs of meningeal irritability ( Brudzinski and Kernig signs, opisthotonos, cranialnerve paralysis

Changes in the fontanelleso Open- bulging and tense

o Close- development of papilledema

Diagnosis LP with CSF analysis

o Results:

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Increased WBC

Increased protein levels

Lowered glucose level

CT scan/ MRI/ Ultrasound- for abscesses.Nursing management:

Antibiotic therapy as indicated by sensitivity studieso Usually given IV for rapid effect, but intrathecal injections may be

necessary to reduce infection.o For H. Influenzae- ampicillin is the DOC

o Cephalosporin(Clarofan)/ Ceftriaxone (Rocephin)- 8-10 days

o Corticosteroids: dexamethasone

o Osmotic diuretic: mannitol

Place children on respiratory precaution for 24 hours.

3.2. GROUP B -HEMOLYTIC STREPTOCOCCAL MENINGITIS- Major cause is group B - hemolytic streptococci. It is contracted either in utero or from secretions in the birth canal at birth.

- Late-onset type often leads to meningitis instead of pneumonia.

3.3. ENCEPHALITIS- an inflammation of brain tissue and possibly, the meninges as well.- can result from direct invasion of the CSF during lumbar puncture.Assessment:

Headache

High temperature

Signs of menigeal irritation (nuchal rigidity, Brudzinski and Kernigs sign)

Ataxia

Muscle weakness or paralysis

Diplopia Confusion and irritability

Nursing Management:Take and record vital signs frequently, because brainstem involvement can

affect cardiac or respiratory rates.

Follow-up care after hospitalization is important for the childs rehabilitation andto help parents deal with their grief, shock and anger.

Monitor the patients response to medications and observe for adverse reactions.

Monitor neurologic status closely. Watch for subtle changes, such as behavior orpersonality changes, weakness, or cranial nerve involvement.

Monitor fluid intake and output to ensure adequate hydration.

Maintain quiet environment and provide care gently, to avoid excessivestimulation and agitation, which may cause increase ICP.

Maintain seizure precautions; pad side rails of bed and have airway and suctionequipment available at bedside.

Maintain standard precautions and additional isolation according to hospitalpolicy to prevent transmission.

Administer antipyretics and other cooling measures as indicated.

Provide fluid replacement through I.V. lines as needed.

Reorient patient frequently.

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Provide supportive care if coma develops; may last several weeks.

Encourage significant others to interact with patient with even while in coma andto participate in care to promote rehabilitation.

3.4. REYES SYNDROME- is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs,pancreas and skeletal muscle. It occurs in children from 1-18 years of age regardlessof gender.

Etiology: Idiopathic

Viral infection: varicella, influenzaAssessment:

Lethargy

Vomiting

Agitation

Anorexia

Confusion

Combativeness

Hypothrombinemia

Hypoglycemia Elevated blood ammonia levels

Diagnosis: Elevated liver enzyme levels (alanine aminotransferase and

aspartate aminotransferase )

normal direct bilirubin

elevated serum ammonia

delayed prothrombin time and PTT

decreased blood glucose

elevated BUN

elevated serum amylase

elevated short-chain fatty acids elevated WBC

Nursing Management: Avoid taking aspirins.

Hypertonic IV glucose solutions

Intensive supportive nursing

Mechanical ventilation

Close Monitoring

3.5. GUILLAIN-BARR SYNDROME( inflammatory polyradiculoneuropathy)- a perplexing syndrome that involves both motor and sensory portions of peripheral

nerves. It affects both sexes and occurs most often in school-age children andadolescents.Etiology:

Unknown, possibly autoimmune

Often develops after viral infections, immunizations, fever, injury and surgeryAssessment:

Peripheral neuritis several days after the primary infection

tendon reflexes are decreased or absent

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ascending muscle paralysis and paresthesiaNursing management:

Prevent all of the effects of extreme immobility while guarding respiratory function.

Closely monitor the childs cardiac and respiratory effort.

An indwelling catheter is usually inserted to monitor urine output.

Enteral or total parenteral nutrition may be used to support protein and carbohydrateneeds.

If the child has discomfort from neuritis, adequate analgesia should be administered.

To prevent muscle contractures and effects of immobility, the child should havepassive range-of-motion exercises every 4 hours.

Turning and repositioning every 2 hours is also important in maintaining skinintegrity.

Provide adequate stimulation for the long-weeks when the child is unable to performany care for himself or herself.

4. NEUROLOGIC INJURIES4.1. HEAD INJURY

- can be anything from a mild bump to severe damage to the head. The termencompasses everything from a minor laceration to diffuse brain injury.- one of the most common causes of disability and death in children.Types:a. Skull Fracture- depends on the velocity, force, and mass of object; on the area ofskull involved; and on the age of the child.

Subtypes: Linear fractures- resembles a thin line; usually no other signs than those

found on x-ray film; child is observed for neurologic changes, and the fractureheals on its own.

Comminuted fractures- cracked eggshell appearance Depressed fractures- skull is indented at the point of impact, which may

cause compression, shifting of the brain tissue, and intracranial damage.

Basal fractures- most serious and consists of a linear fracture through thebase of the skull.

Diastatic fracture- occur along a suture line; usually do not occur at the siteof impact and are frequently seen in newborns.

b. Brain injury- signs and symptoms depend on the location and severity of thehead injuryc. Hematomas- epidural( between skull and dura) and subdural (between duraandarachnoid layer) are the most common types of hematoma.

Etiology: Motor vehicle accidents

Abuse

Falls

Birth traumaRisk factors:

Seizure disorders

Gait instability

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Cognitive delays

Poor judgment

Alcohol and drug useAssessment:

Altered LOC changes

Increased ICP ForBasal fracture

o Rhinorrhea/ otorrhea

oHemotympanum

o Raccoon eyes- periorbital ecchymosis

o Battle sign- postmastoid ecchymosis

For Brain injury- may occur up to 2 years after the injuryo Post-traumatic syndromes(seizures, hydrocephalus, or focal neurologic

deficits)o Metabolic complications( diabetes insipidus, hyponatremia,

hypernatremia, hyperglycemic hyperosmolar states)

Epidural hematomao Rapid onset; life threatening and characterized by rapid deterioration,

headache, seizures, coma and brain herniation with compression of thebrain stem.

Subdural hematomaoOccurs within 48 hours of injury and is characterized by headache,

agitation, confusion, drowsiness, decreased LOC and increased ICP.

Head traumao Loss of consciousness

oTransient confusion

o Listlessness and irritability

o Pallor and vomiting

Signs of Injury Progressiono Altered mental status

o Increasing agitation

oDevelopment of focal signs

oMarked changes in vital signs

oHyporesponsive, hyperresponsive or nonexistent reflexes

Diagnosis: Radiography- reveal fracture

CT/ MRI scan- used to view brain injuries and hematoma

CBC, blood chemistries, toxicology screening, urinalysisNursing Management:

Promote prevention, especially falls. Urge children to wear bike helmets,use seat belts and practice safe driving. Perform the following neurologic assessments:

o Cerebral functioning (alertness, orientation, memory and speech)

o Vital signs( check for increased BP and decreased pulse)

oMotor and sensory function( must be appropriate for childs

developmental age)

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Assess for other injuries, especially cervical injuries. Do not move thechild until the possibility of cervical injury has been ruled out or managed.Raise the head of the bed to 30 if there is no cervical injury.

Monitor for complications which can develop rapidly.o Monitor vital signs and neurologic status frequently.

o Check for increased ICP.

o Check for drainage from the nose and ears.

Use planning and intervention strategies for increased ICP. Provide child and family teaching.

oTeach signs of increased ICP.

oWhen warranted, teach that seizures may occur for up to 2 years after the

injury.oWhen warranted, explain that the child may also have extensive damage

requiring rehabilitation.o Encourage the child and family to verbalize their concerns.

5. CEREBRAL PALSY

- a group of non-progressive disorders of upper motor neuron impairment that resultin motor dysfunction. Affected children may also have speech or ocular difficulties,seizures, cognitive challenges, or hyperactivity.Etiology:

IDIOPATHIC

Low birth weight

Premature birth

Birth injury

Nutritional deficiencies

Drugs

Maternal infections

Direct birth injury

*caused by brain anoxia leading to cell destruction of the motor tracts. Ifintrauterine anoxia occurs for some reason, this type of brain cell dysfunction mayresult.

Types of Cerebral Palsy:Spastic typeThe child has hypertonic muscles, abnormal clonus, exaggeration of deep tendon

reflexes, abnormal reflexes such as a positive Babinski reflex, and continuationof neonatal reflexes, such as tonic neck reflex, past the age at which theseusually disappear.

Dyskinetic or Athenoid type Involves abnormal involuntary movement. Early in life, the child is limp and

flaccid. Later, in the place of voluntary movement, he or she makes slow,

writhing motions. This may involve all four extremities, plus the face, neck, andtongue. Because of poor tongue and swallowing movements, the child droolsand speech is difficult to understand. With emotional stress, the involuntarymovements may become irregular and jerking (choreoid) with disorderedmuscle tone (dyskinetic).

Ataxic type Children have an awkward, wide-based gait. They are unable to perform finger-

to-nose test or to perform rapid, repetitive movements (tests of cerebellarfunction) or fine coordinated motions.

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Mixed type Some children show symptoms of both spasticity and athenoid movements.

Ataxic and athenoid movements also may be present together. Thiscombination results in a severe degree of physical impairment.

Clinical Manifestations: delayed gross motor development (delay in all motor accomplishments; delay

becomes more profound as the child grows)

sensory alterations ( strabismus, refractive disorders, visual perceptionproblems, visual field defects, speech disorders)

attention deficit or autism

deafness caused by kernicterus in connection with athetoid CP.

abnormal motor performance (e.g. early dominant hand preference, abnormaland asymmetrical crawl, poor sucking, feeding problems or persistent tonguethrust)

alterations of muscle tone (e.g. increased or decrease resistance to passivemovements, child feels stiff when handling or dressing, difficulty in diapering oropisthotonos)

abnormal postures (e.g. scissoring legs or persistent infantile posturing) reflex abnormalities (e.g. persistent primitive reflexes, such as tonic neck of

hyperreflexia)Diagnosis:

Skull radiograph or sonogram cerebral asymmetry

CT/MRI scan

EEGNursing management:

Prevent physical injury by providing the child with a safe environment,appropriate toys, and protective gear (helmet, kneepads) if needed.

Prevent physical deformity by ensuring correct use of prescribed braces and

other devices and by performing ROM exercises. Promote mobility by encouraging the child to perform age-and condition-

appropriate motor activities.

Promote adequate fluid and nutritional intake.

Foster relaxation and general health by providing rest periods.

Administer prescribed medications which may include sedatives, musclerelaxants and anticonvulsants.

Encourage self-care by urging the child to participate in activities of daily living(ADLs) (e.g. using utensils and implements that are appropriate for the childsage and condition).

Facilitated communicationoTalk to the child deliberately ad slowly, using pictures to reinforce speech

when needed.o Encourage early speech therapy to prevent poor or maladaptive

communication habits.o Provide means of articulate speech such as sign language or a picture

board.oTechnology such as computer use may help children with severe

articulation problems.

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As necessary, seek referrals for corrective lenses and hearing devices todecrease sensory deprivation related to vision and hearing losses.

Help promote a positive self-image in the child:o Praise his accomplishments

o Set realistic and attainable goals

o Encourage and appealing physical appearance

o Encourage his involvement with age and condition- appropriate peer

group activities.

Promote optimal family functioningo Encourage family members to express anxieties, frustrations and

concerns and to explore support networks.o Provide emotional support and help with problem solving as necessary.

o Refer the family to support organizations such as the United Cerebral

Palsy Association.

Prepare the child and family for procedures, treatments, appliances andsurgeries if needed.

Assist in multidisciplinary therapeutic measures designed to establish

locomotion, communication and self-help, gain optimal appearance andintegration of motor functions; correct associated defects as effectively aspossible and provide educational opportunities based on the individuals needsand capabilities. Therapeutic measures include:

o Braces to help prevent or reduce deformities, increase energy of gait, and

control alignment.oMotorized devices to permit self-propulsion.

oOrthopedic surgery to correct deformities and decrease spasticity

(medications are not helpful for spasticity).oMedications to control possible seizure activity or attention deficit

disorder.o Speech therapy and physical therapy.

Inform parents that their child will need considerable help and patience inaccomplishing each new task.

o Encourage them not to focus solely on the childs inability to accomplish

certain tasks.oUrge them to relax and demonstrate patience.

o Explain the importance of providing positive feedback.

Encourage the family to seek appropriate functional, adaptive and vocationaltraining for the child.

Encourage family members to achieve balance in their lives between caring fortheir disabled child and other family and personal matters.

6. HEADACHESTypes:Tension or Stress Headache

Sinus Headache

Migraine Headache-refers to a specific headache that may or may not begin with an aura or visualdisturbance such as diplopia or a zigzag pattern across the visual field.

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- pain is usually unilateral and extremely intense, with throbbing that ismoderate to severe.- The cause is not well understood. It probably results from abnormal constrictionof intracranial arteries that temporarily reduces cerebral blood supply.

Nursing Management: Prevent headaches:

oGetting enough rest, eating a healthful diet without skipping meals, andexercising regularly.

oTaking occasional study breaks.

o Avoiding allergens, foods or other factors known to trigger headaches

whenever possible.

Pharmacotherapy:o Ergotamine(Cafergot)- constricts cerebral arteries

o Porpranolol and flunarizine

o Beta-blockers or calcium channel blockers- may be prescribed

prophylactically

SENSORY ALTERATIONS

1. SPEECH AND LANGUAGE DISORDERS basic categories that might be drawn in issues of communication involve

hearing, speech, language, and fluency.

There a variety of major speech disorders. Following are brief definitions of several ofthe more prominent speech disorders:

Apraxia of speech refers specifically to a motor speech disorder. This is aneurological disorder. Individuals suffering from apraxia of speech encounterdifficulty saying sounds, syllables, and words. The difficulties are not due toweakness of muscles, but rather on coordination between the brain and thespecific parts of the body.

Dysarthria is another motor speech disorder that results from a neurologicalinjury. Some stem from central damage, while other stem from peripheralnerve damage. Difficulties may be encountered in respiratory problems, vocalfold function, or velopharyngeal closure, for example.

Orofacial myofunctional disorder refers to problems encountered when thetongue thrusts forward inappropriately during speech. While this is typical ininfants, most children outgrow this. Children that continue to exaggerate the

tongue movement may incorrectly produce speech sounds, such as /s/, /z/,sh, ch, and j. For example, the word, some, might be pronounced asthumb.

Stuttering is a disruption in the fluency of an individuals speech, whichbegins in childhood and may persist over a lifetime.

Several of the language disorders are:

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Language-based learning disabilities - refer to difficulties with reading,spelling, and/or writing that are evidenced in a significant lag behind theindividuals same-age peers. Most children with these disabilities are at least ofaverage intelligence, ruling out intellectual impairments as the causal factor.

Selective mutism is a disorder that manifests as a child that does not speakin at least one social setting, despite being able to speak in other situations.

Selective mutism is normally discovered when the child first starts school Aphasia -a family of language disorders that usually stem from injury or lesion

to the left side of the brain that result in reception, perception, and recall oflanguage; in addition, language formation and expressive capacities may beinhibited.

Nursing management:Treatment for articulation/phonological disorders is usually based on increasing

the affected person's awareness about how speech sounds make the meaningof words different. As a result, therapy often involves pronunciation exercisesdesigned to teach how to produce sounds and words more clearly to increaseunderstanding of the differences between the various speech sounds andwords.

Treatment plans for stuttering depend on the severity of the dysfluency and mayinclude seeing a speech-language pathologist. Most treatment plans includebreathing techniques, relaxation strategies to help relax speech-associatedmuscles, posture control, and other exercises designed to help developfluency.

Voice therapy

2. VISUAL IMPAIRMENT2.1. REFRACTIVE ERRORS

- largest category of vision defects in childrenTypes: Myopia(near-sightedness)

Hyperopia(farsightedness)

AstigmatismNursing management: Encourage children to give eyeglasses a try.

Advise parents to choose frames fitted with plastic or safety glass(shatterproof) lenses so that, if the lenses accidentally break, the childs eyewill not be injured.

Contact lenses are possible to be fitted for even young infants.

LASIK (Laser In Situ Keratomileusis)- surgery for correcting myopia.

2.2 AMBLYOPIA- lazy eye or subnormal vision in one eye; the child may be using one eye for

vision and the other is a resting eye. If this continues too long, central vision fails todevelop and the child becomes functionally blind in one eye.

- can also develop from strabismus(crossed eye).Nursing Management:The good eye is covered by a patch held firmly in place.

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The patch is removed for 1 hour each day to prevent amblyopia from developingin the nonamblyopic eye.

Administration of levodopa in addition to occlusion therapy may also beprescribed.

Atropine, which causes pupil dilation, may be another solution.

3. HEARING IMPAIRMENT- ranges from mild to profound and include deaf as well as hard of hearing.

Risk factors: Infants with prenatal, perinatal and postanatal conditions including family history

of hearing impairments

Malformations

Low birthweight

Asphyxia

Infection

Down syndrome History of being administered with ototoxic drugs

Assessment: Failure to startle or awaken to a loud sound

Failure to turn head to the sound by 4 months of age

Failure to babble by 3 months of ageNursing management:

When children are wearing hearing aids, encourage them to view themselves aswhole persons despite their need for their device, rather than as someone withsomething to hide.

Refer them to speech therapy.

COGNITIVE ALTERATIONS

1. MENTAL RETARDATION- part of a broad category of developmental disability and defined by the American

Association of Mental Deficiency as significantly subaverage, general intellectualfunctioning existing concurrently with deficits in adaptive behavior and manifestedduring the developmental period( 18years of age).

-adaptive behaviors include communication, self-care, work, leisure, health andsafety.Etiology: Prenatal infection and intoxication

Trauma or physical agent

Metabolic disturbance

Inadequate prenatal nutrition

Gross postnatal brain disease

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Chromosomal abnormalities

Prematurity

Low birthweight

Autism

Environmental deprivation

Associated Factors: Maternal lifestyles

Chromosomal disorders( most related to Down syndrome)

Specific disorders, such as fetal alcohol syndrome

Cerebral palsy, microcephaly or infantile spasms

Assessment:a. Mild (50-70 IQ)

Preschool. The child often is not noted as retarded, but is slow to walk , talk, andfeed self.

School-age. The child can acquire practical skills, and learn to read and doarithmetic to sixth-grade level with special education classes. The child

achieves a mental stage of 8 to 12 years. Adult. The adult can usually achieve social and vocational skills. Occasional

guidance may be needed. The adult may handle marriage, but not childrearing.

b. Moderate (35- 55 IQ) Preschool. Noticeable delays, especially in speech, are evident.

School-age. The child can learn simple communication, health, and safety habits,and simple manual skills. A mental age of 3 to 7 years is achieved.

Adult. The adult can perform simple tasks under sheltered conditions and cantravel alone to familiar places. Help with self-maintenance is usually needed.

c. Severe (20-40 IQ)

Preschool. The child exhibits marked motor delay and has little to nocommunication skills. The child may respond to training in elementary self-help, such as feeding.

School-age. The child usually walks with disability. Some understanding ofspeech and response is evident. The child can respond to habit training andhas the mental age of a toddler.

Adult. The adult can conform to daily routines and repetitive activities, but needsconstant direction and supervision in a protective environment.

d. Profound (below 20 IQ) Preschool. Gross retardation is evident. There is a capacity for function in

sensorimotor areas, but the child needs total care.

School-age. There are obvious delays in all areas. The child shows basic

emotional response and may respond to skillful training in the use of legs,hands, and jaws. The child needs close supervision and has mental age of ayoung infant.

Adult. The adult may walk but needs complete custodial care. The adult will haveprimitive speech. Regular physical activity is beneficial.

Nursing Management: Assess all children for signs of development delays.

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Administer prescribed medications for associated problems such asanticonvulsants for seizure disorders, and methylphenidate (Ritalin) forattention deficit hyperactivity disorder.

Support the family at the time of initial diagnosis by actively listening totheir feelings and concerns and assessing their composite strengths.

Facilitate the childs self-care abilities by encouraging the parents to enrollthe child in an early stimulation program, establishing a self-feeding program,initiating independent toileting, and establishing an independent groomingprogram (all developmentally appropriate).

Promote optimal development by encouraging self-care goals andemphasizing the universal needs of children, such as play, social interaction,and parental limit setting.

Promote anticipatory guidance and problem solving by encouragingdiscussion regarding physical maturation and sexual behaviors.

Assist the family in planning for the childs future needs; refer them tocommunity agencies.

Provide child and family teaching.o Identify normal developmental milestones and appropriate stimulating

activities including play and socialization.oDiscuss the need for patience with the childs slow attainment of

developmental milestones.o Inform parents about stimulation, safety and motivation.

o Supply information regarding normal speech development and how to

accentuate nonverbal cues, such as facial expressions and bodylanguage, to help cue speech development.

o Explain the need for discipline that is simple, consistent and appropriate

to the childs development.o Review an adolescents need for simple, practical sexual information that

includes anatomy, physical development and conception.oDemonstrate ways to foster learning other than verbal explanation

because the child is better able to deal with concrete objects thanabstract concepts.

o Point out the importance of positive self-esteem, built by accomplishing

small successes, in motivating the child to accomplish other tasks.

Encourage the prevention of mental retardation.oEncourage early and regular prenatal care.

oProvide support for high-risk infants.

oAdminister immunizations, especially rubella immunization.

oEncourage genetic counseling when needed.

oTeach injury prevention- both intentional and unintentional.

2. DOWN SYNDROME- a disorder of chromosome 21, the most common chromosomal abnormalityEtiology:

Unknown

Assessment: Late closure of fontanelles

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Slant of eyes

Epicanthal fold

Large tounge

Clinodactyly

Abnormal dermatoglyphics

Simian crease on palm Brushfield spots

Nursing management: Assess for associated problems.

o Intelligence varies from severe retarded to low normal but is usually in the

mild or moderate range.o Social development may be beyond 2-3 years age beyond mental age

o Congenital anomalies (heart disease, skeletal deformities, etc.)

o Sensory problems (strabismus, nystagmus,myopia and conductive hearing

loss)o Reduced growth and rapid weight gain

o Sexual development is delayed Implement a plan of care that is the same for mental retardation. Encourage genetic counseling. Explain hypertonicity and joint hyperextensibility to parents, and that the

childs resultant lack of clinging is physiologic and not a sign of detachment.

Prevent respiratory infections by clearing the nose with a bulb syringe, usinga cool mist vaporizer, performing chest physiotherapy when needed andavoiding infection.

When feeding infants and young children, use a small straight-handledspoon to push food to the side and back of the mouth.

Encourage fluids and foods rich in fiber.

Provide good skin care.

3. AUTISM- marked by severe deficits in language, perceptual, and motor development;defective reality testing; and an inability to function in social settings.Assessment:

failure to develop social relations

stereotyped behaviors such as hand gestures

extreme resistance to change in routine

abnormal responses to sensory stimuli

decreased sensitivity to pain

inappropriate or decreased emotional expressions specific, limited intellectual problem solving abilities

stereotyped or repetitive use of language

impaired ability to initiate or sustain a conversationNursing management:

Reduce behavioral symptoms and promote learning and development,particularly the acquisition of language skills

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Comprehensive and individualized treatment, including special education andlanguage therapy, is associated with more favorable outcomes.

A day care program can help to promote social awareness.

Pharmacologic treatment:o Antipsychotics( haloperidol, risperidone)

4.FRAGILE X SYNDROME- an X-linked pattern of inheritance in which one long arm of an x-chromosome isweakened.Assessment:

bossing ( prominent forehead)

prominent jaw

large hands

Mental retardation (IQ between 20 and 70)

Difficulty with speech and language development

Hyperactivity

Some autistic behaviors (poor eye contact, extreme shyness, and hand flapping)

Problems paying attention Aggressiveness

About 20 percent of boys with fragile X meet all the diagnostic criteria forautism. Most boys and some girls with fragile X have some symptoms of autism;however, many are socially outgoing and can form relationships with otherpeople.

Nursing management: Nursing management is mainly supportive. Early diagnosis and intervention with

developmental therapies and an individualized pan education are ideal. Care isthe same as those with mental retardation.

5.FETAL ALCOHOL SYNDROME- a pattern of mental and physical defects that can develop in a fetus in associationwith high levels of alcohol consumption during pregnancy.

Etiology: Pre-natal alcohol exposureAssessment:

pre- and post-natal growth restrictions

CNS involvement

Short palpebral fissure

Thin upper lip

Weak sucking reflex

Sleep disturbances

Nursing management: Children with FAS should have psychoeducational evaluation to help plan

appropriate educational interventions.

Common associated diagnoses, such as ADHD, depression, or anxiety should berecognized and appropriately treated.

Within an early childhood intervention program, these children may be taught tofunction within their limitations, learn how to make proper choices, develop

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acceptable interpersonal skills, master basic life skills and, above all, maintainself-esteem. Such educational intervention often means scaling down academicexpectations and emphasizing training for future self-sufficiency. Programmingfor success can result in improved learning and enhanced self-image, which inturn can decrease acting out behaviours.

Strategies for dealing with difficult behaviours include the following.o Keep tasks simple.o Use concrete examples.

o Keep instructions simple and give them one at a time.

o Concentrate on life skills.

REFERENCES:

Textbook references:White, L. Foundations of Maternal and Pediatric Nursing, 2nd edition. Singapore:Delmar Learning. 2005

Muscari, M.E. Lippincotts Review Series: Pediatric Nursing, 3 rd edtion. Philadelphia:Lippincott Williams and Wilkins.(2001)

Pillitteri, A. Nursing Care of a Child with a Neurologic Disorder. Maternal and ChildHealth Nursing: Care of the Childbearing and Childrearing Family, Vol.1, 5 th edition.Philadelphia: Lippincott Williams and Wilkins.(2007)

Pillitteri, A. Nursing Care of a Child with a Neurologic Disorder. Maternal and ChildHealth Nursing: Care of the Childbearing and Childrearing Family, Vol.2, 5 th edition.Philadelphia: Lippincott Williams and Wilkins.(2007)

Videbeck, S.L. Child and Adolescent Disorders. Psychiatric Mental-Health Nursing, 4th

edition. China: Lippincott Williams and Wilkins.(2006)

Online references:Lhynneli, RN. Encephalitis. Online article retrieved from www.nursingcrib.com.

Fragile X syndrome.Online article retrieved from www.cps.ca

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Fetal Alcohol Syndrome. Online article retrieved from www.enotes.com

Reyes syndrome. Online article retrieved from www.rightdiagnosis.com

What is Cerebral Palsy? Online article retrieved from www.nursingcrib.com.

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Elective_neurologic Reporting 1