NeurologyNeurologyNeurologyNeurology

Elisa A. Mancuso, RNC-NIC, MS, Elisa A. Mancuso, RNC-NIC, MS, FNSFNS

Professor of NursingProfessor of Nursing

Peripheral nerves– Not completely myelinated @ birth.

• ↑ Myelinization = ↑ Coordination

1st Gross motor function then fine motor

Primitive reflexes disappear by 5 months. – Moro, Fencing, Step

• Primitive reflexes evolve to meaningful movements

• Reappearance/persistent reflexes – Neurological disease

Assessment

• Cognitive –– √ Appropriateness, speech

• Gross and fine motor- – √ Strength, coordination, gait

• Sensory- – √ Reflexes, pain, temperature

• Cranial nerves I-XII-– √ Motor & sensory

• Developmental milestones-– √ Delay or deviation from expected

milestones. • Obtain accurate history!

– √ family/genetic – √ any past head injuries or trauma at birth

Glasgow Coma Scale• Eye Opening

• Spontaneous 4• To Verbal Stimuli 3• To Pain Only 2• No response 1

• Verbal Response• Coos & babbles/Oriented 5• Irritable cries/Confused 4• Cries to pain/Inappropriate words 3• Moans to pain/Non specific words 2• No response 1

• Motor Response• Moves Purposely/Obeys commands 6• Withdraws to touch/localizes painful stimuli 5• Withdraws to pain 4• Decorticate posturing/Flexion 3• Decerebrate posturing/Extension 2• No response 1

Intracranial Pressure (ICP)

Etiology ↑ ICP1. Mass

•Brain tumor, head trauma2. Generalized brain edema

•Hypoxia, encephalopathy3. ↑ Blood Volume

•IVH, obstruction of jugular veins

4. ↑ CSF production-•Meningitis

Signs and Symptoms • Differ according to developmental

level

Infant1. Poor feeding or vomiting2. Irritability3. Lethargy4. Bulging Anterior Fontanel5. ↑ HC6. High pitched cry7. Sun setting sign-

√ Eyes deviated downward

Signs and Symptoms

Child1. HA2. Diplopia3. Mood swings4. Slurred speech5. Papilledema (48 hours of ↑ICP)6. Altered LOC7. N/V especially in AM

1. ↑ pressure from lying flat

Therapy• Maintain Patent Airway • Supine & ↑ HOB @ 30 • Avoid Prone & head turned to side

– ↓ venous drainage and ICP• Avoid CO2 retention

– CO2 = Cerebral vasodilatation – blood flow and ICP

• Hyperventilation = ↓ CO2 – Cerebral vasoconstriction – ↓ blood flow & ↓ICP– √ for cerebral hypoxia & ischemia

• If Pt mechanically ventilated • only suction PRN!

Therapy

• ICP monitoring – Catheter in ventricle– √ pressure in brain. – Glasgow Coma scale <7

• Manitol– Osmotic diuretic

Unconscious Child• Head trauma, infection, ICP, tumor• √ LOC

– ∆ = earliest indicator of ∆ in neuro status!

– Lethargy• √ Pupillary response

– Fixed and dilated pupils•MEDICAL EMERGENCY!!!•↑ pressure on oculomotor nerve

• √ VS =↓ HR ↓ RR ↑ BP ↑ Temp

Nursing Interventions• ↓ ICP & Maintain ABCs• Turn and position q2H• Passive ROM• Don’t leave on affected side > 30

min • Seizure precautions• Assess skin• Thermoregulation (↑ temp can ↑ICP)

Nursing Interventions

• Eye care– Artificial tears– Cover to prevent corneal abrasions

• Mouth care– Tooth brushing– Dental Care

• Incontinence – Foley care– May need suppositories to

stimulate BM

Nursing Interventions

Nutrition • Tube feedings

•NGT- Short term•PEG- Gastrostomy- Long term

• TPN– Broviac – √ Labs, Glucose, LFTs,

Neoplasms

• High incidence in 5-10 years old

• Prognosis is best – when tumor is completely

removed

• >60% found in– cerebellum and brain stem

Signs and Symptoms

• First cardinal sign = ↑ ICP• HA• Irritability• Projectile vomiting • Personality changes• Location/size of tumor

– Focal Affects (Behavior, Speech) – Cerebellar tumor = Ataxia

Glioblastoma (Astrocytoma)

• Tumor of brain or spinal cord (astrocytes)

• Most common brain tumor in children

• 75% survival rate

Signs and symptoms

• Depends on location of tumor• Headache • Ataxia• Eyes deviating (cover/uncover

test)• Hemiparesis• + Babinski• Staring spells• ↑ ICP

Diagnosis• Complete Neuro exam & cranial

nerves• CT scan, MRI, Pet Scan

Treatment • Chemotherapy• Radiation• Surgery

– Retain as much viable tissue as possible!

Nursing Interventions

• Pre-op: Prepare child and family– Assess developmental milestones– Shave all/part of head – Extensive dsg with multiple drains

• Post-Op– √ LOC & Glasgow Coma Scale – √ VS– √ Infection– Restrict fluids post-op– √ I & O– External shunts/drains/monitors (√ for

ICP)– Increase HOB slowly- No

trendelenburg!– No Narcotics = ↓ cerebral functioning

Seizure Disorder• Epilepsy is recurrent seizure activity

– Does not occur with a known cause i.e. infection, tumor

• Seizure is excessive discharge of neurons.

• Status Epilepticus – Prolonged or recurrent seizures – Not regaining consciousness >30

minutes

Etiology • Primary

– Linked to genetic predisposition – Include febrile, absence and benign seizures– Early infancy from birth trauma or

congenital defects

• Secondary or symptomatic seizure – A temporary or permanent structural or

metabolic abnormality. – Cerebral lesions, malformations, metabolic

disorders and hypoxia. – Late infancy and early childhood from acute

infections – meningitis.• Idiopathic

– Most common = >3 years 50% of seizures.

Diagnosis• Family Hx & Hx of symptoms

– Behavior before, during and after seizure

• Any predisposing illnesses/fever• LP

– √ Infection or metabolic causes• CT scan, MRI

– √ trauma, tumor, malformation• √ Labs

– Serum Calcium, Glucose, & Magnesium • Electroencephalogram (EEG)

– Measures voltage in brain – Sharp waves on EEG = Epilepsy– ↓sensory stimulation during exam

Classification of Seizures

Generalized • Both cerebral hemispheres and ∆ in

LOC •Tonic-Clonic•Absence•Myoclonic•Atonic

Partial • One hemisphere affected & ∆ in LOC• Symptoms occur on one side of body

• Partial• Simple partial• Complex partial

Generalized Seizures

1. Tonic clonic• Aura• LOC• Tonic phase (10-20 secs)• Clonic phase (>30 sec)• Post-ictal State

Generalized Seizure2. Absence seizure “petit-mal”• ↑ Incidence btwn 4-12 years• RT brain immaturity• Usually cease at puberty • Brief LOC may be mistaken for

daydreaming• Minimal or no alteration in muscle

tone• Sudden arrest of activity with no

memory of event• Lasts 5-20 seconds up to 20 times/day

Partial Seizures1. Simple partial• Localized motor symptoms• Somatosensory and autonomic

symptoms• Unilateral hand or 1 side of body• No LOC!• Eyes deviate toward opposite side• Jacksonian• Sylvian/Rolandic

Partial Seizures2. Complex• Psychomotor seizures-most

common• Age 3-adolescence• Period of altered behavior &

repeated purposeless activities• Last 5-10 minutes• Aura• Lip, smacking, chewing, drooling• May yell out, inappropriate

behavior

Status Epilepticus• Medical emergency • Prolonged or recurrent seizures • Not regaining consciousness >30

minutes• Most common cause

– Sudden withdrawal of anticonvulsant meds

• LOC can last hours or days• Maintain airway • Will most likely be intubated• Ativan (lorazipam)

– Quicker onset & longer acting – Less respiratory depression than

valium

Medication Therapy• Controls symptoms• Prevent seizures or decrease # & activity• Raise the seizure threshold• Decrease responsiveness to neurons• Loading & maintenance doses• Phenobarbital (luminal)

– Therapeutic level 10-40 mcg/ml √ respirations can cause respiratory

arrest!

• Dilantin (phenytoin) – Therapeutic level 10-20mcg/ml. – SE hyperplasia of gums!

Medication Therapy

• Tegretol (carbamazepine)– Therapeutic level 4-12 mcg/ml-– Monitor LFT’s! Hepatotoxic. – SE neutropenia √ WBC’s!

• Valproic Acid (depakene)– Therapeutic level 50-110

mcg/ml-– Monitor LFT’s!

Nursing Interventions• Monitor serum drug levels• Seizure precautions

– Padded bed rails– O2 & Suction

• Teaching plan– Parents, Pt, School, Sports, Community

etc.– Type of seizure– Medications & SEs

• Med alert bracelet• Protocol for discontinuing seizure meds:

1. Pt should be seizure free for 2 years2. Normal EEG3. Slowly taper doses 4. EEG’s Q 6 months

Meningitis • Bacterial meningitis 10-15% mortality

rate• Acute inflammation of the meninges

– Infection: URI, OM or sinusitis– Bacteria enters CNS/brain via nasal cavity,

sinuses.– HIB, Group B strep, S.pneumoniae and

Neisseria meningitides

• N. Meningitides is most invasive disease. – 13 serogroups– Vaccine only covers A,B,C,Y and W-135

Incidence • ↑ Risk <1 year of age and >15

yrs• Deficiencies in terminal

complement• URI• HIV• Asplenia• Crowding• Smoking or passive exposure

Clinical Signs • Depend on age and organism• Nucchal Rigidity “stiff neck”• Brudzinski’s sign• Kernig’s sign• Abrupt onset fever and chills• Vomiting & No Nausea• HA• Seizures• Irritability• Anorexia• Petechiae and pupura = Sepsis

– disseminated disease

Diagnosis• CBC with Diff• BC• NP/Pharyngeal cultures• Lumbar Puncture LP

– √ CSF color, consistency, pressure of fluid.

– Sterile procedure– √ Complications;

•Infection, bleeding, spinal fluid leak,

•Hematoma, Spinal HA

CSF Fluid Analysis• Clear, cloudy or bloody• Bacterial or viral meningitis

– ↑ Protein– ↓ Glucose– WBC (PMN cells)

• Gram stain- +/- • Culture-identifies organism • √ pressure >15 = ↑ ICP• ↑ Blood = ↓ skill or traumatic tap

Contraindications to LP

• ↑ ICP- – Need CT scan. – If LP done fatal herniation can occur

• Bleeding disorders• Overlying skin infection

(Staph/MRSA)• Unstable patient

Therapy• Respiratory isolation right away!• Antibiotics 2-3 immediately!!!!

– Meningitic dose (2x usual dose)– Cephalosporins and Ampicillin

• Dexamethasone– ↓ inflammation

• Phenobarbital– ↓ seizure activity

• Mannitol – ↓ brain edema

Nursing Interventions

• Keep HOB >30%• Quiet environment • Frequent neurochecks & VS• Maintain Isolation• Prophylaxis medication =

Rifampin – Persons in close contact – Urine turns orange and stains

contact lenses

Reyes SyndromeAcute Toxic Encephalopathy• ↑ Incidence with 6-11 years & virus infection • (flu/varicella)

• + Relationship when treating fever with ASA

• NH4 accumulates and builds up urea →– Brain edema, necrosis of neurons and cell

death– Fatty infiltration of liver cells, kidney and

myocardium– Impaired hepatic, renal and cardiac function

Signs and symptoms• A history of preceding URI or chickenpox • Nausea and vomiting x 24

hours/intractable• Mental status changes • Lethargy • Confusion • Combative behavior • Loss of consciousness or coma may

develop • Seizures • Hepatomegaly

Diagnosis

• ↑↑ LFT’s 2x normal• Prolonged pt/ptt• ↑↑ NH4 4x normal• Palliative Support• ↑↑ Mortality if pt is in coma =

40%

Cerebral Palsy• Impaired neuromuscular control

– Abnormality in cortex, basal ganglia and cerebellum

• Brain injured area determines type of neuromuscular disability

• Non-progressive

Etiology

• Developmental anomalies• Infections• Toxins• Cerebral trauma• Hypoxia • Vascular occlusion RT IVH

Clinical signs

• Abnormal muscle tone: hyper or hypotonicity

• Impaired coordination and motor function

• Delayed gross motor development• Abnormal postures • Persistent primitive reflexes• Spasticity or uncontrolled movements • Seizures• Sensory impairments

ClassificationsSpastic• Most common with cortex

involvement. • Muscles very tense with any

stimulus• Sudden jerking movements

Dyskinetic• Injury at basal ganglia. • Slow, writhing, uncontrolled,

involuntary movements involving all extremities

ClassificationsAtaxic• Cerebellum affected. • “Clumsy” characterized by loss of

coordination, equilibrium and kinesthetic sense

Rigid• Rare form with poor prognosis. • Rigidity of flexor and extensor

muscles. • Tremors at rest and with

movement Mixed

Therapy• Early recognition and intervention is

goal• Maximize child physical abilities

– (Child intellectually intact)• Multidisciplinary team approach-

– PT, OT, Neurologist, Orthopedic surgeon, RN, social worker

• Family support & community via UCP• Treat symptoms

– Baclofen pump- skeletal muscle relaxant• Increase locomotion, communication

and self-help• Correct defects

– Contractures or spastic deformities– Braces

Retinoblastoma

• Most common congenital intraocular tumor

• 60% non-hereditary and unilateral• 25% genetic & bilateral• 15% genetic & unilateral• Red inflamed eye. • Persistent redness, irritation & itchy• Leukokoria • Loss of red reflex• Strabismus-25% present • Glaucoma

Therapy • Genetic counseling • Early stage

– Radiation or cyrosurgery• Late stage

– Radiation, Chemo– Enucleation– Fit with prosthesis in 3 weeks

• 90% survival rate• Unaffected eye is fine!