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Neurologic disorders can be divided into several categories, including

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structural disorders, seizure disorders, infectious disorders, trauma to the neurologic system, blood flow disruption disorders, and chronic disorders.

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Development of the CNS (brain and spinal cord) occurs in the first 3-4 weeks of gestation.

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Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal CNS development

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Cranial bones at birth

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-not well developed and are not fused - leading to increased risk of fracture

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The brain is highly vascularized

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leading to increased risk of hemorrhage

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Premature infants are at greater risk of brain damage due to:

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-capillaries are fragile and at greater risk of rupture, leading to intracranial bleeding -cranium is very soft, external pressure can change its shape and cause increased pressure in areas of the brain and possible hemorrhage

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The sutures and fontanels present in the newborn help make the skull more flexible and help to accommodate for brain growth that continues after birth.

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Closure of the fontanels too early or too late can be indicative of problems with brain growth

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The child's spine is very mobile, especially the cervical spine region,

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resulting in a high risk for cervical spine injury.

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The development of the nervous system is complete but immature at birth.

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-born with all nerves; however, myelinization , which covers and protects the nerves, is incomplete

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The immaturity of the CNS in premature infants can result in:

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-delayed development of motor skills -difficulty in coordinating sucking and swallowing which leads to feeding and growth concerns -episodes of apnea

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Head size

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-infant - 1/4 of body height (large in proportion to the body) -adult - 1/8 of the body height

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The head is the fastest growing body part during infancy

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and continues to grow until the child is 5 yoa

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Assessment of a child with a neurologic disorder

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-include health history, physical exam, and diagnostic testing

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Neurologic assessment should proceed from least invasive to most invasive.

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The use of toys and familiar objects, as well as incorporating play, will help promote cooperation from the child.

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Past medical history includes:

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-mother's pregnancy history -family history -history of present illness (when the symptoms started and how they have progressed) -treatments used at home -prematurity -difficult birth -infection during pregnancy -nausea & vomiting -headaches -changes in gait -falls -visual disturbances -recent trauma

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Family history might be significant for

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genetic disorders with neurologic manifestations, seizure disorders, or headaches

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When eliciting the history of the present illness, inquire about the following:

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Nausea Vomiting Changes in gait Visual disturbances Complaints of headaches Recent trauma Changes in cognition Change in consciousness, including any loss of consciousness Poor feeding Lethargy Increased irritability Fever Pain Altered muscle tonicity Delays in growth and development Ingestion or inhalation of neurotoxic substances or chemicals

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Physical Exam

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-inspection and observation -palpation -auscultation

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Inspection and Observation: specific areas to inspect and observe

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Level of consciousness (LOC) Vital signs Head, face, and neck Cranial nerve function Motor function Reflexes Sensory function Increased intracranial pressure (ICP) (a rise in the normal pressure within the skull)

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LOC is the earliest indicator of improvement or deterioration of neurologic status

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Extreme irritability or lethargy is considered an abnormal finding

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Consciousness consists of

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alertness, which is a wakeful state and includes the ability to respond to stimuli, and cognition, which includes the ability to process stimuli and demonstrate a verbal or motor response

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5 different states of level of consciousness

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1. full consciousness 2. confusion 3. obtunded 4. stupor 5. coma

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Full consciousness

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is defined as a state in which the child is awake and alert; is oriented to time, place, and person; and exhibits age-appropriate behaviors.

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Confusion

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is defined as a state in which disorientation exists. The child may be alert but responds inappropriately to questions.

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Obtunded

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is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided.

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Stupor

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exists when the child only responds to vigorous stimulation.

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Coma

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defines a state in which the child cannot be aroused, even with painful stimuli.

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The Pediatric Glasgow Coma Scale is a popular scale used to standardize degree of consciousness.

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It consists of three parts: eye opening, verbal response, and motor response

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A smaller than normal head circumference, which measures around the child's head at the largest area, may indicate microcephaly,

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and a larger than normal head circumference may indicate hydrocephalus.

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Alterations in cranial nerve function can be the result of

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compression of a specific nerve, infection, or trauma leading to brain injury.

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Immediately report

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the sudden presence of fixed and dilated pupils.

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Observe for nystagmus by looking for involuntary, rapid, rhythmic eye movements that may be present at rest or with eye movement.

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-Horizontal nystagmus may occur with lesions in the brain stem and can be the result of certain medications (phenytoin in particular) -Vertical nystagmus indicates brain stem dysfunction.

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Sunsetting is when the sclera of the eyes is showing over the top of the iris

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Sunset eyes may indicate increased ICP as seen in hydrocephalus

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Pupillary response is often abnormal when a neurologic disorder is present

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-Pinpoint is commonly observed in poisonings, brain stem dysfunction, and opiate use -Dilated but reactive is seen after seizures. Fixed and dilated is associated with brain stem herniation secondary to increased intracranial pressure -One dilated but reactive is associated with intracranial mass.

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Alterations in motor function, like changes in gait, muscle tone, or strength,

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may indicate certain neurologic problems such as increased ICP, head injury, and cerebral infections

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Because cortical control of motor function is lost in certain neurologic disorders, postural reflexes re-emerge and are directly related to the area of the brain that is damaged.

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Therefore, it is important to assess for two distinct types of posturing that may occur

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Decorticate posturing (extremities flexed)

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occurs with damage of the cerebral cortex

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Decerebrate posturing (extremities extended and pronated)

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occurs with damage at the level of the brain stem

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The Moro, tonic neck, and withdrawal reflexes are important in assessing neurologic health in infants

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Absence of certain reflexes, persistence of primitive reflexes after age of normal disappearance, or increases in reflexes may be present in specific neurologic conditions.

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When assessing sensory function, the child should be able to distinguish between light touch, pain, vibration, heat, and cold

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Alterations in sensory function can result from brain or spinal cord lesions.

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Increased Intracranial Pressure

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It may result from head trauma, birth trauma, hydrocephalus, infection, and brain tumors.

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Early signs of increased intracranial pressure

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-Headache -Vomiting, possibly projectile -Blurred vision, double vision (diplopia) -Dizziness -Decreased pulse and respirations -Increased blood pressure or pulse pressure -Pupil reaction time decreased and unequal -Sunset eyes -Changes in level of consciousness, irritability -Seizure activity -In infant will also see: -Bulging, tense fontanel -Wide sutures and increased head circumference -Dilated scalp veins -High-pitched cry

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Late signs of increased intracranial pressure

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-Lowered level of consciousness -Decreased motor and sensory responses -Bradycardia -Irregular respirations -Cheyne-Stokes respirations -Decerebrate or decorticate posturing -Fixed and dilated pupils

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Changes in size or fullness of the fontanels may exist in certain neurologic conditions and must be noted.

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-A bulging fontanel can be a sign of increased ICP and is seen in such neurologic disorders as hydrocephalus and head traumas -It is normal for the fontanels to be full or bulging during crying

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The posterior fontanel normally closes by 2 months of age and the anterior fontanel normally closes by 12 to 18 months of age.

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In children with hydrocephalus, widening of the fontanels may be noted, along with a tense appearance and a resulting increase in head circumference.

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Physicians or nurse practitioners may perform auscultation of the skull.

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-Soft, symmetric bruits may be found in children younger than 4 years of age or in children with acute febrile illness -A finding of a loud or localized bruit is usually significant and requires immediate further investigation -Increased ICP, resulting from conditions such as hydrocephalus, tumor, or meningitis, frequently produces intracranial bruits -Arterial venous malformations may also produce large bruits.

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Common medical treatments

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-shunt placement -ventilation -Physical therapy -occupational therapy -speech therapy -External ventricular drainage (EVD) -ventricular trap -vagal nerve stimulator -ketogenic diet

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Shunt placement

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-A catheter is placed in the ventricle to pass the CSF to the peritoneal cavity, atrium of the heart, or pleural spaces. -Hydrocephalus, increased ICP

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Nursing implications

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Monitor: • For signs and symptoms of increased ICP • Neurologic status closely • Level of consciousness and vital signs • For signs and symptoms of infection

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External ventricular drainage (EVD)

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-A catheter is temporarily placed in the ventricle and CSF is drained in a closed system to an external reservoir -treats acute-onset hydrocephalus, meningitis, encephalitis, tumors that cause blockage of CSF, closed head injury, subarachnoid hemorrhage, increased ICP; also can be used to monitor ICP

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Nursing implications

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Monitor: • For signs and symptoms of increased ICP • Neurologic status closely • Level of consciousness and vital signs • For signs and symptoms of infection • Level of collection container when drain is unclamped

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Ventricular trap

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-To reduce accumulation of CSF and decrease ICP -Increased ICP

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Nursing implications

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Monitor: • Level of consciousness • Neurologic status

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Vagal nerve stimulator

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-A nerve stimulator is implanted and a lead wire running under the skin is wrapped around the vagus nerve. The stimulator is programmed to provide the appropriate dose of stimulation at preset intervals; additional stimulation can be administered. -Short- and long-term seizure management in children older than 12 years of age

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Nursing Implications

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Monitor: • For signs and symptoms of infection • For seizure activity

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Ketogenic diet

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used for prevention, control, and reduction of seizures

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Nursing Implicatons

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Monitor: • Input and output closely • For seizure activity • Growth and nutritional status • The diet is time consuming and many children find it unpalatable; therefore, all families and children do not accept it. • Recommended for a minimum of 3 months, maximum of 2 years • Alternative diets include: the medium chain triglyceride diet, modified Atkins diet and a low glycemic index diet

Nurse 4 – Module 8 – Pediatric neurological assessment – Flashcards

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