Neurology

Care of the Child with a Neurological Disorder (NUR 430)

Child vs. Adult Head

  • Differences in Head Structure:

    • Poor head control

    • Rapid myelination

    • Larger head size relative to body.

    • Thinner skulls

Abnormal Neuro Exam Associations

  • Key Areas to Consider:

    • Head

    • Reflexes

    • Musculoskeletal

    • Gastrointestinal

    • Eyes

    • Behavior

Warning Signs

  • Behavioral Changes:

    • Change in behavior is the first warning sign.

    • High-pitched cry

    • Lethargy

    • Loss of milestones

    • Poor feeding

  • Late vs. Early Signs:

Traumatic Brain Injury (TBI)

  • Types of TBI:

    • Concussion: NO SIGNS ON IMAGING

    • Severe head trauma: Accidental & non-accidental

Risk Factors for TBI

  • Developmental stage (infants, toddlers, adolescents).

    Lack of supervision

  • Inappropriate/absent safety practices

  • Improper use of safety devices (helmets, seat belts).

  • Prevention is the greatest PROTECTION

Abusive Head Trauma

  • Types of Abusive Head Trauma:

    • Shaken Baby Syndrome.

    • Blunt head trauma

    • Diffuse brain injury.

Classic signs of Abusive Head Trauma

  • Apnea

  • Subdural & retinal hemorrhage

  • History/story does not match what you’re seeing

Nursing Interventions

  • Maintain airway

  • Promote skin integrity

  • Promote pain relief

  • Nutrition

  • Safety first

  • Injury Types:

    • Coup injury: direct blow to the head.

    • Contrecoup injury: secondary impact as the brain moves.

    • Signs of abusive head trauma and discrepancies in history.

Nursing Interventions for kid with Increased Intracranial Pressure (ICP)

  • Elevate HOB 15-30 degrees

  • Maintain head in midline position

  • Avoid pressure on neck veins

  • Avoid flexion or hyperextension of neck

  • Avoid respiratory procedures such as suctioning

  • Prevent constipation

  • Prevent/relieve pain

  • Monitor ICP

    • Must treat if > 20 mmHg

    • Life threatening if > 40 mmHg

  • Use gentle movements with ROM exercises

  • Minimize emotional stress & crying

  • Keep noise level & lights down

  • Use padded restraints for clients who have agitation to prevent injury.

  • Assess for clear fluid drainage from ears or nose (cerebral spinal fluid) and report to the provider.

  • Assess for bleeding from the ear (indicates basal skull fracture) and report to the provider.

  • Implement measures to prevent complications of immobility (turn every 2 hr, maintain footboard and splints). Specialty beds might be used.

  • Insert and maintain an indwelling urinary catheter.

  • Monitor fluid and electrolyte values and osmolarity to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia.

  • Provide adequate fluids to maintain cerebral perfusion. When a large amount of IV fluids is prescribed, monitor the client for excess fluid volume, which might increase ICP.

  • Maintain the client’s safety (side rails up, padded side rails, call light within reach. 

  • Provide nutritional support (parenteral nutrition, enteral nutrition). If nasogastric tube is used for nutritional support, do not overfeed due to the risk for aspiration

What if a child bumps their head?

Guide to mild head injury

  • NO ICP SUSPECTED

  • Watch closely

  • Ice 20 mins on/off

  • Clear liquids 2 hours

  • When to call back

What is a concussion?

  • Physical

  • Mood

  • Sleep

  • Thinking

  • Remembering

Myths on concussions-

Returning to sports-

Headaches

  • Most important thing:

    • Rule out worrisome vs. non-worrisome headaches.

  • Headaches that progress in frequency and severity

  • Headaches that awaken a child from sleep

  • Headaches that occur early in the morning

  • Headaches that become worse upon arising

  • Headaches that are accompanied by nausea and/or vomiting that are unexplained (not related to flulike illnesses)

  • Headaches that are persistent and located in the frontal or occipital areas

  • Headaches that are accompanied by a change in gait, personality, or behavior

  • Headaches that are made worse by the Valsalva maneuver

Non-Worrisome Headaches

  • Management:

    • Keep a journal for patterns and triggers.

Headache Hygiene

  • Adequate sleep, regular meals, hydration.

  • Ibuprofen as an effective treatment if needed.

Migraines

Migraine article

  • What comorbidities are associated with migraines?

  • What testing should a child w/ migraines have?

  • What classifies a migraine?

  • Are kids more likely to have unilateral or bilateral migraines?

  • What is the first line of tx for migraines?

  • Which type of headache is hard to treat?

  • What should the school nurse do to help?

  • What group of meds should be avoided?

  • What is second line tx?

  • What happens if you take too much Acetaminophen or Ibuprofen?

  • Child vs. Adult Migraines:

Seizures

What is Epilepsy?

  • Seizure- there can be multiple reasons for a seizure. It does not mean a person has epilepsy from just one seizure

  • Epilepsy- 2 or more unprovoked seizures

Seizure Types and Etiology

Risk Factors for Seizures

  • Genetic conditions

  • Brain tumors

  • Fever

  • Toxins

  • Metabolic conditions

  • Lead poisoning

  • Cerebral edema

  • Intracranial infection

Seize the day: My patient is seizing..what do I do?

Post-Seizure Care

  • Maintain seizure precautions

    • Pads; bed in lowest position, emergency equipment ready

    • Vital signs

    • Neuro check

    • Do not offer anything to eat until fully awake

    • Keep child in the side lying position until fully awake

    • Find out if they had an aura before seizure

    • Determine triggers

Treatment for Epilepsy

  • Treatment Options:

    • Medications

    • Brain mapping

    • Vagal nerve stimulator

    • Keto diet

Medications for Seizures

  • Scheduled vs. PRN

  • Monotherapy & broad spectrum

  • Drug levels for some

  • Give meds on time

  • Start after 2nd unprovoked seizure

  • Carbamazepine, Valproic Acid, Phenytoin

Seizure Education for Caregivers

  • Triggers and Precautions:

    • Importance of awareness and management of seizure triggers.

    • Parents must learn CPR

    • Know triggers

    • Educate do not stop medicine suddenly

    • Wear a helmet and keep area safe.

    • Obtain a medical bracelet

Health Inequities

  • Discussion on Health Inequities:

Developmental Concerns

  • Plagiocephaly- No ICP

    • Frequent repositioning 30-60 mins/day of tummy time; orthotics if severe

    • Risk Factors

      • Premature birth

      • Developmental milestone delays

      • Decreased time in prone position

Craniosynostosis: risk of ICP

  • Increased ICP & head malformations

  • Surgery before 6 months with post-op helmet afterwards

  • Surgery can cause large blood loss- monitor for signs of shock & neuro changes

Reye's Syndrome

  • Can lead to permanent neurological problems & liver failure