neurology

CHAPTER 23: ALTERATIONS IN NEUROLOGICAL AND SENSORY FUNCTION

PEDIATRIC VERSUS ADULT NEUROLOGICAL SYSTEMS

  • Development of the neurological system differs significantly between infants/children and adults.

    • Rapid development occurs during the first years of life (infant and toddler stages).

    • Fontanelles and sutures in the skull facilitate growth of the brain:

    • Fontanelles fuse after brain growth slows down.

    • Skull thickness and structural integrity increase with age.

    • Skull pliability decreases as the child matures.

    • Young children possess relatively larger heads relative to their body size.

    • Increased cerebral metabolism is evident in children.

    • Rapid myelination happens particularly during the first three years of life.

NEURO ASSESSMENT IN INFANTS AND CHILDREN

  • A structured approach is essential for assessing neurological status in younger populations, with unique considerations compared to adults.

GCS: ADULT VS. PEDIATRICS

  • The Glasgow Coma Scale (GCS) is used to assess consciousness and neurological function.

  • Eye Opening Score (E):

    • Adults:

    • 4: Spontaneous

    • 3: To voice

    • 2: To pain

    • 1: None

    • Pediatrics:

    • 4: Spontaneous

    • 3: To voice

    • 2: To pain

    • 1: None

  • Verbal Response Score (V):

    • Adults:

    • 5: Oriented

    • 4: Confused

    • 3: Words

    • 2: Incomprehensible sounds

    • 1: None

    • Pediatrics:

    • 5: Coos/babbles

    • 4: Irritable/cries

    • 1: None

  • Motor Response Score (M):

    • Adults:

    • 6: Follows commands

    • 5: Localizes pain

    • 4: Withdraws to touch

    • 3: Withdraws to pain

    • 2: Abnormal flexure posturing

    • 1: None

    • Pediatrics:

    • 6: Spontaneous movement

    • 5: Withdraws to touch

    • 4: Withdraws to pain

    • 3: Abnormal flexure posturing

    • 2: Abnormal extension posturing

    • 1: None

VESTIBULAR FUNCTION ASSESSMENT

  • Techniques to assess vestibular function include:

    • Running a cotton swab on the extremity.

    • Moving a toy through the child's field of vision.

    • Whispering a word and observing head movement.

    • Observing the child’s posture and gait.

CRANIAL DEFECTS

CRANIOSYNOSTOSIS

  • Definition: Premature closure of one or more cranial sutures leading to head malformations.

    • Types:

    • Simple craniosynostosis (involves one suture)

    • Complex craniosynostosis (involves multiple sutures)

    • Complications: Increased intracranial pressure (ICP) and associated head malformations.

    • Symptoms: Abnormal fontanelle shape with a hard ridge at the suture line.

    • Diagnosis (Dx): MRI or CT scans and genetic testing.

    • Surgical Intervention: Time-sensitive; recommended before 6 months, with postoperative helmet therapy 23 hours a day for 3-4 months.

    • Postoperative Concerns: Potential for anemia due to blood loss during surgery.

DEFORMATIONAL PLAGIOCEPHALY (DP)

  • Definition: Asymmetry and flattening of the head caused by external mechanical forces.

    • Peaks in prevalence at approximately 4 months of age.

    • Associated with the Back to Sleep Campaign.

    • Risk Factor: Congenital muscular torticollis.

    • Symptoms: Observable skull deformation; right occiput more pronounced than left; potential facial abnormalities.

    • Evaluation for developmental delays and deformities is essential.

    • Management: Frequent repositioning and the use of orthotic devices.

MICROCEPHALY

  • Definition: A condition characterized by an abnormally small head size, either primary or secondary.

    • Cognitive Impairments: Associated with overall cognitive deficits as well.

    • Measurement: Head circumference that is 2 standard deviations below the mean.

    • Care: Primarily supportive.

HYDROCEPHALUS

  • Definition: Characterized by the buildup of cerebrospinal fluid (CSF) in the brain, which may arise from:

    • Increased production of CSF.

    • Decreased absorption of CSF.

    • Obstruction to CSF flow.

  • Types:

    • Communicating (normal flow) vs. non-communicating (obstruction).

  • Manifestations depend on age and severity:

    • Symptoms may include dilated scalp veins, bulging fontanel, apnea, irritability, headaches, and vomiting.

  • Guidelines:

    • Avoid lumbar punctures for non-communicating conditions due to risk of brain herniation.

    • Treatment: Ventriculoperitoneal shunt placement is the common surgical intervention.

    • Monitoring: Risk of infection; the shunt may need replacement throughout the child’s lifetime.

    • Constant monitoring of head circumference is necessary to assess shunt patency.

INTRACRANIAL ARTERIOVENOUS (AV) MALFORMATIONS

  • Definition: Rare congenital vascular lesions often asymptomatic at birth.

  • Common Causes: Major cause of spontaneous hemorrhage within the brain.

  • Pathophysiology: Caused by failure of normal differentiation of vascular channels, often seen in posterior fossa, basal ganglia, and thalamus.

  • Symptoms: Commonly include seizures, headaches, weakness, and paralysis.

  • Diagnostic Technique: Utilization of four-vessel angiography for assessment and monitoring.

  • Treatment Options: May involve microsurgical resection or endovascular embolization.

MENINGITIS

  • Definition: An infection affecting the meninges, protective membranes enclosing the brain.

  • Types:

    • Aseptic (viral) which is generally self-limiting.

    • Septic (bacterial), which is more severe.

  • Signs and Symptoms: Classic symptoms include fever, headache, stiff neck, photophobia, and a purplish rash.

  • Diagnostic Measures: Diagnosis made via lumbar puncture, positive Kernig’s sign, and/or positive Brudzinski’s sign.

    • Septic meningitis necessitates:

    • Isolation, intravenous (IV) antibiotics, and rigorous neurological monitoring.

    • Prophylactic antibiotics may be required for individuals in close contact with the infected patient.

    • Aseptic meningitis generally resolves with supportive care.

MENINGOCOCCAL SYMPTOMS IN INFANTS AND YOUNG CHILDREN

  • Key symptoms to identify include:

    • Deterioration in tolerance for handling (dislike of touch).

    • Extreme tiredness and drowsiness.

    • Aversion to light (turning away from brightness).

    • Refusal to feed; potential presence of fever.

    • The rash may manifest as red-purple pinprick spots or bruise-like areas.

    • Signs may also include irritability, convulsions, or twitching.

    • Nausea and vomiting are common as well.

    • The infant may exhibit floppiness.

BRUDZINSKI SIGN

  • Definition: A clinical examination sign raising suspicion of meningitis, indicating meningeal irritation.

  • Mechanism: Believed to occur due to passive flexion of the neck stretching nerve roots through inflamed meninges, inducing reflex flexion of hips and knees for pain relief.

  • Limitations: Initially described over 100 years ago, typically in late-stage tuberculosis or bacterial meningitis cases.

  • Procedure:

    1. Patient positioned supine.

    2. One hand placed behind the patient's head, and the other on their chest to prevent rising.

    3. Positive test indicated by neck flexion causing hip and knee flexion.

KERNIG SIGN

  • Definition: A clinical sign used alongside Brudzinski’s sign to assess for meningitis.

  • Procedure:

    1. Patient lies supine.

    2. One leg is raised with the knee flexed at a 90-degree angle.

    3. The leg is straightened at the knee slowly hereafter.

  • Positive Indicator: Resistance, pain, or inability to extend the knee signifies irritation of the meninges.

CASE STUDY: LUCAS M.

  • Patient Information:

    • Name: Lucas M.

    • Age: 5 months

    • Weight: 6.8 kg

  • Presenting Complaint: Brought to the emergency department (ED) due to irritability, fever, and poor feeding.

  • Initial Presentation:

    • Fever for 12 hours with a Tmax of 102.9°F (39.4°C).

    • Increasing irritability with inconsolable crying and poor feeding observed over the last 6 hours.

    • One episode of vomiting noted.

    • No documented allergies and immunizations are current.

  • Physical Exam Findings:

    • Temperature at 103.2°F, Heart Rate (HR) at 170 bpm, Respiratory Rate (RR) at 42/min, Blood Pressure (BP) at 82/45, and Oxygen saturation at 95%.

    • Notable bulging anterior fontanelle.

    • High-pitched cry and lethargy but arousable.

  • Provider Orders:

    1. Obtain IV access and blood cultures.

    2. Administer IV fluids (D5 0.9% NaCl at 25 mL/hr).

    3. Perform lumbar puncture for CSF studies.

    4. Begin IV cefotaxime and vancomycin after cultures are taken.

    5. Administer acetaminophen prn for fever >101.5°F.

    6. Implement droplet precautions.

  • CSF Results (from lumbar puncture):

    • Appearance: Cloudy

    • WBC: 1,200/mm³ (increased, predominantly neutrophils)

    • Protein: 210 mg/dL (elevated)

    • Glucose: 25 mg/dL (decreased; serum glucose at 90 mg/dL)

    • Gram stain: Demonstrated gram-positive diplococci.

SELECTING ABNORMAL FINDINGS FROM CSF RESULTS (BACTERIAL MENINGITIS)

  • WBC count: Elevated

  • Protein: Elevated

  • Glucose: Decreased

NURSING ACTIONS

  • Assess appropriate actions:

    • Appropriate: Initiate droplet precautions, administer IV antibiotics prior to obtaining cultures, monitor for seizures.

    • Not Appropriate: Keep an infant NPO until stable, delay lumbar puncture until antibiotics are given.

PRIORITIZATION OF INTERVENTIONS

  1. Obtain blood cultures.

  2. Start IV antibiotics.

  3. Administer acetaminophen for fever.

  4. Don a mask.

SEIZURE MANAGEMENT

  • Immediate Nursing Actions During a Seizure:

    • Raise padded side rails.

    • Insert a padded tongue blade if indicated.

    • Administer IV lorazepam as ordered.

    • Document seizure onset, duration, and characteristics.

    • Provide suction and oxygen post-seizure as necessary.

VITAL SIGNS MONITORING

  • Following 2-hour monitoring of vital signs:

    • Notable data:

    • Time 1200: Temp 103.2°F, HR 170 bpm, RR 42/min, BP 82/45, O2 Sat 95%.

    • Time 1300: Temp 102.6°F, HR 165 bpm, RR 40/min, BP 78/42, O2 Sat 94%.

    • Time 1400: Temp 101.9°F, HR 160 bpm, RR 38/min, BP 74/40, O2 Sat 92%.

    • Complication Developing:

    • A. Sepsis with septic shock.

LUMBAR PUNCTURE: BACTERIAL VS. VIRAL MENINGITIS

CSF Analysis Characteristics

Appearance

Opening Pressure (mmHg)

WBC (cell/L)

Protein (mg/dL)

Glucose (mg/dL)

Normal

Clear

90-180

<8

15-45

Bacterial

Turbid

>1000-2000

>200

<40

Viral

Clear

Lymphocytic <200

Normal

Normal

REYE SYNDROME

  • Definition: Extremely rare condition leading to rapid multi-organ failure with poor prognosis, particularly associated with aspirin usage during viral illnesses.

  • Severity Staging: Graded from 0 to 6 based on symptom severity:

    • Stage 1: Mild-moderate symptoms (vomiting, lab evidence of liver dysfunction, lethargy).

    • Stage 2: Deeply lethargic, restless, confused, potentially hyperventilating.

    • Stage 3: Presenting with light coma and rigidity.

    • Stage 4: Deepening coma with seizures and decerebrate rigidity.

    • Stage 5: Severe symptoms leading to flaccid paralysis and respiratory arrest.

  • Diagnosis: Liver biopsy, liver function tests (LFTs), lumbar puncture, ammonia levels.

  • Anticipatory Guidance: Advising to avoid aspirin in any child under the age of 19 due to the risk of developing Reye syndrome.

ENCEPHALITIS

  • Definition: Infection resulting in inflammation of the meninges with concurrent cerebral edema, mimicking aseptic meningitis but typically viral in nature (examples: HSV, enterovirus).

  • sources: Can also arise from toxins, fungi, bacteria, or parasites.

  • Risk Factors: Often associated with vector-borne viruses transmitted via mosquitoes.

  • Symptoms: Increased incidence of seizures, flaccid paralysis, headaches, photophobia, lethargy, and stiff neck observed.

  • Diagnostic Approach: MRI scans to identify changes indicative of encephalitis.

  • Treatment Plan: Would involve IV antibacterial or antiviral depending on the specific etiology, with close monitoring and seizure precautions essential during care.

SEIZURES

  • Definition: Electrical disturbances within the brain leading to various alterations in motor, sensory, and cognitive function depending on their location and severity.

  • Classification: Based according to the origin (focal vs. generalized), frequency, duration, and etiology.

SEIZURE DIAGNOSTICS

  • Electroencephalogram (EEG): Used to analyze brainwave activity using electrodes placed on the scalp.

EPILEPSY

  • Definition: Characterized by recurrent, unprovoked seizures.

  • Criteria for Resolution: Considered resolved if no seizure occurs for 10 years or longer, or if the patient has been off antiepileptic medications for 5 years without seizures.

  • Onset: May vary in relation to age.

  • Diagnostic Criteria:

    1. Two unprovoked seizures occurring more than 24 hours apart.

    2. A single unprovoked seizure with a high probability of repetition within the next decade.

    3. Evidence of an epileptic syndrome.

  • Management: Vaginal nerve stimulation as a non-medication option when conventional medication fails.

STATUS EPILEPTICUS

  • Definition: A medical emergency involving prolonged seizures or continuous seizure activity without full recuperation (acts more than 5 minutes).

  • Classification: Convulsive or non-convulsive based on observable motor activities.

  • Intervention Strategies: Initiate IV fluids, provide oxygen, and deploy IV medications to stop the seizure activity. Medically induced coma can be employed to halt continuous seizures if needed.

FEBRILE SEIZURES

  • Definition: Acute seizure events triggered by an elevated body temperature, principally observed in children under 7 years of age, with fever often exceeding 102°F (38.4°C).

  • Prognosis: Generally self-limiting but can be distressing for caregivers.

  • Diagnostic Consideration: Utilization of EEG is required for appropriate evaluations.

ANTIEPILEPTIC MEDICATIONS

  • Fundamentals of Administration: Consistency plays a vital role for efficacy; monotherapy is often preferred.

  • Specific medications based on seizure categorizations include:

    • Focal (motor onset):

    • Carbamazepine (Tegretol)

    • Phenytoin (Dilantin)

    • Gabapentin (Neurontin)

    • Generalized (tonic-clonic):

    • Valproic acid (Depakene)

    • Phenobarbital (Luminal)

    • Generalized (nonmotor onset):

    • Ethosuximide (Zarontin)

    • Topiramate (Topamax) for focal (nonmotor onset).

  • Considerations and Monitoring: Must monitor blood levels to ensure therapeutic efficacy and pinpoint possible interactions or side effects like bradycardia or GI distress.

CRITICAL THINKING IN MEDICATION ADMINISTRATION

  • Assess potential medications that can be given if IV access is not available.

POP UP QUESTION: CRANIOSYNOSTOSIS NURSING INTERVENTION PRIORITY

  • Priority nursing intervention:

    • A. Monitor for signs of increased intracranial pressure (ICP) such as bulging fontanels and irritability.

HEAD TRAUMA

  • Definition: Traumatic brain injury (TBI) following a blow or jolt to the head which can be classified either as primary or secondary, and either accidental or non-accidental (e.g., shaken baby syndrome).

  • Risk Profile: Infants and toddlers are particularly vulnerable due to their proportionally larger heads.

  • Symptoms: Vary based on injury's severity; shaken baby syndrome may present insidiously, necessitating high vigilance.

    • Assessment Tools: Measuring cerebral perfusion pressure (CPP), regularly assessing Glasgow Coma Scale scores, and being observant for general posturing (decorticate vs. decerebrate).

NURSING INTERVENTIONS FOR NEUROLOGICAL DISORDERS

  • Essential nursing actions should encompass:

    • Maintaining a patent airway and effective ventilation.

    • Ensuring adequate hydration and nutrition is upheld.

    • Promoting safety and skin integrity.

    • Preserving neurological function while preventing or managing infections.

    • Pain relief, comfort, and rest should be emphasized.

  • Medication Management: Administration and continual management of prescribed medications required.

HEADACHES

  • Classification:

    • Acute.

    • Acute recurrent.

    • Chronic progressive.

    • Chronic non-progressive.

  • Pathophysiology: Varies for each classification.

  • Symptoms: Patients may range from mild to severe manifestations.

  • Management: Treatments based primarily on the underlying cause:

    • Relaxation techniques, common management approaches, and over-the-counter medications may be employed.

    • Encouragement of a headache journal to map patterns and pinpoint triggers.

STRUCTURAL AND REFRACTORY DISORDERS OF THE EYE

  • Common conditions include:

    • Astigmatism: Characterized by unequal refractory curvatures.

    • Nystagmus: Involuntary, abnormal eye movements.

    • Strabismus: Known as “cross eyes.” Management may include occlusion therapy.

    • Infantile Glaucoma: Suggestive of increased intraocular pressure.

    • Congenital Cataracts: Presence of cloudiness over corneal lens.

  • Intervention Guidelines: Determining the root cause of vision disturbances will dictate the treatment pathway. Regular vision screenings are crucial to early identification.

  • Correction Path: Corrective lenses may be indicated to improve visual acuity.

NASOLACRIMAL DUCT OBSTRUCTION

  • Definition: Blockage of the tear duct leads to excessive tearing.

  • Pathophysiology: Arises from failure of canalization between the nose and nasolacrimal duct.

  • Symptoms: Red, swollen eyelids mimicking conjunctivitis.

  • Resolution: Generally spontaneous within the first year. Lacrimal massage and topical antibiotics until resolution or probe dilation if ineffective.

PERIORBITAL CELLULITIS

  • Definition: Also referred to as “preseptal cellulitis,” referring to infection in eyelid and surrounding tissues of the eye.

  • Treatment: Timely intervention is crucial to avoid complications like vision loss, abscess formation, etc.

  • Symptoms: Marked swelling of the eyelid, vision changes, and increased intraocular pressure.

    • Consideration: Methicillin-resistant Staphylococcus aureus (MRSA) should be suspected if multiple abscesses are present.

    • Management Method: Typically necessitating hospitalization for IV antibiotics and close monitoring.

    • Decongestants may also be employed for secretion reduction.

HEARING DEFECTS

  • Causes of hearing impairment can be genetic or acquired, with some instances remaining unknown.

  • Red Flag Signs: In children, suspect hearing loss if the startle reflex is absent or if there’s no turning towards voice/noise by six months.

    • Speech delays or inattentiveness may also indicate impairment.

  • Screening Recommendations: Regular hearing screenings are essential for early detection.

  • Intervention Options: Technological aids, American Sign Language, or other forms of communication may be vital to support affected individuals.

POP UP QUESTION: PROMOTING COMMUNICATION AND LEARNING FOR DEAF CHILDREN

  • Suggested intervention strategies for effective communication include:

    • A. Maintaining eye contact and speaking at the child’s eye level.

    • B. Utilizing sign language, gestures, and visual aids for reinforcement of communication.

    • C. Positioning the child wisely in classrooms away from auditory distractions.

    • E. Advocating for the regular use of hearing-assistive devices when awake.