Neuro

  • Prevention = highest priority, as neural tissue does not regenerate, leading to likely permanent nervous system degeneration.

  • Nursing interventions focus on:

    • Preventive measures

    • Supporting families and children in coping with mental or physical function loss

    • Providing comfort

    • Crafting an environment that promotes the child's development and self-esteem.

Assessing Neurologic Disorders

History Taking

  • Chief Concerns:

    • Seizures

    • Loss of consciousness

    • Delayed developmental tasks

    • Headaches

    • Clumsiness in motor tasks

  • Past Medical History:

    • Infection during pregnancy

    • Difficult birth process

    • Head injury history

  • Family Medical History:

    • Seizures or headaches in family members.

Physical Examination Findings

  • Signs indicating neurologic issues:

    • Increased head circumference

    • Bulging fontanelles and forehead

    • Unequal pupil sizes and responses

    • Projectile vomiting

    • Widening blood pressure measurements

    • Decreased pulse rate

    • Headache

    • Elevated body temperature

    • Pain upon neck flexion

    • Ineffective sucking

    • Decreased respiratory rate

    • Spasticity of muscles

Neurologic Examination

Key Components

  • Cerebral Function: Assessment of overall cognitive and emotional state.

  • Cranial Nerve Function: Detailing the functions of each cranial nerve and how to assess them (see TABLE 49.2).

  • Cerebellar Function: Evaluating balance and coordination.

  • Motor Function: Testing muscle strength and mobility.

  • Sensory Function: Assessing sensation across various modalities.

TABLE 49.2 - Cranial Nerve Function

Cranial Nerve

Function

Assessment

I (Olfactory)

Sense of smell

Ability to recognize common odors while eyes are closed.

II (Optic)

Vision

Assess vision fields and acuity; examine retinas.

III (Oculomotor)

Motor control of upper eyelid and eye muscles

Pupillary reaction and eye movement abilities.

IV (Trochlear)

Movement of major eye muscles

Similar to III assessment.

V (Trigeminal)

Facial sensation, mastication

Assess sensory touch and strength of bite.

VI (Abducens)

Eye movement

Similar to III assessment.

VII (Facial)

Facial muscles, salivation

Observe facial symmetry and identify taste sensations.

VIII (Acoustic)

Hearing and equilibrium

Respond to whispered words and perform balance tests.

IX (Glossopharyngeal)

Swallowing

Assess gag reflex and swallowing ability.

X (Vagus)

Sensation from internal organs

Similar to IX assessment.

XI (Accessory)

Neck and shoulder movement

Assess shoulder elevation and neck rotation.

XII (Hypoglossal)

Tongue movement

Assess symmetry and strength of tongue.

Diagnostic Testing

  • Common Procedures:

    • Lumbar puncture

    • Ventricular tap

    • Imaging studies such as X-rays, CT scans, and MRIs

    • Electroencephalography (EEG)

    • Nuclear medicine studies (brain scans)

Normal Properties of Cerebrospinal Fluid (CSF)

  • Parameters Include:

    • Opening pressure: Newborns (8-10 cm H₂O), Children (10-18 cm H₂O)

    • Appearance: Clear and colorless

    • Cell count: 0-8/mm³

    • Protein content: 15-45 mg/100 ml

    • Glucose level: 60%-80% of serum glucose.

    • Albumin/globulin (A/G) ratio: 8:1

Abnormal Findings and Implications

  • High/Low Pressures:

    • Lowered pressure may indicate obstruction, while elevated pressure can suggest infection or hemorrhage.

  • CSF Appearance:

    • Cloudy fluid may indicate infection; red discoloration may indicate bleeding.

  • Cell Count:

    • Elevated WBC counts could suggest viral, bacterial, or fungal infections.

Increased Intracranial Pressure (ICP)

  • Causes:

    • Increased CSF volume

    • Blood entering CSF

    • Cerebral edema

    • Head trauma

    • Hydrocephalus

    • Space-occupying lesions

Signs and Symptoms of Increased ICP

  • Increased head circumference, bulging fontanelles, vomiting, eye changes, vital sign changes (elevated temperature, BP changes), and altered mentation such as irritability or confusion.

Neurocutaneous Syndromes

Sturge-Weber Syndrome

  • Characteristics:

    • Port-wine birthmark

    • Associated hemiparesis

    • Cognitive challenges

    • Possible seizures and glaucoma.

Neurofibromatosis (Von Recklinghausen Disease)

  • Characteristics:

    • Irregular skin pigmentation with café-au-lait spots

    • Possible hearing impairment and vision loss.

Cerebral Palsy

Types of Cerebral Palsy

  • Pyramidal (spastic)

  • Extrapyramidal (dyskinetic)

  • Ataxic

  • Mixed type

Assessment Considerations for Cerebral Palsy

  • History of potential anoxia at birth or prenatal issues.

  • Physical assessments can include strabismus, visual perception problems, and possibly cognitive delays.

Infection of the Nervous System

  • Types of infections include bacterial meningitis, viral meningitis, encephalitis, Reye syndrome, Guillain-Barré syndrome, and botulism.

Assessment and Symptoms of Infections

  • Bacterial Meningitis:

    • Symptoms can include high fever, severe headache, vomiting, altered consciousness, and signs of nuchal rigidity. CSF typically cloudy with elevated WBC and decreased glucose.

  • Viral Meningitis:

    • Symptoms include mild headache and fever; CSF is clear and shows normal glucose levels.

  • Encephalitis:

    • Symptoms such as high fever, headache, confusion, and potential lethargy.

  • Guillain-Barré Syndrome:

    • Symptoms include muscle weakness that typically starts in the legs and can progress upwards.

Therapeutic Techniques for Neurologic Disorders

Bacterial Meningitis

  • Treatment typically involves antibiotics, potential corticosteroids, and supportive care.

Encephalitis

  • Supportive treatments may include antipyretics and possibly antivirals like acyclovir.

Guillain-Barré Syndrome

  • Supportive care focused on monitoring respiratory function and may involve immune therapies.

Inflammatory Disorders

Carpal Tunnel Syndrome

  • Symptoms include numbness and pain in the thumb and fingers.

Bell's Palsy

  • Abrupt onset typically associated with viral infections like herpes.

Assessing Paroxysmal Disorders

Recurrent Seizures

  • Requires a history of the events preceding the seizure and thorough neurological evaluation.

Breath Holding Episodes

  • Often tied to stress or anger, characterized by temporary loss of consciousness.

Headaches

  • Requires careful history taking and assessment of associated symptoms.

Spinal Cord Injury

Assessment Considerations

  • Critical to maintain spinal precautions if an injury is suspected following trauma. Various assessment protocols must be followed to ensure the safety of the child during evaluation.

Ataxic Disorders

Ataxia-Telangiectasia & Friedreich Ataxia

  • Assessment focuses on developmental delays, gait disturbances, and signs of progressive neurological decline.

Nursing Diagnoses

  • Risk for Disuse Syndrome and Interrupted Family Processes can be prominent diagnoses within the context of care for children with neurologic disorders.

Questions and Answers Section

  1. Question: What may frighten a child with bacterial meningitis the most? Answer: Masks worn by staff due to the need for respiratory isolation precautions.

  2. Question: What is a common finding in Reye syndrome? Answer: Recent influenza illness and the possible use of aspirin following viral illness.

  3. Question: What is a typical manifestation of absence seizures? Answer: Rapid blinking for 10 seconds.

  4. Question: Which drug might be prescribed for a child with migraines? Answer: Ergotamine tartrate (Cafergot) to relieve headache.