The Child With a Neurologic Alteration - Chapter 52

Hydrocephalus Diagnostic Evaluation

Because of anatomic differences between infants and children, manifestations of hydrocephalus differ according to developmental stage

Nursing Care The Child With Guillain-Barré Syndrome Assessment

A complete history and physical examination are important to determine the presence of an antecedent viral illness and establish baseline clinical status. Special emphasis is given to evaluating the respiratory and neurologic systems. Respiratory status should be assessed hourly or more frequently in some cases because of the risk of respiratory compromise and the need for prompt action, including intubation and ventilator support, if the child's respiratory status deteriorates. Major assessment parameters include respiratory rate, chest excursion, energy expended to breathe, and breath sounds. Pulse oximetry assesses the effectiveness of gas exchange. Daily pulmonary function testing might be ordered. A thorough neurologic assessment is generally performed every 1 to 2 hours, although this may be done more frequently depending on the child's clinical condition. Neurologic parameters to address include cranial nerve function, motor capabilities, sensory perception, and deep tendon reflexes.

Head Injury Diagnostic Evaluation

A complete history of the event helps determine the mechanism of injury and whether the child lost consciousness. Spinal radiographs are obtained to ascertain any cervical spinal cord injury; these are followed by a complete neurologic examination. Any indication of increased ICP is quickly reported to the physician. CT scan and MRI are the most commonly used studies to evaluate head injury and rule out serious brain injuries such as intracranial hemorrhage and hematomas. When ordering a CT scan, providers must balance the risk of exposure to ionizing radiation and missing a clinically important head injury. Many guidelines agree that CT scans of the head are not routinely recommended and unnecessary CT scans in children should be avoided Despite these recommendations, there has been a significant increase in the use of CT scans for children with a head injury in the past 2 decades In response, recent studies have published prediction rules to identify children at risk for clinically significant head injury

Concussion

A concussion is transient and reversible neuronal dysfunction, with instantaneous loss of awareness and responsiveness.

Cerebral Palsy Diagnostic Evaluation and Therapeutic Management

A diagnostic evaluation includes EEG, CT scan or MRI, electrolyte levels, metabolic workup, a thorough history, and a complete neurologic examination. Additional genetic evaluation may be considered with patients who have congenital malformations. Assessment for developmental disorders is important since there is an increased incidence in children with CP The goal of managing the child with CP is early recognition and intervention to maximize the child's abilities. Cerebral palsy often is not diagnosed before the child is 2 years old. Before age 2, the child may be diagnosed with static encephalopathy, a nonspecific term referring to permanent brain damage. Repetition of motor activities facilitates development of new brain pathways through alternative receptor sites and enhances appropriate motor function. The child might be intellectually intact, but this factor can be overlooked because of the child's physical limitations. Intrathecal baclofen, a skeletal muscle relaxant, administered via an infusion pump can be used to treat severe spasticity in children with CP. Benzodiazepines are also used to treat spasticity Botulinum toxin A injected into the muscle is an option for nonambulatory children to help with comfort and care Close monitoring of the child for infection and the pump for malfunction, as well as correct pump assembly and programming, are required.

Pathophysiology Cerebral Palsy

A number of neuromuscular disabilities are associated with cerebral palsy. The alteration in voluntary muscular control is related to a cerebral insult. The area of the brain that is affected determines the type of neuromuscular disability. The five classifications of cerebral palsy are dyskinetic, spastic, ataxic, rigid, and mixed: • Dyskinetic (athetoid) palsy refers to a disorder in the basal ganglia. Slow, writhing, uncontrolled, involuntary movements involving all extremities characterize this type. • Spastic cerebral palsy is the most common type. The affected area of the brain is the cortex. Spastic cerebral palsy is characterized by increased deep tendon reflexes, hypertonia, flexion, and sometimes contractures. The child's muscles are very tense, and any stimulus can cause a sudden jerking movement. The child has to make a conscious effort to relax. Scissors gait, hip flexion with adduction and internal rotation, or toe walking because of tight heel cords may be present. • In ataxic cerebral palsy, the affected area of the brain is the cerebellum. This type of cerebral palsy is characterized by a loss of coordination, equilibrium, and kinesthetic sense. Overall, the child appears clumsy. • Rigid (tremor, atonic) cerebral palsy is relatively rare in children. The child has rigidity of both flexor and extensor muscles. In a child with tremors, the tremors are apparent both at rest and during movement. The prognosis for a child with this type of cerebral palsy is poor because of associated deformities and lack of active movement. • Mixed is more than one type of cerebral palsy. A common combination is spastic and dyskinetic. Approximately half of children with cerebral palsy have other disabilities, including epilepsy, a cognitive disability, learning problems, poor attention span, hyperactivity, hearing or visual impairment, and emotional problems. Gastroesophageal reflux can occur Intense movements that cause a high expenditure of calories along with feeding challenges can lead to a calorie deficit and poor nutritional status.

Seizure Disorders

A seizure consists of brief paroxysmal behavior caused by excessive abnormal discharge of neurons. Epilepsy is marked by recurrent seizure activity that does not occur in association with an acute illness. Epilepsy is diagnosed after 2 or more unprovoked seizures Seizures are classified into three major categories: focal, generalized, and unknown. Focal seizures occur in one part of the brain and may or may not alter consciousness. Generalized seizures occur over the entire brain and do alter consciousness A seizure of the unknown type cannot be characterized as focal or generalized; epileptic and infantile spasms are examples

Meningitis Therapeutic Management

Acute bacterial meningitis is a medical emergency requiring early recognition and prompt, aggressive management to avoid adverse outcomes. The child is placed in a private room on droplet transmission precautions, and these are maintained for at least 24 hours after antibiotics are initiated. Immediate initiation and uninterrupted IV administration of appropriate antibiotics are essential in cases of suspected bacterial meningitis; a delay could be fatal. Treatment is started before the causative organism is identified because cultures take up to 3 days to yield results. Selection of the broad-spectrum antibiotics initially used is based on the age of the child, the suspected pathogens most frequently encountered in the child's age-group, and the initial appearance of the CSF. If IV access is difficult to achieve, the first dose of antibiotics should be administered intramuscularly. Treatment for neonatal bacterial meningitis consists of ampicillin and an aminoglycoside or a third-generation cephalosporin antibiotic. Monitoring of peak and trough antibiotic levels is essential to prevent ototoxicity and nephrotoxicity from aminoglycosides. For older children and adolescents, the treatment of choice is ampicillin, penicillin G, or a third-generation cephalosporin. When the culture and sensitivity test results are available, treatment regimens can be refined. Morbidity and mortality associated with bacterial meningitis is reduced by adjunctive treatment with dexamethasone, which can decrease intracranial pressure The treatment for viral meningitis is managed at home by providing symptomatic and supportive care, usually with complete recovery Current recommendations are that children be vaccinated with meningococcal vaccine at the age of 11 to 12 years, or by the age of 18 years if previously unvaccinated. It is important that prospective college students receive meningococcal vaccine before college entry to prevent meningococcal meningitis and that children receive the H. influenzae type B (Hib) vaccine as part of their routine immunization schedule during infancy and early childhood

Parents Want to Know Guidelines for the Child With a Head Injury

After the injury, apply cold (cool pack wrapped in a towel or cool wet compresses) to the site for 20 minutes to prevent or reduce swelling. Clean any scrapes or cuts with soap and water. Encourage the child to rest and limit foods if vomiting. You will need to watch your child closely for the first 24 to 48 hours after the injury in case the child develops a problem and needs to be taken to the healthcare provider. Follow your health provider's directions as to whether the child should be awakened at night. Some providers suggest waking the child every few hours to be sure the child becomes alert and answers questions appropriately. The following are signs of more serious injury, and you should call the physician or emergency transport immediately after the injury if the child: • Has bleeding that does not stop after pressure has been applied for 10 minutes or is oozing from the nose or ears • Needs sutures • Is younger than 2 years • Has trouble breathing • Vomits or complains of a severe headache that does not go away • Had a seizure after the head injury • Was unconscious or confused • Has a severe headache or vomiting • Has slurred speech or blurred vision • Has blood or watery fluid coming from the ear or nose • Has unequal pupils or crossed eyes • Has difficulty walking or crawling or weakness in the arms • Becomes hard to wake up • Becomes pale and remains that way for more than an hour • Has other symptoms that concern you

Spinal Cord Injury Diagnostic Evaluation

After the nurse takes the history of the injury and performs a complete neurologic examination, the extent of the spinal cord injury is determined by radiography or MRI. The extent of the motor or sensory deficit may resolve somewhat as spinal shock resolves. Spinal cord injury without radiologic abnormalities (SCIWORA), which is more common in children, is a neurologic consequence of injury to the spinal cord related to anatomic differences in the structure of the spinal column and cord

Increased Intracranial Pressure Etiology

Alterations in the brain can result from a space-occupying lesion, such as a brain tumor or hematoma. The brain can swell as a result of head trauma, infection, or a hypoxic episode. Overproduction of fluid, malabsorption of fluid, or a communication problem within the system can disrupt CSF dynamics. Aneurysms within the brain and acute liver failure can also lead to increased ICP.

Increased Intracranial Pressure Manifestations Pupil Evaluation

As ICP rises, compression of the third cranial nerve occurs, resulting in pupil dilation with sluggish or absent constriction in response to light. A fixed, dilated pupil is an ominous sign in an unconscious child. This condition suggests herniation of the center section of the brain (also known as a transtentorial herniation). Other eye dysfunctions associated with increased ICP include ptosis and ovoid pupil. Older children might complain of blurry vision, diplopia, or decreased visual acuity.

Atonic Seizures

Atonic seizures cause an abrupt loss of postural tone, impairment of consciousness, confusion, lethargy, and sleep. A child might have multiple episodes of sudden and brief head drop or a drop attack, during which they fall to the ground, often face down, lose consciousness for a few seconds, and then get back up as if nothing happened.

Guillain-Barré Syndrome Diagnostic Evaluation

Bilateral ascending weakness or paralysis occurring 2 to 4 weeks after an upper respiratory infection or gastric illness is a diagnostic indicator. The paralysis can affect the respiratory muscles quickly, and any indications of respiratory distress should prompt elective intubation The CSF may demonstrate high protein levels. Nerve conduction studies, LP, and MRI can help confirm the diagnosis

Cerebral Palsy

Cerebral palsy is a chronic, nonprogressive disorder of posture and movement. It is characterized by difficulty in controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system (motor cortex, basal ganglia, cerebellum). Co-morbidities such as cognitive, hearing, speech, and visual impairments, as well as seizures, are common but vary widely from one affected child to another.

Increased Intracranial Pressure Manifestations Behavior

Changes in the child's normal behavior pattern may be an important early sign of increased ICP. Parents often are the first to notice a change in the child's behavior; therefore, a parent's comment that "he isn't acting like himself" should be taken seriously. Irritability, mild confusion, and agitation are symptoms that warrant further assessment. The child who no longer recognizes parents, cannot follow commands, or has minimal response to pain is deteriorating. Decreased responsiveness to painful stimuli is a significant sign of alteration in level of consciousness.

Increased Intracranial Pressure Manifestations Level of Consciousness

Children with increased ICP often have an altered level of consciousness. The Glasgow Coma Scale (GCS) is a standardized scale that, in a modified form, is frequently used to assess level of consciousness in infants and children. It consists of a three-part assessment: eye opening, verbal response, and motor response Each level of response is assigned a numeric value. When the assessment of each response is complete, the scores are added, providing an objective measure of the child's level of consciousness and the severity of the injury The total scores 1282range from 15, indicating no change in level of consciousness, to 3, indicating a deep coma and poor prognosis. A score of 8 or less requires aggressive management and monitoring of ICP This tool can help detect brain injury early to prevent permanent damage

Review of the Central Nervous System (CNS)

Composed of the brain and spinal cord Myelinization of the nerves begins in the 3rd month of gestation and is completed by adolescence. The axial skeleton protects the underlying structure of the CNS. The brain and spinal cord are covered by the meninges.

Contusion

Contusions are petechial hemorrhages along the superficial aspects of the brain. They can occur at the site of impact or in association with a lesion remote from the site of direct impact.

Spinal Cord Injury Therapeutic Management

Current treatment of spinal cord injury includes immobilization and steroid therapy. If used, steroids must be administered within 8 hours of the injury as a bolus of 30 mg/kg followed by a continuous infusion of 5.4 mg/kg/hr for 23 hours. Because of adverse effects associated with steroid administration, use of steroids is controversial. More research is needed to evaluate the effectiveness of steroid therapy for cervical spine injuries and to determine protocols for steroid administration times after spinal injury Until permanent surgical stabilization can be performed, other treatments such as halo traction and Gardner-Wells tongs might be used for temporary stabilization. Autonomic dysreflexia (AD) is characterized by severe peripheral hypertension. AD can occur in children following spinal cord injuries at or above the T6 (thoracic vertebrae 6) level. Early signs include a sudden, significant rise in systolic and diastolic blood pressure, usually with bradycardia; flushing of the face, neck, and shoulders; goose bumps above T6; blurred vision; spots in the child's visual field; and nasal congestion. Recognition of these signs followed by emergency treatment to lower the blood pressure is essential to preventing cerebral and retinal hemorrhage, seizures, and myocardial infarction

Status Epilepticus Diagnostic Evaluation

Diagnostic laboratory tests should include blood glucose, ABGs, electrolytes, anticonvulsant drug levels, a toxicology screen, and possibly lumbar puncture. Results may be similar to those of the child with increased ICP. An MRI might also be performed.

Increased Intracranial Pressure Diagnostic Evaluation and Therapeutic Management

Diagnostic tests for increased ICP include computed tomography (CT), magnetic resonance imaging (MRI), lumbar puncture, serum and urine electrolytes, arterial blood gas determinations, a complete blood cell count, electroencephalography (EEG), and radiography. Normal blood gas levels are PaO2 greater than 80 mm Hg and PaCO2 less than 45 mm Hg in a child with normal ICP. The management of increased ICP is multimodal and is directed toward treating its underlying cause, reducing the volume of the CSF, preserving cerebral metabolic function, and avoiding situations that increase ICP. An intraventricular catheter may be used to measure ICP, drain CSF, and/or administer medications The head of the child's bed should be elevated 30 degrees with midline positioning of the head, and normothermia should be maintained. The child may be given an osmotic diuretic (e.g., mannitol) or hypertonic saline, sedation and analgesia, and anticonvulsant medications Blood glucose levels are closely monitored to maintain normal levels and prevent further increases in metabolic demands. Intravenous fluid boluses with normal saline are used for children with hypovolemia Hyperventilation is used if there are signs of cerebral herniation Corticosteroids are no longer used in the treatment of increased ICP due to traumatic brain injury (TBI)

Spina Bifida Diagnostic Evaluation

Diagnostic tests include determining alpha-fetoprotein (AFP) levels in blood at 16 to 18 weeks of gestation. If the AFP screen is elevated, amniocentesis and fetal ultrasound are performed. After delivery, the infant may undergo a CT scan or myelography.

Seizure Disorders Pathophysiology

During a seizure, excessive, self-limiting neuronal discharges occur. The result of these discharges is activation of associated motor or sensory organs. The extent of the seizure depends on the location and extent of the abnormal neuronal discharges. The brain consists of millions of nerve cells; electrical impulses are sent between many of these cells by neurotransmitters. When numerous nerve cells fire abnormally at the same time, a seizure can result.

Nursing Care Plan The Child With a Neurologic System Disorder

Focused Assessment • Assess child's level of consciousness using the Glasgow Coma Scale (GCS) modified for children. • Assess child's orientation, mood, and behavior. • Compare with normal developmental milestones for age. • Observe interactions with family and environment. • Note lethargy, drowsiness, hyperactivity, tremors, or jitteriness. • Assess motor skills, balance, and coordination. • Observe child dressing, playing, throwing a ball, using a pencil, or touching finger to nose. • Observe child walking to assess gait (look for hemiplegia, scissors gait, wide-spaced gait). • Check muscle development, strength, and tone. • Determine range of motion for all joints. • Test deep tendon reflexes, comparing side to side. • Assess for sensory function and symmetry of both sides of face, trunk, arms, and legs. • Test for vibration, superficial tactile sensation, superficial pain, and temperature.

Nursing Care Plan The Child With a Seizure Disorder in the Community Setting

Focused Assessment • Obtain a detailed prenatal, perinatal, and neonatal history to determine factors that may have caused the child's seizures. • Pathologic factors include hypoxia, cerebral trauma, high fever, lead poisoning, metabolic disorders, brain tumors, birth trauma, and central nervous system (CNS) infections. • Nonpathologic factors include overhydration, oversedation, drug abuse, alcohol intoxication, sleep deprivation, antihistamine drug use, and family history. • Ask parents for detailed description of child's seizures. A video tape of the seizure activity. • Age at onset of child's seizure activity • Time of day when seizures occur • Precipitating event(s) • Child's behavior before, during, and after a seizure • How the child looks during the seizure • How the seizure progresses • How long the seizure lasts • Perform comprehensive physical examination with emphasis on the nervous system. • Assess behavior, motor skills, and developmental level. • Assess emotional responses of the child and of the family to the child's seizure disorder. • For the school-age child with a known seizure history, the school nurse maintains pertinent information in the child's record and communicates appropriate information to teachers, if needed. • During a seizure, first provide for the child's safety. Observe the child closely and document findings; observations can assist with seizure management.

Tonic, Clonic, and Tonic-Clonic Seizures

Formerly called grand mal seizures, tonic-clonic seizures cause an abrupt arrest of activity and impairment of consciousness. The tonic phase consists of a sustained, generalized stiffening of muscles, including the diaphragm, lasting a few seconds. The clonic phase is symmetric and rhythmic, consisting of alternating contraction and relaxation of major muscle groups. This phase usually ends spontaneously in less than 5 minutes. Respirations are irregular, and the child may have stridor. Sphincter incontinence (stool and/or urine) occurs in some. The tonic-clonic seizure is followed by a variable period of confusion, lethargy, and sleep (postictal phase).

Absence Seizures

Formerly called petit mal seizures, absence seizures are very brief episodes of altered consciousness. Typically, no muscle activity occurs except for upward rolling of the eyes. The child has a blank facial expression. Absence seizures last only 5 to 20 seconds or less, but they can occur up to hundreds of times per day. Absence seizures account for 8% to 15% of childhood epilepsies. They are characterized by the immediate return to the activities the child was involved in just before the seizure. Children with atypical absence seizures might experience some myoclonic movements (eyelid fluttering) and muscle tone changes (head bobbing). The onset of absence seizures is usually between ages 4 and 10 years, with a peak incidence between 6 and 8 years. Eighty percent of children outgrow absence seizures by adolescence.

Status Epilepticus Therapeutic Management

Generalized status epilepticus is a medical emergency. Treatment consists of maintaining optimal respiratory and hemodynamic function and identifying and treating the causes of the seizure activity. Diazepam (Valium), lorazepam (Ativan), or midazolam (Versed) is given intravenously. If intravenous (IV) access cannot be obtained, medication can be given orally or rectally. Fosphenytoin (Cerebyx) or phenobarbital may be given IV as a second round of drugs if diazepam or lorazepam does not stop the seizures. The intramuscular route is not used because absorption of the medication is unpredictable.

Safety Alert Drug Therapy for Generalized Status Epilepticus

Generalized status epilepticus is a medical emergency. Intravenous (IV) diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) is given. IV diazepam must be given directly into the vein (not the tubing, because it interacts with plastic) at a rate no greater than 1 to 2 mg/min. Diazepam should not be mixed with other drugs or solutions, and it can be diluted only with normal saline. Diazepam rectal gel can be administered in a community or hospital setting and is useful when the child does not have a readily accessible IV. Other pharmaceutical options for emergency treatment include buccal administration of midazolam and intranasal lorazepam. The use of newer antiepileptic drugs such as valproate and levetiracetam for the treatment of status epilepticus is an alternative. Resuscitation equipment should be at the bedside and the child's respirations closely monitored during IV antiepileptic drug administration.

Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an autoimmune neurologic disorder of the peripheral nervous system characterized by rapidly progressing limb weakness and the loss of deep tendon reflexes. In rare cases, the motor and cranial nerves are also affected. Symptoms result from acute demyelinization of the nerves. In approximately half of the cases, the illness originates as an upper respiratory or gastrointestinal (GI) viral infection that is followed by signs of GBS in 2 to 4 weeks Associated viruses include rubella, enterovirus, Epstein-Barr virus, cytomegalovirus (CMV), mycoplasma, and varicella. Campylobacter jejuni is the most commonly identified pathogen linked to Guillain-Barré. The syndrome also occurs as a toxic response to seasonal influenza vaccines.

Increased Intracranial Pressure Manifestations

Infant • Poor feeding or vomiting • Irritability or restlessness • Lethargy • Bulging fontanel • High-pitched cry • Increased head circumference • Separation of cranial sutures • Distended scalp veins • Eyes deviated downward ("setting-sun" sign) • Increased or decreased response to pain Child • Headache • Diplopia • Mood swings • Slurred speech • Papilledema (after 48 hr) • Altered level of consciousness • Nausea and vomiting, especially in the morning

Head Injury Manifestations

Head injuries are classified as minor, moderate, or severe as correlated with the GCS. Children with minor head injuries score 13 or higher on the GCS and can have a change in level of consciousness and also exhibit transient periods of confusion, irritability, vomiting, somnolence, and headache Moderate HI's score between 9 and 12, and a severe injury scores less than 8 Moderate to severe head injuries are marked by a decreased level of consciousness, changes in vital signs, signs of increased ICP, retinal hemorrhage, hemiparesis, and papilledema Seizures may occur within the first 7 days after a moderate to severe head injury

Head Injury

Head injury refers to the pathologic result of any mechanical force to the scalp, skull, meninges, or brain.

Headaches

Headaches are a common disorder in children of all ages, and their prevalence has significantly increased in western countries and in Asia over the past 30 years. Up to 75% of children and adolescents complain of occasional headaches, with 20% of these children being affected by chronic tension and migraine headaches The three primary sources of recurrent headache are vascular, tension (stress), and increased ICP. Vascular headaches include migraines and headaches that occur as a result of arteriovenous malformations. Tension headaches frequently are the result of stress. Contributing factors to increased ICP are space-occupying lesions and hydrocephalus.

Hydrocephalus

Hydrocephalus develops as a result of an imbalance between the production and absorption of CSF. As excess CSF accumulates in the ventricular system, the ventricles become dilated and the brain is compressed against the skull. This results in enlargement of the skull if the sutures are open; it results in signs and symptoms of increased ICP if the sutures are fused.

Hydrocephalus Etiology

Hydrocephalus may be congenital, acquired, or of unknown etiology. In infancy, hydrocephalus is most often congenital or related to prematurity. Congenital hydrocephalus results from developmental defects such as Arnold-Chiari malformations,congenital arachnoid cysts, congenital tumors, or aqueductal stenosis. In premature infants, neonatal meningitis or subarachnoid hemorrhage can result in hydrocephalus. Hydrocephalus is often associated with myelomeningocele. Intrauterine infection and perinatal hemorrhage cause hydrocephalus in some infants. In older children, hydrocephalus is usually acquired as a complication of meningitis, tumor, or hemorrhage.

Hydrocephalus Manifestations

INFANT Early Rapid head growth: increase in head circumference above the normal growth curve Full, bulging anterior fontanel Irritability Poor feeding Distended, prominent scalp veins Widely separated cranial sutures Late Setting-sun sign: sclera visible above the iris Frontal bone enlargement or bossing Vomiting, difficulty feeding and swallowing Increased blood pressure, decreased heart rate Altered respiratory pattern Shrill, high-pitched cry Sluggish or unequal pupillary response to light CHILD Early Strabismus Frontal headache that occurs in the morning and is relieved by emesis or by sitting upright Nausea and vomiting (can be projectile) Diplopia Restlessness Changes in ability to do schoolwork Behavior or personality changes Ataxia Papilledema Irritability Sluggish and unequal pupillary response to light Confusion Lethargy Late Seizures Increased blood pressure Decreased heart rate Alteration in respiratory pattern Blindness from herniation of the optic disc Decerebrate, extension posturing and rigidity

Lumbar Puncture: Educating the Family

If the child is old enough to understand, explain the following: • The child will need to lie on his or her side with body bent and knees and chin touching. Explain that you will help hold the child in that position by "hugging" the knees to the chin. If there is time, allow the child to practice the position. (An infant can be in a side-lying position or a sitting position with the infant facing you and your thumbs across the infant's scapulae; steady the infant's head against your body.) For an older child, consider demonstrating the procedure on a stuffed animal or doll. • Tell the child that the physician will wash the child's back with a cool liquid. After that, the child might feel a "pinch" or "sting" as the needle is inserted. A topical anesthetic should be used whenever possible to decrease the pain caused by the needle. The child must remain still. • Encourage the child to relax, sing, take deep breaths, or use guided imagery throughout the procedure to help decrease anxiety. The collection of CSF samples and pressure measurement usually takes several minutes. When the needle is withdrawn, the child will feel light pressure and the application of a small dressing. Remember to do the following: • Monitor the child's cardiorespiratory status throughout the procedure. • Maintain the child's position with shoulders and hips aligned to prevent rotation of the spine. • Help the parents comfort the child during and after the procedure.

Second Impact Syndrome

If your child is diagnosed with concussion, a second concussion that occurs before healing of the first can cause more harm to the brain and even lead to death. Be sure to talk with your health provider about whether and when the child can return to activities or sports.

Spina Bifida Manifestations

In addition to the appearance of the lesion, manifestations relate to the degree of deficit, which is determined by the level of the lesion T12: Flaccid lower extremities, decreased sensation, and bowel and bladder incontinence L1 to L3: Hip flexion, flail feet L2 to L4: Hip adduction L3 to S2: Hip adduction, hip extension, knee flexion S3 and below: No motor impairment Sacral roots: Plantar flexion

Increased Intracranial Pressure

Increased intracranial pressure (ICP) reflects the pressure exerted by the blood, brain, CSF, and any other space-occupying fluid or mass. Increased ICP results from a disturbance in autoregulation and is defined as pressure sustained at 20 mm Hg or higher for 5 minutes or longer.

Head Injury Nursing Considerations

Initial and ongoing assessment of the child with a head injury includes evaluation of the ABCDEs; airway, breathing, circulation, disability (level of consciousness), and exposure The child's neck must be immobilized because there is a higher incidence of associated cervical spine injury with head trauma. The child's level of consciousness (using the GCS), pupil size, and pupil reactivity to light are assessed frequently. Cranial nerve function is tested to identify deficits resulting from the injury and monitor for increased ICP. The clinical signs and symptoms of increased ICP, with or without actual measurement of the ICP, determine both the child's clinical status and medical and nursing interventions. Nasotracheal suctioning or placement of a nasogastric tube is contraindicated in a child with a basilar skull fracture; because of the nature of the injury, the suction catheter or tube could be introduced into the brain. CSF may leak from the nose or ears; packing or blowing of the nose is contraindicated. Nursing care of the child with a head injury is similar to nursing care of any child with increased ICP. The nurse must closely monitor for signs and symptoms of increased ICP as well as avoid activities and stimuli that can elevate ICP. Positioning with the head of the bed elevated 30 to 45 degrees promotes venous drainage Any child with a head injury needs to be assessed for fluid and electrolyte alterations. The child with a head injury can have a postinjury alteration in antidiuretic hormone (ADH). Possibly as a result of injury to the hypothalamus or posterior pituitary, the child can exhibit signs of excess ADH (syndrome of inappropriate antidiuretic hormone [SIADH]) or deficient ADH (diabetes insipidus) The nurse carefully monitors intravenous and oral fluid intake, determines hourly fluid output, documents all data, and evaluates the child's fluid balance status. Laboratory data for serum electrolytes is frequently checked and abnormalities reported to the physician. If the child develops SIADH, diuretics may be administered and fluids may be restricted to reduce the risk of increasing ICP from cerebral edema Fluid restriction is a nursing challenge because it involves the cooperation of parents and others involved in the child's care. Placing a sign at the child's bedside to alert others of the restriction is useful. The nurse selects fluids the child likes and distributes the allocated amounts over the course of the child's waking hours. If the child is discharged from the emergency department, written instructions should be given to parents for home monitoring, signs and symptoms to be immediately reported to the physician, and follow-up care. Some children with severe head injuries require surgical intervention, intensive care, prolonged acute-care hospitalization, and multidisciplinary rehabilitative care in a specialized unit or facility.

Head Injury Therapeutic Management

Initial management of the child with a head injury includes assessment of airway, ventilatory function, neurologic status, and any other injuries present Interventions to maintain vital functions, including adequate oxygenation and perfusion, are provided until all injuries are determined. The goal of treatment is to minimize long-term sequelae. Increased ICP or seizures can develop in a child with a head injury. In children with TBI, the presence of hypoventilation, hypoxemia, and hypotension is concerning and correlates with increased mortality

Intracranial Hemorrhage

Intracranial hemorrhages are defined as the following two types: Epidural: Blood accumulates between the dura and the skull. Arterial damage is the usual type of injury; therefore, the hemorrhage develops rapidly

Nursing Quality Alert Standard Terms for Level of Consciousness

Level of consciousness should be described by the nurse using standard terminology: • Full consciousness: Awake, alert, oriented, interacts with environment • Confused: Lacks ability to think clearly and rapidly; usually oriented to person • Delirious: Not oriented to person, place, or time; impairment of reality with auditory or visual hallucinations possible • Disoriented: Lacks ability to recognize place or person • Lethargic: Very drowsy and needs increased stimuli to be awakened • Obtunded: Sleeps unless aroused; once aroused has limited interaction with the environment; answers questions with minimal response • Stupor: Requires vigorous stimulation to arouse • Coma: Vigorous stimulation produces no motor or verbal response

Spinal Cord Injury Manifestations

Manifestations of spinal cord injury include loss of some or all movement or sensation below the level of injury, respiratory depression or apnea, hypotension and bradycardia, hypothermia, and neck pain. These signs vary with the level of injury as well as whether the spinal cord injury is complete or incomplete. If complete, the cord is completely severed and no spinal innervation is present below the injury. For example, with a complete injury at the C2 level (cervical vertebrae 2), the child is apneic and requires ventilatory support. With an incomplete spinal cord injury, the cord has some function remaining below the level of injury

Meningitis Pathophysiology

Meningitis is an inflammation of the meninges of the brain that results from a pathogen entering the central nervous system (CNS) and causing a toxic response. As the process continues, increased intracranial pressure (ICP) develops along with subdural empyema. If the infection spreads to the ventricles, edema and tissue scarring around the ventricle cause obstruction of the cerebrospinal fluid (CSF) and subsequent hydrocephalus. This process can happen quite rapidly; CSF is an excellent growth medium for bacteria because it contains nutrient substances such as protein and glucose. Leukocytes are unable to function as a defense mechanism in the fluid environment of the CSF. Leukocytes require a tissue surface to destroy bacteria, so there is little defense to stop the growth of bacteria, which multiply quickly. As the infection spreads further into brain tissue, changes occur in the permeability of capillaries and blood vessels in the dura mater. These changes lead to increased passage of albumin and water into the subdural space, with a subsequent accumulation of protein and fluid that further increases the ICP. Neurologic sequelae occur is approximately 10% to 30% of patients; the most common neurologic sequelae of meningitis are hearing loss, intellectual impairment, seizures, visual impairment, and behavioral problems Other complications include cranial nerve dysfunction, brain abscess, and syndrome of inappropriate antidiuretic hormone (SIADH). Meningococcemia, a fulminating manifestation of Neisseria meningitides infection that manifests with petechiae and purpura and signs of viral-type illness, can proceed in a matter of a few hours to adrenal insufficiency, bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome), and septic shock.

Meningitis

Meningitis is the most common infectious process affecting the CNS. It can occur as a primary disease or as a result of complications of neurosurgery, trauma, systemic infection, or sinus or ear infections. A wide variety of bacteria and viruses can be responsible for the primary infection. Earlier diagnosis and prompt antibiotic therapy reduce mortality rates, which remain high, and the incidence of complications from bacterial meningitis

Headaches Manifestations

Migraine Symptoms range from mild episodes, in which case the child can continue with daily activities, to episodes that force the child to go to a quiet, dark room for relief. In some cases, an aura occurs before the headache begins. The aura can include seeing flashing lights; smelling specific odors; blurry, double, or lost vision; and tingling in the arms or legs. Once the headache begins, the most common symptoms include throbbing pain, often on both sides of the head, nausea and vomiting, irritability, abdominal pain, photophobia, and phonophobia. The pain of a typical migraine lasts from 1 hour to more than 48 hours. Depression and anxiety frequently coexist with migraine headaches Tension-Type Headaches The pain associated with tension-type headaches is usually more generalized than that of a migraine. The child may describe the pain as a band-like tightness or pressure, tight neck muscles, or soreness of the scalp. Nausea is rare, but fatigue and dizziness are common. These headaches can last for days or weeks but usually do not interfere with the child's regular activities.

Classification of Severity of Head Injuries Based on Glasgow Coma Scale (GCS)*

Minor (mild) head injury: GCS score = 13-15 Moderate head injury: GCS score = 9-12 Severe head injury: GCS score = 3-8

Head Injury Incidence

Multiple trauma is the leading cause of death in children beyond infancy. In the United States, nearly 500,000 children between infancy and 14 years of age are seen in emergency departments for assessment and treatment of traumatic brain injury (TBI); falls and motor vehicle crashes are the primary causes of TBI in this age-group Other causes of head injuries include bicycle collisions, sports injuries, child abuse, and gunshot wounds.

Myoclonic Seizures

Myoclonic seizures are brief, random contractions of a muscle group, followed by loss of muscle tone and forward falling. They can occur on both sides of the body, singly or in clusters. Impairment of consciousness sometimes occurs during myoclonic seizures. Onset can be as early as age 2 months, but myoclonic seizures are more frequently seen in school-age children or adolescents than in very young children.

Nursing Care The Child With Status Epilepticus Assessment

On arrival at the hospital, the child will exhibit seizure activity and have unstable vital signs. Along with general seizure precautions, this child requires rapid assessment and vigorous supportive therapy. Supportive measures include assessing and maintaining a patent airway and administering oxygen. IV hydration and drug therapy are initiated to arrest the seizure activity.

Generalized Seizures

Onset at any age. Clinical features indicate involvement of both cerebral hemispheres. Consciousness is impaired.

Focal Seizures

Onset is at any age. The clinical features suggest that only a limited functional area in one hemisphere of the brain is involved, with symptoms seen on only one side of the body. Focal seizures are described according to the features exhibited by the child during the seizure. Types of features are awareness/responsiveness (altered or intact), sensory/psychic (aura), motor, and autonomic. Impairment in consciousness or awareness and decreased responsiveness occur with some but not all focal seizures. An aura (the sensation of an upcoming seizure) is actually part of a focal seizure. Other sensory symptoms include a rising abdominal feeling, an unexplained sense of fear, déjà vu feeling, an odd taste in the mouth or odd smell, and visual/auditory hallucinations. Children under 7 years of age are less likely to report sensory symptoms; however, parents might observe them staring or looking around without purpose, being less responsive, and exhibiting automatisms. Motor features, which are commonly seen, include involuntary, brief movements (tonic, clonic, or atonic) that are localized to one area, and turning eyes and head away from the side of the seizure. During a focal seizure, children can exhibit automatisms, repetitive, nonpurposeful movements of mouth and extremities such as lip smacking, chewing, teeth grinding, scratching, pulling at clothing or sheets, and shuffling. Salivation, dilation of pupils, and skin flushing occur as well. The average duration of a focal seizure is 1 to 2 minutes. A variable period of confusion, lethargy, and sleep follows the event. A focal seizure can become a bilateral, convulsive seizure when the electrical impulses pass across the corpus callosum to the other hemisphere. In this case, the child may experience bilateral tonic and clonic movements, urinary and stool incontinence, and loss of consciousness.

Factors Associated With Cerebral Palsy

Prenatal • Maternal diabetes • Rh or ABO blood type incompatibility • Rubella in the first trimester • Genetic causes • Intrauterine ischemic event • Toxoplasmosis • Cytomegalovirus • Congenital brain abnormality • Prenatal exposure to maternal infection • Precipitous delivery • Pregnancy-induced hypertension • Birth trauma • Anoxia • Prolonged labor • Perinatal metabolic condition (diabetes) • Intracranial hemorrhage • Other congenital anomalies Perinatal • Asphyxia • Low birth weight • Prematurity Postnatal • Infections • Trauma • Stroke • Poisoning

Spina Bifida Therapeutic Management

Prenatal microsurgical closure of the myelomeningocele, performed at approximately 19 to 25 weeks of gestation, shows promise for reducing the severity of Chiari type II malformations and incidence of hydrocephalus Risks associated with prenatal surgery include premature birth, with its associated consequences, and possible fetal death. Maternal risks (e.g., abruptio placentae, preterm membrane rupture, preterm labor, wound infection, chorioamnionitis, uterine hemorrhage, loss of uterus, and damage to adjacent organs) are directly related to the hysterotomy. Following birth, immediate surgical closure of the defect decreases the risk of infection, morbidity, and mortality. Other benefits are improved prognosis without further cord deterioration and earlier and easier physical handling and bonding between the newborn and the parents. The child will need lifelong management of neurologic, orthopedic, and urinary problems and is best managed in a multispecialty outpatient setting. Urodynamic studies are performed early, and a bladder-emptying program is initiated, with close monitoring of the child's urinary tract infection status. In most instances, the child will require orthopedic bracing and possibly orthopedic surgery to maximize the child's mobility. Spina bifida clinics that coordinate care between the multiple providers to implement the plan of care for a patient in one visit have fewer complications and hospitalizations of patients and improved communication between providers and the patient and their family

Seizure Disorders Etiology

Seizures are symptomatic of altered neuronal activity in the CNS. Seizures can occur for many reasons and are categorized according to etiology, genetics, structural/metabolic causes, or unknown Genetic seizures occur as the direct result of a genetic defect (known or presumed). Structural/metabolic seizures are associated with specific conditions or diseases and including strokes, trauma, and infection. If the cause is not known, the seizure etiology is categorized as unknown, which accounts for one third of all epilepsies

Meningitis Manifestations

Signs and symptoms of meningitis vary according to the age of the child and the duration of the preceding illness. No single hallmark sign or symptom exists. In the neonate, infant, and young child, the symptoms of meningitis are frequently vague and nonspecific. The clinical signs of meningitis in the neonate include poor feeding; poor sucking; vomiting; diarrhea; poor muscle tone; weak cry; hypothermia or hyperthermia; apnea; seizures; sepsis; disseminated intravascular coagulation (DIC); a full, tense, and bulging fontanel; and lethargy. Clinical signs of meningitis in the infant and preschool-age child include fever, poor feeding, vomiting, irritability, seizures, a high-pitched cry, a bulging anterior fontanel, and lethargy. Early clinical signs of meningitis in children and adolescents include severe headache, photophobia, nuchal rigidity, fever, altered level of consciousness (lethargy, irritability), decreased appetite, vomiting, diarrhea, agitation, and drowsiness. Muscle or joint pain and purpura may be noted. Kernig sign (pain with extension of leg and knee) and Brudzinski sign (flexion of head causing flexion of hips and knees) are often exhibited. In the case of a meningococcal infection, a petechial or purpuric rash may be observed. Late signs include a decreased level of consciousness and seizures.

Skull Fractures

Skull fractures include the following types: • Linear: Straight-line fracture; dura not involved • Depressed: Bone pressing downward, indented • Basilar: Fracture of the base of the skull; symptoms are Battle sign, raccoon eyes, rhinorrhea, otorrhea, and hemotympanum (blood behind the eardrum) • Comminuted: Fragmentation of the bone into many pieces or a multiple fracture line

Postconcussion Syndrome

Some children who have had a head injury can have an after-effect called postconcussion syndrome. If your child has this condition, he or she may be upset easily and become irritable if tired or stressed. Memory problems are common, as are learning difficulties, double vision, dizziness, headaches, fatigue, and light sensitivity. Younger patients are at greater risk. These symptoms can last many months.

Spina Bifida

Spina bifida is a congenital neural tube defect (NTD) characterized by incomplete closure of the vertebrae and neural tube during fetal 1285development. Spina bifida is classified as spina bifida occulta and spina bifida cystica Spina bifida occulta usually occurs between the L5 and S1 vertebrae, with failure of the vertebrae to completely fuse. Some children with spina bifida occulta have no sensory or motor defects. The only clinical manifestation may be a dimple, a small tuft of hair, a hemangioma, or a lipoma in the lower lumbar or sacral area, detected accidentally on routine radiographs. Spina bifida cystica is a more extensive defect with a range of sensory and motor impairments.

Pathophysiology Spina Bifida

Spina bifida occurs during the 4th week of gestation (days 24 to 28), when ventral induction of the neural tube fails to occur. The degree of impairment corresponds to the level of the defect on the spinal cord and the size of the defect. Ninety percent of spinal cord lesions are at or below the L2 vertebra. The lesion results in paralysis, partial paralysis, or varying sensory defects. Clubfeet, scoliosis, and contracture and dislocation of the hips often accompany the defect. Spina bifida cystica results in incomplete closure of the vertebrae and neural tube, evidenced by a sac-like protrusion in the lumbar or sacral area with varying degrees of nervous tissue involvement. Spina bifida cystica is further described as meningocele, myelomeningocele, lipomeningocele, and lipomyelomeningocele. Meningocele is a sac-like protrusion filled with spinal fluid and meninges. The most severe form is myelomeningocele, in which the sac is filled with spinal fluid, meninges, nerve roots, and spinal cord. Hydrocephalus and Arnold-Chiari malformation occurs in 80% of patients with myelomeningocele. The mortality rate is approximately 10% to 15%. The incidence of myelomeningocele is 1 in 4000 live births. In the United States, this number is declining. Awareness of the importance of folic acid supplementation during pregnancy and prenatal diagnostic techniques have contributed to a reduction in children born with this defect. Nearly 80% of infants with myelomeningocele will require shunting to treat associated hydrocephalus.

Spinal Cord Injury Pathophysiology

Spinal cord injuries occur in children when vertebral bodies are fractured or subluxation of the vertebra occurs. Subluxation results in malalignment of contiguous vertebrae so that the spinal cord is compressed. The cord may be crushed, stretched beyond tolerance, or completely divided. All neurons carrying sensations from those parts of the body below the lesion are unable to pass their message on to the brain. A cord injury causes complete paralysis and complete loss of sensation below the level where the spinal cord was severely damaged or severed. Flaccid paralysis of the affected limbs immediately follows a spinal cord injury. Paralysis is caused by spinal shock, which can last 4 to 6 weeks or longer. The flaccidity changes to spasticity when the spinal shock resolves. Hypotension, bradycardia, and peripheral vasodilation result from spinal shock and associated loss of vasomotor tone.

Spinal Cord Injury

Spinal cord injury can result from any trauma or injury to the spinal cord or its vascular supply or venous drainage. Spinal cord injuries in children are usually caused by motor vehicle crashes, falls, diving accidents, sports injuries, tumor, congenital anomalies, gunshot or knife wounds, or attempted suicide. In the infant, a common cause of spinal cord injury is intentional, aggressive shaking by an older person. Spinal cord injuries are less common in children than in adults, with 12,000 spinal cord injuries occurring each year in the Unites States Most spinal cord injuries in children occur in the cervical spine, between the occiput and C3 Young children are more susceptible to upper spinal cord injury because of their larger head size in relation to body size. As the child grows older, the likely site of the spinal cord injury moves distally.

Guillain-Barré Syndrome Therapeutic Management

Spontaneous recovery occurs with 2 to 3 weeks, and most patients regain full muscular strength Children with rapidly progressing paralysis are treated with high-dose IV immune globulin (IVIG) for several days. A recent study showed that some children benefit from a second course of IVIG because of patient differences in pharmacokinetics For patients who fail to recover with IVIG, plasmapheresis is an alternative treatment Medical management of the child with Guillain-Barré syndrome is supportive, with attention given to the neurologic, respiratory, and cardiovascular systems. Respiratory support is of critical importance because most deaths are attributed to respiratory failure.

Status Epilepticus

Status epilepticus is a medical emergency. It is marked by prolonged seizure activity, in the form of either a single seizure lasting 5 minutes or more or recurrent seizures lasting more than 5 minutes with no return to a normal level of consciousness between seizures The most common form of status epilepticus is generalized status, which has the highest potential for complications and possible death.

Status Epilepticus Pathophysiology

Status epilepticus is caused by the random discharge of large numbers of neurons firing abnormally. The discharges cause abnormal repetitive motor activity. In the CNS, the metabolic rate increases, glucose stores are depleted, and oxygen consumption increases. If cerebral metabolic demands are not met, these changes cause neuronal injury. Prolonged seizures cause lactic acidosis, an altered blood-brain barrier, and increased ICP.

Instruments for Monitoring Increased Intracranial Pressure

Subarachnoid Bolt The end of the bolt is placed in the subarachnoid space. The top of the bolt is attached to a transducer to conduct a waveform to the monitor. The neurosurgeon adjusts the transducer to produce a waveform on the monitor. Intraventricular Catheter The catheter is placed in the lateral ventricle or subarachnoid space. The catheter provides a method for measuring pressure, as well as a conduit to drain off extra fluid into the drainage bag. The manometer and drainage bag are part of a sterile, closed system.

Increased Intracranial Pressure Manifestations Vital Signs

Temperature elevation may occur in children with increased ICP. Cushing's response, which consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in respiratory rate and pattern, is usually apparent just before or at the time of brainstem herniation. This response usually indicates an alteration in brainstem perfusion, with the body attempting to improve cerebral blood flow by increasing blood pressure. In children, Cushing's response is a late sign of increased ICP. As ICP rises, the child's baseline respiratory pattern may change, exhibiting Cheyne-Stokes respiration, central neurogenic hyperventilation, or apneustic breathing. Cheyne-Stokes respiration refers to a pattern of breathing characterized by increasing rate and depth and then decreasing rate and depth with a pause of variable length. The cycle will be repeated again and again. Central neurogenic hyperventilation is identified by a rapid rate despite normal arterial blood gas values. This type of breathing pattern usually indicates midbrain or pontine involvement. Apneustic breathing occurs when the child demonstrates prolonged inspiration and expiration. As Cushing's response occurs, the child will develop apnea. Late signs of increased ICP include tachycardia that leads to bradycardia, apnea, systolic hypertension, widening pulse pressure, and flexion or extension posturing.

Headaches Diagnostic Evaluation

The International Headache Society published revised clinical criteria for classifying and diagnosing headaches in 2013 Clinical manifestations and diagnostic criteria are more precisely identified allowing for the development of targeted treatment plans In addition to addressing the signs and symptoms of headache as described in the ICHD-3, the child's blood pressure is evaluated and head size is measured, looking for evidence of chronically increased ICP. A detailed neurologic examination should be performed, with special attention given to auscultating for a bruit in the head (suggesting an arteriovenous malformation), assessing mental status, and examining both optic disks for papilledema. CT or MRI may be performed in children with chronic headaches or those with abnormalities found on the neurologic examination. A thorough assessment also includes asking questions about medication history, since daily use of analgesics can cause rebound headaches

Seizure Disorders Therapeutic Management

The basic tenet of treatment for the child with seizures is to treat the whole child. Antiepileptic medications are commonly used to manage seizures. Treatment goals are to identify and correct the cause of the seizure, eliminate the seizure with a minimum of side effects and the least amount of medication, and normalize the lives of the child and the family

Spina Bifida Etiology and Incidence

The cause of spina bifida is unknown in most cases. Evidence suggests a possible genetic predisposition. Maternal folic acid deficiency has been strongly linked to neural tube defects. Daily consumption of 0.4 mg of folic acid by all women of childbearing age is recommended and 4 mg if the mother has had a previous child with a NTD. Evidence of a viral origin has prompted research, but other than folic acid, no cause or preventive measures have been identified Children with spina bifida are at high risk for developing latex allergies because of frequent exposure to latex during catheterizations, shunt placements, and other operations. Latex allergy is estimated to occur in approximately 73% of children with spina bifida. Allergic reactions can range from mild signs and symptoms to anaphylactic shock. Children should be tested for latex allergy, and precautions should be taken from birth to decrease exposures. The nurse should check equipment and supplies for latex and select nonlatex alternatives for use.

Status Epilepticus Etiology/Incidence

The causes of status epilepticus are numerous. Acute CNS injury from head trauma, meningitis, or electrolyte imbalance frequently precipitates status epilepticus. The condition can also be caused by toxins, 1298specific medications, chronic CNS injury, and sudden withdrawal from antiepileptic medications. Status epilepticus occurs in 5% to 10% of children with epilepsy and occurs more often in children under the age of 5 years. The most common form in children younger than 3 years is febrile status epilepticus.

Increased Intracranial Pressure Manifestations Motor Function

The child with increased ICP exhibits changes in motor function. Purposeful movement will decrease, and abnormal posturing may be observed. Flexion, or decorticate posturing, refers to flexion of the upper extremities (elbows, wrists) and extension of the lower extremities. Plantar flexion of the feet may also be observed. This type of posturing implies an injury to the cerebral hemispheres. Extension, or decerebrate posturing, involves extension of the upper extremities with internal rotation of the upper arm and wrist. The lower extremities will extend, with some internal rotation noted at the knees and feet. This type of posturing indicates damage to more areas of the brain, such as the diencephalon, midbrain, or pons. The progression from flexion to extension posturing usually indicates deteriorating neurologic function and warrants physician notification Flaccid paralysis indicates further deterioration in the child's condition.

Seizure Disorders Diagnostic Evaluation

The child's health history and family history are important parts of the initial workup. A thorough description of the child's behavior before, during, and after the seizure activity is important to delineate the type of seizure. V ideo recording and EEG monitoring help identify the seizure. Serum electrolyte determinations, complete blood count (CBC), blood glucose determination, lumbar puncture, and other laboratory tests are only needed if the child has additional concerning symptoms such as lethargy, vomiting, and dehydration, since these tests can help uncover metabolic causes. Both CT and MRI will indicate trauma, tumor, or congenital malformation; MRI provides a better detail of the brain structure and does not involve radiation In neonates, several other laboratory tests may be included, such as toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex virus (TORCH) titers—to exclude congenital viral infections, as well as amino acid and organic acid studies to exclude inborn errors of metabolism.

Head Injury Pathophysiology

The cranium is a rigid structure that contains blood, brain tissue, and cerebrospinal fluid (CSF). The pressure exerted by these components on the cranium is between 2 and 10 mm Hg, depending on the age and activity level of the child. According to the Monro-Kellie doctrine, an increase in one of these components must be accompanied by a decrease in one of the other components to maintain intracranial pressure (ICP) within normal range. Cerebral function depends on adequate delivery of nutrients such as oxygen, glucose, and other substrates; an abnormal increase in ICP interferes with the balance and delivery of these nutrients. Head injuries are either primary or secondary. Primary head injuries are those in which damage is sustained at the time of injury; secondary head injuries refer to the consequences of the primary injury, particularly increased ICP. The severity of the injury depends on the amount of stress to the cranium and brain. Head injuries include concussions, contusions, lacerations, fractures, and hematomas. Motor vehicle collisions, falls, sports injuries, and child abuse cause most head injuries in children. Acceleration-deceleration is the term used to describe the mechanism of injury. The shearing force of the initial impact moves the brain forward in the brain, followed by a countering, backward movement of the brain in the skull. The shearing force produces bruising, tearing, and bleeding. Abusive head trauma (formerly referred to as shaken baby or infant syndrome) is a type of child abuse that can result in epidural hematomas and retinal hemorrhages

Cerebral Palsy Etiology and Incidence

The damage to the motor system can occur prenatally, perinatally, or postnatally Cerebral palsy (CP) is one of the most common chronic neurologic impairments in children, and more that 500,000 Americans are affected. The rate of cerebral palsy is 3.6/1000 live births Problems associated with prematurity and low birth weight are related to the occurrence of CP. Aggressive neonatal intensive care, administration of surfactant to mature infant lungs, and administering steroids to mothers before delivery has improved survival rates and also resulted in an increased prevalence of CP, with 59.5/1000 weighing less than 1000 g affected Infants with the lowest birth weights (less than 1000 g) may be at increased risk for CP because of intracerebral hemorrhage or periventricular leukomalacia However, in general, children diagnosed with CP are born at term after a normal labor and delivery

Meningitis Diagnostic Evaluation

The diagnosis is made by testing CSF obtained by lumbar puncture. Findings usually include increased CSF pressure, cloudy CSF (in the case of bacterial meningitis), high protein concentration, and low glucose level. Blood cultures are obtained; nose and throat cultures may be done, particularly if the CSF culture is negative.

Spinal Cord Injury Interventions

The goals of nursing care are to minimize the potential for further injury, prevent the sequelae of immobility, and promote maximal spinal cord recovery. The spinal cord is first immobilized with the use of tongs or halo traction. The child remains in traction for several weeks The nurse is responsible for maintaining proper alignment by monitoring the status of the traction every 1 to 2 hours. Towels and rolls can be useful to help position the child. The nurse should perform a motor and sensory assessment after each change of position If the child's condition becomes unstable, surgical stabilization may become necessary. Progressive neurologic deterioration is the major indicator for surgery. The child who is immobilized and neurologically impaired is at risk for respiratory complications as a result of muscle weakness and immobility. Respiratory status and pulse oximetry readings are assessed and recorded every 1 to 2 hours. Supplemental oxygen may be indicated. Nebulizer, incentive spirometry, and intermittent positive-pressure breathing (IPPB) are administered as ordered. Some children need a tracheostomy for prolonged mechanical ventilation if the respiratory muscles are involved. The nurse evaluates perfusion and neurologic integrity by continuously monitoring circulation, sensation, and motion. In addition, the nurse assesses hourly vital signs, color, core body temperature, skin, and intake and output. If alterations in perfusion occur; the child receives crystalloids by bolus infusion. Vasopressors can also be used and are often required for cervical spinal injuries. Children with spinal cord injuries often have difficulty with body temperature control. Some are unable to maintain body heat because of dermal vasodilatation (poikilothermia) These children will need to be gradually warmed or cooled as indicated. If the child has an elevated temperature, samples of wound material and blood are obtained for culture. Sputum cultures might be ordered. Antipyretic and broad-spectrum antibiotic therapies are initiated after the specimens are sent to the laboratory. Each time the child is repositioned (every 1 to 2 hours); the nurse thoroughly inspects the child's skin and administers skin care. Pressure on the bony prominences is minimized with the use of special mattresses and padding. Because of bladder muscle weakness or paralysis, an indwelling urinary catheter is often used to facilitate bladder emptying and permit accurate measurement of intake and output on an hourly basis. While the indwelling catheter is in place, care is taken to prevent infection. Intermittent catheterization may eventually be initiated. The child may have a nasogastric tube in place with gravity drainage or low, intermittent suction. The nurse maintains tube patency and observes and records the characteristics and quantity of the drainage. Since these children are at risk for stress ulcers and gastrointestinal hemorrhage, the pH of the gastric fluid is tested and the child treated with antacids or histamine blockers as indicated. A bowel regimen is initiated and maintained to prevent impaction. Bowel training includes ingestion of a high-fiber diet (when the child is able to eat), the use of stool softeners, and increased water intake. Adequate nutrition is essential to the healing process. Caloric intake is monitored, and the child may receive nutrition by oral intake, tube feeding, or total parenteral nutrition. A good indicator of a favorable response to the nutrition is timely healing of wounds. Spinal cord injury is a catastrophic event. The lives of the child and family have been suddenly and permanently altered. They will need intense assistance and support. These nursing care goals can be achieved through therapeutic play, promotion of independent functioning, referral to a multidisciplinary rehabilitation team, referral to support groups, psychological counseling, and thorough discharge planning. Following stabilization, most children are transferred to a rehabilitation unit for ongoing interdisciplinary care, therapy, and teaching in preparation for returning home.

Pathophysiology Increased Intracranial Pressure

The major pathophysiologic changes associated with increased intracranial pressure (ICP) result from alterations in the brain, cerebrospinal fluid (CSF) dynamics, and cerebral blood flow. To maintain cerebral pressure and volume within normal range, changes in one or more of the contents of the cranium must be compensated for by changes in the others; this is referred to as the Monro-Kellie doctrine. Compensatory mechanisms include a reduction in CSF production, an increase in CSF absorption, and a reduction in cerebral mass as a result of fluid displacement. Once the limits of compensation are reached, any further increase in volume or pressure will cause a sudden increase in ICP and an associated decline in the child's clinical status. Ultimately, increased ICP will compromise cerebral perfusion and produce shifting of brain tissue, causing herniation. The consequences of herniation depend on its severity and location.

Cerebral Palsy Manifestations

The manifestations of CP vary widely from one child to the other. A child with CP can have persistence of primitive reflexes, delayed gross motor development, abnormal muscle tone, and lack of progression through developmental milestones. Abnormal posturing with inability to maintain normal posture and balance may be present, as well as spasticity or uncontrollable movements in the extremities. Also seen are disturbances of gait (particularly ataxia and toe walking), seizures, attention-deficit disorder, sensory impairment, failure of automatic reactions (equilibrium), and speech and swallowing impairments.

Guillain-Barré Syndrome Pathophysiology

The most prominent feature of Guillain-Barré syndrome is the infiltration of lymphocytes into peripheral nerves and subsequent inflammation. Initially, the myelin sheath becomes edematous; as further inflammation takes place, segmental demyelinization occurs. This process takes place along the membrane surrounding the Schwann cells. As the inflammatory process continues, myelin loss increases and results in axonal degeneration.

Meningitis Etiology/Incidence

The primary organisms responsible for causing bacterial meningitis vary according to age. The organisms primarily responsible for neonatal meningitis are group B streptococci and Escherichia coli. Among children aged 2 months to 12 years, three pathogens seem to be the most prevalent; Haemophilus influenzae type B, Neisseria meningitidis, and Streptococcus pneumoniae cause 95% of the cases of purulent meningitis in this age-group. Tuberculous and Borrelia burgdorferi (Lyme disease) meningitis are becoming more common. These types of meningitis usually result from extension of a localized infection, such as otitis media, sinusitis, pharyngitis, or pneumonia, into the CSF. Organisms also can be introduced directly after an injury in which the skin is broken and communication between skin, sinuses, and CSF occurs. Entry can occur in association with a lumbar puncture, skull fracture, or surgery. Meningococcal meningitis caused by N. meningitidis usually occurs in older children and adolescents. Because it is transmitted primarily by droplet infection, the risk increases as the number of contacts increases. Viral meningitis is associated with the mumps virus, paramyxovirus, herpesvirus, and enterovirus. In rare cases, protozoa or fungi cause meningitis, usually in children with acquired immunodeficiency syndrome (AIDS). Meningitis most commonly affects children between ages 1 month and 5 years, but it can occur at any age. Boys are affected more frequently than girls, and the incidence is higher among Black children than among white children. The incidence of H. influenzae type B meningitis has declined rapidly since the institution of routine immunization of infants.

Nursing Care The Child With a Spinal Cord Injury Assessment

The spine must be immobilized before any attempt is made to move the child. The airway is assessed immediately, and if intubation is necessary, it is done without hyperextending the neck Circulation is then assessed; hypotension can result from either hypovolemia or neurologic shock. Bradycardia and hypothermia may occur. The nurse closely monitors the child's body temperature and oxygenation status. The neurologic assessment by the nurse includes evaluating mobility, sensation, and reflexes. The nurse considers the suspected level of spinal cord injury and whether the injury is thought to be complete or incomplete. The neurologic assessment is ongoing and carefully documented so that changes can be promptly reported. The child is also assessed for other areas of trauma and the impact of the spinal cord injury on other systems including genitourinary, gastrointestinal, and integumentary.

Hydrocephalus Therapeutic Management

Therapy is aimed at preventing further CSF accumulation and reducing disability and death. The objective is to bypass the blockage and drain the fluid from the ventricles to an area where it can be reabsorbed into the circulation. A ventriculoperitoneal shunt, a tube leading from the ventricles out of the skull and passing under the skin to the peritoneal cavity, accomplishes this goal An alternative shunt, the ventriculoatrial shunt, which is used in older children, drains the fluid from the ventricles to the right atrium of the heart. Shunt infection in the first 6 months occurs in 10% of infants, and shunt malformation in the first 2 years is also common; therefore, children should be monitored closely, especially for fever Shunt infection is decreasing with the use of antibiotic-coated ventroperitoneal shunts The shunt may need to be revised as the child grows. Long-term follow-up is essential. A surgical procedure, endoscopic third ventriculostomy, facilitates the rerouting of CSF around the obstructed ventricular system This technique has become increasingly popular over the past 20 years. For this procedure, the surgeon creates a small burr hole in the skull through which an endoscope is passed. The third ventricle is visualized, and a small opening is created in its floor. This opening allows the CSF to bypass the fourth ventricle and return to circulation, where it is reabsorbed. The procedure is 50% to 80% successful in children older than 2 years. Other surgical techniques for treating hydrocephalus are preferred in some children, since a repeat of the procedure may be necessary

Types of Head Injuries

Types of head injury include the following: • Closed head injury: Nonpenetrating injury to the head in which no break occurs in the integrity of the barrier between the outside environment and the intracranial cavity • Open head injury: Penetrating injury to the head in which there is a break in the integrity of the barrier (skull, meninges) between the outside environment and the intracranial cavity; infection is a major concern • Coup injury: Cerebral injury sustained directly below the site of impact 1291 • Contrecoup injury: Cerebral injury sustained in the region or pole opposite the site of impact; caused by the rapid movements of the semisolid brain within the cranial vault • Missile injury: Penetrating injury of the skull or brain, most often caused by a bullet • Impalement injury: Penetrating injury caused by piercing of the scalp, skull, or brain by a sharp object

Nursing Quality Alert Observations and Nursing Care During a Seizure

• As the seizure begins, look at your watch or a clock. You should be able to describe how long seizure activity lasts. • Protect the child from injury by loosening clothing at the neck and turning the child gently onto the side, removing any obstacles in the child's environment. Do not restrain the child or insert any object into the child's mouth. • Carefully observe in which body part the seizure begins, its progression, and how it ends. • Be able to describe any preceding or accompanying sensory or motor manifestations. • When the seizure is over, allow the child to rest if she or he desires. Record the child's behavior before, during, and after the seizure and the approximate duration of the seizure. • In neonates, if the movement can be initiated by a stimulus, such as touch, it is probably a tremor. If the movement cannot be stopped or controlled with gentle restraint or passive flexion, it is probably a seizure.

Recommendations from the American Academy of Pediatrics state that all young athletes who have sustained a sport-related concussion must do the following:

• Be evaluated by a physician • Be restricted from physical activity until they are asymptomatic at rest and with exertion • Be allowed a minimum of 7 to 10 days and up to weeks and months to fully recover • Be provided neuropsychological testing to obtain objective data • Be informed there is no evidence that treatment with medications is safe or effective • Be told to consider retirement from contact sports if multiple concussions have been sustained or if postconcussion symptoms have persisted for more than 3 months Under no circumstances should a child or adolescent resume playing a sport the same day of the concussion; protocols have been developed to guide the gradual return of the young athlete to "return to play" after a concussion All states have enacted legislation that requires school districts to have guidelines regarding concussion prevention and management. Many schools have implemented baseline cognitive function assessment tools to compare to post injury scores

Guillain-Barré Syndrome Manifestations

• Limb paresthesia and/or pain, including numbness, tingling, and weakness of the lower extremities with an ascending loss of deep tendon reflexes leading to a flaccid paralysis. • Autonomic instability, including blood pressure fluctuations, cardiac arrhythmias, postural hypotension, and urinary and bowel incontinence. • Cranial nerve dysfunction, with facial nerve paralysis; dysphagia; and inadequate cough, gag, and swallow reflexes. In such cases, respiratory function will be impaired. • Respiratory failure resulting from the progressive motor paralysis of the intercostal and phrenic nerves. Respiratory failure occurs in 15% to 25% of children with Guillain-Barré syndrome and is one of the major causes of mortality • Neuromuscular impairment (bilateral ascending weakness or paralysis) usually progresses upward from the feet to the head. (As healing takes place, neuromuscular function returns gradually in reverse order—head to feet.)

Patient-Centered Teaching Guidelines for the Child or Adolescent Taking Seizure Medication

• Oral care is very important for children taking phenytoin (Dilantin) because phenytoin can cause gum problems. Your child should brush with a soft brush and floss after every meal. Take your child to the dentist every 3 to 6 months for a checkup and teeth cleaning. • Once your child has started taking the medication, blood levels should be monitored to determine that the medication has reached and maintained a therapeutic level and to monitor for a toxic level. In addition, other blood tests may be needed to ensure that the medication is not harming the liver or blood cells. Blood levels should be measured periodically as your physician recommends, if a seizure occurs, or if side effects are noticed. • If your child is taking valproic acid, be alert for any signs of unusual bleeding or bruising. Valproic acid can affect the platelets (cells that help the blood clot) and cause the platelet counts to drop. Valproic acid can also increase the appetite. Offer healthy snacks and small meal portions. • Be sure your child does not suddenly stop taking antiepileptic medications without discussing it with a physician or nurse. Suddenly stopping medications can cause the child to have a seizure or status epilepticus. • Some states require a driver to be seizure free for a time ranging from a few months to a few years to obtain a driver's license. If your child is of driving age, discuss this matter with your healthcare provider.* • Birth control pills can be less effective while taking antiepileptic medications. If sexually active, your adolescent should consult a nurse or physician for additional forms of birth control. Folic acid supplementation may be advised for teen females taking antiepileptic medications. • Cognitive and behavior changes are sometimes seen with some of the antiepileptic medications. Attention span, memory, and interpersonal interactions can be impaired. • Alcohol, marijuana, and street drugs lower the seizure threshold. These drugs should be avoided. • Contact sports such as football and wrestling are not advised. • Showers are preferred over baths for children who are concerned about privacy. Younger children with epilepsy should never be left alone in a tub of water. Swimming activities should be supervised by a strong swimmer who can rescue a child who has a seizure in the water. • Depression is a diagnosis that often accompanies epilepsy and is associated with antiepileptic medications. Report any symptoms of depression to the physician. • Maintaining a seizure diary that lists seizure frequency, associated triggers, and details of seizure activity is a good way for parents to collaborate with the healthcare team in determining the effectiveness of the treatment plan. • Call 911 if your child has a seizure that does not resolve after 5 minutes. • Your child should wear a medical alert bracelet to alert others of potential problems if they appear.

Key Concepts

• The CNS is composed of the brain and spinal cord. The bones of the skull do not become fused until 12 to 18 months of life. The brain and spinal cord are covered by a fibrous connective structure containing many blood vessels known as meninges. • CSF surrounds the brain and spinal cord. The brain is composed of the cerebrum, cerebellum, and brainstem. • The peripheral nervous system comprises 12 pairs of cranial nerves and 31 pairs of spinal nerves. The autonomic nervous system includes the sympathetic and parasympathetic systems. • The physiologic process of autoregulation helps the body regulate blood flow. When autoregulation fails to change vascular diameter in response to changes in cerebral perfusion pressure, cerebrovascular dilation is impaired, and cerebral blood flow decreases. • Hypercapnia or hypoxia leads to cerebral dilation and increased ICP. Hypocapnia leads to cerebral arterial constriction and decreased ICP. • An infant's brain is two thirds the size of an adult's brain. The brain grows to 80% of adult size by age 1 year. • Head circumference can change in the infant and young child, but the head of the adolescent and adult is unyielding. This change has implications for head circumference measurement for growth and development in the infant and young child. • The spinal cord, cranial nerves, and peripheral nerves become longer during childhood; the spinal cord terminates at L3 in the newborn and L1 to L2 in the adult. • Myelinization of nerves begins in the third month of gestation and is completed in adolescence, as demonstrated by progressive development and coordination. • Neurologic changes may be more subtle in the infant or child than in the adult and can be indicated by irritability or poor feeding behaviors. • The neurologic examination assesses level of consciousness, pupil size and reaction to light, cranial nerve function, motor and sensory functions, respiratory status and function, vital signs, and head circumference. • Different seizure types are treated with specific antiepileptic medications to achieve optimal seizure control. These medications have many side effects. CBC, liver enzyme levels, and medication levels should be determined routinely. • When antiepileptics are given via IV, the most common side effect is respiratory depression. • Mannitol and furosemide (Lasix) are diuretics used to decrease ICP. Their effect is monitored through serum electrolyte levels and serum osmolality. • Cerebral edema is decreased by maintaining adequate oxygenation and perfusion of the brain, administering diuretics, elevating the head of the bed 30 to 45 degrees, keeping the child in good alignment so that venous drainage is not impaired, and reducing agitation and noxious stimuli. • Abnormal posturing (flexion or extension) is an ominous neurologic sign. • Hydrocephalus can be communicating or noncommunicating. Enlarged ventricles and increased ICP can result. If the cranial sutures are not ossified, the head circumference will be abnormally large. • Teaching for the child with a neurologic deficit and the child's family is begun after the child's and family's needs have been assessed. The family's grieving may be verbalized; emotions and fears should be expressed and validated. The nurse reinforces information that has been supplied by other members of the healthcare team. • The nurse encourages parents in their caregiving efforts when appropriate, assists the family in setting realistic goals for the child, and identifies support systems and refers to community agencies. • The nurse has family members demonstrate skills necessary for home care and encourages therapeutic play and peer contact. The nurse provides incentives for accomplishments and identifies the child's positive qualities and coping mechanisms.

Pediatric Differences in the Central Nervous System

• The brain constitutes 12% of a newborn's body weight compared with only 2% of an adult's body weight. • The brain of a term infant is two thirds the weight of an adult's brain. By the age of 1 year, it weighs 80% as much as an adult's brain, and by the age of 6 years, it weighs approximately 90% as much as an adult's brain. • An infant has approximately 50 mL of cerebrospinal fluid (CSF) compared with 150 mL in an adult. • The peripheral nerves are not completely myelinated by birth. As myelinization progresses, so do the child's coordination and fine muscle movements. • The head circumference in a term infant is 34 to 35 cm. By the age of 6 months, the head circumference is 44 cm; by the age of 12 months, it is 47 cm. • Papilledema rarely occurs in infancy because of the open fontanels and sutures, which can expand with increased intracranial pressure. • The primitive reflexes of Moro, grasp, and rooting, present at birth, disappear at various times during the first 5 months. These primitive reflexes may reappear with neurologic disease.

Nursing Quality Alert Guidelines for the Child With Meningitis

• The close contacts of the child with Haemophilus influenzae infection need prophylactic treatment with rifampin. • In households with a person with Haemophilus influenzae infection where there is a household member younger than 48 months and unimmunized or incompletely immunized, rifampin is recommended for all household members. • All close contacts of children with Neisseria meningitidis, regardless of age or immunization status, need prophylactic treatment, usually with oral rifampin or ciprofloxacin • Rifampin colors the urine and sweat red-orange and will stain contact lenses.

Herniation is classified into four types:

• Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. This condition can be unilateral or bilateral, involving the anterior or posterior regions of the brain. If a large amount of tissue is involved, it can cause death because vital brain structures are compressed and become unable to perform their functions. • Temporal lobe herniation, or uncal herniation, refers to a shifting of the temporal lobe laterally across the tentorial notch. This condition produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil dilation, pupil fixation, and death will result. • Tonsillar herniation occurs when the cerebellar tonsils herniate through the foramen magnum. The child will develop nuchal rigidity, shoulder or arm numbness, and changes in heart and respiratory rates and patterns. Arnold-Chiari malformation, a condition sometimes associated with hydrocephalus, includes herniation of the cerebellar tonsils. • Brainstem herniation through the foramen magnum results in death from compression of vital cardiorespiratory centers. Infants are somewhat able to compensate for increasing ICP because their cranial sutures remain open. Craniosynostosis is premature closure of the cranial sutures. This abnormal skull development causes an abnormally shaped skull. In some cases, craniectomy is needed to manage the increased ICP.