CHAPTER 29 Child With a Neurological Condition

PSYCHOGENIC HEADACHES

-Psychogenic headaches may be difficult to diagnose. They are associated with a mental health issue, such as conversion disorder, also called functional neurological symptom disorder, in which an individual experiences stress in physical symptoms that do not have a physical cause. -Psychogenic headaches require treatment because pain is a subjective experience and requires professional assessments, interventions, and an evaluation of the effectiveness of the interventions.

CONTUSSION

-A contusion is considered a bruising of the brain tissue. -It is typically associated with blunt trauma, which causes tears to the vasculature and tissue. -Both head concussions and head contusions are serious. -A concussion represents more wide-spread injury and can be in more than one location, while a contusion is considered a localized bruising occurring in one area of the brain tissue.

RECORDING SEIZURE ACTIVITY

-A log should be maintained for health-care professionals to review. -The log should document the date; time; precipitating events; type of seizure activity, including motor movements; the length of time of the seizure; and any associated events, such as loss of consciousness, bladder or bowel incontinence, nausea or vomiting, and the postictal state, including periods of drowsiness and complaints of headache.

SEIZURE DISORDERS

-A seizure is a disruption of the electrical communication among the neurons within the child's brain. -Recurrent seizures are commonly known as epilepsy. - A seizure may also be called a paroxysmal involuntary brain disturbance. -. Full body seizures are called grand mal seizures. -Common causes of seizures in pediatric clients include: • Trauma • Hemorrhage • Brain malformations • Genetic disorders • Brain dysmaturity (ie, small brain size and function related to fetal development) • Infection, such as meningitis • Fever • Electrolyte abnormalities, especially related to sodium, and the presence of hyperglycemia or hypoglycemia • Inborn errors of metabolism • Drug-related injuries or significant exposures (eg, cocaine, chemotherapy, alcohol, lead, and cyclic antidepressants) • Structural CNS lesions

CONCUSSION

-Also called a mild traumatic brain injury,this condition is associated with a transient loss of consciousness from shearing and/or compression of the brain's nerve tissue. -Children with concussions tend to have what is called postconcussion syndrome, in which they have headaches, difficulty with memory, problems at school, photophobia (ie, extreme sensitivity to light), and possible personality changes

MEDICATIONS COMMONLY USED IN NEUROLOGICAL DISORDERS

-Anticonvulsants to prevent or manage seizure activity Drug Used • Gabapentin (Neurontin) • Clonazepam (Klonopin) -Diuretics to decrease increased ICP -CNS stimulants to treat attention deficit hyperactivity disorders • Mannitol (Osmitrol) • Furosemide (Lasix) •Methylphenidate (Concerta, Ritalin) • Dextroamphetamine (Adderall) -Neuromuscular blockers to prevent resistance to mechanical ventilation and agitation • Pancuronium (Pavulon) • Rocuronium (Zemuron)

assessment/interventions

-Assessments for a child brought into the health-care arena for postsubmersion injury involve assessing the airway, ventilation ability, quality of respirations, presence of effective heart rate and blood pressure, arterial blood gases (ABGs), and level of hypothermia. Level of neurological intactness and level of consciousness should be assessed -Interventions for drowning victims include rapid and effective advanced resuscitation, including ventilator support using oxygen, restoration of cardiac rhythm, correction of hypercapnia and hypoxia, correction of shock (signs are altered mental status, cool extremities, and slow capillary refill), and IV fluid administration with boluses of a nondextrose-containing solu- tion such as lactated Ringer's (LR) solution or NS.

ASSESS/INTERVENTIONS

-Assessments of suspected or actual hydrocephalus include frequent measurements of the circumference of the child's head. -These measurements should take place directly above the eyebrow, on the widest part of the child's head -The child should also be assessed for "sunset eyes," in which the white sclera is visible above and around the iris as the eyes appear to be looking down -In severe hydrocephalus, the child may not have the neck and upper back strength to hold their head up or support the weight of the head for any period of time -The main intervention for the development of hydrocephalus is the placement of a ventral-peritoneal (VP) shunt, which is placed surgically -This shunt is used in the presence of increasing pressure; it allows the flow of CSF to descend from the ventricle through the shunt tubing into the child's peritoneal cavity, where it is absorbed and eliminated. -The child may need to have constant head support.The pediatric nurse must know how to manage an obstruc- tion in the shunt and teach the family this management.

CEREBRAL PALSY

-CP is considered a birth accident from anoxia before, during, or after the birth process up to the second year of life. -Premature infants have a higher risk of developing CP because of the higher incidence of bleeding in the brain, brain infections, severe jaundice, and head injuries. -CP is a nonprogressive injury of the brain and nervous system directly related to a low level of oxygen to the CNS structures, which is termed hypoxia.

TENSION HEADACHES

-Causing a feeling of tightness around the head or on both sides of the child's head, tension headaches present as a dull ache rather than throbbing. -Children with tension headaches often become more symptomatic with physical exercise and play. -Tension headaches are differentiated by their pain presentation, as well as a lack of nausea and vomiting, which are so often associated with migraines. Sleep deprivation headaches are a type of tension headache associated with obese children who have sleep apnea or those with conditions that cause chronic hypoxia.

CLUSTER HEADACHES

-Cluster headaches are uncommon for children who are school-aged and younger. The sensory ex- perience can be described as "stabbing, sharp pain" unilater- ally that can last anywhere from 15 min to as long as 3 hours. Children with cluster headaches often experience associated symptoms of agitation, congestion, runny nose, and teary eyes

ASSESSMENT/INTERVENTION REYE SYNDROME

-Early symptoms of Reye's syndrome may be irritability, diarrhea, and rapid breathing. -• Encephalopathy • Increased ICP • Metabolic dysfunction • Hepatic dysfunction • Renal damage • Fatty infiltration of the viscera -• Monitoring the child carefully for progression through the stages of Reye's syndrome • Monitoring the child for changes in neurological status and immediately reporting any slight change in neurological status, including the level of consciousness, confusion, and neurological deficits • Assessing the child for symptoms of GI bleeding, pancreatitis, or liver failure • Providing hydration with a source of glucose (mainly IV fluids) • Implementing seizure precautions to keep the child safe if seizures occur • Monitoring the child's respiratory status and immediately reporting any signs of dyspnea • Checking the child's Glasgow Coma Scale (GCS) score • Assessing for the presence of increasing ICP • Elevating the child's head of bed (HOB) by 30 to 45 degrees • Keeping the child free of discomfort and pain, and helping the child to avoid crying • Providing a quiet environment to rest • Reinforcing the patient/family teaching session about the importance of follow up, including auditory, speech, and potential motor and/or intellectual deficits

ASSESS/INTERVENTION

-Frequent head circumferences will be ordered to assess for hydrocephalus. Because nerves for bowel and bladder innervate below the site of the defect, the nurse should assess bowel and bladder function. -After birth, the abnormal sac should be handled with care and the nurse assesses for leaks, rupture, and infection around the sac area or infection in the CNS in general. -The sac should be kept moist by carefully applying NS-soaked gauze -The child will have routine postoperative care that focuses on fluid balance, preventing infection, and special care to the skin at the operative site. -The child should be provided early ROM and support for the lower extremities that may have neurological deficits. -The bladder may need intermittent catheterization.

I Olfactory: Provides the ability to transmit a sense of smell to nasal cavity (tested with a cotton ball soaked with stimulus such as vanilla oil) II Optic: Provides the ability to transmit visual signals from the retina of the eye to the brain (tested with various visual cues) III Oculomotor: Provides the ability to perform most eye movements (tested by requesting the patient follow finger commands)

-IV Trochlear: Provides the ability to laterally rotate the eyeball (tested by asking the patient to rotate the eyeball inward, down, up, and outward) -V Trigeminal: Provides the ability to feel sensations in the face and perform mastication (tested by requesting the patient to perform chewing movements on command and testing the patient's response to cotton ball sensations to the full face) -VI Abducens: Provides the ability to perform abducted movements of the eye (tested by requesting that the patient follow commands to move eyes left and right)

intraventricular hemorrhage (IVH)

-In IVH, the child experiences a rupture of the vascular network of the circulation within the germinal matrix and a bleed within the brain develops. -.The most common age group for an IVH is prematurity, when the infant is less than 32 weeks' gestation. -Depending on severity of the bleed, the child may have full recovery or may experience severe brain damage or death from the anoxia associated with the bleed and pressure.

INCREASED INTRACRANIAL PRESSURE

-Increased ICP can result in the child's brain being herniated, which results in progressive deterioration of the brainstem, and, without treatment, causes apnea and death -. ICP that is caused by cerebral edema can be caused by abscesses, meningitis, tumors, water intoxication, hypoxia, hydrocephalus, and other causes.

INTERVENTIONS

-Interventions for a child with CI start with ensuring the child is safe and cared for. -Using Maslow's hierarchy of needs, the pediatric nurse can assist the family with basic support for nutrition, safety, and socialization. -Goals should be made that are realistic for the child's level of functioning -Participating in activities of daily living, appropriate socializing, and safety precautions are all possible goals that can be worked on.

NURSE CONSIDERS

-It is important that the pediatric nurse find meaningful and effective ways to help alleviate symptoms, including prescribed medications, rest and relaxation, stimulation reduction, massage, warm or cold packs to the forehead, and other means of complementary therapy. -Children may respond to sleep, resting in a dark and quiet room, nonsteroidal anti-inflammatory drugs, antiemetics, and the headache medications sumatriptan succinate, isometheptene, and ergotamine. -If the headaches continue, stronger medications, including propranolol, cypro- heptadine, verapamil valproate, and several of the antidepressants may be used.

LEAD POISONING

-Lead poisoning is particularly tragic in children because undetected high levels of lead can lead to encephalopathy, poor school performance, and lower intelligence levels. --*Encephalopathy* is a generalized brain dysfunction of varying degrees that causes an impairment of arousal, orientation, speech, and cognitive processing. -This impairment causes the brain tissues to become affected, leading to acute encephalopathy. -This encephalopathy is often preceded by behavioral changes such as attention disorders, intellectual disabilities, hyperactivity, colic, constipation, and severe abdominal pain.

MENINGITIS

-Meningitis is a condition of inflammation of the membranes of the brain or spinal cord, often caused by an infectious process. -This inflammation can be caused by bacteria, viruses, or chemical agents that enter the bloodstream and spread through the CSF. -When exposed, the pathogen causes severe inflammation of the meninges and possible cerebral edema. Causative organisms include Escherichia coli and group B streptococcus (GBS) for newborns and infants, and Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis for older children. -If bacterial or viral in nature, meningitis can be spread by droplets of mucus during sneezing, coughing, or nasal congestion.

NURSING CONSIDER

-Nursing considerations when caring for children with SCIs include caring for their elimination needs. -The child with an SCI may need to be catheterized and the child and/or family may need to be taught how to catheterize using clean technique for long-term care. -Teens should be encouraged to have a frank discussion with his or her pediatric nurse about sexuality and sexual function.

NURSING CONSIDERATION

-Pediatric nurses must teach the public about the importance of taking folic acid starting before conception and continuing during pregnancy as part of healthy eating and adhering to prenatal vitamins. -Nursing considerations for neural tube defects include paying special consideration to the development of latex allergy because this population has a much higher incidence in the development of this allergy.

NURSING CONSIDERATIONS FOR CP

-Teaching the family how to maintain a clear airway is imperative. -Demonstrating how to perform passive ROM exercises helps to slow the process of contractures. -Pediatric nurses need to monitor for the development of poor nutrition, failure to thrive (FTT), constipation, bowel obstruction, and osteoporosis. -Safety is a key component to the care of a child with CP and includes all aspects of the child's life, including the prevention of aspiration, falls, and contractures.

autonomic nervous system

-The ANS is responsible for involuntary body functions. -The ANS regulates salivation, digestion, respiration, perspiration, urination, cardiovascular function, and sexual arousal by way of the hypothalamus, which supervises the sympathetic nervous system (SNS) and the parasympathetic nervous system.

CENTRAL NERVOUS SYSTEM

-The CNS is composed of the brain and the complete spinal cord. -The brain contains the cerebrum, which is the center of consciousness, and the two cerebral hemispheres. -The frontal lobe controls speech, voluntary muscle movements, center for personality, and areas for behavioral, autonomic, and intellectual functions. -The brain also contains the temporal lobe for taste, hearing, and smell; the parietal lobe for sensory coordination and interpretation; and the occipital lobe for visual stimuli interpretation. -Other anatomical components of the brain are the diencephalon, which houses the thalamus (sensory relay for pain, pressure, and temperature), -the hypothalamus (controls the ANS; regulates emotion, behavior, hunger, and thirst; and secretes antidiuretic hormone and oxytocin), the cerebellum, and the brainstem

PERIPHERAL NERVOUS SYSTEM

-The PNS is composed of the 12 pairs of cranial nerves and the 31 pairs of the spinal nerves. -Cranial nerves are numbered by order they contact the brain; they originate in the cranial cavity and innervate the head -This system connects the brain to the remote areas of the child's body. -The PNS has both afferent neurons (ie, sensory) that transmit information from the organs, skin, and tissue to the brain, and efferent neurons (ie, motor) that transmit regulatory and control information from the brain to the body

sympathetic nervous system

-The SNS provides the emergency responses the body needs to respond to stimuli. -This includes the "fight or flight" response, which entails decreased peristalsis, increased heart contractions, peripheral blood vessel constriction, increased perspiration, bronchiole dilation for effective breathing, and dilation of the heart and peripheral blood vessels. -All of these contribute to a response to physical or emotional stress.

the brain

-The brain, which includes the three protective membranes— dura mater, arachnoid membrane, and pia mater—provides the coordination of the entire nervous system -Myelination needs to take place throughout the brain for motor control and coordination, as well as for cognitive maturity. -The ability of infants' cranial sutures and fontanels to respond to pressure allows for compensation when increased ICP is occurring.

SPINAL CORD INJURY (SCI)

-The causes of SCI include trauma, tumors, infections, and congenital disorders. Motor vehicle accidents (MVA) account for more than 50% of SCIs. Previous conditions such as tri- somy 21, spina bifida, rheumatoid arthritis, and degenerative disc disease put a child at greater risk for SCI. -There are three types of SCI: 1. Complete SCI, which causes a complete loss of sensorimotor and reflex activity below the site of injury. 2. Incomplete SCI, which causes the preservation of some motor and/or sensory function below the site of injury. 3. Sacral sparing of the SCI, in which motor/sensory activity at the anal mucocutaneous border exists

ASSESSMENTS/ INTERVENTIONS

-The child with suspected IVH will have an MRI or a CT scan to confirm the bleed. Serial hemoglobin and hematocrit levels will be drawn to assess the severity and con- tinuation of the bleed -The child with IVH will show somnolence, very poor muscle tone, and the absence of Moro's reflex. In very severe cases, the child may demonstrate bulging and tense fontanels. -Interventions for IVH include providing a reduced stimuli environment and minimal handling of the child -The child may require transfusion therapy while being treated for ICP and acidosis, which is provided with catheter placement (ie, ventriculostomy) and removal of the subdural fluid collection.

TRAUMATIC BRAIN INJURY

-The complications of head injury that lead to severe outcomes relate to both increased ICP and cerebral edema. -Primary brain injuries develop at the time of trauma when the brain tissue suffers initial damage. -Secondary brain trauma develops as the child's body is responding to the injury. Here brain damage occurs secondary to developing cerebral edema, hypoxia, hypotension, increased ICP, and hemorrhage. -Secondary brain trauma can develop hours or days after the injury with irreversible consequences if not treated.

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-The most dangerous form of meningitis is meningococcal meningitis. -This type of bacterial meningitis is caused by N meningitidis and leads to a sudden, rapid, fulminate infection, resulting in disseminated intravascular coagulation (DIC), a life-threatening critical condition; massive adrenal hemor- rhages; and purpura; and carries a high mortality rate of 90% or more. -If a child of any age presents with abrupt eruption of a purplish rash or petechial rash, the health-care team must suspect meningococcemia and initiate immediate medical attention.

A cluster of seizures that are back to back are dangerous. This is called status epilepticus (SE) and can cause both significant injury as well as death from hypoglycemia. -One technology being used to treat seizures is vagal nerve stimulation, which is a treatment to reduce the frequency and intensity of seizures by placing a small electric stimulator in the neck around the vagal nerve. -While sending intermittent electrical signals to the brain, this technology interrupts a seizure that is just starting to develop.

-The nursing care of a child with a seizure disorder begins by securing a safe environment. -Assess the child's mobility and the need for safety devices. -Seizure precautions should be maintained while the child is hospitalized. -This includes padding the side rails, providing constant supervision while the child is ambulating in the halls or playing in the playroom, and maintaining safety while the child is being transported via gurney or wheelchair. -Suction and oxygen should be available at all times. -If a helmet is ordered for protection of the child with frequent tonic-clonic seizures, the family must be educated about having the child wear the helmet when awake. -Families need to be reminded about the importance of exactly following the prescribed medications and participating with monitoring routine serum blood levels of the anticonvulsant therapy to ensure therapeutic blood levels.

COGNITIVE IMPAIRMENT

-The term cognitive impairment has replaced mental retardation. - CI is considered a disability because it involves significant limitations in intellectual functioning and adaptive behaviors -• Mild: IQ of 50 to 55 and up to 70; most prevalent, at 80% of those with CI. Considered educable to a mental age of 12 to 13 years old, mostly independent. • Moderate: IQ of 35 to 40 and up to 50 to 55, and found in 15% of those classified with CI. Most Down's syndrome children function at this level. Considered "trainable" to the mental age of an 8- to 10-year-old. • Severe: IQ of 20 to 25 and up to 35 to 40. Considered the mental age of a toddler, this status requires complete custodial care for safety and activities of daily living. • Profound: IQ below 20 to 25. Considered having a mental age of an infant; requires complete care, supervision, and protection

drowing and near drowing

-The two peak periods for drowning or near drowning are in the preschool period and during later adolescence. -Drowning is defined as a submersion in a liquid medium followed by suffocation and asphyxia. -. When a child dies with the 24-hour time period after submersion, it is titled drowning. -If the child lives beyond 24 hours, even if the child later recovers or dies, it is titled near drowning. -Cardiopulmonary resuscitation (CPR) should start at the scene to rapidly restore oxygenation, ventilation, and circulation

INTERVENTIONS FOR CEREBRAL PALSY

-There are no treatments or cure for CP. -Medications exist that assist with spasticity, drooling, and tremors. Surgical procedures exist to reduce joint contractures and severe gastroesophageal reflux.

BRAIN TUMORS

-Tumors are classified according to their physical location and grade. -Tumor locations include the supratentorial regions, the subtentorial region, the temporal lobe, and the posterior fossa. -The most prevalent brain tumor in children under 7 years of age is the medulloblastoma. -Cerebellar astrocytoma is the most common subtentorial tumor of childhood and has a 5-year survival rate of 90%.

ASSESS/INTERVENTION

-Typically, the initial emergency team will perform a complete neurological examination followed quickly by either a CT or an MRI. -The child must be placed on a straight back board with neutral head and neck alignment. -A cervical collar is often applied. -Respiratory stabilization is imperative because respiratory insufficiency may be delayed after injury - The treatment often includes high-dose methylprednisolone, which is administered within 8 hours of the injury

THE 5 SENSES

-hearing is considered fully intact at birth after the amniotic fluid is removed from the external ear canal. -Olfactory (ie, smell) is also considered fully intact at birth. -Visual acuity is dependent on nerve maturation. -An infant's visual acuity is thought to range between 20/200 and 20/300 and is not fully intact until close to the child's fifth birthday. -Touch is thought to be fully intact at birth, but the sense of taste must develop.

NURSING CONSIDERS

-include providing a great deal of support for the family. A diagnosis of cancer causes fear, anxiety, sadness, and bewilderment -Assess VSs frequently before and after brain surgery for tumor removal and report signs of increased ICP. -Cancer treatment is often prolonged, with untoward associated symptoms. Cancer treatment can cause nausea, hair loss, bone marrow suppression, neutropenia, pain, life- threatening infections, and emotional distress.

HYDROCEPHALUS

-is a condition that presents with an increased production, a decreased reabsorption, or an obstructed flow of CSF within the ventricles and subarachnoid spaces of the brain. -An obstructed flow of CSF is also called noncommunicating hydrocephalus, whereas impaired absorption of CSF is called communicating hydrocephalus. -In the presence of tumors, structural abnormalities, trauma, or hemorrhage, noncommunicating hydrocephalus can develop, causing significant CNS symptoms and impairment.

KETOGENIC DIET

-is a special diet that has been widely studied and provides relief from seizures for some children. -the ketogenic diet is a special high-fat, low- carbohydrate diet that is thought to help control seizures in some people who have a documented history of epilepsy. -The term ketogenic means that the diet produces ketones within the body as the high-fat primary source of energy is processed and broken down. -The theory behind the diet is that the process of ketone breakdown leads to a higher ketone blood level, thereby improving seizure control. -. Conditions for which a ketogenic diet is suggested for seizure reduction include: • Focal seizures • Infantile spasms • Dravet's syndrome • Doose's syndrome • Rett's syndrome • Glucose transporter 1 (GLUT-1) deficiency

NURSING CONSIDERATIONS

-meticulous maintenance of a patent IV catheter for antibiotic therapy, symptoms management, and fluid as needed. -Care should be taken to keep antibiotics administration on time and therapeutic serum values of antibiotics on target. -The nurse should keep the child's condition guarded and, until the causative agent is identified, the child should be on strict airborne and contact isolation. -The combination of these two forms of isolation is often termed respiratory isolation and should be left in place for 24 to 48 hours after the administration of antibiotics begins -If there is a change in head circumference, the child may be experiencing the complication of meningitis called obstructive hydrocephalus

NURSING CONSIDERATIONS

-monitoring for very subtle signs of changes in clinical presentation and then rapidly reporting them to the health-care team. -Managing the airway is always the top nursing care priority for a child who presents with a traumatic head injury. -The child is typically admitted for observation and diagnostics, placed on NPO status until a thorough neurological evaluation is performed (ie, swal- lowing, choking, and aspiration risks evaluated), -Treatments for TBIs include meticulous monitoring for symptoms of ICP; medications to reducing swelling of brain tissue, such as diuretics and corticosteroids; and anticonvulsants if warranted.

ASSESS/INTERVENTION

-the child will present with both signs and symptoms of ICP and focal neurological signs that are associated with the size and location of the tumor -These behaviors can include poor school performance, irritability, hyperactivity, forgetfulness, and lethargy. -Many brain tumors cause nausea, vomiting, visual acuity changes, and headaches -Typical treatment includes surgery, irradiation, and chemotherapy. -Complications of a tumor growing within the bony cranium include ICP, the compression of vital brain structures, hydrocephalus, brainstem herniation, and the complications associated with the negative effects of radiating the brain

5 TYPES OF CP

1. Ataxic: Poor muscle coordination, poor equilibrium, and unsteady gait with possible wide-based gait 2. Spastic: Hypertonicity with poor posture control, legs scissoring, altered quality of speech, persistent primitive reflexes, and persistent muscle contractions with potential development of contractures 3. Hypotonic: Generalized poor muscle control with muscle dystrophy 4. Dyskinetic: Also called dyskinetic-athetoid, this type involves constant involuntary wormlike movements that diminish during sleep and that affect facial musculature 5. Mixed: Child presents with a variety of CP clinical presentations

TEAM WORKS

Assessment with the GCS is imperative for a child with a TBI. Severe scores (ie, 3 to 8) require life support. The pediatric health-care team members work together to determine the child's GCS score and assess for subtle changes in clinical status.

ASSESSMENT/INTERVENTIONS

Assessments for meningitis include early identification of the following symptoms: • Poor feeding habits • Fever • Irritability, high-pitched cry, and inconsolable when held • Lethargy • Bulging fontanels • Opisthotonos positioning: Hyperextension of the child's neck and back, or nuchal rigidity where the child holds the neck very still • Kernig's sign: Resistance and sudden pain with knee extension when child is in a supine position with knees flexed up • Brudzinski's sign: When the child's neck is flexed during supine position, the child will suddenly flex the knees and hips -After laboratory specimens are rapidly collected for accurate urinalysis, including CBC, CSF culture, and blood culture, antibiotics are started immediately. The antibiotic administered must match the causative organism for the best prognosis and rapid recovery. -CORTICOSTEROIDS

ASSESSMENT/INTERVENTIONS

Children may present with the following symptoms of lead poisoning: • Metallic taste in mouth • Gastrointestinal (GI) upset, including abdominal cramping • Decreased UOP • Alteration in mentation • Parents describing their child as having a "personality change" • Black-blue discoloration or line along the gums • Paresthesia or abnormal sensations -Interventions for lead poisoning begin with the confirmation of the child's blood level.

CHRONIC DAILY HEADACHES

Chronic daily headaches can cause symptoms similar to migraines but are presented in increasing frequency. If a child experiences headaches for more than 15 days per month and for at least 3 consecutive months, then further diagnostics are warranted to rule out infection, abscess, or head injury.

SAFETY STAT

For SE, anticonvulsant therapy will be for short-term emer- gency management and includes the following medications: • Diazepam (Valium or Diastat) per rectum • Phenobarbital (Solfoton) • Fosphenytoin (Cerebyx

STAGES AND SYMPTOMS OF REYE'S SYNDROME

I=Lethargy, vomiting, sleepiness, normal posture, brisk pupil reaction, and purposeful response to pain stimuli II Follows 5-7 days after stage I= Combative, stuporous (ie, not fully conscious), and disoriented, with a normal posture, a sluggish pupil reaction, and purposeful or non- purposeful response to pain stimuli III= Coma, seizures, decerebrate posture, and sluggish pupil reaction IV=Coma, decorticate posture, and sluggish pupil reaction V=Coma, apnea, limpness, and no pupil reaction

Increased intracranial pressure (ICP)

Increased intracranial pressure (ICP) is increased pressure within the brain's ventricles that is caused by either an overproduction or a lack of absorption of CSF. -The ability of the cranial sutures to open, if needed, and the ability of the fontanels to bulge under pressure, abruptly stops when the bones completely fuse.

NURSING CONSIDERATIONS

One of the most important nursing considerations for a child receiving care for IVH is to keep the child's head midline, comfortable, and supported. Any movement of the child's head should be done with great caution and should require the assistance of two staff members

ASSSES/INTERVENTION

• Precipitating factors surrounding the seizure event or seizure disorder • Description of the child's clinical presentation during the seizure (helps to determine the possible type) such as grand mal or *myoclonic* (spasmodic jerky movements) • The presence of an aura, a loss of consciousness, injury dur- ing seizure (ie, head injury with a fall) and the postictal state • Current medications, including past or current anticonvulsant therapies • Compliance with the current medication regimen

VII Facial: Provides the ability to demonstrate motor movements of facial expressions and taste of anterior 2/3 of tongue (tested by requesting the patient to move her face in various expressions, and by testing taste on the front of the tongue VIII Acoustic: Provides the ability to detect sound, body rotation, and gravity (tested by assessing the patient's ability to hear bilaterally, close the eyes, and know where his or her body is in relation to gravitational pull) IX Glossopharyngeal: Provides the ability to taste in the posterior 1/3 of the tongue (tested by providing the patient with various tastes by providing stimuli such as salt, sugar, and bitters)

X Vagus: Provides the ability to vocalize and swallow effectively (tested by assessing the ability of the patient to vocalize and the effectiveness of the patient's ability to swallow) XI Spinal accessory: Provides the ability to use the sternocleidomastoid and trapezius muscles (tested by asking the patient to shrug and move the head effectively side-to- side and up-and-down) XII Hypoglossal: Provides the ability to move all muscles of the tongue (tested by requesting the patient perform bolus swallowing and speech articulation) The following is a common mnemonic that helps to remember the cranial nerves: On Old Olympus' Towering Tops, A Finn And German Viewed Some Hops

REYES SYNDROME

is a nonspecific, noninflammatory encephalopathy with organ involvement, including the liver, spleen, kidney, pancreas, and lymph. -Death, although rare, can occur because of brain tissue herniation in association with severe cerebral edema, sepsis, and shock. -Reye's syndrome is strongly associated with the use of salicylates (ie, aspirin) to treat symptoms of varicella infections or influenza.

NEURAL TUBE DEFECTS

• *Anencephaly:* The child is born with a severe brain anomaly that is associated with the absence of both hemi-spheres and the presence of a brainstem and cerebellum only. If the newborn survives, the child's condition is incompatible with life and death will occur in time. • *Encephalocele:* The child is born with an abnormal sac of fluid that causes the brain tissue to herniate through an abnormal defect in the skull. The brain tissue may be found within this sac. • *Spina Bifida:* The child is born with a defect within the spinal column. Spina bifida occulta means there are no signs other than the possibility of skin dimpling at the site of the defect. When the defect is apparent, there are two general types of spina bifida: • *Type 1: Myelomeningocele:* The child is born with a portion of the vertebral column not closed, leading to the protrusion of a sac containing not only CSF but also the meninges and a portion of the child's spinal cord. • *Type 2: Meningocele:* The child is born with a defect in the bony spinal column resulting in an abnormal protrusion of a CSF-filled sac located externally to the child's spinal column.

ASSESSMENTS OF CHILDHOOD HEADACHES

• A health history of previous headaches in younger years, a family history that indicates a genetic predisposition, and any neurological disorders, deficits, birth trauma, or vision disorders • Risk factors such as extreme sports that cause dehydration and previous head injury • A physical examination, including the location, severity, intensity, and description of pain, as well as associated symptoms such as nausea, vomiting, behavioral changes, photophobia, sound phobia, and congestion • Assessment for any clinical signs of infection, including fever, a stiff neck, or a pertinent history of recent communicable diseases • A head CT scan if the child demonstrates neurological symptoms such as seizures, pain upon rising in the morning, headache associated with vomiting, or any change in mental status, such as personality, mood, or school performance

ASSESSMENTS/ INTERVENTION

• Assessing airway for patency and effective breathing patterns • Monitoring VSs and neurological checks frequently to look for signs of shock, poor perfusion, and increased -Complications in- clude brain hypoxemia with swelling, increased ICP, enlarging hematomas, seizures, and hyperthermia. -Airway management is the priority intervention. -TBI can cause post-traumatic hyperthermia, so the child's core body temperature must be managed. -The child will need the HOB raised to help decrease ICP

Laboratory studies that may be ordered to assess a child's neurological health include:

• Electrolytes to rule out disturbances such as hypernatremia or hyponatremia • Complete blood cell count (CBC) to rule out signs of infection • Serum lead level to assess for lead exposure or toxicity • Blood culture to rule out severe infections • Diagnostic tests that may be ordered to assess a child's neurological status include: • Lumbar puncture to collect CSF and cultures for infections •Electroencephalogram (EEG) • Urinalysis to rule out toxic exposures

Foods that are encouraged for consumption during the ketogenic diet include

• Heavy whipping cream • Butter • Canola oil • Olive oil • Mayonnaise • Coconut oil • Bacon • Peanut butter • Sour cream • Cheese -The child must not ingest carbohydrates. This diet highly restricts carbohydrates, and includes avoiding starchy fruits and vegetables, breads, pasta, grains, and all sugars; the child must be 100% compliant. -Because the diet is so restricted, the child will need to take vitamin and mineral supplements, including folic acid, vitamin D, calcium, and iron

The following neonate and young infant reflexes are assessed:

• Moro's: Movement with a change in equilibrium, such as a sudden movement down that causes the child to reach his or her arms up and grasp with the fingers • Sucking: Ability to demonstrate effective sucking movements when an area around infant's mouth is touched • Startle: Movement when exposed to a loud sound, with pulling of the arms and legs in toward the trunk • Fencing/Tonic Neck: Movement of arms with a rapid, small movement of head; child will pose in fencing position with the arm extended and the fist opened on the side the head is turned toward, bringing in the arm on the opposite side while clenching that fist • Dancing/Step: Small stepping motions when the child is held carefully up by the trunk (not under the arms); child demonstrates small steps when the sole of the foot touches a surface

RAPID NEUROLOGICAL EXAMINATION

• Overall level of consciousness and ability to respond to verbal and tactile/pain stimuli • Short- and long-term memory • Ability to speak without slurring, delay, or regression • Ability to swallow effectively • Use of accessory muscles • Strength of hand grip and strength of movement of legs • Incontinence in a potty-trained child • Cerebellar status of balance, coordination, and gait -For the new-born and young infant, primitive reflexes are assessed to investigate neurological health. -Primitive reflexes occur in the infant's brainstem or areas of the spinal cord.

PHYSICAL EXAMINIATION

• Rapid visual assessment: Rapid assessment of the level of consciousness, skin color for cyanosis, and ability to breathe effectively • Further inspection of child including level of consciousness (ie, full, confused, disoriented, lethargic, obtunded, coma) and posturing (ie, decorticate and decerebrate), as well as abnormal movements such as tremors, seizure activity, or tics • Vital signs (VSs) assessing for hypertension or hypotension, widening pulse pressure, bradycardia, and dyspnea/ apnea. Temperature should be taken to assess for abnormal core body temperatures. (Do not attempt oral temperatures in a neurologically impaired or seizing child.) • Remember! A fixed and dilated pupil is a serious neurosurgical emergency! • Remember! A brainstem herniation presents with opisthotonos, nuchal rigidity, poor PERRLA (ie, Pupils Equal, Round, and Reactive to Light and Accommodation), bradycardia, abnormal respiratory patterns, and increased blood pressure read- ing for age with widening pulse pressure (ie, widening systolic and diastolic readings)!

health history

• Risk factors for neurological system injury (eg, accidents, intentional injuries such as child abusE) • Risk factors associated with perinatal period such as injury, infections, maternal toxic exposures, illicit drug use, alcohol use, and prematurity • Familial history of seizures, cranial deformities, mental illness, neural tube defects, and chromosomal anomalies

Lead can also be consumed by children through the following sources:

• Root vegetables that uptake lead from contaminated soil • Imported cans that contain food processed in other countries • Pottery or ceramic when the layer of protective glaze wears off • Brass fixtures, lead pipes, solder, and older plumbing in homes built before 1986 • Candies such as the chili-based sweets imported from Mexico

TESTS FOR SEIZURE DISORDERS

• Serum electrolytes, including calcium levels and glucose levels, to rule out metabolic disorders, hypoglycemia, and hypocalcemia • Anticonvulsant serum drug levels: These drugs must be kept in a therapeutic range because low levels may cause seizures to occur and high levels can lead to toxicity. Report immediately any subtherapeutic or toxic levels. Common laboratory safe ranges are the following: • Diazepam: 0.2 to 1.5 mcg/mL • Carbamazepine: 4 to 12 mcg/mL • Phenobarbital: 15 to 30 mcg/mL • Phenytoin: 10 to 20 mcg/mL • Valproic acid: 50 to 125 mcg/mL • Primidone: 7 to 10 mcg/mL Diagnostic Studies • EEG to identify the location and type of seizure; this testing may be a 24-hour video monitoring EEG • CT or MRI to rule out injury, brain tissue abnormalities, tumors, abscesses, and intracranial bleeds • Skull x-rays if trauma is identified or suspected

INTERVENTIONS/ CONSIDERS

• Stabilizing the airway by administering CPR as needed • Maintaining a patent airway • Providing a source of oxygen to maintain stable oxygen saturations and ABGs • Suctioning the child carefully and only if needed (suction-ing can cause rebound increased ICP) • Monitoring the child's pediatric GCS score; if the team determines the value is 8 or less, the child will need to be rapidly intubated • Elevating the HOB • Treating the child's presenting seizure activities if needed • Turning down the lights and providing an environment with low visual and auditory stimulation • Preparing to assist the team in transferring the child to the highest level of care, such as the PICU • Assisting in the rapid transfer to a diagnostic department, such as MRI or CT scanning • Carefully managing the child's IV to maintain a portal for emergency medications such as diuretics and anticonvulsants • Administering diuretics, corticosteroids, or both -. The role of the pediatric nurse is to support an interdisciplinary team in stabilizing the child and then to monitor the child for any sudden change in clinical status

ASSESSMENT

• Sunset Eyes: The white of the sclera is present above the iris • Posturing: Can be decerebrate (ie, damage to nerve pathway between the spinal cord and the brain, which is typically found with brainstem injuries) or decorticate (ie, caused by a stroke, another anterior brain injury, or brain hemorrhages within the cerebral hemispheres) • Seizures: May be generalized or focal • Macewen's Sign: "Cracked pot," with enlarged bluish scalp veins • Diplopia: Double vision • Unequal Pupils: PERRLA should be performed to assess for this condition • Sudden change in feeding habits • Irritability, restlessness, and crying with holding or cuddling

NURSING CONSIDERATION

• Symptoms of hypoxia • Presence of seizures • Hypoglycemia • Coagulopathies • Electrolyte imbalances • Hyperthermia Care of a wound after liver biopsies are performed

Assessments for CP include identifying the presence of one or more of the following signs:

• Tight muscles that do not stretch, possibly worsening over time • "Scissors" movements of arms and legs • Joint contractures in which the joints do not open and do not have full range of motion (ROM) • Paralysis or muscle weakness • Determination if the motor symptoms are present bilaterally or unilaterally • The presence of tremors • Floppy extremities or overextension of joint areas • Ability to suck, swallow, and manage secretions • The presence of pain • Effectiveness of airway for ventilation, airway clearance, and the containment of saliva