Peds Exam 4
Chapter 38: nursing care of the child with an alteration in intracranial regulation/ neurological disorders
Head size
- Neck muscles are not well developed
- This leads to an increased incidence of head injury from falls
Neuro assessment
- Should proceed least invasive to most invasive
- Use toys, familiar objects, and play to promote cooperation
- Do not attempt assessment that involves movement of the head and neck in cases of trauma
or suspected trauma until cervical injury is ruled out
o Maintain complete immobilization of the cervical spine until that time
- Used doll’s eye maneuver to evaluate cranial nerves III, IV, and VI.
o Can be helpful when assessing infant, uncooperative child, or comatose child
o It examines horizontal and vertical eye movements by turning the head in one
direction and assessing if the eyes move symmetrically in the other direction
- Immediately report the sudden presence of fixed and dilated pupils
- Alterations in motor function
o Changes in gait, muscle tone, strength
o May indicate certain neurological problems such as increased ICP, head injury, and
cerebral infections
- Reflexes
o Testing primitive and protective reflexes in the infant is important because infants
cannot perform tasks on command
o Moro, tonic neck, and withdrawal reflexes are important in assessing neurologic
health in infants
- Early signs of ICP
o HA, vomiting, possibly projectile, blurred vision, double vision, dizziness, decreased
pulse and respirations, increased blood pressure or pulse pressure, pupil reaction
time decreased and unequal, sunset eyes, changes in LOC, irritability, seizure activity
o Infants: bulging, tense fontanel and high pitched cry
- Late signs of ICP
o Fixed and dilated pupils
- Palpation
o Posterior fontanel normally closes by 2 months of age and the anterior fontanele
normally closes by 12-18 months
- Lab testing
o Lumbar puncture
Assist with proper positioning and help child remain still
Keep child flat for 1 hour if ordered
Apply EMLA cream to puncture site 30-60 mins before procedure ro reduce
pain, if ordered
, o Electroencephalogram
Measures electrical activity of the brain
To diagnose seizures and brain death
Must remain still, but avoid sedatives
o Video EEG
Measures electrical activity of brain continuously alone with recorded
actions and behaviors
Health history
- Past medical history might be significant for prematurity, difficult birth, infection during
pregnancy, nausea, vomiting, headaches, changes in gait, falls, visual disturbances, or recent
trauma
Present history
- Inquire about changes in gait, increased irritability, altered muscle tonicity, and delays in
growth and development
Medical treatment:
- Shunt placement
o Monitor for signs and symptoms of increased ICP, neurologic status, LOC, vital signs,
and infection
- PT/OT/ST
o Therapies are used to improve motor function and ability of children with neurologic
disorders
- Vagal nerve stimulation
o Short and long term seizure management in children older than 12 years of age
- Ketogenic diet
o Diet involves high intake of fats, adequate protein, and a very low intake of carbs,
resulting in a ketosis state.
o Child is kept in a mild state of dehydration
Medications
- Anticonvulsants (oral and parenteral)
o Stopping abruptly may precipitate seizures or even status epilepticus
LOC
- Earliest indicator of improvement or deterioration of neurological status
- Abnormal finding> extreme irritability
- Parents will notice changes first
Pediatric Glasgow coma scale
- Popular scale used to standardize degree of consciousness
, - Three parts: eye opening, verbal response, and motor response
Seizure disorders
- Mostly caused by disorders that originate outside of the brain such as a high fever, infection
head trauma, hypoxia, toxins, or cardiac arrhythmias
Epilepsy
- Practical definition of epilepsy is defined by the presence of:
o Two or more unprovoked (or reflex) seizures, which occur more than 24 hours apart
o One unprovoked (or reflexed) seizure and a chance of further seizures the same as
the general recurrence risk (at least 60%) after two unprovoked seizures, happening
over the next 10 years
o Diagnosis of an epilepsy syndrome
- Pathophysiology
o Clinical manifestations are recurrent or unprovoked seizures of epilepsy
o Results from a disruption of electrical communication among the neurons of the
brain
- Therapeutic management
o Focuses on controlling seizures or reducing their frequency
o Helping the child who has recurrent seizures and his or her family to learn to live
with the seizures
- Health history
o Gain information to help characterize the episode as a seizure or as a nonepileptic
event
o Questions should include:
Where did the event occur—while sleeping, eating, playing, or
just after waking?
Description of child’s behavior during the event—what types of
movements, progression, length, respiratory status, apnea?
How did the child act after the event?
Have the episodes been recurrent? If so, how frequent?
Any precipitating factors such as a fever, fall, activity, anxiety,
infection, or exposure to strong stimuli such as flashing lights
or loud noises?
- Nonepileptic events
o Syncope, breath holding, apnea, gastroesophageal reflux
- Common types of seizures
o Epileptic spasm such as infantile spasms
Cry may precede or follow
o Absence (formerly petit mal)
Abrupt onset and offset, sudden cessation of motor activity or
speech with a blank facial expression or rhythmic twitching of
the mouth, eyebrows, chin, eyelids, or other parts of the face
o Tonic-clonic (formerly grand mal)
Most dramatic seizure type
Loss of sphincter control, especially the bladder, is common
Chapter 38: nursing care of the child with an alteration in intracranial regulation/ neurological disorders
Head size
- Neck muscles are not well developed
- This leads to an increased incidence of head injury from falls
Neuro assessment
- Should proceed least invasive to most invasive
- Use toys, familiar objects, and play to promote cooperation
- Do not attempt assessment that involves movement of the head and neck in cases of trauma
or suspected trauma until cervical injury is ruled out
o Maintain complete immobilization of the cervical spine until that time
- Used doll’s eye maneuver to evaluate cranial nerves III, IV, and VI.
o Can be helpful when assessing infant, uncooperative child, or comatose child
o It examines horizontal and vertical eye movements by turning the head in one
direction and assessing if the eyes move symmetrically in the other direction
- Immediately report the sudden presence of fixed and dilated pupils
- Alterations in motor function
o Changes in gait, muscle tone, strength
o May indicate certain neurological problems such as increased ICP, head injury, and
cerebral infections
- Reflexes
o Testing primitive and protective reflexes in the infant is important because infants
cannot perform tasks on command
o Moro, tonic neck, and withdrawal reflexes are important in assessing neurologic
health in infants
- Early signs of ICP
o HA, vomiting, possibly projectile, blurred vision, double vision, dizziness, decreased
pulse and respirations, increased blood pressure or pulse pressure, pupil reaction
time decreased and unequal, sunset eyes, changes in LOC, irritability, seizure activity
o Infants: bulging, tense fontanel and high pitched cry
- Late signs of ICP
o Fixed and dilated pupils
- Palpation
o Posterior fontanel normally closes by 2 months of age and the anterior fontanele
normally closes by 12-18 months
- Lab testing
o Lumbar puncture
Assist with proper positioning and help child remain still
Keep child flat for 1 hour if ordered
Apply EMLA cream to puncture site 30-60 mins before procedure ro reduce
pain, if ordered
, o Electroencephalogram
Measures electrical activity of the brain
To diagnose seizures and brain death
Must remain still, but avoid sedatives
o Video EEG
Measures electrical activity of brain continuously alone with recorded
actions and behaviors
Health history
- Past medical history might be significant for prematurity, difficult birth, infection during
pregnancy, nausea, vomiting, headaches, changes in gait, falls, visual disturbances, or recent
trauma
Present history
- Inquire about changes in gait, increased irritability, altered muscle tonicity, and delays in
growth and development
Medical treatment:
- Shunt placement
o Monitor for signs and symptoms of increased ICP, neurologic status, LOC, vital signs,
and infection
- PT/OT/ST
o Therapies are used to improve motor function and ability of children with neurologic
disorders
- Vagal nerve stimulation
o Short and long term seizure management in children older than 12 years of age
- Ketogenic diet
o Diet involves high intake of fats, adequate protein, and a very low intake of carbs,
resulting in a ketosis state.
o Child is kept in a mild state of dehydration
Medications
- Anticonvulsants (oral and parenteral)
o Stopping abruptly may precipitate seizures or even status epilepticus
LOC
- Earliest indicator of improvement or deterioration of neurological status
- Abnormal finding> extreme irritability
- Parents will notice changes first
Pediatric Glasgow coma scale
- Popular scale used to standardize degree of consciousness
, - Three parts: eye opening, verbal response, and motor response
Seizure disorders
- Mostly caused by disorders that originate outside of the brain such as a high fever, infection
head trauma, hypoxia, toxins, or cardiac arrhythmias
Epilepsy
- Practical definition of epilepsy is defined by the presence of:
o Two or more unprovoked (or reflex) seizures, which occur more than 24 hours apart
o One unprovoked (or reflexed) seizure and a chance of further seizures the same as
the general recurrence risk (at least 60%) after two unprovoked seizures, happening
over the next 10 years
o Diagnosis of an epilepsy syndrome
- Pathophysiology
o Clinical manifestations are recurrent or unprovoked seizures of epilepsy
o Results from a disruption of electrical communication among the neurons of the
brain
- Therapeutic management
o Focuses on controlling seizures or reducing their frequency
o Helping the child who has recurrent seizures and his or her family to learn to live
with the seizures
- Health history
o Gain information to help characterize the episode as a seizure or as a nonepileptic
event
o Questions should include:
Where did the event occur—while sleeping, eating, playing, or
just after waking?
Description of child’s behavior during the event—what types of
movements, progression, length, respiratory status, apnea?
How did the child act after the event?
Have the episodes been recurrent? If so, how frequent?
Any precipitating factors such as a fever, fall, activity, anxiety,
infection, or exposure to strong stimuli such as flashing lights
or loud noises?
- Nonepileptic events
o Syncope, breath holding, apnea, gastroesophageal reflux
- Common types of seizures
o Epileptic spasm such as infantile spasms
Cry may precede or follow
o Absence (formerly petit mal)
Abrupt onset and offset, sudden cessation of motor activity or
speech with a blank facial expression or rhythmic twitching of
the mouth, eyebrows, chin, eyelids, or other parts of the face
o Tonic-clonic (formerly grand mal)
Most dramatic seizure type
Loss of sphincter control, especially the bladder, is common
