NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Neurological System

Focus topic:Pediatric Nursing

The central nervous system (CNS) (brain and spinal cord), the peripheral nervous system (cranial and spinal nerves), and the autonomic nervous system comprise the neurological system; together these provide control functions for the entire body.

Pediatric Nursing: Neurological Disorders

Focus topic:Pediatric Nursing

Pediatric Nursing: Cerebral Palsy

Focus topic: Pediatric Nursing

Definition: A nonspecific term used to describe a group of disorders characterized by motor and postural impairments due to abnormal muscle tone; cerebral palsy may also involve language, perceptual, and intellectual deficits.The most common permanent physical disability of childhood, occurring in approximately 1.1 in 1000 live births.

Assessment

A. Etiology is thought to be multi-factorial, with many types of prenatal, perinatal, and postnatal causes possible.

  •  Cerebral palsy is associated with premature and low-birth-weight infants.
  •  However in many cases, no cause is found and the infant is born at term and has a normal weight.

B. Assess for abnormal movements.

  •  Spasticity.
    a. Voluntary muscles lose normal smooth movements and respond with difficulty to both active and passive movement.
    b. Increased deep tendon reflexes, scissoring, increased hip flexion, and toe-walking.
    c. Contractures of anti-gravity muscles.
    d. Persistence of primitive (infant) reflexes.
    e. Lack of normal postural control.
  •  Athetoid (dyskinetic).
    a. Involuntary muscle action with smooth, writhing movement of extremities.
    b. Reflexes usually normal.
  •  Ataxia: lack of coordination and possibly hypotonia.

C. Assess for seizures, which occur in many children with cerebral palsy.

D. Check for vision disturbance, which occurs in 20% of these children.

E. Assess mental functioning; at least 50% function at a subnormal level. Many cerebral palsy children are diagnosed as mentally retarded due to slow motor skills or aphasia, but possess normal or high intelligence.

F. Speech and swallowing difficulties because of muscle spasticity and lack of coordination.

 

Implementation

A. Each child requires an individualized program according to the particular manifestations of the disease and the child’s capacities.

B. Major focus of interventions is to:

  • Develop motor control and increase mobility.
    a. Intrathecal continuous infusion pump with Lioresal (baclofen) to decrease spasticity may be used.
  • Develop communication skills.
  • Provide adequate nutrition.
  • Prevent orthopedic complications.

Pediatric Nursing

 

Pediatric Nursing: Seizure Disorders

Focus topic: Pediatric Nursing

Definition: A series of seizures that result from focal or diffuse paroxysmal discharges in cortical neurons symptoms of abnormal brain function. May be congenital or acquired.

Etiology

A. Seizure disorders are idiopathic (cause unknown or acquired) or the result of brain injury caused by trauma, hypoxia, infection, toxins, or other acquired factors.

B. Seizures more common during first 2 years than any other period.

C. Most common cause by age group.

  •  Young infants: birth injury, hemorrhage, anoxia, and congenital defects of the brain.
  •  Late infancy and early childhood: infections, trauma; middle childhood–onset epilepsy is uncommon.
  •  Children older than 3 years: idiopathic epilepsy most common.

Assessment
A. Febrile seizures.

  •  Very common; occurs in 3–4% of all children, usually in children 6 months to 6 years of age. Usually occurs within 24 hours of onset of fever to > 102.2°F or 39°C (but rapidity of rise in fever may be more important than height of fever).
  •  Simple febrile seizure—lasts < 15 minutes, generalized may occur once per 24 hours.
  •  Complex febrile seizure lasts > 15 minutes, has focal onset, and occurs more than once per 24 hours.
  •  Seizure is generally benign, but lab work indicated to locate source of fever. An LP may be performed depending on the child’s history. Not usually hospitalized. Risk of developing epileptic syndrome is low.
  •  Treatment: prn rectal Valium (diazepam) occasionally prescribed. Long-term prophylaxis not indicated.

B. Simple partial seizures (focal seizures without loss of consciousness).

  •  Localized (begins focally in one hemisphere) and does not impair level of consciousness. May involve motor symptoms, accompanied by autonomic or somatosensory symptoms.
  •  Localized (confined to a specific area) motor symptoms, accompanied by autonomic or somatosensory symptoms.
  •  Manifestations.
    a. Aversive seizure—most common motor seizure in children. Eye(s) turn away from focus side.
    b. Sylvan seizures—most common during sleep. Tonic–clonic movements involving face.

C. Complex partial (psychomotor) seizures (focal WITH loss of consciousness).

  • Jacksonian march—rare in children. Sequential clonic movements.
  •  Area of brain most involved is temporal lobe (thus, this type of seizure is called psychomotor).
  •  Most common in children from 3 years to adolescence.
  •  Characterized by complex sensory phenomena, a period of altered behavior, and amnesia (child is not aware of behavior). Seizure begins focally in one hemisphere and impairs LOC.
  •  May perform such mannerisms as lip smacking, chewing, picking at clothes, etc.
  •  Seizure lasts several minutes and is accompanied by aura and postictal phase. May have secondary generalization (such as Jacksonian march; spreads to other hemisphere).

D. Generalized seizures.

  • Definitions: Tonic: sustained muscle contraction; Clonic: rapid jerking and flexor spasms of extremities.
  •  Tonic–clonic seizures, formerly known as “grand mal.”
    a. May begin with an aura, then a tonic phase (lasting 10–20 seconds): stiffening or rigidity of muscles, particularly arms and legs; eyes roll up; followed by loss of consciousness; may be apneic and become cyanotic.
    b. Clonic phase follows (lasts about 30 seconds, but may last as long as 30 minutes): hyperventilation with rhythmic violent jerking of all extremities; may foam at the mouth and become incontinent; full recovery may take several hours.
    c. Status epilepticus—a series of seizures that run together and do not allow the child to regain consciousness between attacks.
    (1) A neurological emergency with generalized tonic–clonic seizures.
    (2) Status epilepticus can lead to exhaustion, respiratory failure, and death.
    (3) Usually treated with IV Valium or Ativan (lorazepam). Respiratory monitoring is essential after administration of benzodiazepines.
  • Absence seizures, formerly known as “petit mal.”
    a. Brief duration, often just 5–10 seconds, brief loss of consciousness; almost no change in muscle tone.
    b. May occur 20–30 times/day.
    c. Common in children; may appear to be daydreaming, or inattentive.
    d. The child may have a blank stare or roll eyes as only symptoms.
  •  Myoclonic seizure.
    a. Characterized by a brief, generalized jerking or stiffening of the extremities.
    b. Seizure may throw person to the floor; no loss of consciousness.
  • 5. Atonic or akinetic seizures, also called “drop attacks.”
    a. Onset between 2 and 5 years of age.
    b. Characterized by sudden, brief loss of muscle tone.
    c. Child may fall to ground, momentary loss of consciousness.
  •  Infantile spasms.
    a. Most common in first 6–8 months of life; more common in males; usually associated with low intelligence later in life.
    b. Characterized by sudden, brief, symmetrical contractions; head flexed, legs drawn up, arms extended.
    c. May experience numerous attacks during the day without postictal drowsiness.

Implementation
A. Prevent injury during seizure.

  •  Remove any objects that may cause harm.
  •  Remain with child during seizure and provide privacy if possible.
  •  Do not force jaws open during seizure no padded tongue blades necessary.
  •  Do not restrict limbs or restrain.
  •  Loosen restrictive clothing.
  •  Check that airway is open. Do not initiate artificial ventilation during a tonic–clonic seizure without first administering appropriate antiepileptic medications.
  •  Apply oxygen by blow-by if available or appropriate.
  •  Following seizure, turn head to side to prevent aspiration and allow secretions to drain; suction as needed.

B. Observe and document seizure pattern.

  •  Note time, LOC, and presence of aura before seizure.
  •  Record type, character, progression of movements.
  •  Note duration of seizure and child’s condition throughout.
  •  Observe and record postictal state.

C. Administer and monitor medications complete control achieved in 50–70% of epileptic children.

  •  Commonly used antiseizure medications include: Tegretol (carbamazepine), Dilantin (phenytoin), Luminal (phenobarbital), and Depakene or Depakote (valproic acid), most of which require serum drug levels.
  • Absence seizures: Zarontin (ethosuximide) and others.
  •  Newer antiseizure medications such as Keppra (levetiracetam), Neurontin (gabapentin),Topamax (topiramate), Gabitril (tiagabine), and Lamictal (lamotrigine) are generally indicated as second-line medications, but their use is increasing, even in young children. Most have fewer side effects, fewer drug interactions, and do not require serum drug levels.

D. Implement postseizure procedures increases speed of recovery.

  •  Reduce stimuli noise, lights, conversation.
    a. Place sources of light behind client.
    b. Keep away from fluorescent lights.
  •  Remain with child after consciousness returns.
    a. Speak and move slowly.
    b. Use simple phrases—give child time to respond.
  •  Encourage rest following a seizure child will be exhausted and maintain privacy.
  •  Provide seizure precautions in hospital keep bed rails raised, pad side rails of bed, suction and oxygen on standby.
  •  At home, child should carry medical identification, wear helmet (if atonic seizures), and use precautions with hazardous activities or activities requiring supervision (e.g., swimming).
  •  A ketogenic diet and vagal nerve stimulation may be adjunctive measures if antiseizure medication fails to control the seizures.

 Pediatric Nursing: Traumatic Brain Injury

Focus topic: Pediatric Nursing

Definition: Any trauma to the scalp, skull, meninges, or brain caused by mechanical force or penetration.

Characteristics

A. Accidental injury is the major single cause of death in the pediatric age group, primarily from head injury sustained in motor vehicle accidents (MVAs). Approximately 500,000 children present in the emergency room every year for evaluation and treatment of head and brain injury.

B. Causes.

  • Falls occur most frequently under 1 year of age; 75% result in some type of head injury.
    a. More boys than girls are injured by falls.
    b. 5- to 19-year-old age group result of accidents involving bicycles, skate boarding, or athletics. Helmets have significantly reduced the incidence of traumatic brain injuries as a result of accidents.
  •  Motor vehicle accidents are the most frequent cause in adolescents. Athletic injuries are also common.

C. Types of injuries.

  •  Most head injuries are caused by physical forces that impact on the head through acceleration and deceleration.
    a. Acceleration: Slower-moving contents of cranium strike bony prominences or dura (coup).
    b. Deceleration: Moving head strikes fixed object and brain rebounds, striking opposite side of cranium (contrecoup).
  •  Concussion is most common: violent jarring of the brain within the skull, temporary loss of consciousness, seizure activity.
    a. Postconcussion syndrome manifested by memory loss, confusion, headache, dizziness, inability to concentrate, irritability, and fatigue.
    b. There have been recent efforts to prevent athletes from returning to play after sustaining a concussion and to allow for “cognitive rest” so that the brain can recover. Investigation continues regarding long term effects of concussion.
  • Contusion and laceration: the bruising of the brain and tearing of cerebral tissue.
  • Closed head injuries: Skull is intact.
  • Open head injuries include deep scalp lacerations that require suturing.
  • Fractures: The majority of fractures are linear; other types are depressed, compound, and comminuted. A child’s skull can withstand a great amount of force before it fractures.

D. Complications.

  • Epidural hemorrhage: usually the result of skull fracture. Bleeding is generally arterial, and brain compression develops quickly. Blood accumulates between dura and skull and forms a hematoma.
    a. Signs of intracranial compression occur within a few minutes or hours after the injury with classic Cushing’s triad symptoms (hypertension, bradycardia, and altered respirations). Often there is a period of lucidity followed by rapid increase of intracranial pressure.
    b. Clinical signs include headache, vomiting, hemiparesis, and loss of consciousness.
  • Subdural hemorrhage: bleeding between dura and cerebrum (common in infants due to birth trauma). Bleeding is usually venous and develops more gradually than epidurals. Much more common than epidurals.
    a. Most common clinical signs are seizures, vomiting, and irritability.
    b. May be evidence of increased intracranial pressure.
  • Subarachnoid and intracerebral hemorrhages may also occur from head injury.
  • Cerebral edema (diffuse brain swelling) leads to signs of increased intracranial pressure but no focal signs.

Assessment

A. Assess LOC; changes appear earlier than changes in vital signs.

B. Check for nausea and vomiting.

C. Observe for pupillary changes: pupil dilates on ipsilateral side of injury.

D. Monitor changes in vital signs, reflecting increased intracranial pressure or shock.

E. Observe for seizure activity and describe fully if noted.

F. Observe for changes in position and movement: nuchal rigidity; opisthotonos.

G. Check for headache. (If child is too young to verbalize, he or she may be fussy and irritable.)

H. Observe for vasomotor or sensory losses.

I. Assess for rhinorrhea and otorrhea due to CSF leak (infrequent in children).

  •  Bleeding from ear suggests basilar skull fracture.
  •  Drainage from nose should be tested with Dextrostix; if glucose present, it is evidence of cerebrospinal damage.

J. Observe child for any unusual behavior: Make interpretation of this behavior in terms of child’s normal behavior.

K. Identify any overt scalp or skull trauma.

Implementation

A. Monitor for complications: Determine neurological status.

  • Check for signs of increased intracranial pressure.
    a. LOC: alert and easily aroused or lethargic; in a stupor or coma.
    b. Restless, irritable, crying behavior.
    c. Vital signs: changes in respiratory rate, increased blood pressure, pulse pressure, decreased pulse.
  • Avoid actions that might increase intracranial pressure.
    a. Sudden changes in position.
    b. Bowel straining.
    c. Confused, noisy environment.

B. Monitor vital signs. Report changes immediately.

C. Maintain adequate respiratory exchange. Increased carbon dioxide levels increase cerebral edema.

D. Protect from injury by using safety measures.

  •  Maintain bed rest.
  •  Keep padded side rails up.

E. Position head to promote fluid drainage, promoting venous return from brain: Elevate head of bed 15–30 degrees with head straight.

F. Monitor and protect child if seizure activity.

  •  Observe and record type of seizure.
  •  Note behavior that preceded seizure.

G. Prevent infection if there is drainage from auditory canal or nose.

  •  Place dry, sterile cotton loosely at orifice.
  •  If drainage from nose is positive for glucose, do not suction nares risk of secondary infection.
  •  Maintain strict a sepsis.

H. Provide adequate nutrition and hydration.

  •  Provide clear liquids as ordered.
  •  Measure intake and output accurately.
  •  Monitor IV if in place.

Pediatric Nursing: Neurological Infections

Focus topic: Pediatric Nursing

Pediatric Nursing: Meningitis

Focus topic: Pediatric Nursing

Definition: An acute inflammation of meninges that is caused by bacteria or viruses and may progress rapidly to neurologic problems, permanent brain damage, or death. Highest incidence is between birth and 2 years, greatest risk immediately following birth and 3–8 months.

Assessment

A. Assess airway, breathing, circulation, and fever; act immediately on abnormalities.

B. Complete neurological examination; assess for nuchal rigidity, positive Kernig’s and Brudzinski’s signs, headache, irritability, nausea, vomiting, seizure activity, other signs of increased ICP.

C. Often results from sepsis and invasion of the blood–brain barrier; may be caused by direct spread of otitis media or sinusitis, direct inoculation during surgery or trauma.

D. Diagnosis is confirmed by LP and CSF examination.

  • Usual causes vary with age.
    a. Immediately after birth, cause is usually Group B Streptococcus, Escherichia coli, or Listeria.
    b. After 1 month, usual cause is Streptococcus pneumoniae, Haemophilus influenzae type B, or Neisseria meningitidis.
  • Viral meningitis is much less serious.

E. Prevention—incidence of meningitis due to H. influenzae Type B, S. pneumoniae, and N. meningiditis have decreased with compliance with current immunization schedules (HIB, PCV, and MCV4 vaccines, respectively). Nevertheless, N. meningitidis meningitis persists in adolescents and young adults who live in crowded conditions military barracks and college dormitories.

Implementation

A. Evaluate airway, breathing, and circulation—client may present in septic shock.

B. Maintain patent airway; administer oxygen as ordered; respiratory arrest possible with deteriorating neurologic status.

C. Isolate child until the causative agent is identified.

D. Maintain optimal fluid balance, support cardiovascular system, monitor ICP.

E. Monitor neurological signs carefully.

F. Observe for signs of subdural effusion collection of fluid in the subdural space.

  •  Increasing intracranial pressure.
  •  Irritability.

G. Administer antibiotics on time if bacterial cause.

H. If cause is Neisseria meningococcus, contacts should receive antibiotic prophylaxis.

I. Maintain bed rest and position child comfortably; most children prefer a side-lying or flat position; sitting up increases pain. May elevate head of bed with increased ICP.

Pediatric Nursing: Encephalitis

Focus topic: Pediatric Nursing

Definition: Inflammation of the parenchyma of the brain, resulting from direct viral invasion or hypersensitivity initiated by a virus or another foreign protein.

Assessment

A. Fever, headache, altered LOC, sometimes with seizures and focal neurologic deficits.

B. A GI or respiratory prodrome may precede neurological symptoms.

C. Diagnosis: Requires CSF analysis and neuroimaging.

  •  Most common cause is herpes simplex virus (type 1 or type 2).
  •  Usual mortality rate is around 1%, but morbidity is higher.
  •  West Nile encephalitis has spread throughout the United States, with an associated mortality of about 9%.

Implementation

A. Mainly supportive, and may include antiviral medications.

B. Monitor for status epilepticus or coma, which suggests severe brain inflammation and poor prognosis.

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Pediatric Nursing: Reye’s Syndrome

Focus topic: Pediatric Nursing

Definition: Acute encephalopathy with fatty degeneration resulting in marked cerebral edema and enlargement of the liver with marked fatty infiltration.

Characteristics

A. Children from 2 months to adolescence contract illness; ages 6 to 11 years most often affected.

B. Usually follows a viral infection, especially varicella and influenza B.

C. Aspirin because of links to development of Reye’s is now contraindicated with influenza—Tylenol (acetaminophen) is medication of choice.

D. Incidence of Reye’s decreased dramatically with decreased use of aspirin in nonspecific viral illness.

Assessment

A. Assess for prodromal symptoms: malaise, cough, rhinorrhea, sore throat.

B. Evaluate LOC.

C. Observe temperature changes.

D. Evaluate clinical stages of the syndrome.

  • Stage 1: vomiting, lethargy, and drowsiness.
  • Stage 2: CNS changes, disorientation, delirium, aggressiveness and combativeness, central neurologic hyperventilation, hyperactive reflexes, and stupor.
  • Stage 3: comatose, hyperventilation, decorticate posturing.
  • Stage 4: increasing comatose state; loss of ocular reflexes; fixed, dilated pupils.
  • Stage 5: seizures, loss of deep tendon reflexes, flaccidity, and respiratory arrest.

E. Evaluate lab findings.

  •  Associated with liver dysfunction; serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), and lactic dehydrogenase (LDH) are all elevated, dependent clotting factors, decreased prothrombin time (PT), bilirubin, and alkaline phosphate unchanged.
  •  Associated with renal dysfunction: reduced blood sugar levels to below 50 mg/100 mL, reduced insulin levels, and decreased glucagon response.

F. Assess fluid and electrolyte balance; intake and output.

Implementation

Applies to increased intracranial pressure in general and to Reye’s syndrome.

A. Most important nursing function is to monitor for signs of increased intracranial pressure; rapidly increasing ICP can result in death.

  •  Invasive ICP monitoring usually used.
  •  Major effort is toward recognizing and reducing cerebral edema, as this may lead to death.
  •  Administer IV Osmitrol (mannitol) as ordered to reduce blood osmolarity while increasing urine output, thus reducing cerebral edema.

B. Prepare for tracheal intubation and controlled ventilation to decrease ICP.

C. Provide respiratory care; suctioning, ventilation, and oxygen as ordered.

D. Monitor vital signs frequently and decrease temperature as needed.

E. Monitor closely for signs of seizure activity, treat promptly, and utilize seizure precautions.

F. Provide nursing care appropriate for semiconscious and unconscious client as neurological status alters.

  •  Maintain head elevation at 15–30 degrees depend on degree of increased intracranial pressure.
  •  Monitor reflexes as indicative of clinical stage of syndrome.

G. Provide adequate fluid balance.

  •  Ensure adequate urinary output of at least approximately 2 mL/kg/hr (actual value depends on the age of the child).
  •  Provide and monitor intravenous fluids.
  •  Observe closely for cerebral edema or dehydration.

H. Provide emotional and supportive care for client and family.

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