Pediatric Neurologic

1. Alterations in
Neurologic
Function in
Children
Joy A. Shepard, PhD, RN-C, CNE
Joyce Buck, PhD(c), MSN, RN-C, CNE
1

2. Objectives
Describe the anatomy and physiology of the neurologic system and
pediatric differences
Choose the appropriate assessment guidelines and tools to examine
infants and children with altered level of consciousness and other
neurologic conditions
Differentiate between the signs of a seizure and status epilepticus in
infants and children, and plan appropriate nursing care for each condition
Plan family-centered nursing care for the child with hydrocephalus,
neural tube defects, and cerebral palsy
Describe the nursing management for traumatic brain injury
2

3. Overview of the Neurologic
System
3

4. Nervous System
Consists of the brain, spinal
cord, and nerves
Seat of intellect and
reasoning
Communication and
coordination system of the
body
Affects and is affected by all
other body systems
4

5. Key Brain Parts Involved in Thinking
5

6. 6

7. Cranial Nerves
12 pairs, begin in the brain
Many important sensory
and motor functions
Designated by number and name:
7

8. 8
Cranial nerve I: olfactory nerve, or smell
Cranial nerve II: the eye – pupillary response
Cranial nerves III, IV, VI: eye movements
Cranial nerves V and VII: the face
Cranial nerve VIII: auditory nerve
Cranial nerves IX, X, XII: the mouth, tongue, swallowing
Cranial nerve XI: accessory nerve, ability to shrug shoulders

9. 9

10. 10

11. Spinal Nerves
31 pairs: originate at spinal
cord and go through openings
in vertebrae
Convey sensory information;
relay impulses that stimulate
motor responses
Send and receive
information to specific body
locations
11
A superhighway of nerves that
connect your brain to every
tissue in your body

12. 12

13. Brain Architecture: Neurons,
Nerve Impulse
Neuron: information processing cells;
basic cells of nervous system
Make connections with other neurons
to form the information processing
networks
A stimulus creates an impulse
The impulse travels into the neuron
on the dendrite (s) and out on the axon
At axon’s end, neurotransmitter
released to carry impulse across
synapse to next dendrite
13

14. Brain Architecture: Neural
Interconnectivity
Neural interconnectivity occurs
with growth.
During the 1st 2 years, billions of
new connections established and
become more complex
Vast system of interconnectivity
(connectome) – biological hardware
from which all thoughts, feelings,
and behavior emerge
This interconnectivity
developmental process depends on
serve and return interaction
14
The development of a
child’s brain architecture
provides the foundation
for all future learning,
behavior, and health
The Science of Early Childhood & The Brain Architecture Game

15. Brain Architecture: Myelination,
Neurilemma (Myelin Sheath)
Covering that speeds up the
nerve impulse along the axon
Fatty protein substance that
protects the axon
Synapse- space between
neurons, messages go from one
cell to the next
Responsible for speed and
accuracy of nerve impulses
15

16. Myelination = White Matter
Progressive covering of axons with layers of myelin
Incomplete at birth
Proceeds in cephalocaudal direction
Accounts for progressive acquisition of gross and fine motor
skills, coordination
Axon diameters and myelin sheaths undergo conspicuous
growth during the first two years of life, but may not be fully
mature until a person’s early 20s
16

17. Cephalocaudal/ Proximodistal
17

18. Pediatric Differences
18

19. Anatomic Differences in the Structures
of the Nervous System Between
Children and Adults (p. 742 [new], 808 [old])
19

20. Anatomic & Physiologic Differences
20

21. Neurological System of Children
Complete but immature nervous system
Top heavy
Cranial bones- thin, not well developed
Brain highly vascular with small subarachnoid
space
Excessive spinal mobility
Wedge-shaped cartilaginous vertebral bodies
Bones in neck don’t harden and fuse until ~ age 6
21

22. “Top Heavy”
22

23. Unfused Sutures
Fibrous union of suture lines
and interlocking of edges
occurs by 6 months
Suture lines between skull
bones ossified by age 12
Posterior fontanel closes by 3
months
Anterior fontanel closes by 18
to 24 months
Prone to brain injury and
skull fractures with falls
23

24. Rapidly-Developing Brain
At birth, brain is 25% of
adult size
Develops rapidly until age 4
Brain increases four-fold in
size during preschool period
By age 6, brain is 90% of
adult size
Myelination is complete by
early adulthood
24
A child’s adult capacities rest heavily
on neural foundations developed
through early learning experiences

25. 25

26. Developmental Differences
Neurological assessment of the child is limited to the child’s developmental level
Children progress cognitively through the sensorimotor, preoperational, concrete
operational, and formal operational stages
Primitive reflexes present at birth disappear by 1 year
Children are developing their ability to recognize and manage their emotions or
feelings up until and including their late teens or early twenties
Children and adolescents are still in a period of social development which involves
learning the values, knowledge and skills that enable them to relate to others
Adolescents cannot reason as well as adults; they are more inclined to act
impulsively and irrationally and take part in high-risk behaviors
26

27. 27

28. Assessment of the Neurologic
System in Children
28

29. 29

30. 30

31. Neurologic Assessment
Normal growth &
development parameters/
Developmental milestones
Infant: Primitive reflexes
“Locomotion:” Gross motor
“Manipulation:” Fine motor
“Cognitive:” Language &
Social
Parents’ evaluation of their
child
History
Prenatal
Birth history
Postnatal
31
Review “Assessing the Nervous System,” pp. 134-141 (new), 152-159 (old)
SeeVideo“PediatricAssessment,”25:50-28:30

32. Birth History (p. 101 [new], 116 [old])
32

33. Neurologic Assessment Cont’d…
Behavior
Personality, affect, level of activity, social interaction, attention span
LOC – alertness, any subtle changes?
Communication skills
Speech, language, social skills
Table 5-16: Expected Language Development for Age, p.136 (new), 152 (old)
Motor function
Muscle - size, tone, strength
Gait, balance, coordination
Spontaneous movements; abnormal movements
Sensory function
Discrimination of touch with eyes closed
33

34. Expected Language Development
for Age (p. 136 [new], 154 [old])
34

35. Expected Balance Development for
Age (p. 136 [new], 153 [old])
35

36. Romberg Procedure (p. 136 [new], 153 [old])
36

37. Expected Fine Motor Development
for Age (p. 137 [new], 153 [old])
37

38. Tests of Coordination (p. 137 [new], 154 [old])
38

39. Neurologic Assessment Cont’d…
Vital signs:
Respiratory status:
Assess 1st
Changes in BP, HR
Eyes: Changes in
pupils, focus, gaze
39

40. Pupillary Response
The pupil’s response to light
is checked
Does the pupil dilate and
constrict appropriately?
A light beam is directed at
and away from the eye and the
reaction is noted
Observe if the pupils
constrict and dilate as
expected: CN II & CN III
Young children: PERRL
Older children: PERRLA
40

41. 41

42. Diagnostic Procedures
Computer Tomography (CT)
Visualizes horizontal and
vertical cross section of the
brain
Distinguishes density
MRI
Permits tissue discrimination
unavailable with other
techniques
42

43. Diagnostic Procedures
Lumbar puncture
Measure pressure and
sample for analysis
Subdural tap
R/O subdural effusions,
relieves ICP
EEG
Measures electoral activity
Detects abnormalities
43

44. Review Question
The nurse places the young child scheduled for a lumbar
puncture in a side-lying position with head flexed and knees
drawn up to the chest. The mother asks why the child has to be
positioned this way. The nurse explains the rationale for the
positioning is that:
A. Pain is decreased through this comfort measure.
B. Injury to the spinal fluid is prevented.
C. Access to the spinal fluid is facilitated.
D. Restraint is needed to prevent unnecessary movement.
44

45. Review Question
A nurse employed in an outpatient diagnostic laboratory department
assesses a preschooler who arrives to have an electroencephalogram
(EEG). The nurse determines that the diagnostic test may need to be
rescheduled if which of the following noted?
A. The child’s hair is shampooed.
B. The child took an anticonvulsant.
C. The child ate a full breakfast.
D. The child drank orange juice for breakfast.
45

46. Laboratory Tests
CSF
Blood glucose
Electrolytes
Ca, Mg, Na
Clotting studies
Liver function tests
Blood cultures
Drug titer
46

47. Altered States of Consciousness
47

48. ***The most sensitive indicator of neurologic function**
Consciousness
Responsiveness to or
awareness of sensory stimuli
Divided into two categories
Level of Consciousness: state of being alert, arousable
The ability to react to stimuli
Reflects function of the cerebral hemisphere and brainstem
May change rapidly, within seconds
Orientation Status: state of being aware, cognitive power
The ability to process the data and respond either verbally or physically
Reflects the cerebral cortex activity
48

49. Altered States of Consciousness
(p. 744 [new], 811 [old])
1. Confusion
• Disorientation to time, place, or person
2. Delirium
• Characterized by confusion, fear, agitation, hyperactivity, or anxiety
3. Lethargy = less than full alertness; senses blunted
4. Stupor = response to vigorous stimuli only
5. Coma = unconscious; cannot be aroused
49
If a client is lethargic, check the blood sugar first,
then perform the neuro assessment.

50. Glasgow Coma Scale/ AVPU Scale
Glasgow (p. 749 [new], 811 [old]):
Designed as a standardized assessment of the patient with disturbed
consciousness
Different criteria for infants and older children
Decline in LOC follows a pattern of confusion, delirium, lethargy, stupor, to
coma
The lower the score at time of admission the poorer the outcomes
AVPU (p. 746 [new], 812 [old]):
Alert, Verbal, Painful and Unresponsive
Only ‘Alert’ state is normal
50

51. 51

52. AVPU Scale
52Only ALERT state is NORMAL!
Assess
• Alertness
What stimuli is needed?
What is quality of the
response?
What is length of response?

53. The Child With Altered Consciousness
(pp. 744-746 [new], 811-813 [old])
Altered consciousness is a
state in which a child’s
cerebral function is
depressed
Ranges from stupor to
coma
Care of the child with altered
consciousness
Monitor vital signs
Manage the airway
Manage bladder and bowel
elimination
Maintain hydration & nutrition
Provide proper hygiene
Position and perform exercise
53

54. Persistent Vegetative State
A complete unawareness of the environment accompanied
by sleep–wake cycles
The diagnosis is established if it is present for 1 month
after acute or nontraumatic brain injury or has lasted for 1
month in children with degenerative or metabolic disorders
or developmental malformations
Family support is needed
Not the same as “Brain Death”!
54

55. Review Question
A child on a pediatric unit has been in a coma for the past
two months. When caring for a child in a coma which of the
following nursing diagnoses would be most important?
A. Risk for Impaired Skin Integrity
B. Impaired Physical Mobility
C. Risk for Imbalanced Nutrition: Less than Body Requirements
D. Ineffective Airway Clearance
55

56. Pupil Changes (p. 745 [new], 811 [old])
56Fixed and dilated pupil(s) is neuro emergency!

57. Increased Intracranial Pressure
Causes
Tumors
Accumulation of fluid within
the ventricular system
Bleeding
Edema in cerebral tissues
Early signs and symptoms are often
subtle and assume many patterns
57

58. SuddenincreasedintracranialpressureisanEMERGENCY!CatchitEARLY!
Assess for signs of Increased
Intracranial Pressure
Level of consciousness (LOC)
Earliest and most subtle indicator of changes in neurological status
As ICP increases, LOC decreases
Early signs:
Confusion, restlessness, lethargy, and disorientation first to time, then to
place, and then to person
Headache, visual disturbance, nausea/vomiting, pupils unequal or slow
Infants: increased head circumference, bulging fontanels, separated
sutures, vomiting, high-pitched cry
58

59. Assess for signs of Increased
Intracranial Pressure
Late signs:
Stupor and coma
Significant LOC decrease
Increased systolic BP and pulse pressure
Bradycardia
Irregular respirations
Fixed, dilated pupils
Decorticate/ decerebrate posturing
59
See Table 27-4 “Signs of Increased Intracranial Pressure,” p. 744 (new), 810 (old)

60. 60

61. 61

62. 62
NOT

63. Review Question
Which of the following signs and symptoms of
increased ICP after head trauma would appear
first?
A. Bradycardia
B. Restlessness and confusion
C. Vomiting
D. Widened pulse pressure
63

64. Increased Intracranial Pressure
Posturing
Decorticate
Adduction and flexion
Decerebrate
Rigid extension and
pronation
64

65. 65

66. Review Question
The nurse is caring for a child with a head injury and is monitoring
the child for decerebrate posturing. Which of the following is
characteristic of this type of posturing?
A. Flexion of the extremities after a noxious stimulus
B. Extension of the extremities after a noxious stimulus
C. Upper extremity flexion with lower extremity extension
D. Upper extremity extension with lower extremity flexion
66

67. Common Nursing Diagnoses
Ineffective Breathing Pattern
Risk for Aspiration
Ineffective Airway Clearance
Impaired Verbal Communication
Impaired Physical Mobility
Interrupted Family Processes
Risk for Delayed Growth and Development
Risk for Impaired Skin Integrity
Risk for Injury / Risk for Falls
67

68. Seizure Disorders
68

69. Epilepsy (p. 747 [new], 813 [old])
Seizure disorder of brain;
characterized by recurring and
excessive discharge from neurons
Repeated, unpredictable seizures
One in 20 children will have a seizure
by age 18
45,000 children develop epilepsy
each year
Seizures – excessive discharge of
neurons
69
An estimated 460,000
children have active epilepsy

70. Seizure Disorders: Causes
(p. 747 [new], 813 [old])
Traumatic brain injury (TBI)
Infection
Congenital brain defects
Metabolism disorders (such as
phenylketonuria)
Brain tumor
Abnormal blood vessels (brain)
Toxic ingestion
Anoxic or hypoxic events
Hypoglycemia
Fever
70
Electrical storm on the
surface of the brain

71. Classification of Seizures
(pp. 748-749 [new], 814-815 [old])
*Partial or Focal
Starts in just one part of the brain
Simple partial: no loss of
consciousness
Complex partial: affect level of
consciousness
Symptoms depend on what area of
the brain is involved
Often presents as a staring
episode (absence seizures) or
slight twitching of eyes and drooling
*Generalized
Starts simultaneously on the entire
surface of the brain
Tonic-clonic (grand mal)
Tonic – stiff
Clonic – jerking
Sudden loss of muscle tone
Eye blinking, altered awareness,
mouth, or facial movement
71See “Types of Seizures/ Clinical Manifestations,” pp. 748-9 (new), 814-815 (old)
*Occur as a result of insult to the
nervous system

72. 72

73. *Febrile Seizures (p. 747 [new], 813 [old])
Age
Most common between 6 months
and 5 years
Occurrence
Seizure accompanied by fever
without CNS infection; last < 15
minutes
Occurs during the temperature rise
Treatment
Fever - Tylenol
Seizure - Ativan, Valium
(only if second febrile seizure)
73
*Occur as a result of rapidly
increasing core temperature

74. *Status Epilepticus
(pp. 747, 749 [new], 813 [old])
Malignant seizure condition
where the patient seizes
constantly or has seizure
after seizure without
abatement
Seizures lasting more than
20 minutes without return to
baseline
Neurologic Emergency!
74
*In children, the major cause of
status epilepticus is infections
accompanied by fever

75. Management of Status Epilepticus
(p. 749 [new], 816 [old])
75

76. Seizure Disorders: Nursing Care
Maintain airway patency
Remain calm and stay with child
Reassure and provide support to child and others
Protect child from injury
Implement seizure precautions (padded side rails, oxygen, suction
equipment, IV access, and anticonvulsant medications)
Provide continuous cardiac, respiratory, and oxygen monitoring
Suction equipment at bedside!
76

77. Seizure Disorders: Nursing Care
Cont’d….
Protect the child from injury
Clear area of objects
Place on side in recovery position
Maintain anticonvulsant therapy
See Medications Used to Treat
Seizures, pp. 750-751 (new), 816-
817 (old)
Accurately observe & document
events
77
Goals of therapy: no seizures, no
side effects, best quality of life

78. Review Question
An eighteen-month-old child is observed having a seizure. The
nurse notes that the child’s jaws are clamped. The priority
nursing responsibility at this time would be:
A. Start oxygen via mask.
B. Insert padded tongue blade.
C. Restrain child to prevent injury to soft tissue.
D. Protect the child from harm from the environment.
78

79. Documentation
When seizures began
Duration
Warning signs
Clinical characteristics
Level of consciousness
Signs and symptoms when
seizure stops
Vital signs
79

80. Clinical Therapy (p. 747 [new], 815 [old])
Diagnostic Tests
CBC, blood chemistry, ABG, urine culture
Metabolic screen for glucose, phosphorus, & lead levels
Lumbar puncture
EEG
CT Scan/ MRI
Medications (pp. 750-751 [new], 816-817 [old])
Ketogenic diet (p. 751 [new], 818 [old]) for intractable seizures
80

81. **Ketogenic Diet**
81
Side effects: dyslipidemia, constipation,
kidney stones, and slowed growth
Very high fat, very low carbohydrate, moderate protein diet

82. Long-Term Goal for Children with
Seizure Disorders
Identify the cause and
eliminate the seizure
with minimum side
effects using the least
amount of medication
while maintaining a
normal lifestyle for the
child
82

83. Hydrocephalus
83

84. Hydrocephalus (p. 761 [new], 829 [old])
An imbalance of CSF absorption or production caused by
congenital anomalies, CNS malformations, tumor, hemorrhage,
infection, or head injuries
Results in head enlargement & increased ICP
Commonly associated with myelomeningocele
Brain compressed against the skull 84

85. Hydrocephalus: Clinical Manifestations
(p. 763 [new], 830 [old])
Infant
Increased HC, separated skull sutures, full or
bulging fontanels
“Sunsetting eyes”
Poor feeding, poor sucking, projectile vomiting
Child
Behavioral changes – irritability & lethargy
HA on awakening, N & V
Delays in walking or talking, unstable balance, poor coordination
Blurred or double vision
85

86. Bulging Anterior Fontanel;
Sunsetting Eyes
86
Head enlargement with prominent forehead

87. Diagnostic Tests
Prenatal US
Daily serial HC
measurements
CT scan/ MRI
MRI/ CT scan
Skull X-ray
Transillumination
87

88. Collaborative Care: Surgical
Intervention
Removing obstruction (e.g.,
tumor)
Creating new pathway
Shunting to bypass the point of
obstruction by shunting the fluid
to another point of absorption
Four parts to shunt: ventricular
catheter, pumping reservoir, one-
way valve, & distal catheter
88

89. Review Question
The parents of an infant who has just had a
ventriculoperitoneal shunt inserted for hydrocephalus are
concerned about the infant’s prognosis and ongoing care. The
nurse should explain that:
A. The prognosis is excellent and the shunt is permanent.
B. The shunt will need to be revised as the child gets older.
C. During the first year of life, any brain damage that has occurred is
reversible.
D. Hydrocephalus is usually self-limiting by 2 years of age and the shunt
will then be removed.
89

90. Complications: Ventriculoperitoneal
Shunts
Blocked shunts
Infections
Seizures
90
See “Signs of Shunt Malfunction or Infection,” p. 764 (new), 832 (old)

91. Review Question
Following surgery for the insertion of a shunt for hydrocephalus,
the infant demonstrated irritability, high-pitched cry, elevated pulse
rate, and temperature of 40 degrees C (104 degrees F). These
symptoms are consistent with which of the following postoperative
complications?
A. Shunt obstruction.
B. Increased intracranial pressure.
C. Decreased intracranial pressure.
D. Infection.
91

92. Hydrocephalus: Nursing Care
(p. 764 [new], 831 [old])
Preoperative:
Assess ICP, neurological status, VS, HC
Reposition head frequently to prevent pressure sores
Provide education on the shunt, surgery, & postop care
Postoperative:
Assess for ICP, neurological status, VS, HC, infection
Assess shunt functioning
Assess operative site
Position child on the unoperated side
Keep child flat as ordered & elevate HOB 30° for s/s increased ICP
Assess abdominal status (pain, bowel sounds, and circumference)
92

93. Critical Thinking
What is the most important assessment data on a child who
has just had a shunt placement for hydrocephalus?
What is the most important teaching for the parents or
caregivers?
93

94. Neural Tube Defects
94

95. Neural Tube Defects
Abnormalities of brain, spine,
or spinal column; present at
birth
Failure of the osseous spine
to close around the spinal
column
Spina bifida: most common
type
Spina bifida occulta
Meningocele
Meningomyelocele
95

96. Spina Bifida Occulta
96

97. Visible Types of Spina Bifida
Meningocele: sac filled
with spinal fluid and
meninges
Meningomyelocele
(Myelodysplasia): more
severe, sac filled with
spinal fluid, meninges,
nerve roots and spinal cord
97

98. Spina Bifida: Clinical Manifestations
Vary depending on the level of the lesion and defect
Motor, sensory, reflex and sphincter abnormalities
Lower extremity weakness
Ambulation difficulties
Flaccid paralysis of legs- absent sensation and reflexes, or spasticity
Bowel and bladder control issues
Hydrocephalus
Learning, attention, memory, and reasoning problems
98See “Clinical Manifestations Myelodysplasia,” p. 767 [new], 833 [old]

99. Spina Bifida: Diagnostic Tests
Prenatal detection
Ultrasound
Alpha-fetoprotein
Following Birth:
NB assessment
Ultrasound
CT scan/ MRI
X-ray of spine
X-ray of skull
99

100. Spina Bifida: Surgical Intervention
Immediate surgical
closure
Prior to closure keep sac
moist & sterile
Maintain NB in prone
position with legs in
abduction preoperatively
100

101. Review Question
A newborn has been admitted to the unit with a
meningomyelocele. Preoperative concern would include:
A. Measure the head circumference on a daily basis.
B. Preventing increased intracranial pressure by laying the
baby in semi-Fowler’s position.
C. Positioning the infant on his abdomen to protect the spinal
defect.
D. Monitoring the child for signs of irritability and vomiting.
101

102. Spina Bifida: Collaborative Care
Extensive interdisciplinary treatment
Antibiotics, sac closure (neonatal neurosurgery), and
ventriculoperitoneal shunt placement
Monitoring of head size (hydrocephalus), evaluation of sphincters, and
institution of bowel and bladder regimen
Dietary fiber, stool softeners, suppositories
Clean intermittent catheterization
Physical therapy, occupational therapy, speech therapy
Braces, assistive devices, weight-bearing exercises
Calcium, vitamin D, high-fiber diet
102

103. Spina Bifida: Nursing Care
Pre-OP:
Place in prone position
Sterile moist dressing with NS or
antibiotic solution
Maintain proper abduction of legs
and alignment of hips
Meticulous skin care
Protect from injury, feces or urine
Keep in isolette
Post-OP:
Assess surgical site, keep clean & dry
Monitor VS and neuro status
Institute latex precautions
Encourage contact with parents/care
givers
Positioning
Skin care
Discharge planning and teaching well
in advance of discharge
103**Emphasize the normal, positive abilities of the child**

104. Review Question
An infant undergoes surgery to remove a meningomyelocele. To
detect increased intracranial pressure (ICP) as early as possible, the
nurse should stay alert for which postoperative finding?
A. Decreased urine output
B. Increased heart rate
C. Bulging fontanels
D. Sunken eyeballs
104

105. Critical Thinking
Would you expect a 5-year-old with meningomyelocele to have
bladder/ bowel sphincter control?
Which type of neural tube defect is most likely to have no
outward signs or symptoms?
105

106. Cerebral Palsy
106

107. Cerebral Palsy (p. 772 [new], 838 [old])
Group of permanent disorders of movement,
muscle tone or posture that is caused by a
nonprogressive insult to the immature, developing
brain, most often before birth
Primarily a motor disorder (i.e., affects body
movement, muscle control, muscle coordination,
muscle tone, reflex, posture and balance)
May also have sensory, perceptual, cognitive,
communicative, and behavior problems
1.5 – 2 cases per 1000 live births
Most common motor disability in children
107

108. Types of Cerebral Palsy
 Spastic: most common type, 75% of
cases; causes increased muscle
tone (muscles feel stiff and tight)
 Dyskinetic-athetosis: 10-15% of
cases; involuntary movements that
are slow, ‘stormy,’ and writhing
 Dyskinetic-dystonia: twisting and
repetitive involuntary movements
 Ataxic: 5-10% of cases; shaky
movements; poor balance,
coordination
 Mixed (e.g., spastic-dyskinetic)
108

109. Cerebral Palsy: Etiology &
Pathophysiology (p. 772 [new], 839 [old])
Damage to motor control centers of developing brain; may
occur prenatally, perinatally, or postnatally
Many possible causes:
Abnormal brain development/ brain injury prior to birth
Prenatal or perinatal asphyxia/ anoxia (severe lack of
oxygen in the brain)
Low birth weight, preterm birth
Bleeding in the brain (intraventricular hemorrhage)
Prenatal and postnatal infections, such as cytomegalovirus,
rubella, toxoplasmosis, neonatal sepsis, meningitis
Head injury (motor vehicle crash, fall, child abuse)
Hyperbilirubinemia (kernicterus)
https://www.ninds.nih.gov/Disorders/All-Disorders/Cerebral-Palsy-Information-Page
109

110. 110

111. CP Clinical Manifestations: Infants
(p. 773 [new], 839 [old])
Vary individually depending on the area of
the brain involved and the extent of damage:
Problems with sucking and swallowing
A weak or shrill cry
Extreme irritability & crying
Jittery (easily startled)
Unusual positions (either very relaxed and floppy
or very stiff)
Delay in reaching motor skills milestones (such as
sitting up alone or crawling)
Delays in speech development or difficulty
speaking
111See “Clinical Manifestations Cerebral Palsy,” p. 773 [new], 840 [old]

112. CP Clinical Manifestations: Children
(p. 773 [new], 840 [old])
Abnormal motor development
Persistent primitive infantile reflexes
Increased or decreased muscle tone
Hypertonia, rigidity, muscles stiff
Keeps legs extended or crossed
Rigid and unbending
Exaggerated deep tendon reflexes
Opisthotonus
Abnormal increased muscle development in arms & legs
Hypotonia, muscles floppy
Smaller muscles in affected arms & legs
Diminished reflexes
112

113. Opisthotonus and Hypotonia
113

114. CP Clinical Manifestations: Children
Cont’d... (p. 773 [new], 840 [old])
Abnormal posture
Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees
crossing or a wide-based unsteady gait
Persistent fetal position (>5 months)
Abnormal voluntary movements
Tremors or involuntary movements
Slow, writhing movements (athetosis)
Difficulty with precise motions (hand movements)
Lack of muscle coordination (ataxia)
Abnormal sensations
Abnormal touch or pain perceptions
Seizures
114

115. Cerebral Palsy: Gait Abnormalities
115Risk for Falls/ Injury related to unsteady gait

116. Cerebral Palsy: Diagnostic Tests
(pp. 773 [new], 840-841 [old])
Clinical findings
Neurologic examination
Developmental assessment
Ultrasound
EEG, CT/ MRI, PET
Electrolyte levels and metabolic workup
116

117. Cerebral Palsy: Clinical Therapy
(p. 773 [new], 840 [old])
Early Recognition & Multidisciplinary Approach
CP cannot be cured, but disabilities can be managed through planning and timely
early intervention (Tertiary Prevention)
Physical, Occupational, Speech therapy
Nursing Management (p. 774 [new], 841 [old])
Assess the child’s developmental level & intelligence
Use splints and braces
Promote self-care, physical mobility
Maintain skin integrity
Administer medications (reduce muscle spasms, spasticity, anxiety, and seizure)
Surgery (e.g., selective dorsal rhizotomy, tendon releases)
Address feeding problems
Provide intellectual stimulation
Ensure safe environment
117Care Plan: The Child with Cerebral Palsy, pp. 775-776 [new], 842-843 [old]

118. 118

119. Baclofen to Decrease Spasticity
119

120. Selective Dorsal Rhizotomy
120

121. Cerebral Palsy: Complications
Increased incidence of
respiratory infection
Muscle contractures
Skin breakdown
Injury/ Falls
Constipation
121

122. Review Question
Upon performing a physical assessment of a 7-month-old child,
the nurse notes an abnormal finding that could suggest cerebral
palsy. The finding suggestive of cerebral palsy is that the child
has:
A. No head lag when pulled to a sitting position.
B. No Moro or startle reflex.
C. Positive tonic neck reflex.
D. Absence of tongue extrusion.
122

123. Traumatic Brain Injury
123

124. Traumatic Brain Injury (TBI)
(p. 777 [new], 844 [old])
Trauma to the head that causes a change in LOC or an anatomic
abnormality of the brain
Leading cause of death & disability among children
Up to 90% of deaths of injured children are associated with TBI
Infants: shaken baby syndrome; child abuse; falls; motor-vehicle crash
Toddlers/ preschoolers: falls (head-first); motor-vehicle crash
School-age/ adolescents: motor vehicle crash; sports & athletic
injuries; assaults
124

125. TBI – Common Causes
(p. 777 [new], 844 [old])
125

126. Coup & Contracoup Brain Injury:
Pathophysiology (p. 778 [new], 845 [old])
126

127. TBI: Clinical Manifestations
(pp. 778-779 [new], 845-846 [old])
Obvious signs: blood on the scalp, depression of the skull, penetrating wound,
etc.
Mild (Concussion)
No or brief loss of consciousness
Alteration LOC
Headache, memory loss, unsteady, tired
Moderate
Five- to ten-minute loss of consciousness
Headache, nausea
Glasgow Coma Scale: 9–12
See “Clinical Manifestations: TBI by Severity,” p. 778 (new), 846 (old)

128. TBI: Clinical Manifestations
Cont’d...
Severe
Loss of consciousness of more than ten minutes
Glasgow Coma Scale: less than 8
Amnesia for more than 24 hours preinjury
Coma
Seizures & combativeness

129. TBI: Diagnostic Tests
(p. 779 [new], 846 [old])
CBC, blood chemistry,
toxicology, UA
X-ray: skull, cervical vertebrae
CT scan: fractures, intracranial
hemorrhage, swelling, tearing of
nerve fibers throughout the brain
MRI: during recovery to
determine extent of brain damage
PET scan: blood flow to brain
129

130. TBI: Clinical Therapy
(p. 779 [new], 846 [old])
Detection of primary injury; prevention or treatment of secondary brain injury (prevent
hypoxia, hypercapnia, hypotension, hypoglycemia, electrolyte abnormalities)
Secure the airway (may need intubation, mechanical ventilation)
Minimize cerebral metabolic rate of oxygen consumption (minimal stimulation, quiet
environment, cluster care)
Prevent elevated ICP (sedation, analgesia; avoid suctioning)
Hypertonic saline, mannitol, high-dose barbituate therapy, burr holes, surgical
evacuation of intracranial hematoma
Elevation of the head to 30° in the midline position (once cervical spine injury has
been ruled out)
130

131. Review Question
The nurse is caring for a child admitted to the pediatric intensive
care unit after sustaining a head injury. In which of the following
positions should the nurse place the child to prevent increased
intracranial pressure (ICP)?
A. In left Sims position
B. In reverse Trendelenburg
C. With the head elevated on a pillow
D. With the head of the bed elevated 30 degrees
131

132. TBI: Nursing Management
(pp. 780-781 [new], 848-849 [old])
Nursing care focus: maintain cerebral perfusion, minimize increases in ICP,
prevent complications, & provide emotional support
Maintain airway patency and oxygen administration
Continuous cardiopulmonary monitoring
Insert IV and administer hypertonic fluid
Assess neurological status
Assess ICP
Cluster care, low-stimulation environment
Skin care/ oral care
Support/ educate family & caregivers
Discharge instructions
132

133. Review Question
The nurse is providing discharge instructions for a child who
has suffered a head injury within the last four hours. The nurse
will recognize the need for additional teaching when the mother
states:
A. “I will call my doctor immediately if my child starts vomiting.”
B. “I won’t give my child anything stronger than Tylenol for headache.”
C. “My child should sleep for at least 8 hours without arousing after we get
home.”
D. “I recognize that continued amnesia about the injury is not uncommon.”
133

134. 134

135. Shaken Baby Syndrome
Don’t ever shake a baby!
Brain sensitive to injury
Shaking can lead to brain
rotation within skull
Blood vessels tear severe
medical problems, long-term
disabilities, and sometimes death
Subdural hematomas
Retinal hemorrhages/ detachment
135
Classic signs of shaken baby syndrome are seizures, slow apical
pulse, difficulty breathing, and retinal hemorrhage.

136. Damage Caused When a Baby is Shaken
136Shaken Baby Simulator

137. Review Question
The pediatric nurse understands that the concepts related to
shaken baby syndrome include: (Select all that apply.)
A. Infants are susceptible to injury due to their neck muscles being weak
B. After this injury infants may have seizures, lethargy, and respiratory
difficulties
C. The infant will display a sunken fontanel
D. Jarring motion causes tearing of the nerve fibers of the brain
E. Vision impairment or loss of hearing may result from this injury
137

138. 138