Nursing Care of the Child and Family Adapting to Alterations in Neurological Function Neurological Assessment of the Pediatric Patient

t First step is to complete a comprehensive history of the childs developmental and neurological status prior to hospitalization Basic Components of the Neurological Assessment - Level of Consciousness (L C!" Pupillary #esponse" $otor Function" and %ital &igns Assess child in most alert a'a(e state) Level of Consciousness (L C! Assess amount of stimulation re*uired to a'a(en child) Assess if stimulation is re*uired to (eep a'a(e +o' much does it ta(e to 'a(e them and (eep them a'a(e) ,lasgo' Coma &cale Fig -.-/ pg 010- (no need to memorize the num2ers3! Consists of - parts4 5ye pening #esponse" %er2al #esponse and $otor #esponse 6ocumented as Best 5ye pening #esponses" etc)

,lasgo' Coma &cale Best 5ye pening #esponses 7 &ame for all ages 8 - &pontaneous 5ye pening - - 5yes pen to &peech / - 5yes pen to Pain 0 - No #esponse Best %er2al #esponse Adult/Child Infant 1 7 riented and Appropriate Cooing 8 7 6isoriented Conversation 9rrita2le Cry - 7 9nappropriate :ords Cries to Pain / 7 9ncomprehensi2le $oans to Pain 0 7 No #esponse No #esponse Best $otor #esponse Adult/Child Infant ; 7 2eys Commands Normal spontaneous 1 7 Localizing to Pain :ithdra's to <ouch 8 7 :ithdra's from Pain :ithdra's from Pain - 7 6ecorticate (Fle=or! Posturing to Pain (all ages! / 7 6ecere2rate (5=tensor! Posturing to Pain (all ages! 0 7 No #esponse to Pain (all ages!

 $inimal Attaina2le &core 7 $a=imal Attaina2le &cored - 01 &core of 01 7 >naltered L C &core of ? or less 7 ,enerally accepted as Coma &core of @ - 7 6eep Coma or 6eath Changes should 2e documented and reported to the physician immediately Levels of Consciousness (L C!Bo= -.-8 Page 010 Full Consciousness 7 A'a(e and Alert" riented to <ime" Place and Person) Behavior appropriate for age Confusion 7 9mpaired 6ecision $a(ing Disorientation 7 Confusion re4 <ime and Place) 6ecreased L C Lethargy 7 Limited spontaneous movement) &luggish speech Obtundation 7 Arousa2le 'ith stimulation Stupor 7 #emains in deep sleep" responsive only to vigorous and repeated stimulation Coma 7 No motor or ver2al response to no=ious (painful! stimuli Persistent Vegetati e State !PVS" 7 Permanently lost function of the cere2ral corte=) 5yes follo' o2Aects only 'hen 2y refle= or 'hen attracted to the direction 2y loud sounds) All 8 e=tremities are spastic 2ut can 'ithdra' from painful stimuli) +ands sho' refle=ive grasping and groping) Face can grimace" some food may 2e s'allo'ed and the child may groan or cry 2ut utter no 'ords No 2rain responsiveness) Loss of cere2ral corte=3 Big decisions need to 2e made) Pupillary #esponses Normal &ize /-; mm 5=amine eyes in a dar(ened room 'ith a 2right light 6irect #esponse Consensual #esponse - B ConAugate ,aze - 2oth eyes are moving in the same direction) normal neuro finding) $otor Function Posture and $uscle <one - canCt do foot strength due to understanding of age) ,rip &trength &ymmetry of $ovements $ade to Commands %ital &igns +eart #ate should 2e :NL - D to pain and fear Normal respiratory rate 7 Normal for neonates to have episodes of periodic 2reathing Blood Pressure should 2e :NL <emperature should 2e :NL 6ecreasing L C Infant Child ,radual loss of eye contact Confusion :ea( irrita2le cry Less responsive Less responsive Lethargy Lethargy Coma

 Coma +igh pitched cry - increased 9CP Pupillary #esponses Could 2ecome 7 Larger" &maller" >ne*ual and &luggish 6isconAugate ,aze - one eye loo(s left" and one to the right 'hile loo(ing straight ahead) 6ilation and >nresponsiveness to Light (5$5#,5NCE3 BL :N P>P9L&3 +ave to relieve pressure) Chec( to see 'hy it is fi=ed and non responsive) !

$otor Function :ill diminish as neurological status deteriorates %ital &igns Change as neurological changes occur 7 changes in Pulse and Blood Pressure are more important then direction of change <achycardia then Bradycardia Could 2e D or F :idening Pulse pressure 9ndicative of 9ncreased 9CP Can 2e +yper- or +ypothermic) 5=treme) Can 2e e=tremely +EP <+5#$9C) 6onCt 2e s'ayed that they donCt have a high temp) Note 7 Cushing #efle= 7 9ncrease in 9ntracranial Pressure leads to a <riad of &ymptoms4 Badycardia and an 9ncrease in BP and 9rregular Breathing and is uncommon in children 7 if it occurs it is a very late sign and an ominous (#AAAAAAAAAAAAAAD!sign) Actually means the Brain may 2e a2out to +erniate #espiratory Changes >sually 2est to descri2e 'hat is happening rather then placing a la2el on it Periodic Breathing 7'hich is an ominous sign 'hich indicates 2rainstem (especially medullary! dysfunction 7 usually preceeds complete Apnea P5##LA - testing accomodation means you tell them to focus on the pen (pupils constriction!) P5##LA does not apply 1 years or younger3 6eep <endon #efle=es 7 6iminished or A2sent culocephalic #efle=es (6olls 5yes! ('hen the 2rainstem for eye movement is normal 'hen you are moving the head 2ac( and forth the eyes opposite to the head) ma(e sure you have cervical sta2le spine)! and culovesti2ular #efle=es (9ce :ater Calorics! 7 Normal in neurologically intact child (if done on the right side nystagmus 'ill go to'ards the same direction NLE 'hile A&L55P! Neurological Assessment of the 9nfant +ead Circumference - fuses 2y 0?-/8 months) #oom for 9CP to 2uild up 2efore you start seeing signs li(e 2ulging fontanel" vomiting" high pitched cry) if it hits the roof then they 'ill crash) chec( vitals) familial macrocephalos - 2ig head is normal for some families) Palpate Anterior Fontanel - a pulse is N #$AL) usually 69A$ N6 shaped)

Palpate Cranial &utures 9ncreased Fle=or <one 6ocument #esponse to &timulation 6ocument A2ility to &uc( Assess &uc(Gs'allo' coordination (helps determine neuro status! Note Pupillary #esponse +ead Control 7&hould 2e sta2le at 8 months of age Assess Cry :ea( Lusty &hrill Appropriate to &timulus Cridedasha' - sounds li(e cat 'hen you step on tail) high pitched shrill) :hat is the pro2lem hereB #efle=es Hno' 'hen #ooting" &uc(ing" Palmar ,rasp" $oro and Ba2ins(i #efle=es Appear and 'hen they should 2e gone (0? months to / years 'hen they are 'al(ing! ,rading of #efle=es 8I +yperactive -I Bris(er than Normal /I Normal 0I 6iminished J A2sent Neurological Assessment of the lder Child ( slide /.! Assess #esponse to Command and Assess &peech Alert rientation 7 Person" Place" <ime and 5vent Note $ood Pupillary #esponse A2ility to read" 'rite" dra' or copy shapes Assessing gro'th motor and fine motor activity Nursing 9mplications of 6evelopmental 6ifferences o Nurses must 2e a'are that the assessment of infants and children is limited 2y the childs developmental level o <he childs neurological status can appear to change rapidly 2ecause of the limitations of the assessment) Also 2ecause of open cranial sutures and fontanelCs help to compensate for an increase in 9CP o Neurological signs may 2e evident or they may manifest themselves in more su2tle 'ays" such as lac( of interest in eating or irrita2ility Assessment of Neurological Function o Factors 9nfluencing the Assessment #ate of Change &everity of the Pro2lem &tatic or Progressive Nature and Location of the Pro2lem Focal $ulti-Focal 6iffuse Diagnostic $ests for Determining %eurological Dysfunction o Non-9nvasive 6iagnostic <ests

Computerized <omagraphy 7 C)<) &can $agnetic #esonance 9maging &can 7 $)#)9) 5lectroencephalogram 5vo(ed Potentials 5choencephalogram 9nvasive 6iagnostic <ests Lum2ar Puncture 7 L)P) Cisternal Puncture &u2dural <ap $yelogram Cere2ral Angiography Pneumoencephalogram

Lumbar Puncture and Cerebral spinal Fluid !CSF" &'amination o Normal Findings Pressure @ /JJ cm +/ Color 7 Clear and Colorless #lood ( %one) bleeding Cells #BC 7 J o :BC 76o not need to memorize <otal Neonate - J--J cellsGmL 0-1 years 7 J-/J cellsGmL ;-0? years - J-0J cellsGmL Adults J-1 cellsGmL 6ifferential Neutrophils 7 J-;K Lymphocytes - 8J-?JK $onocytes - 01-81K Protein 7 01-81 mgGdL (>p to .J mgGdL in children and elderly ,lucose 7 1J-.1 mgGdL or ;J-.J K of Blood ,lucose Level Comparging serum gGc to spinal glucose 6ra' the cappililary and send to the la2 2efore hand ,et 81-0 hr of serum gGc 2efore spinal Age *elated Differences o Brain ,ro'th +,- of the brain.s gro/th is completed by 0 year1of1age 2+- by 3 years1of1age 4,- by 5 years1of1age o Cere2ral Blood Flo' (CBF! and =ygen ( L! Consumption Muestion 7 9s CBF and L consumption the same" faster or slo'er in childrenB Faster 9t is important to note that the 2rain is an NinactiveO organ uses 0, times the L used 2y the rest of the 2ody) o Fontanel Closure 6icrocephaly Primary vs) &econdary

$acrocephaly Primary vs) &econdary Clinical $anifestations of $acrocephaly Accelerated +ead ,ro'th 6elayed Fontanel Closure $ental and Physical #etardation &eizures No increase in 9CP

Craniosynostosis !A7A Craniostenosis" o Pathophysiology 7 Premature closure at birth of one or more cranial sutures1 #rain to gro/ against the close /all $ost common form4 Premature closure of the sagittal suture" 'ith resulting elongation of the s(ull in the anterior-posterior direction (similar shape seen in premature infants due to postnatal positioning!

Clinical $anifestations Increased ICP 7 :hich may or may not cause mental retardation) Can result in progressive papilledema" optic atrophy and eventual 2lindness Part of NB-assessment <herapeutic $anagement &urgical e=cision of long 2ars of 2one along or parallel to the fused suture :hen should surgery 2e performedB By ; month of age Nursing Considerations Assessment of Premature Closure Neurological &tatus 2serve post-operatively for hemorrhage and infection

%ursing Care of the Child /ith Increased Intracranial Pressure o 6ynamics of 9CP 6efinition4 Pressure e=erted 2y C&F 'ithin ventricles of 2rain Continually fluctuates7 responds to arterial pulsation and respiratory cycle %alsalva maneuver (cough" sneeze" straining! increases 9CP" standing up or sitting erect decrease 9CP Normally measures ?J-00J mm +/ G J-01mm +g - A2ove/Jmm+gG/JJmm+/J is a2normally high o Physiology S8ull is rigid compartment9 filled to capacity !04,,cc" /ith essentially noncompressible contents #rain matter ) :, Intra ascular blood ) 0, CSF ) 0, $hese amount needs to remain constant9 if one increase the other needs to be decrease other/ise ICP

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%olume of these - remain nearly constant 9f any one component increases in volume" another component must decrease for overall volume to remain constant 7 other'ise 9CP increases Increased ICP is significant because it diminishes cerebral perfusion ( leads to brain ischemia9 infarction ) poor prognosis Sustained increased ICP result in brainstem compression and herniation of the brain from one compartment to another 7 this 2ecomes irreversi2le and fatalPherniations force the cere2ellum and 2rainstem do'n'ard through the foramen magnum" compresses 2rainstem leading to respiratory arrest Complications of 9ncreased 9CP 9nade*uate cere2ral perfusion Cere2ral herniation -Fal= cere2ri (thin 'all of dura folded 2et'een the corte=" separating the / cere2ral hemispheres! -<enorium cere2elli (rigid fold of dura that separates cere2ral hemispheres from cere2ellum

Clinical 6anifestations of Increased ICP ( #o' 3210 page 0502 o Anterior Fontanel 7 #ulging9 tense Absence of normal pulsations o +ead Circumference 7 OFC ; <cms/month first 3 months o +eadaches 7 ,eneralized or Localized) Pain increases 'ith valsalva maneuver o Altered $ental &tatus 7 9rrita2le-Fatigued o Vomiting 7 $ay or may not 2e nauseous 7may occur after rising in the morning o Altered %ital &igns 7 Bradycardia 7late sign o Altered %ision 7 6iplopia" setting sun sign" restricted fields" papilledema o Pupillary Changes 1 normalsluggishfi'ed and dilated !=#lo/n>" o Altered L C- parents 'ill say this my child" they are not themselves o +igh Pitched Cry Strategies for the %ursing Care of the Child /ith Increased ICP o 5arly recognition and treatment of increased 9CP 5sta2lish a neurological 2aseline $onitor vital signs fre*uently o #ecognition of +ypercapnia and +ypo=ia 1 6aintain patent air/ay? 6ay need to suction and hyper entilate o $aintenance of normothermia or temperature regulation 7 $aintain temp 2et'een -;)1 C and -? C (Q.). F-0JJF! 9ncreased temp causes L needs) Fever causes vasodilation 'hich CBF o $aintain optimal head and nec( position Prevent nec( fle=ion or e=tension) 5levate + B -JR- Promotes venous drainage and prevents in CBF %ursing Care of the Child /ith a #rain $umor o Brain tumors 7 $ost common solid tumor of childhood 7 o Clinical $anifestations-<a2le -;-8 p 08?Q 6irectly related to anatomic location 9n infants 'hose sutures are still open" no symptoms may 2e detected early 7 :hen o2struction to C&F occurs then FC 'ill increase $ost common symptoms @eadacheA #rain is insensiti e to painB compression of /alls of arteries and eins9 and cranial ner es can produce headachesB often continuous9 but /orse in A6 /ith rising? Straining or mo ement may increase pain? VomitingA Csually not preceded by nausea - 9ncreased 9CP compresses 2rainstem 'hich directly stimulates the vomiting center in the medulla

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6iagnostic 5valuation $)#)9) C< &can Cere2ral Angiography 5lectroencephalogram L)P) Biopsy <herapeutic $anagement &urgery &terotatic 7 9nvolves use of $#9 and C< &can) #econstructs the tumor in - dimensions) Lasers are used) Brain scanning clearly delineates area of 2rain to 2e avoided #adiotherapy 7 >sed to shrin( tumor Chemotherapy 7 Controversial 7 >sed in com2ination 'ith surgery and radiation :hat are the conse*uences of these treatments on childrenB #adiation &omnolence &yndrome 7 $ay develop 1-? 'ee(s after CN& irradiation 7 Last 8-01days) $ay indicate long term CN& se*uelae Nursing Considerations Assess for &igns and &ymptoms 7 5sta2lish a 2aseline Child and Family Preparation Prevent Post- perative Complications Assessment Positioning Fluid #egulation Pain Control &upport Family Promote #eturn to ptimum Functioning

6yelodysplasia !A7A Spina #ifida or %eural $ube Defects !%$Ds"" o <ypes of $yelodysplasia Anencephaly 7 A2sence of 2rain tissue a2ove rudimentary 2rainstem &ncephalocele 7 5=ternal mass or sac that may occur at any place a2ove the s(ull) $ay 2e covered 'ith scalp or transparent mem2rane Spina #ifida Cystica 6yelomeningocele 7 Contains meninges" spinal fluid" and neural tissue) &pinal nerve roots may end at the sac) &ensory and motor function 'ill end at this point 6eningocele 7 Contains meninges and C&F Spina #ifida Occulta

Pathophysiology 6egree of functional impairment depends on the level and the e=tent of the defect) Neurological findings correlate 'ith the particular muscle groups involved) 6ysfunction can range from incompati2ility 'ith life or total paralysis to minimal involvement

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rthopedic Pro2lems associated 'ith N<6s Clu2 Feet (<alipes 5*uinovarus!" Contractures" dislocated hips and scoliosis are very common in children 'ith a N<6 in the lum2rosacral region Bo'el and Bladder dysfunction are almost al'ays apparent) <he nerves that supply these organs are located in the sacral region

6itrofanoff Procedure o Appendi= is used to provide an alternative route for intermittent catheterization) <he appendi= is removed from the colon and used to create a contnent conduit 2et'een the a2dominal 'all and 2ladder o 9f the Appendi= 'ont 'or( 7 A $onti tu2e- part of the intestine" ileum or colon is used to create the conduit

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<herapeutic $anagement &urgery 7 Close the &ac Nursing 6iagnoses #is( for 9nfection <rauma 9mpaired &(in 9ntegrity 9nAury #elated to 5=posure to Late= Products #elated to neuromuscular 9mpairment Chronic Pro2lems 5ncountered 2y Children 'ith N<6s Four Prognostic Factors <he degree of neural involvement &ize and location of the sac Presence of other anomalies Complications that occur

@ydrocephalus o Communicating vs) Non-Communicating Communicating 7 9mpaired a2sorption of C&F 'ithin the &u2arachnoid &pace Non-Communicating 7 2struction to the flo' of C&F through the ventricular system >sually caused 2y a developmental malformation 6efect is usually apparent at 2irth o &igns and &ymptoms of +ydrocephalus +ead gro's at a2normal rate Bulging anterior fontanel &etting-&un &ign 7 5yes rotated do'n'ard 'ith the sclera visi2le a2ove the iris Poor feeding 9rrita2le 'ith increasing lethargy Changes in L C pisthotonos ( ften 5=treme! Lo'er 5=tremity &pasticity

<reatment Placement of %entriculoperitoneal (%P! &hunt #arely 7 Placement of %entriculoatrial (%A! &hunt Complications of &hunt Placement $alfunction 7 &igns and &ymptomsBBB 9nfection

$aAor Nursing 6iagnoses for the Child 'ith +ydrocephalus +igh #is( For4 9nAury related to increased 9CP 9nfection related to presence of mechanical drainage system and surgical procedure 9mpaired s(in integrity related to pressure areas" paralysis" rela=ed anal sphincter Altered Family Processes related to situational crisis (child 'ith a physical defect!

Intracranial Infections 6eningitis o Children - Also seasonal) $ost often seen in children under the age of 1 years) Pea( incidence 2et'een ;-0/ months of age) $ost common organisms are4 +aemophilus 9nfluenzae <ype B"Neisseria $eningiditis ($eningococcal! and &treptococcus pneumoniae (Pneumoccocal!) $enigococcal and Pneumococcal are the most commonly seen versions of the disease seen in children 2et'een / months and 0/ years o Neonatal $eningitis 7 ,roup B &treptococci" 5) Coli" and Listeria $onocytogenes o Clinical $anifestations 7 6epend on the age of the Child Neonates 7 %ery difficult to diagnose in this age group) &ymptoms may 2e vague) $ay 2egin to refuse feedings" have poor suc(ing a2ility" vomiting and diarrhea) $ay not have 2ulging fontanel until late in course of disease Nec( is usually supple 6isease 'ill progress if untreated and 'ill cause cardiovascular collapse" seizures and apnea 9nfants and Eoung Children Classic picture is rarely seen in children 2et'een the ages of - months and / years-of-age Fever" poor feeding vomiting" mar(ed irrita2ility" restlessness" and seizures" Bulging fontanel is the most significant finding

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Nuchal rigidity and I Brudzins(i and Hernig signs occur late in the young child I Brudzins(i 7 Fle= head 7 Pain or involuntary fle=ing of (nees is a2normal I Hernig 7 Child lies supine 7 Leg fle=ed at hips 7 resistance or pain upon e=tension is a2normal lder Child and Adolescent 9llness a2rupt 'ith fever" chills" headache and vomiting that are associated 'ith or follo'ed 2y changes in the sensorium) $ay have seizure 2e e=tremely irrita2le and agitated) have photopho2ia have nuchal rigidity 7 resistance to fle=ion of the nec( 5=hi2it pisthotonis (5=treme vere=tension! +ave I Brudzins(i and Hernigs sign +yperactive refle=es &igns of cardiovascular collapse Petechiae or Purpura if infected 'ith meningococcal organism 7 'hyB Complications 2structive hydrocephalus &u2dural 5ffusions <hrom2osis in meningeal veins or venous sinuses Brain a2cesses 6eafness" Blindness and Paralysis :aterhouse-Friderichesen &yndrome ver'helming &eptic &hoc( 69C $assive 2ilateral adrenal hemorrhage Purpura &yndrome of 9nappropriate Antidiuretic &yndrome (&9A6+! 7 ccurs in QJK of children 'ith 2acterial meningitis 7 Also have decreased NaI" Cl- and smolality Levels :hat complication 'as left outB &eizures 7 Caused 2y irritation and destructive changes in the cere2ral corte= and hyponatremia as a result of &yndrome of 9nappropriate Antidiuretic +ormone (&9A6+! &eizures - :ithin first - days does not interfere 'ith prognosis 6iagnostic 5valuation L)P) is the 6efinitive <est &amples are o2tained for4 Culture and ,ram &tain Blood Cell Count Protein ,lucose 7 relationship 2et'een &erum glucose and C&F ,lucose is important) &erum ,lucose is dra'n S hour 2efore L)P) Pressure is measured Blood" Nasal and <hroat Cultures may 2e +elpful <herapeutic $anagement 9solation Precautions 7 #espiratoryG6roplet for first /8 hours 9nitiation of Antimicro2rial <herapy $aintenance of 4 +ydration 7 may do fluid restriction if &9A6+ occurs %entilation

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#eduction of 9ncreased 9CP $anagement of Bacterial &hoc( Control of &eizures Control of 5=tremes of <emperature Correction of Anemia <reatment of Complication Preventive $easures 7 Prompt treatment for >#9s" titis $edia" etc) 9mmunization 'ith +i2 %accine Prophylactic treatment for family and vulnera2le population Anyone e=posed to an individual 'ith Neisseria $enigitidis ($eningococcal $eningitis! should 2e given prophyla=is Anyone @ 8? months 'ho has not 2een fully immunized against +aemophilus 9nfluenzae <ype B or is immunocompromised or lives 'ith these children and has 2een e=posed" should 2e treated prophylactically Nursing 6iagnoses +igh ris( for inAury related to presence of infection Pain related to inflammatory process Altered family processes related to a child 'ith a serious illness

SeiDures and &pilepsy 1 Idiopathic s AcEuired o Partial (FocalGLocal! &eizures 7 Bo= -.-0J pg 018; &imple Partial Comple= Partial o ,eneralized &eizures 7 Bo= -.-0J pg 018;-018. A2sence $yoclonic <onic <onic-Clonic Atonic

SeiDure $erminology o SeiDure 7 &udden" involuntary" time-limited alteration in function) A2normal discharge of cortical neurons o &pilepsy 7 Chronic condition o Ictal State 7 6uring &eizure o Post1ictal State 7 Period follo'ing the seizure o Status &pilepticus 7 &eizure that lasts T -J minutes or series of seizures that do not allo' the child to regain consciousness in 2et'een each seizure o 9nfantile &pasms 7 AHA infantile $yoclonus $ost commonly occur 'ithin first ;-? months of life <'ice as common in 2oys than girls Numerous seizures during the day 'ithout postictal dro'siness Poor outloo( for normal intelligence Clinical $anifestations Possi2le series of sudden" 2rief" symmetric" muscular contractions +ead fle=ed" arms e=tended" and legs dra'n up 5yes sometimes rolling up'ard or in'ard) $ay 2e preceded or follo'ed 2y a cry or giggling $ay or may not include loss of consciousness

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&ometimes flushing" pallor or cyanosis Fe2rile &eizures 9ncidence 7 Appro= -K of all children 2et'een ages ; months-- years) Boys /40 ratio) 9ncreased incidence in families and children 'ho attend day care &eizures occur during the temperature spi(e <reatment for Fe2rile &eizures <ylenol and 92uprofen Protect Air'ay Protect from 9nAury Prophylactic 7 Antiepileptic Children 'ith focal or prolonged seizure Child 'ith primary relative 'ho has had fe2rile seizures Children @ 0 year7of-age Children 'ith multiple incidents :ont use Pheno2ar2 as prophylactic 7 9neffective and can lo'er 9M Anticonvulsant $edications &ide 5ffects <herapeutic Level Com2ination 6rug <herapy &tatus 5pilepticus - <reatment Alternative $easures of &eizure Control Hetogenic diet 7 +igh Fat" Lo' Car2ohydrate and Protein 6iet 7 Forces 2ody to shift from using glucose to fat as energy source) <he patient develops a state of (etosis) <his diet is deficient in vitamins and minerals- so supplements should 2e given %agus Nerve &timulator 9mplanta2le device decreases seizures in individuals 'ho have not responded to drug therapy 7 >sually implanted in individuals 0/ years or older) &ends stimulus to the Left %agus Nerve 7 Cranial Nerve U- Caregiver activates stimulator 'ith magnet at the onset of a seizure) #esearch sho's that only 0G- of pts have a 1JK or greater reduction in seizures after 0 year of therapy &urgical <reatment for 5pilepsy :hen seizures are caused 2y a hematoma" tumor or other cere2ral lesion" surgical removal is the treatment) 9f a childs seizures are nonresponsive to drug therapy" surgery may 2e done to remove the focal area of the seizure activity +emispherectomy is used to treat a patient 'ho has severe epilepsy and hemiparesis or nonfunctional hand use Nursing 6iagnoses #is( of 9nAury <ype of &eizure <o hypo=ia and aspiration 7 9mpaired Consciousness and Automatisms Altered Family processes related to having a child 'ith a chronic illness

@eadaches o Muestions for 5valuating headaches 7 Bo= -.-0- pg 01;/ o $igraine +eadaches 7 $ost common cause of recurrent headaches Autosomal dominant 7 ften proceeded 2y aura and accompanied 2y NG% o <ension +eadaches

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Current <reatment for +eadaches 9f trigger identified avoid trigger Biofeed2ac( and rela=ation techni*ues <ylenol and N&A96s 7 First Line of <reatment and then progress as needed to stronger medications Cyprheptadine 7 Periactin (Antihistamine! Propanolol AmitriptylineGNortriptyline Case &tudies4 Alterations in neurological function in 9nfants" Children and Adolescents o Case V 0 o Lauren age - days 'as 2orn 'ith a N<6 ($yelomeningocele! in the lum2rosacral region) &he 'as immediately transferred to the N9C> at a maAor Pediatric +ospital) Lauren is scheduled for surgical repair of her N<6 tomorro') +er parents visit daily and are eager to participate in her care 0):hat assessments 'ould 2e made 2y the nurses in the N9C>B /):hat nursing actions are ta(en pre and postoperatively to prevent infectionB -)+o' can the nurses involve Laurens parents in her care duringhospitalizationB o &everal days after surgery" it is noted 2y a very astute student nurse that Laurens head circumference has 2een increasing) Lauren is irrita2le and her anterior fontanel is tense and 2ulging) o 0):hat is the pro2a2le diagnosis for Lauren at this timeB o /):hat surgical procedure 'ill li(ely 2e performed as soon as possi2leB o -)+o' should Lauren 2e positioned after this procedureB o 8):hat should Laurens neurological assessment includeB o 1):hat should Laurens parents 2e taught a2out shunt complicationsB Case V / o 6uring a clinical day a student nurse 'al(s into his patients room and notes that the patients right arm is NAer(ing)O :hen the student calls the five year-olds name there is no response) o 0):hat is the first thing the student should doB o /):hat assessment data is important to o2tain at this timeB o -):hat should the nurses do to assure this patients safetyB o 8):hat medication if any" should the nurse have ready at the 2edsideB &usie is a 01year-old 'ho developed a headache at school today) <he headache is 2ilateral over the temporal area) &usie denies photopho2ia and there has 2een no vomiting) &he 'as entirely 'ell prior to this afternoon and has no previous history of headaches) o &usie descri2es the pain as a Ndull ache)O &he admits to a heavy after-school sports and activity schedule) &usies entire physical e=am including the neurological e=am is normal e=cept for a dull" aching 2ifrontal headache and muscle tightness in her shoulders) &he has a nonto=ic appearance and is afe2rile) Blood pressure is 0JJG./ o 0):hat type of *uestions should the admitting nurse as( &usie or her motherB o /):hat type of headache is &usie most li(ely e=periencingB o Critical <hin(ing 5=ercise o - year old 5mma had a craniotomy 1 days ago to remove a posterio fossa tumor) An 5=ternal 6rain 6evice (5%6! 'as placed in order to treat her hydrocephalus) 5mma continues to demonstrate signs of 9CP" including holding the 2ac( of her head" anore=ia" crying 'hen moved or 'hen strangers enter the room and intermittent lethargy o n e=amination" fluid drainage is noted on 5mmas moms 2louse and 5mma is e=periencing repetitive" rapid eye2lin(ing) 9s there sufficient evidence to dra' conclusions a2out 5mmas 2ehavior" physical assessment findings and 9CPB :hat priorities for nursing care should 2e esta2lishedB

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