Lesson 5  But if children have complex seizures, neurologic

FEBRILE SEIZURE deficits, or signs of a serious underlying disorder

 are seizures that happen in children (e.g, meningitis, metabolic disorders), testing
should be done
 is associated with high fever but with an absence
of intracranial infection, metabolic conditions, or
Tests to exclude other disorders are determined
previous history of afebrile seizures.
clinically:
CLINICAL PRESENTATION
CSF analysis
 Common cause of seizure in children
 rule out meningitis and encephalitis if < 6 mos.
 6 months to 6 years (mostly occur at age 6 to 36
 have meningeal signs or signs of CNS depression,
mos.)
or have seizures after several days of febrile
 Higher risk in the first 3 years of life
illness analysis if children are not fully immunized
 Febrile seizure maybe simple or complex
or are taking antibiotics
 Most febrile seizure are simple
TREATMENT
TYPE OF FEBRILE SEIZURE
1. Simple Febrile Seizure  Antipyretic therapy
2. Complex Febrile Seizure  Supportive therapy if seizures last < 15 min
 Anticonvulsants and sometimes intubation if
1) SIMPLE FEBRILE SEIZURE seizures last ≥ 15 min
 Most common type (90% of cases)
 last <15 minutes PROGNOSIS
 Occur once with in 24h of the illness  Overall recurrence rate of febrile seizures is about
 Generalized in nature (affect both hands and 35%.
legs, with stiffening and jerking with loss of  Risk of recurrence is higher if children are <1yr
consciousness) when the initial seizure occurs.
 Tonic - Clonic seizures  Increased risk with additional risk factors
 Risk of having epilepsy is low about 1 to 3% (e.g, complex febrile seizures, family history of
seizures, developmental delay)
2) COMPLEX FEBRILE SEIZURE  Simple febrile seizures are not thought to cause
 Occur during initial rapid rise of body neurologic abnormalities.
temperature
 Most develop within 24h of fever onset
 Stiffness, jerking, loss of consciousness
 Urine incontinence
 Sleepiness and drowsiness

FEBRILE SEIZURE AND EPILEPSY

FEBRILE SEIZURE - seizure that occur in the setting
of febrile illness

EPILEPSY - seizures that occur repeatedly over time

without an acute illness or an acute brain injury.

FACTORS:

Infection;
Bacterial and Viral

Genetics
↓ Vaccination;
and Mumps
Familial
Factors ↓
FEBRILE
SEIZURE
100%
↓ Measles
Rubella

DIAGNOSTIC TEST
 Seizures are diagnosed as febrile after exclusion
of other causes.
 A fever may trigger seizures in children with
previous afebrile seizures; such events are not
termed febrile seizures because these children
have already shown a tendency to have seizures.
 Routine testing is not required for simple febrile
seizures other than to look for the source of the Lesson 5
fever
CEREBRAL PALSY
  fail to demonstrate a parachute reflex assume a
 nonprogressive syndromes “scissors gait” because tight adductor thigh
 impaired voluntary movement or posture muscles cause legs to cross when held upright.
 prenatal developmental malformations or perinatal  severe involvement that may lead to subluxated
or postnatal CNS damage hip.
 a brain disease causing paralysis
Spastic involvement may affect both extremities on:
 one side (hemiplegia)
 all four extremities (quadriplegia)
ETIOLOGY
 primarily the lower extremities (diplegia or
PREMATURITY
paraplegia)
o in utero disorders, neonatal encephalopathy,
and kernicterus

PERINATAL FACTORS
o perinatal asphyxia, stroke, CNS infections

DYSKINETIC OR ATHETOID TYPE

 abnormal involuntary movement.
 early in life, the child appears limp and flaccid.
 later, in place of voluntary movement, children
make slow writhing motions.
 can involve all four extremities, plus the face,
neck, and tongue.
 child drools and speech is difficult to understand.
 under emotional stress, the involuntary
movements may become irregular and jerking
(choreoid) with disordered muscle tone
(dyskinetic).

ATAXIC TYPE
 awkward, wide base gait.
 they are unable to perform fine coordinated
SPASTIC TYPE motion
 the finger to nose test or rapid repetitive
movements (test of cerebellar function)

MIXED TYPE
 Some children show symptoms of both
spasticity and athetoid or ataxic and athetoid
movements.
 This combination obviously results in a severe
degree of physical impairment.

STATISTICS AND INCIDENCE

 Brain damage
 Interference with oxygen supply
 excessive tone in the voluntary muscle hypertonic
muscles, abnormal clonus, exaggeration of deep  Maternal infection
tendon reflexes, abnormal reflexes  Nutritional deficiencies
 continuation of neonatal reflexes  Kernicterus
  Teratogenic factors  Etiology is often multifactorial and sometimes
 Prematurity unclear but involves prenatal and perinatal factors
that are associated with CNS malformation or
CLINICAL MANIFESTATIONS damage (genetic and in utero disorders,
 Developmental delay prematurity, kernicterus, perinatal asphyxia,
 Abnormal muscle tone stroke, CNS infections).
 Hand preference  Syndromes manifest before age 2 yrs; later onset
 Problems in crawling of similar symptoms suggests another neurologic
 Growth disturbance disorder.
 Increased reflexes  Do cranial MRI and, if needed, testing for
 Problems in reflexes hereditary metabolic and neurologic disorders.
 Treatment depends on the nature and degree of
ASSESSMENT AND DIAGNOSTIC FINDINGS disability, but physical therapy and occupational
o Cranial ultrasonography therapy are typically used; some children benefit
o Magnetic Resonance Imaging of the brain from bracing, botulinum toxin, benzodiazepines,
other muscle relaxants, intrathecal baclofen,
and/or surgery (muscle-tendon release or transfer,
MEDICAL MANAGEMENT
rarely dorsal rhizotomy).
o Physical therapy
o Orthopedic management (Braces)
o Orthopedic surgery
o Technological aids

PHARMACOLOGIC THERAPY
 Botulinum toxin with or without casting
 Phenol therapy
 Antiparkinsonian, anticonvulsant,
antidopaminergic, and antidepressant agents
(anticholinergic and dopaminergic drugs)
and anti-spasticity agents (baclofen) have
primarily been used in the management

NURSING MANAGEMENT
 Interview history.
 Neurologic examination.

NURSING DIAGNOSIS
 Risk for Injury related to spasms, uncontrolled
movements, and seizures.
 Impaired Physical Mobility related to spasms and
muscle weakness.
 Changes in growth and development related to
neuromuscular disorders.
 Impaired verbal communication related to
difficulty in articulation.
 Risk for aspiration related to neuromuscular
disorders.
 Disturbed thought processes related to cerebral
injury, learning disabilities.
 Self-care deficit related to muscle spasms,
increased activity, cognitive changes.

KEY POINTS
 Cerebral palsy is a syndrome (not a specific
disorder) that involves non-progressive spasticity,
ataxia, and/or involuntary movements.
Otitis Media
The negative pressure pulls fluid and microorganisms
into the middle ear through the eustachian tube
resulting in otitis media with effusion. The illness
usually follows a URI or cold. The older child runs a
fever, is irritable, and complains of a severe earache, Etiology
while a neonate may be afebrile and appear lethargic. 1. Viral Pathogens
The child may or may not have a purulent discharge RSV - respiratory syncytial virus
from the affected ear. Usually develops after colds, sore throat, or sinus
(left discharge) 2. Bacterial Pathogens
Streptococcus
 pneumoniae
 Is a bacterial or viral infection of middle ear  Haimophilus influenzae
 Ages 3 mos. To 3 tears. Old  Streptococcus pyrogens
 Usually develop after cold, sore throat, sinus
infection Risk factors
Connected to respi system Exposure to environmental risk factors is another
One of the most common illnesses affecting babies important aspect of the history and includes the
and young children. about 1 out of 10 children gets a following:
middle ear infection in the 1st 3 months of life ,  Passive (ie, secondhand) exposure to tobacco
Eustachian tube is structurally and functionally smoke
immature.  Group daycare attendance
During infant bath cover ears with thumb and other  Seasonality – ADM prevalence is much higher in
finger to prevent this kind infection. winter and early spring than in summer and early
fall
 Supine bottle feeding (ie, bottle propping)
 10% - approximately 10% of children have an
episode of acute otitis media by three months of Bottle feeding
age Exposure to cigarette smoke
 3 out of 4 – more than 3 out of 4 kids have had at Day care attendance
least one ear infection by the time they reach 3 A strong family history of otitis media
years of age.
Complications
The eustachian tube works as a release valve to In era of modern medicine
equalize pressure between the middle ear and the Serious complications don’t often occur from single ear
outside world. infection, yet there are instances when they can
Behind the ear drum is the middle ear space. There is serious.
a small amount fluid in this space that drains through It’s rare, but ear infections can spread beyond the ear
the eustachian tube, which runs from the middle to the space into the brain, causing meningitis or intracranial
back of the throat. The eustachian tube works as a abscess.
release valve to equalize pressure between the middle In other cases, fluid can remain in the inner ear even
ear and the outside world. after the infection clears.
Auditory canal. Ossicles are bones that vibrate. This trapped fluid with will restrict movement of the
The hammer states eardrum, affecting hearing.
In young children, this is also can lead to speech
delays
Sometimes they spread locally, resulting in acute
mastoiditis.

Signs and Symptoms

 Earache – usual initial symptoms - otalgia
 Frequently shaking his/her head
 Fever
 Hearing loss
 Irritability, difficulty sleeping
 Intense crying
 Loss of appetite or vomiting

In respiratory infections, the eustachian tube can swell,

shut so it doesn’t open and close the way it’s
supposed to.
Fluid doesn’t drain and pressure doesn’t release.
The stagnant atmosphere is perfect for viruses or
bacteria to reproduce and grow leading to infection.
Another factor in contributing to ear infection is a
child’s anatomy. In children, the eustachian tube is
horizontal. In adults, it’s angled more vertically. If the
tube is horizontal, it’s harder for fluid to drain. Often,
the child will grow out of the ear infections as his or her
anatomy changes.
 5. Anxiety related to surgical procedure, diagnosis,
prognosis, anesthesia, pain, loss of function, the
possibility of a greater hearing loss after surgery.
6. Social isolation related to pain, foul-smelling
otorrhea.
7. Knowledge Deficit regarding treatment, and
prevention of relapse of the disease process.

Key Points
 Give analgesics to all patients
 Antihistamines and decongestants are not
recommended for children; oral or nasal
decongestants may help adults, but antihistamines
The eustachian tube may malfunction. Example, when are reserved for adults with an allergic etiology.
someone has a cold or an allergy affecting the nasal
 Antibiotics should be used selectively based on the
passages, the eustachian tube may become blocked
age of the patient, severity of illness, and
by congestion in it’s lining or by mucus with in the
availability of
tube. This blockage will allow fluid to build up with in
follow-up
the normally air filled middle ear.
1. Ear infection or acute otitis media is an infection of
Diagnosis
the middle ear.
 Clinical evaluation: acute onset of pain, bulging of a. True
TM. Presence of signs of Middle ear effusion b. False
(Pneumatic otoscopy)
2. What is the purpose of the Eustachian tube?
Picture on the left shows a normal Tympanic A. To ventilate the middle ear
Membrane. Is pearly in color B. To maintain air pressure within
Picture on the right shows a red, dull TM that appears the ear
to be bulging secondary to C. drain infections
an effusion (fluids in the middle ear. This is a case of D. All of the above
Acute Otitis Media 3. ______________ is a risk factor for ear infections in
infants.
Treatment A. Diarrhea
 OM treatment varies widely, depending on the B. Bottle feeding
duration of symptoms, past therapeutic failures, C. Premature birth
and severity of current symptoms. D. Being first born
 Oral analgesics – acetamenophen or ibuprofen
 Antibiotics – amoxicillin Identify from the situation given below which baby is at
Commonly resolve spontaneously, antibiotic not risk for ear infections.
recommended A. Baby A is on bottle feeding
Decongestant are given to open the Eustachian B. Baby B is on breastfeeding
tube and air to be admitted to the middle ear
Given for 2 days only – given longer have rebound 4. Ear infections are highly contagious.
effect causing edema, and subsequent increase in a. True
mucous membrane inflammation b. False

Prevention 5. Middle ear infections are caused by bacteria and

 Routine childhood vaccination against viruses.
pneumococci, H influenzae type B, and influenza a. True
decreases the incidence of AOM b. False
 Infants should not sleep with bottle
 Elimination of household smoking 6. Untreated ear infections can lead to complications
such as
meningitis.
Nursing Care Plan a. True
Nursing Diagnosis for Acute Otitis Media and Chronic b. False
Otitis Media
1. Acute Pain / Chronic Pain related to the
inflammatory process.
2. Impaired verbal communication related to the effects
of hearing loss.
3. Disturbed Sensory perception: hearing related to
obstruction, infection of the middle ear or auditory
nerve damage.
4. Risk for injury related to hearing loss, decreased
visual acuity.