Child with

neurological
disorder
Seizure
 Disturbance in normal brain fxn resulting
from abnormal electrical discharge in
the brain,
 which can cause unconsciousness,
uncontrolled body movement,
changes in behavior & sensation, &
changes in autonomic system
 Classified as partial or generalized, or
unclassified
 Major seizure happen on the first yr of
life
epilepsy

 A condition that is characterized by

recurrent 2 or > unprovoked seizure in a
day

 Seizure are symptoms of underlying dse

process
 Brain injury, familial tendency
 Most: unknown
Etiology:
 Unknown
 Head trauma
 Meningitis
 Hypoxia
 Stroke
 Static
encephalopathy
 MR
 Cerebral palsy
Patho Spontaneous electrical discharge
By hyperexcitable cells
: Referred as epileptogenic focus

 Data is
•Brain stem Limited to incomplete &
(midbrain & inadequate
cerebral cortex  neonatal
reticular formation)
centrencephalic

generalized partial unclassified

Epileptic potential
Assessment:

Obtain info from parents about:

 Time of onset,
 Precipitating events,
 Behavior before & after seizure
Dx exam:

 EEG (Electorencephalogram)
=*** most useful tool
=***confirms (+) of abnormal electrical
discharge & provides information on the
seizure type & the focus
categories
 Partial  Generalized
 Simple  Infantile spasm
 complex  Absence seizures
 Tonic-clonic seizure
 Myoclonic seizure
 Atonic seizure
Seizure classification

a. Generalized seizure
1. Tonic –clonic (grand mal)= consist
of tonic s/sx– rigidity, extension of
extremities, fixed jaw, respiratory
cessation, & dilated pupils
clonic s/sx– rhythmic jerking of
extremities, incontinence
2. Tonic seizure– stiffness of the body
3. Clonic seizure– clonic muscle activity
4. Atonic seizure (drop attack)– sudden
loss of muscle tone followed by postictal
confusion (head)
5. Myoclonic seizure- sudden, brief,
massive jerky movement ; may or may
not lose consciousness
6. Absence (petite mal)– blank facial
expression, <30 sec, girls
 b. Partial seizure
1. Simple partial seizure– (+)consciousness.
**10-20 secs
Numbness, tingling, paresthesia, pain
(+) tonic clonic movement in face, neck,
extremities
2. Complex (psychomotor or temporal
lobe) seizure– begin as simple &
progress to unconsciousness.
** Child stop whatever she’s doing & engage
in purposeless movt. (lip smacking or
wandering), or
** may continue doing but in an inappropriate
manner
Automatism and purposeful movement=
most common
c. Status epilepticus

 Involve recurrent or continuous,

generalized seizure activity with the
danger of cardiac arrest
Febrile seizure

 Most common type of seizure seen in

childhood
 <5yo (18-24 mos)
 Boys
 >39 degrees celsius
 Associated with fever or viral infection
 Simple FS last 15 mins once /day
Nursing mgt

 Stops when given medical tx

 Determine the cause
 Rectal Diazepam (as ordered)
 Support & education to family
 Control fever
d. Infantile spasm

 Refers to rare d/o seen in the first few

months of life that is characterized by
signs such as brief flexion of neck, trunk,
or legs
 Simple complex absence

Age Any age 3yo older 3yo older

Frequency/day Variable Rare 1-2x multiple

Duration <30sec >60 sec <10 sec

Aura May be sole Frequent Never
manifestation of
seizure
Impaired Never Always Always, brief
consciousness conscious
Automatism No Frequent Frequent

Clonic movt Frequent Occasional Occasional

Postical Rare Frequent Never

impairment
disorientation rare Common Unusual
Therapeutic mgt:

 Goal: control seizure & reduce

frequency & severity
4 tx for epilepsy:
1. Drug therapy
2. Ketogenic diet
3. Vagus nerve stimulation
4. Epilepsy sx
1. Drug therapy
 Maintain low neuronal excitability
 Antiepileptic drug; combination
 Begin in single drug w/lowest toxicity
 Gradual increase
 Maintain therapeutic dose
 Safe to d/c drug 2yrs seizure free
 Recurrence after 6 mos d/c
 Tapering= x to increase severity of
seizure
 Common anti-epileptic
1. meds:
Phenytoin = tonic-clonic, partial, slow IV w/
normal saline for flushing, x w/ milk
2. fosphenytoin-= may be given IM, can be
mixed w/ glucose or normal saline
3. Phenobarbital & phenytoin = receive Vit D &
folic acid
4. Carbamazepine
5. Valpoic acid= liver toxicity <2yo
Decrease bone mineral density
2. Ketogenic diet

 To control seizure
 High fat, low carbs & low protein
 Develop state of ketosis
 Vit & mineral supplements
 SE: constipation, wt loss, lethargy kidney
stone
 Increase blood lipids- long term
3. Vagus nerve stimulation

 Performed by implanting a special

device, which will reduce seizure in
children who do not achieve adequate
control with medications.
 12yo & older, chest, SC
 Left vagus nerve (CN X)
 Activate device during onset of seizure
4. Surgical therapy:

 When caused by hematoma, tumor,

cerebral lesion, --- sx removal is the tx.

Refractory seizure– persistent seizure

despite of trials of 3 antiepileptic meds or
combination
1. hemispherectomy- to remove all or
most of 1 hemisphere( severe epilepsy)
2. Corpuscallosotomy- separation of the
connection between 2 hemisphere of
brain (generalized )
3. Multiple subpial transection – fiber of
motor cortex are divided to reduce
seizure
SEIZURE PRECAUTIONS:

 Raised side rails- sleeping or resting

 (+)pads
 Wear medical identification
 Instruct precautions to take during
potentially hazardous activity
 Swim- w/ companion
 Helmet & padding
Emergency tx for seizure:
 Airway-patent
 Time the episode
 If sitting- ease child down on floor
placing side lying
 + pillow/folded blanket on head/hand/lap
 Loosen restrictive clothing
 Remove eyeglasses
 Clear area
 Allow to proceed & end w/o interference
 If +vomit,= side lying
 X restrain, x give food or place anything
in mouth
 Meds
 Remain until fully recovers
 document
Nrsg mgt:

 Administer prescribed meds- rectal

meds;until 2 yrs seizure free
 Help prevent seizure
 Stay w/ child during attack & provide
reassurance
 Known trigger factor
 Behavior, AURA
 Time began & ended
Cerebral palsy (CP)
 d/o characterized by impaired movement
& posture caused by non progressive
abnormal brain function
 Most common cause: brain anoxia
 Most common movement d/o of childhood
 Most common clinical type: spastic CP
 More apparent as the child grows older
Patho:
Damage to the motor
area of the brain

Inability to control the

movement and posture
Etio:

 Prenatal brain abnormalities

 Brain anoxia
 Prematurity
 Twin births
 Asphyxia, ischemia, perinatal trauma,
infection, metabolic problems
 unknown
types Description
Spastic Hyper tonicity & permanent
contractures

Athetoid/ Abnormal involuntary

dyskenetic movement

Ataxia Affects balance & depth

perception

mixed Combination of the above

Classification:

 SPASTIC CP- Involve 1 or both side of

body
 Clinical hallmark: HYPERTONICITY with
poor control of posture, balance &
coordinated movt
 Lead to overflow movt in other parts of
the body
Common types of spastic
CP:
1. Hemiparesis- 1 side of the body is
affected
2. Quadriparesis (tetraparesis) –all 4
extremities are affected
3. Diplegia- similar body parts are
affected, (both arms)
Dyskinetic/athetiod

 Involuntary movt that disappear during

sleep & increase w/ stress
 Athetosis- wormlike movt, dysarthia,
drooling
 Choreoid (irregular, jerky)
 Dystonic movt (disordered muscle tone)=
esp. when stressed & adolescence
ataxia

 Wide based-gait, rapid repetitive movt,

 Disintegration of movt of upper
extremities when child reaches for object
 rare
Mixed/ dystonic

 Combination char by spastic & athetoid

CP
 30-50% of px w/ CP are mentally
retarded
Assessment
 Extreme irritability & crying
 Feeding difficulties
 Stiff & rigid arms or legs leg crossed
position= scissoring
 Delay gross devp
 Abnormal motor performance
 Alteration of muscle tone
 Opisthotonus
 + primitive reflexes= moro, tonic neck,
grasp
Nursing Intervention:
 Early recognition--- intervention
 Multidisciplinary team approach
 Therapeutic management- physical, OT,
Speech therapy, education & recreation
 Assess level of intelligence
 Mobilizing device- reduce deformity
 Encourage communication level on his
devp age rather than chronological age
 Injection Meds:sx procedure
** botulinum toxin type A (botox)
- to reduce contracture deformity &
spasticity; onset of axn (24-48hrs)
 Datrolene Na (Dantrium), baclofen &
valium
- Little effectiveness in improving
coordination but decrease overall
spasticity
- Baclofen Pump
 Safe environment
 Appropriate toys
 Upright after meals
 Meds- spasticity
 Sxcal intervention – respond to more
conservative measure for child whose
spasticity causes deformity
hydrocephalus

Water in brain
 Imbalance of CSF absorption or
production caused by malformation,
tumor, hemorrhage, infection or trauma
 Head enlargement & increase ICP
 CSF
volume:
child = 60-100ml
Types:
COMMUNICATING NONCOMMUNICATING
 Impaired absorption  Obstruction of CSF
w/in the subaracnoid flow w/in ventricular
space system
 Interference of CSF  obstructive
w/in ventricular
system does not
occur
 nonobstructive
path CSF formation

o Choroid plexus
Lateral ventricles

Foramen of Monro

Aqueduct of Sylvius

Foramen of Luschka

Foramen of Magendie
Into Cisterna magna

Cerebral &
Cerebral arachnoid

Impaired absorption, obstruction, absorbed

developmental malformation

Increase pressure & dilation of

proximal pathways
Assessment:

INFANT
 Increase head circumference
 Thin, widely separated bones of the head
that produces a cracked-pot sound
(macewen’s sign)
 Bulging fontanels=first sign
 Frontal bossing
 Sunsetting eyes
child

 Irritability & lethargy

 Headache on awakening
 N&V
 Ataxia
 Nystagmus
Late sign: a high shrill cry & seizure
activities
Dx:

 ultrasound= 14wks gestation

 Primary dx tool= CT scan & MRI
Therapeutic mgt:

1. Relief of ventricular pressure

2. Tx caused by ventriculomegaly
3. Tx associated w/ complication
4. Mgt of problems r/t to effect of d/o on
psychomotor devp.
 Meds:
**acetazolamide & isosorbide or
furosemide
= decrease production of CSF
Sx intervention:

 Prevent further CSF accumulation by

bypassing the blockage & draining the
fluid from the ventricles to a location
where it may be reabsorbed
 Provide drainage
VENTRICULOPERITO
NEAL SHUNT
 The CSF drains into
the peritoneal cavity
from the lateral
ventricle
 Most common
ATRIOVENTRICULAR
SHUNT
 CSF drains into the
right atrium of the
heart from the lateral
ventricle, bypassing
obstruction
 **used in older
children or w/
pathological
conditions of
abdomen
 X w/ cardiopulmo dse
 External ventricular drainage EVD= until
CSF is sterile
 Shunt malfunction: headache & lack of
appetite (earliest sign)
 Major complication: infection & malfxn

Most serious

 Subdural hematoma= rapid reduction of

ICP & size
 Comfort measure: meds, diuretics,
antibiotics, anticonvulsant
Intervention post op:
 VS, I&O
 Position on unoperated side = x pressure
on shunt on valves
 Keep flat= avoid rapid reduction of
intracranial fluid
 Observe ICP= if +, 10-15degrees head
 Monitor signs of infection & head
circumference
Neuroblastoma
 Embryonal tumor found in children that
arises from the neural crest (adrenal
medulla)
 Most common: extra cranial solid tumor
 “silent tumor”
 Males; 50% is <2yo
 Primary site: Abdomen (Tumor arises
from adrenal gland)
 Other site: neck, head, chest or pelvis
 Most presenting sign are caused by tumor
compressing adjacent normal tissue &
organs
 Dx evaluation: to locate primary site of
tumor
 Prognosis is poor= frequency of
invasiveness of tumor & most of cases
dx is not made until after metastasis
has occurred
 Tumor above the diaphragm have better
prognosis than with abdominal tumor

 Complication: nerve compression

Assessment:
 Firm, non tender mass
 Urinary frequency/retention from
compression
 Lymphadenopathy= cervical &
supraclavicular area
 Bone pain
 Pallor weakness, irritability, anorexia, wt
loss
 Neck/facial swelling
 Bruising/ edema above eyes
 Pallor/bruising
 Cough/difficulty of breathing
 wheeze
Assessment

 Asymmetry abdomen
 Bone pain
 Anorexia
 Vomiting
 Weight loss
 Respi impairement= thoracic lesion
 Neuro impairement= intracranial lesion
 Paralysis= compression of spinal cord
(emergency)
 Periorbital edema,Exopthalmos=
invasion in retrobulbar soft tissue
 Stages:
 Stage I=localized tumor confined in area of
origin (best survival rate)
 Stage II=unilateral tumor w/ incomplete gross
excision
 Stage III=tumor infiltrate in midline w/ regional
lymph node involvement
 Stage IV=metastasis to bone, bone marrow,
liver or other organs
 Stage IV-S=localized primary tumor Stage I &
II, in skin, liver, or bone marrow but x in bone
Dx exam:

 CT scan
 Bone scan
 Biopsies
 24 hour urine collection (+) homovanillic
acid (HVA) & vanillymandelic acid (VMA)
 Metaiodobenzylguanidine scan =
determine bone & tissue involvement
Therapeutic mgt:

 Chemo= DOC: vinscristine, doxorubicin,

cyclosphosphamide, cisplatin, teniposide,
carboplatin= combination
 Radiotherapy=
 Sx
Therapeutic mgt:
 Sx= remove as much tumor as possible;
obtain biopsies; in stage I & II;=
complete sxcal removal is the TOC
 Sx= stage III & IV is limited bcoz of
extensive metastasis
 Radiation is common in stage III,
provide palliation in metastasis lesions
 Chemotheraphy= mainstay tx for
extensive local & disseminated dse
Radiation therapy:
 Destroy cancer cells w/ minimal
exposure to normal cells to the
managing effect of radiation = cell
dies & x divide
 Radiation beam
 Skin changes & irritation, alopecia &
fatigue
 Teletherapy & brachytherapy
teletherapy
 Beam radiation; external radiation to px
 X hazard
 Wash area w/ mild soap; then wash
thoroughly
 X remove markings
 X powder, lotion, cream if x prescribed
 Soft clothing
 X sun & heat exposure
 If + desquamation; warm water the pat
dry, antibiotic cream
Brachytherapy:
 Radiation source comes to direct,
continuous contact w/ tumor tissue for
specific time
 Radiation is w/in client; emit radiation;
hazard to others
UNSEALED SEALED
 Oral/IV  Solid implant win tumor
 Enter body fluids target tissue
 Eliminate excreta  Px emits radiation
 Most is eliminated  Private room & bath
w/in 48hrs  Caution sign px door
 30mins/care/shift
 X pregnant & less 16yo
 Lead shield
 6 feet from source/visitor

REMOVAL
Client is no longer radioactive
Dislodged radiation
source:
 X touch with bare hands
 Use long-handled forceps to place in
lead container; kept in px room, call M.D.
 If unable to locate source = call M.D.
Intervention pre-op:

 Monitor s/sx related to location of tumor

 Provide emotional support to chilc &
parents
 consent
Post-op intervention:

 Monitor post-op complication r/t location

of sx
 Complication of chemo & radiation
therapy
 Support parents & verbalization of
feelings
 Refer support groups
Good day!!
>^^,<