NEUROLOGIC ALTERATIONS 1. SEIZURES A seizure is an involuntary contraction of muscle caused by abnormal electrical brain discharges.

Etiology: Idiopathic Secondary o Birth trauma o Infection o Vascular abnormalities o Trauma o Tumors Classification of Seizures: Partial (Focal) Seizures Simple partial seizures ( no altered level of consciousness) Complex partial (psychomotor ) seizures (some impairment or alteration in the level of consciousness) Generalized Seizures Tonic-clonic seizures (formerly grand-mal) Tonic- sudden onset of muscle rigidity Clonic- sudden onset of jerky movements. Absence seizures (formerly petit mal)- involuntary blinking; with loss of consciousness Atonic seizures (formerly drop attacks)- sudden loss of muscle tone Myoclonic seizures Infantile spasms- characterized by very rapid movements of the trunk with sudden strong contractions of most of the body, including flexion and adduction of the limbs; commonly seen in infants and toddlers. Others: Febrile seizures- seizures associated with high fever (102F to 104F / 38.9C to 40.0C) that is most common among preschool children, although they can occur as early as 3 months or as late as 7 years of age. It shows an active tonic-clonic pattern, which lasts for 15-20 seconds. Status epilepticus- a seizure that lasts continuously for longer than 30 minutes or a series of seizures from which the child does not return to his/her previous level of consciousness. This is an emergency situation requiring immediate treatment. Otherwise, exhaustion, respiratory failure, permanent brain injury or death may occur. Assessment: Thorough pregnancy history Complete physical and neurologic examination Lumbar puncture- for ruling out meningitis or bleeding into the CSF CT scan/ MRI/ skull radiograph/ EEG Nursing Management: 1. Seizure precautions: a. Side rails up and padded 1

b. Side-lying/ supine with the head to the side c. Suction secretions d. Support the head and each extremity e. Sharps and stray objects- put them away f. Stay with the patient-Monitor onset, duration, frequency, interval, and aura of seizure. 2. For febrile seizures: a. Teach parents that after the seizure subsides, they should sponge the child with tepid water to reduce the fever quickly. b. Advise them not to put the child in the bathtub; however, because it would be easy for the child to slip under water should a seizure occur. c. Applying alcohol or cold water is not advisable. Extreme cooling causes shock to an immature nervous system; in addition, alcohol can be absorbed by the skin or the fumes can be inhaled in toxic amounts, compounding the childs problem. d. Parents should not attempt to give oral medications such as acetaminophen, because the child will be in a drowsy, or postictal state after the seizure and might aspirate the medicine. e. If attempts to put the childs temperature down is unsuccessful, advise parents to put washcloths on the childs forehead, axillary and groin areas, and transport the child, lightly clothed, to a health care facility for immediate evaluation. f. Reassure parents that febrile seizures do not lead to brain damage and that the child is completely well afterward. Pharmacotherapy: Infantile spasms Parenteral adrenocorticotropic hormone (ACTH) and pyridoxine (Vit. B6) Valproic acid/ topimarate (Topamax) Complex partial (psychomotor) seizures Carbamazepine( tegretol)- can lead to neutropenia; WBC count shoud be monitored. Valproic acid (Depakene) Phenytion (Dilantin) Phenobarbital * If medications are not effective, surgery to remove the epileptogenic focus may be attempted. 2. STRUCTURAL ABNORMALITIES 2.1. HYDROCEPHALUS - an excess of CSF in the ventricles or the subarachnoid space. It can cause enlargement of the skull. Types: Communicating Hydrocephalus or Extraventricular Hydrocephalus-if fluid can reach the spinal cord Obstructive Hydrocephalus or Intraventricular Hydrocephalus there is a block to the passage of fluid. Congenital Acquired Causes: 2

1.

Overproduction of fluid by a choroid plexus in the first or second ventricle. (rare) 2. Obstruction of the passage of fluid in the narrow aqueduct of Sylvius (common cause) 3. Interference with the absorption of CSF from the subarachnoid space if a portion of of the subarachnoid membrane is removed, as occurs with surgery for meningocele, or after extensive subarachnoid hemorrhage, when portions of the membrane absorption surface become obscured. Assessment: Abnormal rate of head growth Bulging fontanelle Tense anterior fontanelle (often bulging and nonpulsatile) Dilated scalp veins Macewens sign (cracked pot) Frontal bossing Setting sun sign Sluggish and unequal pupils Irritability and lethargy with varying LOC Abnormal infantile reflexes Possible cranial nerve damage Diagnosis: Level II ultrasonography of the fetus will allow a prenatal diagnosis. (Transuterine placement of ventriculoamniotic shunts during late pregnancy is still being developed as a treatment modality). CT scan will diagnose most cases postnatally. MRI can be used if a complex lesion is suspected. Nursing Management: Teach the family about the management required for the disorder o Treatment is surgical by direct removal of an obstruction and insertion of shunt to provide primary drainage of the CSF to an extracranial compartment, usually peritoneum (ventriculoperitoneal shunt) The major complications of shunts are infections and malfunction Other complications include subdural hematoma caused by a too rapid reduction of CSF, peritonitis, abdominal abscess, perforation of organs, fistulas, hernias and ileus. o A third ventriculostomy is a new nonshunting procedure used to treat children with hydrocephalus. Provide preoperative nursing care o Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry. o Firmly support the head and neck when holding the child. o Provide skin care for the head to prevent breakdown. o Give small, frequent feedings to decrease the risk of vomiting. o Encourage parental-newborn bonding. Provide Postoperative nursing care (nursing interventions are the same as those for increased ICP) 3

Assess for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior. o Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain. o Provide shunt care Monitor for shunt infection and malfunction which may be characterized by rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract, and fluid around the shunt valve. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus) Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage may lead to slit ventricle syndrome whereby the ventricle become accustomed to a very small or slitlike configuration, limiting the buffering ability to increased ICP variations. Teach home care o Encourage the child to participate in age-appropriate activities as tolerated. Encourage the parents to provide as normal lifestyle as possible. Remind both the child and parents that contact sports are prohibited. o Explain how to recognize signs and symptoms of increased ICP. Subtle signs include changes in school performance, intermittent headache, and mild behavior changes. o Arrange for the child to have frequent developmental screenings and routine medical checkups. o 2.2. NEURAL TUBE DISORDERS Spina Bifida- latin word for divided spine; often used as a collective term for all spinal cord disorders, but there are well-defined degrees of spina bifida involvement, and not all neural tube disorders involve the spinal cord. All of these disorders, however, occur because of lack of fusion of the posterior surface of the embryo in the early intrauterine life. They can be compared with cleft lip or cleft palate- these are also closure disorders. Types: a. Anencephaly absence of the cerebral hemisphere. occurs when the upper end of the neural tube fails to close in early intrauterine life. It is revealed by an elevated level of AFP in the maternal serum or on amniocentesis and confirmed by a sonogram. it is also called as Aprosencephaly with open cranium. it is one of the most common forms of neural tube disorders. Etiology: environmental toxins (such as lead, chromium, mercury, and nickel) lack of folic acid intake of the mother. b. Microcephaly 4

a disorder in which brain growth is so slow that it falls more than three standard deviations below normal on growth charts. Etiology: intrauterine infection( rubella, cytomegalovirus, toxoplasmosis) severe malnutrition anoxia in early infancy Assessment: appearance of the baby's head is very small high-pitched cry poor feeding seizures increased movement of the arms and legs (spasticity) developmental delays mental retardation

c. Spina Bifida Occulta Occurs when the posterior laminae of the vertebra fail to fuse. This occurs most commonly at the fifth lumbar or first sacral level but may occur at any point along the spinal canal. May be noticeable as a dimpling at the point of poor fusion; abnormal tufts of hair or discolored skin may be present.

d. Meningocele- If the meninges covering the spinal cord herniated through

e. Myelomeningocele- The spinal cord and the meninges protrude through the
vertebrae the same as with meningocele. The difference is that the spinal cord ends at the point, so motor and sensory functions is absent beyond this point. The child will have flaccidity and lack of sensation of the lower extremities and loss of bowel and bladder control. The infants leg are lax, and he or she does not move them; urine and stools continually dribble because of lack of sphincter control. They have accompanying talipes disorders and development hip dysplasia. Hydrocephalus accompanies myelomeningocele due to the lack of subarachnoid membrane for CSF absorption.

f. Encephalocele- Occurs when meningeal and cerebral tissue protrudes in a sac

NURSING MANAGEMENT: Teach the family about the management required for this disorder. o No treatment is indicated for spina bifida occulta unless there is neurologic damage. If a sinus is present, it may need to be closed. o Meningocele requires closure as soon after birth is possible. The child should be monitored for hydrocephalus, meningitis, and spinal cord dysfunction. o Myelomeningocele requires a multidisciplinary approach. There is no cure. Closure is performed within 24 hours to minimize infection and prevent further damage to the spinal cord and roots; skin grafting may be necessary. Shunting is performed for hydrocephalus and antibiotics are initiated to prevent infection. The child will need correction of musculoskeletal deformities and management of urologic and bowel control problems. During the newborn period, assess and monitor vital signs, measure head circumference, and assess neurologic status, including signs of ICP. Monitor the child throughout childhood to detect the true extent of the disorder. Administer prescribed medications. Antibiotics, anti-convulsants, anticholinergics Prevent infection and injury. o Preoperatively, apply a sterile dressing, constantly moistened with saline, to the lesion. Use protective devices and handle the infant with care. o Preoperatively, and postoperatively, perform the following: Maintain a sterile dressing. Examine the dressing for leakage. Avoid placing a diaper or other covering directly over the lesion (could cause fecal contamination). Monitor the child for signs of local infection and meningitis. o Position the infant in a prone or side-lying position to prevent contamination by stool or urine. o Prevent hip subluxation by maintaining legs in abduction with pads between the knees and the feet in a neutral position with a roll under the ankles. o Prevent skin breakdown by padding the bony prominences. Prevent trauma from increased ICP because many children have associated hydrocephalus. o Monitor head circumference and observe for signs of increased ICP o Minimize stress( increases ICP) Prevent urinary complications. o Assess urologic status. o Instruct the child and family on self-catheterization. o Prevent urinary tract infections o Maintain urinary diversion of the child has this procedure. Prevent trauma from latex allergy. o Screen for latex allergy. o Administer antihistamines or steroids before surgery or procedures. o Ensure that the child and family are aware of the childs allergy to latex and that they will inform medical and school personnel. o Maintain a latex-free environment. 6

 Prevent injury due to neuromuscular impairment. o Carefully monitor the childs skin condition. o Promote mobility and turn the child frequently. o Use caution in positioning the child because a lack of sensation makes the child unable to detect potential skin irritants. Promote optimal bowel functioning. o Instruct the parents on colon training which consists of timing, diet, exercise, posture and rectal stimulation. o Encourage a diet high in fiber and low in carbohydrates. o Exercise the lower part of the body. o Use the knee-chest position to put pressure on the abdomen and aid in bowel evacuation. o Use rectal stimulation with digit or suppository. Promote family coping. o Explain the essentials of infant care. o Promote parent-infant relationship by encouraging parental participation with feeding, cuddling and stimulation. o Emphasize infection prevention and recognition of early S/Sx of infection and increased ICP. o Explain and demonstrate bladder and bowel management and skin care. o Discuss the effects of immobilization and how to deal with them. o Discuss the need for lifelong care. o Encourage as much normalcy as possible. o Carefully assess the familys ability to care for the child and refer them for further assistance is needed. o Encourage parents to verbalize their fear. Prevent the development of neural tube defects. 3. INFECTIONS 3.1. Bacterial Meningitis - an infection of the cerebral meninges that occurs most often in children younger than 24 months of age. -caused frequently by Streptococcus pneumonia or group B Streptococcus. In children younger than 2 months of age, group B Streptococcus and Escherichia coli are the common causes. Assessment: 2-3 days of URTI Irritability because of headache Seizures Signs of meningeal irritability ( Brudzinski and Kernig signs, opisthotonos, cranial nerve paralysis<inability to follow light through full visual fields> Changes in the fontanelles o Open- bulging and tense o Close- development of papilledema Diagnosis LP with CSF analysis o Results: 7

Increased WBC Increased protein levels Lowered glucose level CT scan/ MRI/ Ultrasound- for abscesses. Nursing management: Antibiotic therapy as indicated by sensitivity studies o Usually given IV for rapid effect, but intrathecal injections may be necessary to reduce infection. o For H. Influenzae- ampicillin is the DOC o Cephalosporin(Clarofan)/ Ceftriaxone (Rocephin)- 8-10 days o Corticosteroids: dexamethasone o Osmotic diuretic: mannitol Place children on respiratory precaution for 24 hours. 3.2. GROUP B -HEMOLYTIC STREPTOCOCCAL MENINGITIS - Major cause is group B - hemolytic streptococci. It is contracted either in utero or from secretions in the birth canal at birth. - Late-onset type often leads to meningitis instead of pneumonia. 3.3. ENCEPHALITIS - an inflammation of brain tissue and possibly, the meninges as well. - can result from direct invasion of the CSF during lumbar puncture. Assessment: Headache High temperature Signs of menigeal irritation (nuchal rigidity, Brudzinski and Kernigs sign) Ataxia Muscle weakness or paralysis Diplopia Confusion and irritability Nursing Management: Take and record vital signs frequently, because brainstem involvement can affect cardiac or respiratory rates. Follow-up care after hospitalization is important for the childs rehabilitation and to help parents deal with their grief, shock and anger. Monitor the patients response to medications and observe for adverse reactions. Monitor neurologic status closely. Watch for subtle changes, such as behavior or personality changes, weakness, or cranial nerve involvement. Monitor fluid intake and output to ensure adequate hydration. Maintain quiet environment and provide care gently, to avoid excessive stimulation and agitation, which may cause increase ICP. Maintain seizure precautions; pad side rails of bed and have airway and suction equipment available at bedside. Maintain standard precautions and additional isolation according to hospital policy to prevent transmission. Administer antipyretics and other cooling measures as indicated. Provide fluid replacement through I.V. lines as needed. Reorient patient frequently. 8

 Provide supportive care if coma develops; may last several weeks. Encourage significant others to interact with patient with even while in coma and to participate in care to promote rehabilitation. 3.4. REYES SYNDROME - is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs, pancreas and skeletal muscle. It occurs in children from 1-18 years of age regardless of gender. Etiology: Idiopathic Viral infection: varicella, influenza Assessment: Lethargy Anorexia Vomiting Confusion Agitation Combativeness Hypothrombinemia Hypoglycemia Elevated blood ammonia levels Diagnosis: Elevated liver enzyme levels (alanine aminotransferase <ALT or SGPT> and aspartate aminotransferase <AST or SGOT>) normal direct bilirubin elevated serum ammonia delayed prothrombin time and PTT decreased blood glucose elevated BUN elevated serum amylase elevated short-chain fatty acids elevated WBC Nursing Management: Avoid taking aspirins. Hypertonic IV glucose solutions Intensive supportive nursing Mechanical ventilation Close Monitoring 3.5. GUILLAIN-BARR SYNDROME( inflammatory polyradiculoneuropathy) - a perplexing syndrome that involves both motor and sensory portions of peripheral nerves. It affects both sexes and occurs most often in school-age children and adolescents. Etiology: Unknown, possibly autoimmune Often develops after viral infections, immunizations, fever, injury and surgery Assessment: Peripheral neuritis several days after the primary infection tendon reflexes are decreased or absent 9

ascending muscle paralysis and paresthesia Nursing management: Prevent all of the effects of extreme immobility while guarding respiratory function. Closely monitor the childs cardiac and respiratory effort. An indwelling catheter is usually inserted to monitor urine output. Enteral or total parenteral nutrition may be used to support protein and carbohydrate needs. If the child has discomfort from neuritis, adequate analgesia should be administered. To prevent muscle contractures and effects of immobility, the child should have passive range-of-motion exercises every 4 hours. Turning and repositioning every 2 hours is also important in maintaining skin integrity. Provide adequate stimulation for the long-weeks when the child is unable to perform any care for himself or herself. 4. NEUROLOGIC INJURIES 4.1. HEAD INJURY - can be anything from a mild bump to severe damage to the head. The term encompasses everything from a minor laceration to diffuse brain injury. - one of the most common causes of disability and death in children. Types: a. Skull Fracture- depends on the velocity, force, and mass of object; on the area of skull involved; and on the age of the child. Subtypes: Linear fractures- resembles a thin line; usually no other signs than those found on x-ray film; child is observed for neurologic changes, and the fracture heals on its own. Comminuted fractures- cracked eggshell appearance Depressed fractures- skull is indented at the point of impact, which may cause compression, shifting of the brain tissue, and intracranial damage. Basal fractures- most serious and consists of a linear fracture through the base of the skull. Diastatic fracture- occur along a suture line; usually do not occur at the site of impact and are frequently seen in newborns. b. Brain injury- signs and symptoms depend on the location and severity of the head injury c. Hematomas- epidural( between skull and dura) and subdural (between dura andarachnoid layer) are the most common types of hematoma. Etiology: Motor vehicle accidents Abuse Falls Birth trauma Risk factors: Seizure disorders Gait instability 10

 Cognitive delays Poor judgment Alcohol and drug use Assessment: Altered LOC changes Increased ICP For Basal fracture o Rhinorrhea/ otorrhea o Hemotympanum o Raccoon eyes- periorbital ecchymosis o Battle sign- postmastoid ecchymosis For Brain injury- may occur up to 2 years after the injury o Post-traumatic syndromes(seizures, hydrocephalus, or focal neurologic deficits) o Metabolic complications( diabetes insipidus, hyponatremia, hypernatremia, hyperglycemic hyperosmolar states) Epidural hematoma o Rapid onset; life threatening and characterized by rapid deterioration, headache, seizures, coma and brain herniation with compression of the brain stem. Subdural hematoma o Occurs within 48 hours of injury and is characterized by headache, agitation, confusion, drowsiness, decreased LOC and increased ICP. Head trauma o Loss of consciousness o Transient confusion o Listlessness and irritability o Pallor and vomiting Signs of Injury Progression o Altered mental status o Increasing agitation o Development of focal signs o Marked changes in vital signs o Hyporesponsive, hyperresponsive or nonexistent reflexes Diagnosis: Radiography- reveal fracture CT/ MRI scan- used to view brain injuries and hematoma CBC, blood chemistries, toxicology screening, urinalysis Nursing Management: Promote prevention, especially falls. Urge children to wear bike helmets, use seat belts and practice safe driving. Perform the following neurologic assessments: o Cerebral functioning (alertness, orientation, memory and speech) o Vital signs( check for increased BP and decreased pulse) o Motor and sensory function( must be appropriate for childs developmental age) 11

 Assess for other injuries, especially cervical injuries. Do not move the child until the possibility of cervical injury has been ruled out or managed. Raise the head of the bed to 30 if there is no cervical injury. Monitor for complications which can develop rapidly. o Monitor vital signs and neurologic status frequently. o Check for increased ICP. o Check for drainage from the nose and ears. Use planning and intervention strategies for increased ICP. Provide child and family teaching. o Teach signs of increased ICP. o When warranted, teach that seizures may occur for up to 2 years after the injury. o When warranted, explain that the child may also have extensive damage requiring rehabilitation. o Encourage the child and family to verbalize their concerns. 5. CEREBRAL PALSY - a group of non-progressive disorders of upper motor neuron impairment that result in motor dysfunction. Affected children may also have speech or ocular difficulties, seizures, cognitive challenges, or hyperactivity. Etiology: IDIOPATHIC Nutritional deficiencies Low birth weight Drugs Premature birth Maternal infections Birth injury Direct birth injury *caused by brain anoxia leading to cell destruction of the motor tracts. If intrauterine anoxia occurs for some reason, this type of brain cell dysfunction may result. Types of Cerebral Palsy: Spastic type The child has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski reflex, and continuation of neonatal reflexes, such as tonic neck reflex, past the age at which these usually disappear. Dyskinetic or Athenoid type Involves abnormal involuntary movement. Early in life, the child is limp and flaccid. Later, in the place of voluntary movement, he or she makes slow, writhing motions. This may involve all four extremities, plus the face, neck, and tongue. Because of poor tongue and swallowing movements, the child drools and speech is difficult to understand. With emotional stress, the involuntary movements may become irregular and jerking (choreoid) with disordered muscle tone (dyskinetic). Ataxic type Children have an awkward, wide-based gait. They are unable to perform fingerto-nose test or to perform rapid, repetitive movements (tests of cerebellar function) or fine coordinated motions. 12

Mixed type Some children show symptoms of both spasticity and athenoid movements. Ataxic and athenoid movements also may be present together. This combination results in a severe degree of physical impairment. Clinical Manifestations: delayed gross motor development (delay in all motor accomplishments; delay becomes more profound as the child grows) sensory alterations ( strabismus, refractive disorders, visual perception problems, visual field defects, speech disorders) attention deficit or autism deafness caused by kernicterus in connection with athetoid CP. abnormal motor performance (e.g. early dominant hand preference, abnormal and asymmetrical crawl, poor sucking, feeding problems or persistent tongue thrust) alterations of muscle tone (e.g. increased or decrease resistance to passive movements, child feels stiff when handling or dressing, difficulty in diapering or opisthotonos) abnormal postures (e.g. scissoring legs or persistent infantile posturing) reflex abnormalities (e.g. persistent primitive reflexes, such as tonic neck of hyperreflexia) Diagnosis: Skull radiograph or sonogram cerebral asymmetry CT/MRI scan EEG Nursing management: Prevent physical injury by providing the child with a safe environment, appropriate toys, and protective gear (helmet, kneepads) if needed. Prevent physical deformity by ensuring correct use of prescribed braces and other devices and by performing ROM exercises. Promote mobility by encouraging the child to perform age-and conditionappropriate motor activities. Promote adequate fluid and nutritional intake. Foster relaxation and general health by providing rest periods. Administer prescribed medications which may include sedatives, muscle relaxants and anticonvulsants. Encourage self-care by urging the child to participate in activities of daily living (ADLs) (e.g. using utensils and implements that are appropriate for the childs age and condition). Facilitated communication o Talk to the child deliberately ad slowly, using pictures to reinforce speech when needed. o Encourage early speech therapy to prevent poor or maladaptive communication habits. o Provide means of articulate speech such as sign language or a picture board. o Technology such as computer use may help children with severe articulation problems. 13

 As necessary, seek referrals for corrective lenses and hearing devices to decrease sensory deprivation related to vision and hearing losses. Help promote a positive self-image in the child: o Praise his accomplishments o Set realistic and attainable goals o Encourage and appealing physical appearance o Encourage his involvement with age and condition- appropriate peer group activities. Promote optimal family functioning o Encourage family members to express anxieties, frustrations and concerns and to explore support networks. o Provide emotional support and help with problem solving as necessary. o Refer the family to support organizations such as the United Cerebral Palsy Association. Prepare the child and family for procedures, treatments, appliances and surgeries if needed. Assist in multidisciplinary therapeutic measures designed to establish locomotion, communication and self-help, gain optimal appearance and integration of motor functions; correct associated defects as effectively as possible and provide educational opportunities based on the individuals needs and capabilities. Therapeutic measures include: o Braces to help prevent or reduce deformities, increase energy of gait, and control alignment. o Motorized devices to permit self-propulsion. o Orthopedic surgery to correct deformities and decrease spasticity (medications are not helpful for spasticity). o Medications to control possible seizure activity or attention deficit disorder. o Speech therapy and physical therapy. Inform parents that their child will need considerable help and patience in accomplishing each new task. o Encourage them not to focus solely on the childs inability to accomplish certain tasks. o Urge them to relax and demonstrate patience. o Explain the importance of providing positive feedback. Encourage the family to seek appropriate functional, adaptive and vocational training for the child. Encourage family members to achieve balance in their lives between caring for their disabled child and other family and personal matters. 6. HEADACHES Types: Tension or Stress Headache Sinus Headache Migraine Headache -refers to a specific headache that may or may not begin with an aura or visual disturbance such as diplopia or a zigzag pattern across the visual field. 14

- pain is usually unilateral and extremely intense, with throbbing that is moderate to severe. - The cause is not well understood. It probably results from abnormal constriction of intracranial arteries that temporarily reduces cerebral blood supply. Nursing Management: Prevent headaches: o Getting enough rest, eating a healthful diet without skipping meals, and exercising regularly. o Taking occasional study breaks. o Avoiding allergens, foods or other factors known to trigger headaches whenever possible. Pharmacotherapy: o Ergotamine(Cafergot)- constricts cerebral arteries o Porpranolol and flunarizine o Beta-blockers or calcium channel blockers- may be prescribed prophylactically

SENSORY ALTERATIONS 1. SPEECH AND LANGUAGE DISORDERS basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency. There a variety of major speech disorders. Following are brief definitions of several of the more prominent speech disorders: Apraxia of speech refers specifically to a motor speech disorder. This is a neurological disorder. Individuals suffering from apraxia of speech encounter difficulty saying sounds, syllables, and words. The difficulties are not due to weakness of muscles, but rather on coordination between the brain and the specific parts of the body. Dysarthria is another motor speech disorder that results from a neurological injury. Some stem from central damage, while other stem from peripheral nerve damage. Difficulties may be encountered in respiratory problems, vocal fold function, or velopharyngeal closure, for example. Orofacial myofunctional disorder refers to problems encountered when the tongue thrusts forward inappropriately during speech. While this is typical in infants, most children outgrow this. Children that continue to exaggerate the tongue movement may incorrectly produce speech sounds, such as /s/, /z/, sh, ch, and j. For example, the word, some, might be pronounced as thumb. Stuttering is a disruption in the fluency of an individuals speech, which begins in childhood and may persist over a lifetime. Several of the language disorders are: 15

Language-based learning disabilities - refer to difficulties with reading, spelling, and/or writing that are evidenced in a significant lag behind the individuals same-age peers. Most children with these disabilities are at least of average intelligence, ruling out intellectual impairments as the causal factor. Selective mutism is a disorder that manifests as a child that does not speak in at least one social setting, despite being able to speak in other situations. Selective mutism is normally discovered when the child first starts school Aphasia -a family of language disorders that usually stem from injury or lesion to the left side of the brain that result in reception, perception, and recall of language; in addition, language formation and expressive capacities may be inhibited.

Nursing management: Treatment for articulation/phonological disorders is usually based on increasing the affected person's awareness about how speech sounds make the meaning of words different. As a result, therapy often involves pronunciation exercises designed to teach how to produce sounds and words more clearly to increase understanding of the differences between the various speech sounds and words. Treatment plans for stuttering depend on the severity of the dysfluency and may include seeing a speech-language pathologist. Most treatment plans include breathing techniques, relaxation strategies to help relax speech-associated muscles, posture control, and other exercises designed to help develop fluency. Voice therapy 2. VISUAL IMPAIRMENT 2.1. REFRACTIVE ERRORS - largest category of vision defects in children Types: Myopia(near-sightedness) Hyperopia(farsightedness) Astigmatism Nursing management: Encourage children to give eyeglasses a try. Advise parents to choose frames fitted with plastic or safety glass (shatterproof) lenses so that, if the lenses accidentally break, the childs eye will not be injured. Contact lenses are possible to be fitted for even young infants. LASIK (Laser In Situ Keratomileusis)- surgery for correcting myopia. 2.2 AMBLYOPIA - lazy eye or subnormal vision in one eye; the child may be using one eye for vision and the other is a resting eye. If this continues too long, central vision fails to develop and the child becomes functionally blind in one eye. - can also develop from strabismus(crossed eye). Nursing Management: The good eye is covered by a patch held firmly in place. 16

 The patch is removed for 1 hour each day to prevent amblyopia from developing in the nonamblyopic eye. Administration of levodopa in addition to occlusion therapy may also be prescribed. Atropine, which causes pupil dilation, may be another solution. 3. HEARING IMPAIRMENT - ranges from mild to profound and include deaf as well as hard of hearing. Risk factors: Infants with prenatal, perinatal and postanatal conditions including family history of hearing impairments Malformations Low birthweight Asphyxia Infection Down syndrome History of being administered with ototoxic drugs Assessment: Failure to startle or awaken to a loud sound Failure to turn head to the sound by 4 months of age Failure to babble by 3 months of age Nursing management: When children are wearing hearing aids, encourage them to view themselves as whole persons despite their need for their device, rather than as someone with something to hide. Refer them to speech therapy.

COGNITIVE ALTERATIONS 1. MENTAL RETARDATION - part of a broad category of developmental disability and defined by the American Association of Mental Deficiency as significantly subaverage, general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period( 18years of age). -adaptive behaviors include communication, self-care, work, leisure, health and safety. Etiology: Prenatal infection and intoxication Trauma or physical agent Metabolic disturbance Inadequate prenatal nutrition Gross postnatal brain disease 17

 Chromosomal abnormalities Prematurity Low birthweight Autism Environmental deprivation Associated Factors: Maternal lifestyles Chromosomal disorders( most related to Down syndrome) Specific disorders, such as fetal alcohol syndrome Cerebral palsy, microcephaly or infantile spasms Assessment: a. Mild (50-70 IQ) Preschool. The child often is not noted as retarded, but is slow to walk , talk, and feed self. School-age. The child can acquire practical skills, and learn to read and do arithmetic to sixth-grade level with special education classes. The child achieves a mental stage of 8 to 12 years. Adult. The adult can usually achieve social and vocational skills. Occasional guidance may be needed. The adult may handle marriage, but not child rearing. b. Moderate (35- 55 IQ) Preschool. Noticeable delays, especially in speech, are evident. School-age. The child can learn simple communication, health, and safety habits, and simple manual skills. A mental age of 3 to 7 years is achieved. Adult. The adult can perform simple tasks under sheltered conditions and can travel alone to familiar places. Help with self-maintenance is usually needed. c. Severe (20-40 IQ) Preschool. The child exhibits marked motor delay and has little to no communication skills. The child may respond to training in elementary selfhelp, such as feeding. School-age. The child usually walks with disability. Some understanding of speech and response is evident. The child can respond to habit training and has the mental age of a toddler. Adult. The adult can conform to daily routines and repetitive activities, but needs constant direction and supervision in a protective environment. d. Profound (below 20 IQ) Preschool. Gross retardation is evident. There is a capacity for function in sensorimotor areas, but the child needs total care. School-age. There are obvious delays in all areas. The child shows basic emotional response and may respond to skillful training in the use of legs, hands, and jaws. The child needs close supervision and has mental age of a young infant. Adult. The adult may walk but needs complete custodial care. The adult will have primitive speech. Regular physical activity is beneficial. Nursing Management: Assess all children for signs of development delays. 18

 Administer prescribed medications for associated problems such as anticonvulsants for seizure disorders, and methylphenidate (Ritalin) for attention deficit hyperactivity disorder. Support the family at the time of initial diagnosis by actively listening to their feelings and concerns and assessing their composite strengths. Facilitate the childs self-care abilities by encouraging the parents to enroll the child in an early stimulation program, establishing a self-feeding program, initiating independent toileting, and establishing an independent grooming program (all developmentally appropriate). Promote optimal development by encouraging self-care goals and emphasizing the universal needs of children, such as play, social interaction, and parental limit setting. Promote anticipatory guidance and problem solving by encouraging discussion regarding physical maturation and sexual behaviors. Assist the family in planning for the childs future needs; refer them to community agencies. Provide child and family teaching. o Identify normal developmental milestones and appropriate stimulating activities including play and socialization. o Discuss the need for patience with the childs slow attainment of developmental milestones. o Inform parents about stimulation, safety and motivation. o Supply information regarding normal speech development and how to accentuate nonverbal cues, such as facial expressions and body language, to help cue speech development. o Explain the need for discipline that is simple, consistent and appropriate to the childs development. o Review an adolescents need for simple, practical sexual information that includes anatomy, physical development and conception. o Demonstrate ways to foster learning other than verbal explanation because the child is better able to deal with concrete objects than abstract concepts. o Point out the importance of positive self-esteem, built by accomplishing small successes, in motivating the child to accomplish other tasks. Encourage the prevention of mental retardation. oEncourage early and regular prenatal care. oProvide support for high-risk infants. oAdminister immunizations, especially rubella immunization. oEncourage genetic counseling when needed. oTeach injury prevention- both intentional and unintentional. 2. DOWN SYNDROME - a disorder of chromosome 21, the most common chromosomal abnormality Etiology: Unknown Assessment: Late closure of fontanelles 19

Slant of eyes Epicanthal fold Large tounge Clinodactyly Abnormal dermatoglyphics Simian crease on palm Brushfield spots

Nursing management: Assess for associated problems. o Intelligence varies from severe retarded to low normal but is usually in the mild or moderate range. o Social development may be beyond 2-3 years age beyond mental age o Congenital anomalies (heart disease, skeletal deformities, etc.) o Sensory problems (strabismus, nystagmus,myopia and conductive hearing loss) o Reduced growth and rapid weight gain o Sexual development is delayed Implement a plan of care that is the same for mental retardation. Encourage genetic counseling. Explain hypertonicity and joint hyperextensibility to parents, and that the childs resultant lack of clinging is physiologic and not a sign of detachment. Prevent respiratory infections by clearing the nose with a bulb syringe, using a cool mist vaporizer, performing chest physiotherapy when needed and avoiding infection. When feeding infants and young children, use a small straight-handled spoon to push food to the side and back of the mouth. Encourage fluids and foods rich in fiber. Provide good skin care. 3. AUTISM - marked by severe deficits in language, perceptual, and motor development; defective reality testing; and an inability to function in social settings. Assessment: failure to develop social relations stereotyped behaviors such as hand gestures extreme resistance to change in routine abnormal responses to sensory stimuli decreased sensitivity to pain inappropriate or decreased emotional expressions specific, limited intellectual problem solving abilities stereotyped or repetitive use of language impaired ability to initiate or sustain a conversation Nursing management: Reduce behavioral symptoms and promote learning and development, particularly the acquisition of language skills 20

 Comprehensive and individualized treatment, including special education and language therapy, is associated with more favorable outcomes. A day care program can help to promote social awareness. Pharmacologic treatment: o Antipsychotics( haloperidol, risperidone) 4. FRAGILE X SYNDROME - an X-linked pattern of inheritance in which one long arm of an x-chromosome is weakened. Assessment: bossing ( prominent forehead) prominent jaw large hands Mental retardation (IQ between 20 and 70) Difficulty with speech and language development Hyperactivity Some autistic behaviors (poor eye contact, extreme shyness, and hand flapping) Problems paying attention Aggressiveness About 20 percent of boys with fragile X meet all the diagnostic criteria for autism. Most boys and some girls with fragile X have some symptoms of autism; however, many are socially outgoing and can form relationships with other people. Nursing management: Nursing management is mainly supportive. Early diagnosis and intervention with developmental therapies and an individualized pan education are ideal. Care is the same as those with mental retardation. 5. FETAL ALCOHOL SYNDROME - a pattern of mental and physical defects that can develop in a fetus in association with high levels of alcohol consumption during pregnancy. Etiology: Pre-natal alcohol exposure Assessment: pre- and post-natal growth restrictions CNS involvement Short palpebral fissure Thin upper lip Weak sucking reflex Sleep disturbances Nursing management: Children with FAS should have psychoeducational evaluation to help plan appropriate educational interventions. Common associated diagnoses, such as ADHD, depression, or anxiety should be recognized and appropriately treated. Within an early childhood intervention program, these children may be taught to function within their limitations, learn how to make proper choices, develop 21

acceptable interpersonal skills, master basic life skills and, above all, maintain self-esteem. Such educational intervention often means scaling down academic expectations and emphasizing training for future self-sufficiency. Programming for success can result in improved learning and enhanced self-image, which in turn can decrease acting out behaviours. Strategies for dealing with difficult behaviours include the following. o Keep tasks simple. o Use concrete examples. o Keep instructions simple and give them one at a time. o Concentrate on life skills.

REFERENCES: Textbook references: White, L. Foundations of Maternal and Pediatric Nursing, 2nd edition. Singapore: Delmar Learning. 2005 Muscari, M.E. Lippincotts Review Series: Pediatric Nursing, 3rd edtion. Philadelphia: Lippincott Williams and Wilkins.(2001) Pillitteri, A. Nursing Care of a Child with a Neurologic Disorder. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, Vol.1, 5th edition. Philadelphia: Lippincott Williams and Wilkins.(2007) Pillitteri, A. Nursing Care of a Child with a Neurologic Disorder. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, Vol.2, 5th edition. Philadelphia: Lippincott Williams and Wilkins.(2007) Videbeck, S.L. Child and Adolescent Disorders. Psychiatric Mental-Health Nursing, 4th edition. China: Lippincott Williams and Wilkins.(2006) Online references: Lhynneli, RN. Encephalitis. Online article retrieved from www.nursingcrib.com. Fragile X syndrome.Online article retrieved from www.cps.ca 22

Fetal Alcohol Syndrome. Online article retrieved from www.enotes.com Reyes syndrome. Online article retrieved from www.rightdiagnosis.com What is Cerebral Palsy? Online article retrieved from www.nursingcrib.com.

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