Week 15: Alterations in Perception and Coordination

• PARTS OF CENTRAL NERVOUS SYSTEM

  • Brain
  • Spinal Cord
• Parts of Peripheral Nervous Systems

  • Cranial Nerves
  • Spinal Nerves
  • Autonomic Nervous System (subconscious control system)
  • Somatic Nervous System (voluntary control system)
• THE BRAIN

  a.Cerebrum

  • Frontal lobe (higher executive functions such as emotions, planning, reasoning, and problem solving skill)
  • Parietal lobe (manages sensory information, temperature regulation, and pain)
  • Temporal lobe (responsible for senses, recognizing language, and forming memories)
  • Occipital lobe (responsible for vision)

  b. Brain stem

  • Midbrain (responsible of movement of the body and head)
  • Pons (unconsciousness or sleep-wake cycle)
  • Medulla (responsible heart rate,circulation, and breathing)

  c. Cerebellum (movement coordination, balance, and postural adjustment)
• PROTECTIVE STRUCTURES OF THE BRAIN

  a.Skull - Rigid for injury

  b. Meninges- Fibrous connective tissues that cover the brain and spinal cord

  • Dura mater (outer most layer)

  • Arachnoid mater ( middle membrane)

  • Pia mater (innermost layer)
• Seizures are caused by excessive and disorderly neuronal discharges in the brain.
• TWO MAIN TYPES OF SEIZURE

  a.Partial Seizure

  • begin in one part of the brain

  b. Generalized Seizure

  • involve electrical discharge in the whole brain
• GENERALIZED SEIZURE

  a.Tonic-Clonic (Grand-Mal)

  • alternating muscles rigidity and jerking temporarily with suspended breathing and altered consciousness

  b. Absence (Petit-Mal)

  • characterized by blank stare that last only in few seconds
• PARTIAL SEIZURE

  a.Simple Partial or Jacksonian Seizure

  • Jerking of fingers and toes, may spread to the entire limbs

  b. Complex Partial or Psychomotor Seizure

  • Blank stare that progresses to chewing or random activity

  c. Myoclonic Seizure

  • Sudden, brief, massive muscle jerks of the entire body

  d. Atonic Seizure or “drop attack”

  Characterized by sudden leg collapse
• Nursing management of seizure

  1. Observe and record the sequence of signs

  2. Identify predisposing factors (causes of seizure)

  3. Observe occurrence of aura (signs that seizure will happen)

  4. Observe initial movement or action of patient

  5. Observe type of movement

  6. Observe area of body involved

  7. Observe pupil size

  8. Observe eye movement during seizure

  9. Observe presence or absence of autonomic discharge (is the patient breathing spontaneously while having seizure or not?)

  10. Observe incontinence (Urinating or having bowel movements during the attack)

  11. Observe duration of the seizure

  12. Observe level of consciousness
• During the seizure


  • Provide privacy
  • Provide safety by: ease the floor of obstacles, protect head and do not restrain
  • Place patient on side lying
  • Insert oropharyngeal airway
  • Avoid forced mouth opening and inserting objects in the mouth
• After the seizure


  1. Observe paralysis or weakness, speaking ability, movement, sleepiness, cognitive status

  2. Place in side lying position

  3. Suction if necessary

  4. Reorient and ease agitation (persuasion and gentle restraint)
• STAGES OF GRAND MAL SEIZURE

  a.Aura

  • Involves peculiar sensation

  • May be psychic or sensory

  b. Tonic Phase

  • Loss of consciousness

  • Eye rolls

  • Body rigid

  c. Hypertonic Phase

  • Extreme muscle rigidity and hypertension.

  • Signals end of continuous contractions

  d. Clonic

  • Alternating rigidity and relaxation of muscles

  e. Autonomic Discharge

  • Hyperventilation, salivation, and tachycardia

  f. Post-Ictal Phase

  • All muscles relaxes, patient become unresponsive
• Epilepsy is a condition characterized by two or more unprovoked seizures and can be caused by a variety of pathologic processes in the brain
• ETIOLOGY OF EPILEPSY

  a.Primary - idiopathic

  b. Secondary- known cause such as tumors or infections
• THERAPEUTIC MANAGEMENT OF EPILEPSY

  a.Antiseizure Medications

  • Carbamazepine (Tegretol)
  • Clonazepam
  • Gabapentin
  • Levetiracetam (Keppra)
  • Phenobarbital (Luminal)
  • Valproate (Depakene) - hepatotoxic
  • Phenytoin (Dilantin) - causes gingival hyperplasia
  • Valium should be ready at bedside during admission of known epileptic patient

  b. Surgical management

  for known cause of epileptic episode such as tumor
• Status epilepticus refers to a seizure that lasts continuously for longer than 30 minutes or a series of seizures from which the child does not return to the previous level of consciousness.
• THERAPEUTIC MANAGEMENT OF STATUS EPILEPTICUS

  • An IV benzodiazepine such as diazepam (Valium) or lorazepam (Ativan) halts seizures dramatically
  • Children who continue to have seizures despite this drug treatment may require general anesthesia with a continuous infusion of midazolam, propofol, or pentobarbital.
• Spina bifida refers to a defect in one or more vertebrae that allows spinal cord contents to protrude.
• ETIOLOGY OF SB

  • Folic acid deficiency during pregnancy
• Spina Bifida is categorized into two types

  a.Spina bifida occulta refers to a defect that is not visible externally.

  b. Spina bifida cystica refers to a visible defect with an external saclike protrusion; has 2 sub types

  • Meningocele- intact cord
  • Myelomeningocele- splinted cord
• THERAPEUTIC MANAGEMENT OF SB

  a.SB Occulta

  • needs no immediate surgical correction

  b. SB Cystica (Meningocele and Myolomeningocele)

  • immediate surgery done preferably 24-72 hours after birth
  • A child with myelomeningocele will continue to have paralysis, loss of bowel and bladder control even if its surgically corrected
• NURSING MANAGEMENT OF SB

  a.Care of Myelomeningocele Sac

  • must kept moist
  • Apply moist non- adhesive dressing to be changed every 2-4 hours

  b. Pre op:

  • Diapering is discouraged
  • Place the infant in prone position
  • Gentle range of motion exercise to prevent contractions

  c. Post op

  • Place in prone position
  • Measure head circumference daily
  • Monitor vitals signs
  • Intake and output
  • signs of infection
• Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system.
• ETIOLOGY OF HYDROCEPHALUS

  • Overproduction of CSF

  • Obstruction in the brain

  • Interference in absorption of CSF
• CLINICAL MANIFESTATION OF HYDROCEPHALUS

  • Head enlargement
  • Bulging fontanels
  • Dilated scalp veins
  • Macewen sign (cracked pot sounds due to separation of sutures elicited by percussion)
  • Frontal bossing
  • Sunset eyes
  • Transilluminated skull
  • Shrill-brief high pitched cry
• THERAPEUTIC MANAGEMENT OF HYDROCEPHALUS

  • Acetazolamide
  • Furosemide (Diuretic)

  a.Surgical: Plexectomy, Shunt system

  • Ventriculoperitoneal shunt
  • Ventriculoatrial shunt (Complication: obstruction, infection, perforation of abdominal organs)
  • Endoscopic third ventriculostomy (bypassing the aqueduct of sylvius)
• NURSING MANAGEMENT OF HYDROCEPHALUS

  • Daily head circumference measurement
  • Assessment of child’s level of consciousness
  • Preparing the child for diagnostic examination

  a.Post OP

  • observe sign of increased intracranial pressure
  • Assessment of pupil dilation, abdominal distention and shunt care
• Sprain occurs when trauma to a joint is so severe that a ligament is partially or completely torn or stretched by the force created as a joint is twisted or wrenched
• THERAPEUTIC MANAGEMENT FOR SPRAIN

  • 6-12 hours RICE (Rest, Ice, Compression, Elevation)

  • Encourage early mobilization
• Bone fractures occur when the resistance of bone against the stress being exerted yields to the stress force
• FRACTURE COMPLICATION

  • Circulatory impairment (check for pulse)
  • Nerve compression (check for sensation)
  • Compartment syndrome (check for 5Ps <Pain, Pallor, Pulselessness, Paresthesia, Paralysis>)
  • Physeal damage (length inequalities)
  • Nonunion (bone healing impaired)
  • Malunion (due to incorrect management)
  • Osteomyelitis (infection of the bone)
  • Kidney Stones (due to hypercalcemia)
  • Pulmonary Emboli (lung obstruction)
• TYPES OF FRACTURE

  a.Open or Compound Fracture

  • Broken bone protrudes out of the skin

  b. Closed Fracture

  • broken bone is not visible

  c. Complicated Fracture

  • fracture with organ damage

  d. Comminuted Fracture

  • fracture with tissue damage
• NURSING MANAGEMENT OF FRACTURE

  • Calming and reassuring the child and parent so that assessment can be done easily and effectively
  • Ask the parents about what happened
  • Instruct px to pinpoint painful area
  • Affected limb should not be palpated nor be moved, unless properly splinted
• The goals of fracture management are:

  • To regain alignment and length of the bony fragments (reduction)

  • To retain alignment and length (immobilization)

  • To restore function to the injured parts

  • To prevent further injury and deformity.
• Developmental dysplasia of the hip (DDH) describes a spectrum of disorders related to abnormal development of the hip that may occur at any time during fetal life, infancy, or childhood.
• ETIOLOGY OF DDH

  • Idiopathic

  • Probable cause - Female gender, family history, breech uterine position, first pregnancy, joint laxation
• DEGREE OF DDH

  a.Acetabular Dysplasia

  • loose connection of femur to the acetabulum

  b. Sublaxation

  • partial detachment of femur to the acetabulum

  c. Dislocation

  full detachment of the femur to the acetabulum
• DEGREE OF DDH

  a.Acetabular Dysplasia

  • loose connection of femur to the acetabulum

  b. Sublaxation

  • partial detachment of femur to the acetabulum

  c. Dislocation

  • full detachment of the femur to the acetabulum
• DIAGNOSIS OF DDH

  • Asymmetry of gluteal and thigh folds

  • Limited hip abduction

  • Shortening of femur

  • Ortolani Test (involves abducting the thighs)

  • Barlow Test (the thighs are adducted)

  • Trendelenburg Sign

  • Physical examination

  • Xray
• THERAPEUTIC MANAGEMENT OF DDH

  • Pavlic’s harness for 6-12 weeks of life and then;

  • Surgery after 6-24 months