Chapter 23

The Child with a Sensory or

Neurological Condition

Ears
2 main functions:
hearing & balance

3 divisions:
External, middle, inner
Eustachian tubes: for ventilation, protection, drainage

Assessment:
Examine ears for alignment
Low-set ears may be assoc with kidney dx and mental retardation

Otitis Externa & Media (AOM)

Otitis Externa
acute infection of outer ear; also called swimmers ear
S/S: Pain on touching the outer ear; erythema of ear canal
R/O other causes. Tx: irrigation, topical antibiotics
Otitis Media
inflammation of middle ear.
More common in children because of short or blocked eustachian
tubes.
Occurs most often after URI
Affects children between 6 & 24 mo.
S/S: fever (may be high); pain, N/V, diarrhea
Treatment: antibiotics & analgesics.
Surgical tx: myringotomy
incision into eardrum to relieve pressure; tympanic tubes for
ventilation avoid water in ears

Ear Infections
S/S

Rubbing or pulling @ear

Rolling head side to side
Dont sleep well
Hearing loss
Loud speech
Inattentive behavior
Articulation problems
Speech dev. Problems
Red/bulging eardrum

Hearing Deficit & Ear Trauma

Hearing Deficit
Can affect speech, language, social & emotional develpment
Congenital
hearing loss present @ birth
Acquired
infectious diseases, allergies, meds
Degrees of hearing loss
Complete
difficulty communicating, behavior problems, may be aggressive
Partial
most commonly caused by chronic ear infections or blockage of
eustachian tubes
Lack of response by infant to sounds, music or the startle reflex are
first signs of possible hearing impairment

Nursing Care
Be aware of signs & symptoms of hearing
problems

Behavior problems
Indifference to sound
Poor school performance
Moro reflex lasting more than 4 months
No verbal attempts @ age 18 months

If suspect hearing loss make appropriate referrals

Nursing Care of Hearing-Impaired

Be at eye-level with child

Be face-to-face with child
Establish eye contact
Talk in short sentences
Avoid using exaggerated lip or face movement

Eye
Visual acuity: @ birth is
about 20/400 but matures
to 20/30 to 20/20 by age 23
Eyes may appear crossed
in early weeks of life

Depth perception @ 9 months

Eye Disorders
Dyslexia
a reading disability involving a defect in the brain cortex
Amblyopia (Lazy Eye)
A strong preference for one eye over the other
Tx: patch the good eye to force use of affected eye
Strabismus
cross-eye due to lack of coordination between eye
muscles
s/s: eye squinting or frowning to focus
Missed objects reached for
Covering one eye to see
Tilting head to see
Dizziness and/or HA

Eye Infections & Tumors

Conjunctivitis (Pink Eye)
inflammation of the conjunctiva
caused by: viral or bacterial agents, allergens, toxins,
irritants, systemic dx. or blockage of tear duct.
Tx: warm compresses, antibiotic eye ointments or
drops.
Spreads easily - Use good hand washing and
separate towel
N.I.: teach parents & children to wipe secretions from
inner canthus downward & away from other eye

Signs of conjunctivitis

More

Stuff

Retinoblastoma
malignant tumor of retina

S/S: yellowish white reflex is seen in the

pupil because of tumor behind lens; also
loss of vision, strabismus, pain.
Treatment: Enucleation (removal of eye) if
vision cannot be saved. Small tumors
treated with laser

Reyes Syndrome
Reyes Syndrome
an acute encephalopathy & hepatopathy (pathology of
liver) following a viral infection in children
Discourage the use of aspirin & other medications that
contain salicylates in children with flu-like s/s.

Signs of Increased Intracranial Pressure

12 Cranial Nerves
Pg 540
Table 23-1
Coffee House

Meningitis:
Inflammation of the Meninges
Bacterial
Indirectly (sepsis) r/t teeth, sinuses, tonsils, lungs; or
directly through ear or skull fx
Peak age is between 6 & 12 months
Viral
Readily transmitted to others
Less common in children older than 4
S/S: May be preceded by URI & poor feeding. Severe
HA, drowsiness, delirium, irritability, fever, vomiting,
neck stiffness; convulsions are common; coma.
Infants will have high-pitched cry
Treatment: At first indication, a spinal tap (lumbar
puncture) will be performed to test CSF
Nursing Care: frequent VS Slowed P, irreg. resp. & ^B/P
could indicate increased ICP and are reported immediately

Brain Tumors
The second most common type of neoplasm in children
(1st is leukemia)
The majority of childhood tumors occur in the lower part
of the brain (cerebellum or brain stem)
Symptoms are directly related to the location and size of
the tumor

Most tumors cause increased ICP with hallmark

symptoms of headache, vomiting, drowsiness,
and seizures

Seizure Disorders
Seizures
May be febrile ( rapid rise in temperature) or due
to ^ICP
Common in children 6 months to 5 yo
Parents should be reassured that it is self-limiting

Table 23-2 types of seizures & response, pg545

Epilepsy
recurrent attacks of unconsciousness or
impaired consciousness followed by tonic-clonic
behavior
a disorder of the CNS r/t neurons firing improperly

Seizures, cont.
Grand mal
3 phases: aura, tonic/clonic seizure, lethargy
Petit mal (absence seizure)
temporary loss of awareness
Partial
jerking in one part of body
pt. awake & alert
Complex partial
blank stare followed by random activity
pt. unaware
Atonic
sudden collapse

Treatment of Seizures
EEG to determine type of seizure
Anticonvulsant meds
Nursing Interventions (know med side-effects)

Phenobarbitol causes drowsiness

Dilantin causes gum hyperplasia (massage gums)
Depakene needs to be taken with food
Mysoline can cause aggressive behavior

Ketogenic Diet
high fat, low carbs to produce ketoacidosis &
reduce seizures

N.I. during a seizure, protect patient from nearby

hazards

Cerebral palsy
Disorders of the motor center of brain
One of most common disabling conditions
s/s range from mild to severe
Goal of treatment is to assist child in making the
most of their assets, perform at their maximum
ability, become well-adjusted adults
Help parents to accept the child & guide them to
community resources
Good skin care, prevention of contractures

Types of CP
Spastic

Athetoid

Involves damage to the

cortex of the brain

Involves damage to the

basal nuclei ganglion

Spasms occur with

movement

Continuous involuntary
writhing movements

Related to cerebral
asphyxia

Often associated with

hyperbilirubinemia

Ataxic
Uncoordinated movements
and ataxia from a lesion in
the cerebellum

Mixed
Usually a combination of
spastic and athetoid

Treatment of CP
Botulinum toxin has been used to manage
spasticity problems
Levodopa has helped to control some of the
athetoid problems
Specific treatment is highly individualized
Good skin care is essential
All precautions taken to prevent contractures
Braces are often used to treat these
Orthopedic surgery is sometimes indicated

Treatment Protocol for CP

Establish communication
Establish locomotion
Use and optimize existing motor functions
Provide intellectual stimulation
Promote socialization
Provide technology to encourage self-care and
promote growth and development
Provide multidisciplinary approach to care

Mental Retardation
Below-average mental functioning (IQ below
75)
Nursing Interventions

emphasize the strengths

Communicate with family
Avoid labels, use simple terms
Contact school nurse & plan ahead
Provide daily opportunities for success
Refer to support groups

Head Injuries
Major cause of death in children
older than 1 year
Concussion
temporary disturbance of brain,
usually followed by period of
unconsciousness
Loss of memory for events that
happened immediately before,
during and after accident

Shaken Baby Syndrome

Symptoms
Infants who are roughly
Headache (manifested
shaken can sustain
as fussiness in a toddler)
retinal, subarachnoid, and
Drowsiness
subdural hemorrhages in
Blurred vision
the brain, as well as high Vomiting
level cervical spine
Dyspnea
injuries
In severe cases child
Can result in permanent
may be completely
brain injury or death
unconscious

Neurological Monitoring of Infants

and Children

Pain stimuli response

LOC
Arousal awareness
Cranial nerve
response
Motor response
Posturing
Vital Signs

Pupil response of the

eyes
Bulging fontanels
Scalp vein distention
Ataxia; spasticity of
lower extremities
Moro/tonic neck with
withdrawal reflexes

Posturing
Often seen with severe brain injury
Decerebrate
Rigidity with all 4 limbs extended & hands
pronated
May indicate brainstem injury

Decorticate
Arms, wrists & fingers are flexed; feet show
plantar flexion
May indicate damage to cortex of brain

Abnormal posturing

Near-Drowning
Accidental or near-drowning is the fourth leading
cause of death in children under 19 years of age
Near-drowning is defined as survival beyond 24
hours after submersion
Priorities include immediate treatment of
Hypoxia
Aspiration
Hypothermia

CNS injury remains the major cause of death or

long-term disability

Elsevier items and derived items 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

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