Nursing Care of Children with

Disorders of the Nervous

System
Binol Rajesh Balachandar

Disorders under discussion

Meningitis
Encephalitis
Spina bifida
Hydrocephalus
Seizures

Points for discussion and

objectives

At the end of the lecture-discussion, the class

will be able to:
-identify the similarities and differences
between meningitis and encephalitis
- list the common organisms responsible for
these conditions
-differentiate between bacterial and viral
meningitis
-explain the common complications of the
conditions giving emphasis to seizures and
hydrocephalus
3

Points for discussion and objectivescont

develop nursing care plan for children with

these conditions under the following nursing
diagnoses using evidence based information
-Hyperthermia
-Fatigue
-Acute pain/ Impaired comfort
-Ineffective cerebral tissue perfusion
-Risk for contamination
-Risk for /Imbalanced fluid volume and
electrolyte imbalance
4

Nursing diagnoses-continued
-Risk for /Imbalanced nutrition
-Parental anxiety
-Risk for delayed development
-Deficient knowledge

CSF pressure
CSF pressure ranges from 80 to 100
mmH2O in newborns
< 200 mmH20 in normal children and adults

CSF findings in different forms of meningitis

Cause

Polymorp
Appearanc
honuclear
e
cell

Lymphocy
te

Protein

Glucose

Pyogenic
bacterial
meningitis

Yellowish,
turbid

Markedly
increase

Slightly
increase or
Normal

Markedly
increase

Decrease

Viral
meningitis

Clear fluid

Slightly
increase or
Normal

Markedly
increase

Slightly
increase or
Normal

Normal

Tuberculou
s
meningitis

Yellowish
and
viscous

Slightly
increase or
Normal

Markedly
increase

Increase

Decrease

Fungal
meningitis

Yellowish
and
viscous

Slightly
increase or
Normal

Markedly
increase

Slightly
increase or
Normal

Normal or
decrease

Pathogenesis
Organism gain access to the
subarachnoid space via hematogenous
spread Eg:-from the upper respiratory tract
Less frequently, there is direct spread from
a contiguous focus (eg, sinusitis,
mastoiditis, otitis media) or through an
injury, such as a skull fracture.

Difference- Meningitis and

Encephalitis
Meningitis- infection or inflammation of the the
membranous covering only
Meningeal signs (eg, headache, nuchal rigidity,
positive Kernig and Brudzinski signs) can be elicited

Kernig sign is positive when the leg is fully

bent in the hip and knee, and subsequent
extension in the knee is painful (leading to
resistance).
Brudzinski sign- involuntary lifting of the legs
when lifting patient's head

Differences -continued
Encephalitis infection or inflammation of
the brain substance and subsequently the
meninges. Hence, symptoms of altered
brain function are common
Confusion, seizures, stupor or coma

Similarities Meningitis and

Encephalitis
mostly by virus, bacteria
Fever, headache, irritability are usually
present and nausea and vomiting,
drowsiness, sensitivity to bright light, and
poor appetite
Important signs of encephalitis to watch for in
an infant include vomiting, body stiffness,
constant crying that may become worse
when the child is picked up, and a full or
bulging fontanel

Similarities
Both are temporary from which there is full
recovery in most instances can be severely
damaging to the brain and the vital centres
(Hearing and/or speech loss, blindness, permanent
brain and nerve damage, behavioral changes,
cognitive disabilities, lack of muscle control,
seizures, and memory loss.)
Onset is abrupt
LP is performed to identify specific organism
Bacterial meningitis and encephalitis are mostly
contagious and can be spread through contact
with saliva, nasal discharge, feces, or respiratory
and throat secretions.

Prevention
Good personal hygiene practices
Avoid sharing food, utensils, glasses, and other
objects with a person who may be exposed to or
have the infection.
Wash hands often with soap and rinse under
running water.
Effective vaccination- to prevent pneumonia, H.
influenza, pneumococcal meningitis and
meningococcal meningitis.
Proper treatment with antibiotics in affected cases.
Lessen the risk of being bitten by an infected
mosquito or other insects.
Promote good nutrition and maintain strong
immune system

Prevention in college students

Freshmen who live in dormitories have an
independent, elevated risk of
meningococcal disease compared with
other college students.
Use of the currently available quadrivalent
polysaccharide vaccine among college
students could substantially decrease their
risk of meningococcal disease.(Bruce, M.G.
(2001) and American Academy of Pediatrics
Committee on Infectious Diseases (2005).

Nursing care of children with

Spina Bifida and
Hydrocephalus

Binol Rajesh Balachandar

Objectives
At the end of the class, the students will be able
to
- define hydrocephalus and spina bifida
- list the types of hydrocephalus and spina bifida
- derive the complications from the
pathophysiological alterations of the disease
process
- identify children with increased intracranial
pressure [ICP]
- plan care for children with hydrocephalus,
increased ICP and spina bifida following
principles of care of children with such
conditions using evidence based information.

Hydrocephalus
Differentiate between communicating and
non communicating hydrocephalus
Describe the treatment options available for
hydrocephalus
Compare between ventriculo-peritoneal (VP
shunt)and atrio-ventricular (AV shunt)shunt
List other shunt options currently available
Develop a nursing care plan for a child with
myelomeningocele under the following
nursing diagnoses using evidence based
information
18

Spina bifida
Differentiate between spina bifida occulta and
spina bifida cystica
Identify the similarities and differences
between meningocele and myelomeningocele
Develop preventive strategies for spina bifida
Describe the complications of spina bifida
with special emphasis on neurological deficits
and hydrocephalus

19

 Develop a nursing care plan for a child with

myelomeningocele under the following
nursing diagnoses using evidence based
information
-Risk for injury
-Risk for infection
-Parental anxiety
-Risk for delayed development
-Deficient knowledge
-Hypothermia
-Risk for impaired attachment
-Risk for /Impaired parenting
20

Nursing management
-Ineffective cerebral tissue perfusion
-Acute pain/ Impaired comfort
-Risk for /Imbalanced nutrition
-Risk for injury
-Parental anxiety
-Risk for delayed development
-Deficient knowledge
-Risk for infection-if shunt is placed
21

Ventricles of the Brain and CSF Circulation

Hydrocephalus
Refers to an accumulation of cerebrospinal fluid
[CSF] within the circulatory system of the brain.
Types and pathophysiology
Hydrocephalus occurs when there is a defect in
production, circulation and reabsorption of CSF.
1. Communicating - due to the defect in
production & reabsorption of CSF
2. Non- communicating [obstructive]- due to the
defect in circulation of CSF

Types and pathophysiology

It could be also
Congenital
Acquired trauma, tumor, hemorrhage,
infections.

The total volume of CSF is 125-150 ml.

The normal resting pressure of the CSF is between
150-180 mm H2O.

It has been calculated that 430 to 450 ml of CSF

are produced every day.
When the CSF pressure rises, it eventually interfere
with the blood supply to the brain due to the
pressure produced by the heart to pump the blood.

Clinical features
Congenital Hydrocephalus and in young children
Increased head circumference
Wider fontanells
Gaping of cranial sutures
Features of raised intra cranial pressure [ICP]
-Bradycardia, hypertension, depressed respiration
-Nausea and vomiting and poor feeding
-Restlessness and irritability
-Dilated pupils or unequal pupils
-Protruding scalp veins
-Pappiloedema and Visual disturbances

Clinical features
-Drowsiness

or over sleepiness
-Unresponsiveness
-Sunset eyes
-Coma and cardio-pulmonary arrest.
Older children
- Headache

- Widening pulse pressure- difference between

systolic and diastolic pressure.
- Poor school performance
Investigations
- Physical assessment
- Ophthalmoscopy
- Scull- X-ray, CT Scan, Ventriculography, MRI Scan,

27

Management
Ventricular puncture [tap] to remove excess CSF
Removal of choroid plexus using an endoscope
Third ventriculostomy
Ventriculo-peritoneal shunt [VP shunt]
Ventriculo-atrial shunt.[VA shunt]
Complications of shunt
- Blockage
- Subdural haematoma from collapse of ventricles
which could tear the delicate blood vessels
- Infection
- Growth
- Displacement

29

Signs and symptoms of shunt infection

Tiredness, irritability
Anorexia
Redness over the shunt area &pain
Increased temperature
Positive cultures of blood and CSF and
Signs and symptoms of raised ICP.
Poor academic performance
Photophobia
Dizziness
Less commonly, seizures, abdominal
swelling

Complications of CSF drainage

Infection
Brain stem herniation [coning]through the base of skull if the fluid is
withdrawn too rapidly. The effect is
irreversible as the vital centers of the
brain is damaged and is fatal.
So remember Lumbar Puncture is
contraindicated in suspected patients
with Increased ICP

Nursing care - preoperative

Assessment
-signs of increased ICP
-behaviour and conscious level
-vital signs specially respiration and
heart rate/ pulse.
-parental and childs emotional
status
-financial support
-support system

Nursing diagnoses
Impaired tissue perfusion [cerebral] related to the
congestion of cerebral blood vessels from collected CSF
and increased arterial resistance manifested by
drowsiness, irritability, and a low Glasgow coma scale
score.
Objective
Cerebral tissue perfusion will improve during the shift
following nursing and collaborative interventions
evidenced by increased Glasgow coma scale score and
alertness and reduced irritability.

Spina Bifida
Meaning Spina Bifida is a neural tube defect [ A disorder
involving incomplete development of the brain, spinal
cord, and / or their protective covering] caused by a the
failure/ improper closure of fetuss spine during the first
month of pregnancy [during this time, the tissues
destined to become meninges and vertebrae encloses
the neural tube]
It can occur anywhere along the spinal column from
cervical to sacral region
Most common site is lumbar region
The major risk factor is folic acid deficiency from 3
months before to 12 weeks after conception.

Spina Bifida- types

1. Spina Bifida occulta [mildest form]

one or more vertebrae is malformed and

covered by a layer of skin
2. Spina Bifida cystica or aperta
Meningocele meninges protrude from a
spinal opening.
Myelomeningocele spinal cord and
meninges protrude from a spinal opening.
Encephalocele when the defect in the base of
skull including meninges and/ or CSF and
brain tissue protruding into a sac

36

37

Outcome / complications
Infection affected site, ascending infections
Neuropathic bladder
* UTI - from incomplete emptying
* Hydronephrosis from back flow of urine
* Renal failure.
Neuropathic bowel constipation
Mental retardation [varying degrees] learning
difficulties
Lower limb paralysis - Physical and mobility
difficulties , pressure ulcers, and other complications
of immobility.
Hydrocephalus

Management main areas

Surgery correction of defect within 24 hours of birth
and if needed ongoing surgical interventions to
maximize functional abilities
Measures to prevent infection [pre and post
operatively]

Preserve existing function in the spinal cord

Physiotherapy to strengthen the muscles,

bladder and bowel sphincters

Assistance to improve functional abilities using

assistive devices- crutches, braces and wheel chairs.

Management main areas

Prevention of pressure ulcers and other
complications of immobility
Continence management bowel and bladder
Prevent UTI and constipation
Management of hydrocephalus to improve
cerebral perfusion and to prevent further nerve
cell damage
Help the parents to cope with the situation and
education

Prognosis
Depends on the number and the severity
of abnormality.
Poorest in case of complete paralysis,
hydrocephalus and other congenital
defects

Prevention

Addition of folic acid to the diet of women of child-bearing

age
All women of child-bearing age consume 0.4 mg of folic
acid daily
UK food standard agency to introduce the compulsory
addition of folic acid into UK flour products.
{http://www.food.gov.uk/multimedia/pdfs/fsa070604.pdf}
Consume folic acid for at least one month before getting
pregnant and for three months after conception.
Antiepileptic drugs [AEDs] Carbamazepine [Tegretol]
Phenytoin , Sodium Valproate [ Epilim] can cause spina
bifida women taking AEDs have to plan ahead and avoid
accidental pregnancy.
Tests for Alpha Feto- Protein [AFP]-blood and Amniotic
fluid- during early pregnancy
Genetic counselling

Prevention
Women with the lowest B12 levels had 5 times
the risk of having a child with a neural tube
defect compared to women with the highest B12
levels.
Women who consume little or no meat or animal
based foods are the most likely group of women
to have low B12 levels, along with women who
have intestinal disorders that prevent them from
absorbing sufficient amounts of B12.
{Molloy A. M,2009}
Please refer to the journal study

Nursing care
Important assessment findings newborn period
Location and severity of nerve damage
Signs of infection
Nutritional and electrolyte balance assessment
Vital signs
Parental reactions
Older children
Other than the above
-Continence
-Coping skills
Ability to perform ADL

Nursing diagnoses
Risk for infection related to the presence of an open
lesion / loss of skin barrier and immature immune system
development.
Objective Childs temperature will remain normal during
each shift/ hospitalization following nursing and
therapeutic interventions
Baby will remain free form infection during each shift/
hospitalization following nursing and therapeutic
interventions evidenced by maintaining a normal
temperature.
Interventions Assess for any signs of infection vital signs
especially temperature, redness, swelling or drainage in
the affected area to obtain baseline data which will allow
for comparison. Or Hyperthermia is indicative of infection.

Nursing diagnoses- risk for infection

- Apply sterile saline soaks to the area and cover

the wound to prevent entry of micro organisms

and prevent fluid loss and adhesion of gauze.
- Administer prophylactic antibiotics as prescribed
to eliminate any micro organisms from the body.
- Perform aseptic dressing and care for the wound
using strict asepsis to reduce colonization of
organisms.
- Practice strict hand washing while caring for the
baby to prevent cross infection

Nursing diagnoses- risk for infection

- Minimize visitors and nurses caring for the
child to reduce the risk of transfer of
organisms form persons to the baby.
- Measure temperature every four hourlyhelps early detection of hyperthermia or
hypothermia, both can be indicative of
infection in infants
- Execute ways and means to prevent
contamination of the defect from urine and
stool.
- Parental teaching ways to minimize
transfer of microbes from them to the baby

Nursing diagnoses
Risk for injury related to the possibility of
protrusion of spinal matter through the defect in
the spinal column.
Objective
The child will remain free from protrusion of spinal
matter following nursing management during the
shift evidenced by preservation of motor and
sensory functions distal to the affected area.
Childs motor and sensory functions distal to the
affected area will remain intact following nursing
management during the shift.

Nursing diagnoses-Risk for injury

Interventions
-

Assess baby initially and continuously for any signs of nerve

dysfunction to compare with the initial findings and to identify any
deterioration early and to intervene appropriately.
Handle baby minimally to reduce the risk of prolapse of spinal
matter
Position baby prone to prevent undue pressure to the area
thereby minimize risk of prolapse.
Club nursing activities to minimize handling
Educate parents and caregivers re handling of the child education
will help to better care for the baby ; will minimize risk of prolapse.
Prepare the baby and family for surgical interventions to correct the
defect at the earliest.
Take special care [ support baby at the affected side] when shifting
and transporting baby- to prevent any further nerve prolapse.

Continence management
Bowel
Aim to prevent constipation
Measures- provide:
extra clear fluids
Foods with a high fibre content
Avoid too much food which can cause
constipation full cream milk, eggs
Encourage regular bowel emptying/ regime
Toilet training

Continence management
Bladder - Priority to preserve renal function
For infants
Assess renal and bladder functions
Teach intermittent catheterization
Vesicostomy as a temporary measure.
For pre School children Adult life
Assess renal and bladder functions yearly
Measures to prevent UTI- 6-8 glasses of fluids / day,
cranberry Juice one glass /day.
Focus more on independent Continence management at
home as well as at school, work place
Bladder training

Other Nursing diagnoses

At birth /infancy
Ineffective tissue perfusion [cerebral] related to the
congestion of cerebral blood vessels from collected CSF
and fluids.
Risk for impaired skin integrity
Anxiety and /or greiving Parental
Risk for impaired attachment
Deficient knowledge-parental
Interrupted family process
Risk for care giver role strain
Risk for delayed growth and development

Other Nursing diagnoses

Older children
Risk for /constipation
Bowel incontinence
Impaired urinary elimination
Urinary incontinence-functional
Self care deficit
Disturbed body image
Impaired physical mobility

Other possible diagnoses-older children

http://www.ncbi.nlm.nih.gov/pubmed/17683689

imbalanced nutrition: more than body

requirements
urinary incontinence
impaired transfer ability
risk for infection, risk of impaired skin
integrity, risk for latex allergy.
readiness for enhanced urinary
elimination, and readiness for enhanced
self-concept

Cerebral
Palsy (CP)
Description
Disorders characterized by
early onset
impaired movement & posture
abnormal muscle tone &
coordination
Nonprogressive
Variable etiologies and course
Most common permanent
physical disability in children
Increased prevalence may be r/t
1. Cerebral palsy; 2. Polio, spinal
increased survival of VLBW
muscle atrophy; 3. neuropathies; 4.
infants
myasthenia gravis; 5. Muscular
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dystrophies

2010 Laurel R. Talabere, PhD, RN, AE-C

Cerebral Palsy (CP)

Etiology
Pre-, peri- or postnatal factors
Single or multiple factors
Premature delivery most
important determinant
In 24%, no identifiable cause
known

Pathophysiology
Anoxia most important factor
May or may not be r/t specific
anatomic site in the brain
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Cerebral Palsy (CP)

Classification based on nature &
distribution of neuromuscular
dysfunction
Spastic (hypertonic)
most common
upper motor neuron type of
muscular weakness
Hypotonic
Dyskinetic / athetoid (uncontrolled
movements)
Ataxic (unsteady, shaky movements)
Mixed / dystonic (no dominant
motor pattern)
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Cerebral Palsy (CP)

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Cerebral Palsy (CP)

Early Signs
Delayed gross motor development
Universal manifestation of CP
Very significant if normal language & personal-social
Abnormal motor performance
Early hand dominance (usually not until preschool
years)
Abnormal crawl
Poor sucking and feeding with persistent tongue thrust
Alterations in muscle tone
infant/child feels stiff or floppy
Spasticity of hip adductor
muscles
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Cerebral Palsy (CP)

Early Signs
Abnormal postures when lying down or
walking
Reflex abnormalities - early clue of CP
Persistence of primitive infantile
reflexes
Which reflexes are shown?
When do they disappear?
See Table 5-21 Techniques for assessing
selected primitive reflexes with normal findings
& their expected age of occurrence
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Cerebral Palsy (CP)

Associated disabilities &
problems
Intellect - 70% within normal
limits
ADHD
Seizures
Feeding problems,
aspiration
Speech impairment
Orthopedic complications
Constipation
Dental problems
Vision and hearing problems
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Cerebral Palsy (CP)

Management & nursing
care
No cure
Specific aids to help with
ambulation & feeding
Speech therapy
Surgery for muscle release
Medications - muscle relaxers
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Question
Which is a significant risk factor for
cerebral palsy?
A. Weighed less than 1500 grams at birth
B. Had a positive Moro reflex at birth
C. Was born by elective cesarian section
D. was born to a mother older than 35 years.

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Seizures
Brief malfunctions of the brains electrical
system resulting from cortical neuronal
discharge
Most common neurologic
dysfunction in children
Occurs with many CNS disorders
May be epileptic or non-epileptic
Febrile seizures
Unknown cause
Associated with rapid rise in body
temperature to
at least 102.2F.
May be a family history
Do not lead to epilepsy

Usually disappear by age 3

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64

Seizures
Occurs because of sudden, abnormal
electrical activity in the brain.
Not all seizures cause convulsions.
Seizures fall into two main groups.
Focal seizures, also called partial seizures,
happen in just one part of the brain.
Generalized seizures are a result of
abnormal activity on both sides of the
brain.

Facts
Most seizures last from 30 seconds to 2
minutes
It is a medical emergency
If seizures last longer than 5 minutes or if
a person has many seizures and does not
wake up between them- could be fatal.

Causes in children
High fevers and infections (brain abscess,
meningitis, encephalitis, neurosyphilis, or AIDS)
Head injuries, birth injuries.
Tumors or bleeding in the brain.
Liver, kidney and congenital heart diseases.
Electrolyte and glucose imbalances
Accidents-Poisoning, electrocution etc..
Some medicines and drug withdrawal e.g.barbiturates
Metabolic abnormalities and diseasesPhenylketonuria

First aid and emergency care

The main goal is to protect the person from
injury. Try to prevent a fall. Lay the person
on the ground in a safe area. Clear the
area of furniture or other sharp objects.
Cushion the person's head.
Loosen tight clothing, especially around
the person's neck.
Look for a medical I.D. bracelet with
seizure instructions.

Emergency care cont

Stay with the person until he or she
recovers, or until you have professional
medical help. Meanwhile, monitor the
person's vital signs (pulse, rate of
breathing).
Administer oxygen if available
Suction airway if needed
Administer prescribed antiepileptic eg
Valium

Donts in seizures
DO NOT restrain the person.
DO NOT place anything between the person's
teeth during a seizure (including your fingers).
DO NOT move the person unless he or she is in
danger.
DO NOT try to make the person stop convulsing.
DO NOT give the person anything by mouth until
the convulsions have stopped and the person is
fully awake and alert.
Do not attempt mouth to- mouth breathing or
CPR

NURSING PRIORITIES
1. Prevent/control seizure activity.
2. Protect patient from injury.
3. Maintain airway/respiratory function.
4. Promote positive self-esteem.
5. Provide information about disease
process, prognosis, and treatment needs.

DISCHARGE GOALS
1. Seizures activity controlled.
2. Complications/injury prevented.
3. Capable/competent self-image
displayed.
4. Disease process/prognosis, therapeutic
regimen, and limitations understood.
5. Plan in place to meet needs after
discharge.

Nursing diagnoses
During seizure
-Risk for injury, Risk for aspiration
-Risk for impaired cerebral tissue perfusion
After seizures- Acute Confusion ,Fatigue
-Anxiety
Others -Disturbed self esteem
-Deficient knowledge
-Ineffective or readiness for enhanced
therapeutic regimen management
73

Seizures:
Epilepsy

Video Clip: Portrait of a Child with Epilepsy

Treatment Options for Children with Epilepsy
http://healthology.healingwell.com/focus_index.
asp?b=healingwell&f=epilepsy

Chronic seizure disorder with recurrent, unprovoked

seizures
2.3 million cases in US
Etiology
Usually idiopathic
Can be caused by stroke,
tumor, infection, poisoning
Congenital & familial factors
may be involved
Can be acquired from injury:
pre-, peri- or postnatal
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Seizures: Epilepsy
Pathophysiology
Spontaneous
electrical discharge
begins in
hyperexcitable cells
which are the
epileptogenic focus
Common types & specific
etiologies
Status epilepticus
See Table 26-6:
Management of Status
Epilepticus

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Seizures: Epilepsy
Common myths
Epilepsy is contagious
Someone having a seizure might swallow their
tongue
Someone having a seizure should be restrained
A person cannot die from a seizure
A person with epilepsy has physical limitations

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76

Seizures: Epilepsy
Presenting signs needing further
evaluation

Sudden, unexplained falls

Unusual sleepiness or irritability when awakened
Sudden spasms
Dazed or confused behavior
Nodding head
Rapid blinking
Complaints about funny sights, sounds, tastes
or smells

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Seizures: Epilepsy
Diagnosis
Process:
Determine type of seizure
Understand cause

Thorough family & child hx

Neurological & developmental assessment
Blood studies
EEG including
waking/sleeping
MRI
LP

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Seizures: Epilepsy
Management
Goals
Control seizures
Reduce frequency
& severity
Correct cause
Normalize childs
life
Drug therapy
One drug
(monotherapy)
More than one drug
(adjunctive therapy)
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Seizures: Epilepsy
Management
Ketogenic diet
High-fat, just enough protein for growth, limited CHO
Prevents seizures, reason unknown
Used if poor response to medication(s)

Vagus nerve stimulation

Device in chest with electrode around vagus nerve
Periodic stimulation disrupts abnormal brain activity

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2010 Laurel R. Talabere, PhD, RN, AE-C

Seizures: Epilepsy
Management
Surgical therapy
resection of lesion(s)
Focal excision
Corpus callosum
sectioning

Variable prognosis
Best predictors of
remission:
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< 12 years
normal intelligence
no neonatal seizures

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81

Seizures: Epilepsy
Nursing care

Carefully observe &

document
Insure the childs safety
Observe for drug
complications
Exploration & management
of triggers
School nurse referral
Child and family teaching
Support groups
Seizure precautions

Fig. 26-6. Ball, J.W. & Bindler, R.C. (2008).

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Question
A child, brought to the emergency room after having a
seizure, has no previous history of seizures. The father
says, I cant believe my child has epilepsy. The nurses
best response is:
A. Epilepsy is easily treated with anticonvulsant
medications.
B. Very few children actually develop epilepsy.
C. The seizure may or may not mean your child has
epilepsy.
D. Your child had only one seizure so it probably wont
happen again.
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Question
What is status epilepticus?

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Headaches

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Common etiologies
Emotional stress
Missed breakfast, caffeine withdrawal
Cold, flu, sinusitis
Lack of sleep
Food sensitivities, allergies
Eye strain
Eye, ear, nose, tooth, sinus or neck
inflammation; jaw disorders; neuralgias
Less common etiologies
Substance abuse
Recent head injury
Meningitis
Hypertension
Brain tumors
2010
Laurel
R. Talabere, PhD,
A-V
malformation
or brain aneurysm
RN, AE-C

85

Headaches
Assessment

Facial expression
Fever
Pain
Dizziness / fainting
Change in behavior / LOC
Visual changes
Nausea / vomiting

Ask the child what caused it

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RN, AE-C

86

Headaches
Refer if:

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Persistent emesis
Stiff neck
Seizures
Blurred vision or spots
Lethargy / confusion / fainting
Repeated school absences
Repeatedly seen in school clinic
Pain that interferes with usual activities
HA wakes child from sleep or occurs early AM

2010 Laurel R. Talabere, PhD,

RN, AE-C

87

Onset in childhood
In 5% schoolagers & 20% of adolescents
More frequent in girls
Usually in children with family history
Clinical presentation

Precipitating events:

Up to 90% associated with nausea, vomiting

Morning or night
Pulsating or throbbing pain
May cause lightheadedness, dizziness,
photophobia

Headaches:
Migraines

Menstrual period
Missing meals
Birth control pills
Letdown after stress

Relieved with sleep

Classic

Location

Unilateral

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Prodromal

Well-defined: aura, aphasia,

hemianopsia, scotoma

Common
Generalized
Vague changes: personality 88
2 loss
change, appetite

Headaches: Migraines

http://www.chclibrary.
org/micromed/images
/00011093.jpg
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2010 Laurel R. Talabere, PhD,

RN, AE-C

89

Headaches: Tension
Most common type in children
http://www.nlm.nih.gov/medli
neplus/ency/images/ency/full
size/19247.jpg

Not associated with vomiting, visual changes

Usually dull, aching, steady; like a tight band
around head
Usually bilateral, may also be front & back
Not relieved with sleep
Can occur almost daily
Usually triggered by stress / emotional factors

06/30/15

Pressure / competition at school or home

Arguments with parents or friends
Excessive demands by parents
Feeling90anxious or depressed

Headaches
First line teaching interventions
http://www.cozbaldwin.com/images/do
odledraw/headache.jpg

06/30/15

Regular meals, sleep schedule, exercise

Avoid foods that trigger headaches:
Cheese
Processed meats
Chocolate
Caffeine
MSG / Asian foods
Nuts
Pickles
Shellfish
Sugar
Alcohol
Identify other triggers like stress,
too much exercise or physical
91 certain activities
activity,

Headaches
Management & nursing care
Stress management
Biofeedback
Medications
Symptomatic
Abortive
Preventive

http://images.amazon.com/imag
es/P/0684873095.01.LZZZZZZZ
.jpg

Keep a headache diary

http://my.webmd.com/content/articl
e/46/1826_50671.htm?
z=1826_50690_6512_0000_00_31
06/30/15

Ongoing follow-up care

School nurse referral
Clinic
92

Selected Nursing Diagnoses,

Outcomes & Interventions
Nsg Dx

Outcomes

Major Interventions

Aspiration,
Risk for

Aspiration Prevention

Aspiration Precautions
Swallowing Therapy
Vomiting Management

Disuse
Syndrome,
Risk for

Endurance

Activity Therapy
Energy Management

Family
Processes,
Interrupted

Family Coping

Coping Enhancement
Family Support

Family Functioning

Family Integrity Promotion

Family Process Maintenance

06/30/15

93

References.
Wong, D.L. & Whaley, L.F. (2009). Essentials of
pediatric nursing (5th ed) St. Luis: Mosby.
http://www.food.gov.uk/multimedia/pdfs/fsa070604.
pdf
http://www.ncbi.nlm.nih.gov/pubmed/17683689
Brown, J.P. Orthopaedic care of children with
spina bifida: you've come a long way, baby!
Orthop Nurs. 2001 Jul-Aug;20(4):51-8.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2012
852/?tool=pmcentrez
(Bacterial Meningitis in Spina Bifida Cystica A Review
of 37 Cases John Lorber and Malcolm Segall)

References
Bruce, M.G.& e tal (2001) Risk factors for
meningococcal disease in college students. JAMA.
Aug 8;286(6):688-93. Pediatrics. 2005 Aug;116(2):496505. Epub 2005 Jul 1.
American Academy of Pediatrics Committee on
Infectious Diseases (2005). Prevention and control of
meningococcal disease: recommendations for use
of meningococcal vaccines in pediatric patients
(http://www.scribd.com/doc/12307434/NursingcribcomNURSING-CARE-PLAN-Seizure)