Seizure disorders

- Seizures are disturbance in

normal brain function
resulting from abnormal
electrical discharges in the
brain
- Most seizures happen
within the first years of life
ETIOLOGY :
1. Perinatal hypoxia
2. Infection
3. Congenital malformation
4. Metabolic disturbances lead poisoning
5. Head injury
6. Drug abuse, alcohol misuse
7. Tumor
8. Medication
9. Toxin exposure
10. Genetic
PATHOPHYSIOLOGY :

1. Seizures result from overly

active and hypersensitive
neurons in the brain that
trigger excessive electrical
discharges
2. The location of the
abnormal cells and the
pattern of discharges
determine the clinical
manifestations
Categories :

1. Generalized seizure – involves both hemispheres

of the brain. May or may involve prodromes
2. Partial ( focal) – limited area of cerebral cortex.
Can be partial or complex
3. Unclassified – neonatal seizures
ASSESSMENT FINDINGS :

A. Generalized seizure
1. Tonic- Clonic ( grand mal )
- rigidity, extension of extremities, fixed jaw, respiratory
cessation, dilated pupils (tonic)
- rhythmic jerking of extremities ( clonic)
2. Tonic – stiffening of the body
3. Clonic – clonic muscle activity
4. Atonic – sudden loss of muscle tone, confusion
5. Myoclonic- generalized short-term muscle contractions
6. Absence ( petit mal) – brief periods of unconsciousness
or unawareness
B. Partial seizures
1. Simple partial- maintenance of consciousness,
abnormal movement of leg, tingling sensation,
smell or taste, dejavu or anger
2. Complex – begin as simple and progress to
unconsciousness, lip smacking, wandering, doing
purposeful movements

C. Status epilepticus- continuous, generalized seizure

with danger of cardiac and brain damage
D. Infantile spasm- seen in first few months of life
that is characterized by brief flexion of the neck
trunk or legs
LABORATORY FINDINGS :

1. Electroencephalogram (EEG)
2. CBC
3. Serum medication levels
NURSING MANAGEMENT :
1. Have the child wear a helmet
2. Pad the bedside rails
3. Have oxygen and suction at bedside
4. During the seizure;
 Do not restrain the child
 Do not place anything in the mouth
 Remove harmful objects from the area
 Hyperextend the neck to maintain an airway
 Position to her side to allow flow of secretions
from the mouth
 Loosen tight clothing
 Time the duration of the seizure
Picture 1 - Place your child on his side on a soft surface.
5. Administer Anticonvulsant
Ex: Carbamazepine
(Tegretol)
Phenytoin (Dilantin)
Diazepam ( Valium)
6. Document all seizure
activity
 Triggering factor
 Aura
 Time began and ended
 Clinical manifestations
 Post seizure behavior
and symptoms
7. Avoid exposure to known precipitants
8. Prepare the family for alternative treatments
 FEBRILE SEIZURES
- Associated with high fever ( 38.9 to 40 degree C)
- Most common in preschool (5 months to 5 years) ,
occur as early as 7 months and as late as 7 years
- Seizures shows an active tonic-clonic pattern which
lasts for 15-20 seconds
- EEG tracing is usually normal
Etiology:
1. May occur after immunization
because of fever
2. Family history
- It is unclear whether this type of seizure is initiated by
a consistently high fever or by a sudden spike of
temperature
- The seizures subsides quickly once the fever is lowered

* Meningitis often manifests initially with high fever and

a seizure
Prevention :
1. Acetaminophen
2. Diazepam ( Valium)- if second febrile seizure
occurs
3. A child must be seen by a neurologist
Nursing management :

1. Tepid sponge bath – after the seizures

2. Do not apply or rub alcohol –cause extreme
cooling
3. Do not give antipyretic during seizure – the child
may be drowsy postictal and might aspirate the
medicine
4. Lumbar puncture – to rule out meningitis
 Neural Tube Defects
- A group of related defects of the central nervous system
involving the cranium or spinal cord that vary from
mildly to severely disabling
Etiology:

1. Folic acid deficiency

2. Multifactoral
Pathophysiology:

1. During the 3rd to 4th week of gestation, the neural

plate closes to form the neural tube that eventually
forms the spinal cord and brain
2. The vertebral column develops along with the spinal
cord
3. Neural tube defects result from malformations of the
neural tube during embryonic development
Types of neural tube defects

1. Anencephaly
- absence of cerebral
hemisphere or brain
- Brain stem and cerebellum
may be present
- it is incompatible with life
- most neonates are stillborn
- Some may survive for a
number of days
2. Encephalocele
- Occurs when meningeal
and cerebral tissue
protrudes in a sac through
a defect in in the skull
- Occiput is the most
common site
- Many infants have
hydrocephalus
- In mild forms - little or no
residual neurologic
impairment
3. Spina bifida
- A defective closure of the vertebral column
- May occur anywhere, but usually in the lumbosacral area

a. Occulta
- does not affect the spinal cord
- may go undetected
- most children shows no neurologic signs
- some shows motor or sensory deficits of the lower
extremities, urinary and bladder sphincter

Assessment :
1. Dimpling of the skin
2. Nevi
3. Hair tufts
b. Meningocele
- A sac contains the meninges and
cerebrospinal fluid protrudes
outside the vertebrae
- Little or no neurologic
involvement

Assessment :
1. Protruding mass at the center of
the back approximately the sixe of
an orange
c. Myelomeningocele
- Spinal cord and accompanying nerve roots
are involved
- Involves sensorimotor deficits, urinary and
bowel problems

Assessment :
1. Protruding mass like meningocele
2. Flaccidity of lower extremities
3. Partial or complete paralysis of the legs
4. Weakness of the hips, legs, or feet of a
newborn
5. Urinary incontinence
6. Hydrocephalus (80%)
7. Congenital dislocation of the hip and
club foot (talipes) Loss of bladder or
bowel control
myelomeningocele
Diagnostic findings:

1. Ultrasound
2. Amniocentesis
3. Alpha feto-ptotein ( maternal or fetal)
Management:

1. Occulta
- no treatment indicated unless there’s neurologic
damage

2. Meningocele
- Requires closure as soon after birth as possible – to
prevent infection
- Monitor child for hydrocephalus, meningitis, spinal
cord dysfunction
3. Myelomeningocele
- There is no cure
- Closure within 24 hours – prevents infection and
further damage
- Shunting if with hydrocephalus
- Antibiotics
- Management of musculoskeletal, urologic, bowel
problems
Nursing management:

1. Assess vital signs

2. Measure head circumference
3. Assess neurologic status
- consciousness
- confusion
- disorientation
- lethargy (drowsiness)
- stupor (unresponsiveness)
- coma (unconsiousness)
Nursing diagnosis

1. Risk for infection

2. Risk for imbalanced nutrition
3. Risk for ineffective tissue perfusion
4. Risk for impaired skin integrity
4. Assess for signs of intracranial pressure (ICP)
- Tense, bulging anterior fontanelle
- High-pitched cry
- Increase head circumference
- Irritability, restlessness

- minimize stress if with increase ICP

5. Preoperative - cover the lesion with sterile dressing with
sterile saline
6. Postoperative care
a. examine dressing for leakage
b. avoid placing diaper over the lesions
c. monitor for signs of infection (fever, irritability, poor
feeding)
d. Prone or side-lying position
e. Place a pad between the knees, feet in neutral
position, a roll under the ankles – prevent hip
subluxation
f. Pad bony prominences
7. Prevent urinary complications
a. Instruct family on self-catherization (intermittent) –
every 4 hours
b. Prevent UTI ( perineal hygiene, use cotton
underwear)
8. Prevent injury due to neuromuscular impairment
a. Risk of pressure sores – due to decreased sensation
b. Turn frequently
c. Always check for skin irritants ( wrinkled linen,
wheelchair belts)
9. Promote optimum bowel functioning
a. Colon training
b. High fiber , low carbohydrate diet
c. Exercise the lower extremities
d. Knee-chest position – aids in bowel evacuation
e. Rectal stimulation using digit or suppository
10. Promote family coping
a. Encourage as much normalcy as possible
b. Discuss the need for lifelong care

11. Teach women of child-bearing age – consume 0.4 mg

of folic acid daily
 HYDROCEPHALUS
- A condition caused by an imbalance
in the production and absorption of
cerebrospinal fluid (CSF) in the
ventricular system
- Occurs with a number of anomalies
such as neural tube defects
MRI showing pulsation of CSF
Etiology:
1. Malformation
2. tumors
3. Hemorrhage
4. Infection
5. trauma
The cerebrospinal fluid (CSF) bathes the brain and spinal cord. Most of the CSF
is in the ventricles of the brain, which are large cavities within the brain which
produce and reabsorb the CSF.
In hydrocephalus, the ventricles of the brain become enlarged with cerebrospinal fluid. This condition
causes the brain tissue to become compressed against the skull, thus causing serious neurological
problems. Shunting, called ventriculoperitoneal shunting, is necessary to drain the excess fluid and
relieve the pressure in the brain. This should be done as soon as hydrocephalus is recognized to give the
child the best possible neurological outlook
This procedure is performed in the operating room
under general anesthesia. A flap is cut in the scalp and a
small hole is drilled in the skull.
A small catheter is passed into a ventricle of the brain. A pump is attached to
the catheter to keep the fluid away from the brain. Another catheter is
attached to the pump and tunneled under the skin, behind the ear, down the
neck and chest and into the peritoneal cavity (abdominal cavity). The CSF is
absorbed in the peritoneal cavity.
 Classification
1. Non-communicating
- flow of CSF from the ventricles to subarachnoid space
is obstructed

2. Communicating
- flow is not obstructed, but CSF is inadequately
reabsorbed in the subarachnoid space
Assessment
 Infant to 2 yrs old
- Increase head circumference
- Thin, widely separated bones of the head.
- Macewen’s sign- cracked pot sound
- Tense, bulging anterior fontanel and non-pulsating
- Dilated scalp veins
- Frontal bossing and sun-setting eyes
- Downward rotation of the eye
- Vomiting
- Lethargy
- Irritability
- High-pitched cry
- Abnormal muscle tone
Older Children
- changes on head size less common
- irritability and lethargy
- headache on awakening
- nausea and vomiting
- ataxia (uncoordinated movement)
- nystagmus
- late signs: high shrill cry
: seizure activities
: alteration in consciousness
; papilledema
nystagmus
 Diagnostic test
1. Serial Transillumination- detect
increases in light areas
2. CT Scan – shows dilated
ventricles as well as presence of
mass
- with injection of dye shows
course of CSF flow
 Treatment
1. Surgery
Goal- prevent further CSF
accumulation

Shunting
> insertion of a flexible tube
into the lateral ventricle of
the brain (peritoneum or
right atrium)

a. Ventriculoperitoneal
b. Ventriculoatrial
Nursing management
Preoperative care :
1. Monitor vs and neurological signs
2. Firmly support head when holding the child
3. Small frequent feeding
Postoperative care:
1. Assess signs of increase ICP(increase temp., increase
BP, decreased pulse rate, dec, LOC, poor suck,
vomiting)
2. Position patient on the unoperated site
3. Antibiotics, analgesics
4. Shunt care
- shunt overdrainage – headache, dizziness, nausea
- infection – vomiting, fever, headache, irritability,
lethargy, fluid around the valve
5. Flat on bed, or elevate 30 degrees
Parents instructions
1. Wound care
2. Positioning of infant and how to pump the shunt
3. Signs of infection
4. Signs of inc ICP
5. Need for repeated shunt revisions as child grows or if
shunt become blocked or infected
Cerebral Palsy
 Group of disabilities caused by injury or insult to
the brain either before birth, during birth, or early
infancy
 Chronic, nonprogressive disorder of posture and
movement
 1. Spastic cerebral palsy

• Spastic hemiplegeia
- spasticity (muscle stiffness) on one side of the
body - usually just a hand and arm, but may
also involve a leg
- the side that is affected may not develop
properly.
- may have speech problems
- majority of cases intelligence is not affected
 Spastic diplegia

- lower limbs are affected

- little or no upper body
spasticity
- leg and hip muscles are
tight
- legs cross at the knees,
making walking more
difficult (scissoring)
• Spastic quadriplegia

- legs, arms, and body are affected

- the severest from of spastic cerebral
palsy
- more likely to have mental retardation
- walking and talking will be difficult
 2. Ataxic cerebral palsy
- the child will find it difficult to tie his/her shoelaces,
button up shirts, cut with scissors, and other fine
motor skills
- walk with the feet far apart
- intention tremors - a shaking that starts with a
voluntary movement, such as reaching out for a toy,
the closer he/she gets to the toy the worse the tremors
become
3. Athetoid or dyskinetic (athetoid dyskinetic)
cerebral palsy
- Athetosis (wormlike
movement)
- Dyskinetic movement of
mouth
- Drooling
- Dysarthria
- Jerky movement, dystonia
(impaired muscle tone)
4. Mixed Cerebral Palsy

- have both the tight muscle tone of spastic

cerebral palsy and the involuntary movements
of athetoid cerebral palsy.
Etiology
1. Prenatal brain abnormalities
2. Prematurity
3. Perinatal factors
- asphyxia
- ischemia
- trauma
- infection
- hyperbilirubinemia, hypoglycemia
4. infection, trauma, tumors in early infancy
5. Unknown
Diagnostic exams:

• Magnetic resonance imaging (MRI)

• Cranial ultrasound
• Computerized tomography (CT)
• Electroencephalography (EEG)
Additional tests
- specialists for assessments of other conditions that
are often associated with the disorder
• Vision impairment
• Hearing impairment
• Speech delays or impairments
• Intellectual disabilities or mental retardation
• Other developmental delays
Management
Interventions for CP should be directed at maximizing the
quality of life by improvement in daily function and
reduction of the extent of disability.

Team approach (Multidisciplinary approach)

1. Primary care doctor
2. Dentist (dental check-ups are recommended around
every 6 months)
3. Social worker
4. Nurses
5. Occupational, physical, and speech therapists
Medication
- help control muscle spasms and seizures.
1. Glycopyrrolate (eg, Robinul)-to decrease drooling
2. Pamidronate (eg, Aredia)-to treat Osteoporosis
- use to treat spasticity:
1. Botulinum toxin
2. Baclofen (eg, Lioresal)- muscle relaxant
3. Diazepam (eg, Valium) - anticonvulsant
4. Tizanidine (eg, Zanaflex)- muscle relaxant
Surgery
 Certain operations may improve the ability to sit,
stand, and walk.
Physical Aids
• Braces and splints help keep
limbs in correct alignment and
prevent deformities.
• Positioning devices enable
better posture.
• Walkers , special scooters, and
wheelchairs make it easier to
move around.
Nursing management
1. Provide a safe environment – helmet, kneepads
2. Prevent physical deformity – braces, walkers
3. Promote mobility –allow to do activities
4. Encourage self care
5. Facilitate speech
- talk slowly, use pictures, sign language, picture
board
- early speech therapy6
6. Promote positive self image
7. Promote optimal family functioning
 Meningitis
Most common CNS infectious process: bacterial or
viral
 Primary: bacteria or viruses
 Secondary: neurosurgery, trauma, sinus, ear, or
systemic infections
 Most common between 1 month and 5 years; any
age
Etiology:
- 2mos-12 years: H. influenzae type B, N. menigitidis, &
Streptococcus pneumoniae (95% of bacterial
meningitis)
- Neonatal: E. coli & group B strep
- Older children/adolescents: Meningococcal (droplet
transmission)
Assessment
Children below 2 year old
1. Poor feeding
2. Irritability, lethargy
3. High-pitched cry
4. Bulging fontanel
5. Fever or low temp.
6. opisthotonus
Opisthotonus
Older children
1. Resp. or GI problem
2. Nuchal rigidity (stiff neck)
3. Headache
4. (+) Kernig’s sign
5. (+)Brudzinski’s sign
Classic Signs and Symptoms

1. Nuchal rigidity

2. (+) Kernig’s sign

3. (+)Brudzinski’s
sign
Diagnosis:

1. CSF analysis (by lumbar puncture)

- increased WBC’s and protein; decreased glucose
(bacteria feed on glucose)
- not performed if with increase ICP ( prevent brain
herniation)

2. CBC – increase WBC

3. Blood culture
Lumbar puncture
 Nursing care
1. Frequently assess vital signs, LOC, neurologic
assessment to identify changes in the child’s
condition.
2. Measure head circumference frequently- risk
for hydrocephalus.
3. Monitor intake and output
- limit fluid intake to prevent cerebral edema
4. Promote comfort
- reduced stimulation (dim lights, quiet
room)
5. Side-lying position
6. Identify parents’ concerns, provide support
7. Prevention is a major role for nurses.
8. Encourage parents to get their infants and
children fully immunized!
Therapeutic Management

 Medical Emergency
 Isolation (droplet)
precautions for 24 hours
after antibiotic treatment
begins
 Antimicrobial therapy
 Hydration
 Reduce increased ICP
 Management of bacterial
shock
 Control seizures
 Control temp extremes
 Treatment of complications
Complications
 Life Threatening Condition
 If Survival:
 Hearing loss
 Blindness
 Paresis
 Intellectual impairment
Thank you