HEAD INJURY
Increased head circumference
A. Description
a. Head injury is the pathological result of any
mechanical force to the skull, scalp, meninges,
or brain
b. Manifestations depend on the type of injury and
the subsequent amount of increased intracranial
pressure (ICP).
B. Assessment (ICP)
a. Early Signs
i. Headache
ii.Visual Disturbance, diplopia
iii. Nausea and vomiting
iv. Dizziness or vertigo
v. Slight change in vital signs
vi. Change in papillary response and
equality
vii.Sunsetting eyes
viii.Slight change in level of
consciousness
ix. Infant: bulging fontanel; wide sutures,
increased head circumference; dilated
scalp veins; high-pitched cry
b. Late Signs
i. Significant decrease in level of
consciousness
ii.Cushing’s triad: increased systolic
blood pressure and widened pulse
pressure, bradycardia, and irregular
respirations
iii.Decorticate posturing: adduction of
the arms at the should, the arms being
flexed on the chest with the wrists
flexed and the hands fisted, and the
lower extremities being extended and
adducted; seen with severe
dysfunction of the cerebral cortex.
iv.Decerebrate postuing: rigid extension
and pronation of the arms and the
legs; a sign of dysfunction at the level
of the midbrain.
v. Fixed and dilated pupils
C. Interventions
a. Monitor the airway
b. Assess injuries; immobilize the neck if a cervical
injury is suspected
c. Monitor vital signs and neurological function
d. Monitor for decreased responsiveness to pain
( a significant sign of altered level of
consciousness).
e. Initiate seizure precautions.
f. Maintain a nothing-by-mouth status or provide
clear liquids if prescribed, until it is determined
that vomiting will not occur.
g. Administer oxygen and intravenous fluids as
prescribed.
h. Monitor intravenous fluids carefully to avoid
aggravating any cerebral edema and to
minimize the possibility of overhydration.
i. Elevate the head of the bed 15 to 30 degrees if
not contraindicated.
j. Position the client so that the head is maintained
midline to facilitate venous drainage and avoid
jugular vein compression; turning side to side is
contraindicated because of the risk of jugular
vein compression.
k. Assess wound dressings for the presence of
drainage and monitor for nose or ear drainage,
which could indicate leakage off cerebrospinal
fluid (CSF); drainage that is positive indicates
leakage of CSF from a skull fracture.
l. Administer tepid sponge baths or place on a
hypothermia blanket if hyperthermia occurs.
m. Suctioning through the nares is contraindicated
because of the high risk of a secondary infection
and the probability of the catheter entering the
brain through a fracture.
n. Administer acetaminophen (Tylenol) for
headache, anticonvulsants for seizures,
antibiotics if a laceration is present, and tetanus
toxoid as appropriate.
o. Sedating medications are withheld during the
acute phase of the injury.
p. Monitor for signs of brainstem involvement
i. Deep, rapid, or intermittent and
gasping respirations
ii. Wide fluctuations or noticeable
slowing of the pulse
iii. Widening pulse pressure or extreme
fluctuations in blood pressure
q. Epidural hematoma: monitor for asymmetric
pupils (one dilated, unreactive pupil in a
comatose child is a neurosurgical emergency
that may require evacuation of the hematoma).
HYDROCEPHALUS
A. Description
a. Hydrocephalus is an imbalance of CSF
absorption or production caused by
i. Malformations
ii. Tumors
iii. Hemorrhage
iv. Infections, or
v. Trauma
b. Hydrocephalus results in head enlargement
and increased ICP
B. Types
a. Communicating
i. Hydrocephalus occurs as a result
of impaired absorption within the
subarachnoid space
ii. Interference of the cerebrospinal
fluid within the ventricular system
does not occur.
b. Noncommunicating
i. Obstruction of cerebrospinal flow
within the ventricular system
occurs
C. Assessment
a. Infant
i.
ii.Thin, widely separated bones of
the head that produce a cracked-
pot sound (Macewen’s Sign) on
percussion
iii. Anterior fontanel tense, bulging,
and non-pulsating
iv. Dilated scalp veins
v. Frontal bossing
vi.Sunsetting eyes
b. Child
i. Behaviour changes such as
irritability and lethargy
ii. Headache on awakening
iii. Nausea and vomiting
iv. Ataxia
v. Nystagmus
c. Late signs: a high, shrill cry and seizure
activities
D. Surgical Interventions
a. The goal of surgical treatment is to prevent
further CSF accumulation by bypassing the
blockage and draining the fluid from the
ventricles to a location where it may be
reabsorbed.
b. In a ventriculoperitoneal shunt, the CSF
drains into the peritoneal cavity from the
lateral ventricle.
c. In an atrioventricular shunt, CSF drains into
the right atrium of the heart from the lateral
ventricle, bypassing the obstruction (used
in older children and in children with
pathological conditions of the abdomen).
E. Interventions postoperatively
a. Monitor vital signs and neurological signs
b. Position client on the unoperated side to
prevent pressure on the shunt valve.
c. Keep the child flat as prescribed to avoid
rapid reduction of intracranial fluid
d. Observe for increased ICP; if increased
ICP occurs, elevate the head of the bed to
15 to 30 degrees to enhance gravity flow
through the shunt
e. Monitor for signs of infection and assess
dressings for drainage.
f. Measure head circumference.
g. Monitor intake and output.
h. Provide comfort measures, administer
medications as prescribed, which may
include diuretics, antibiotics, or
anticonvulsants.
i. Instruct parents in how to recognize shunt
infection or malfunction.
j. In a toddler, headache and lack of appetite
are the earliest common signs of shunt
malfunction.
SPINA BIFIDA
A. Description
 a. Spina Bifida is a central nervous system
defect that occurs as result of neural tube
failure to close during embryonic
development
b. Associated deficits include sensory motor
disturbance, dislocated hips, clubfoot, and
hydrocephalus
c. Defect closure usually is done during
infancy
B. Types
a. Spina Bifida occulta
i. Posterior vertebral arches fail to
close in the lumbosacral area
ii. Spinal cord remains intact and
usually is not visible
iii.Meninges are not exposed on
the skin surface
iv. Neurological deficits are not
usually present.
b. Spina bifida cystica
i. Protrusion of the spinal cord
and/or its meninges occur
ii. Defect results in incomplete
closure of the vertebral and
neural tubes, resulting in a
saclike protrusion in the lumbar
or sacral area, with varying
degrees of nervous tissue
involvement
iii.Defect can include
meningocele, myelomeningocele,
REYE’S SYNDROME
lipmeningocele, and
lipomeningomyelocele.
c. Meningocele
i. Protrusion involves meninges
and a saclike cyst that contains
CSF in the midline of the back,
usually in the lumbosacral area
ii. Spinal cord is not involved
iii. Neurological deficits are usually
not present
d. Myelomeningocele
i. Protrusion of meninges, CSF,
nerve roots, and a portion of the
spinal cord occurs.
ii. The sac (defect) is covered by a
thin membrane that is prone to
leakage or rupture.
iii. Neurological deficits are evident.
C. Assessment
a. Depends on the spinal cord involvement
b. Visible spinal defect
c. Flaccid paralysis of the legs
d. Altered bladder and bowel function
e. Hip and joint deformities
D. Interventions
a. Evaluate the sac and measure the lesion
b. Perform neurological assessment
c. Monitor for increased ICP; which might
indicate developing hydrocephalus
d. Measure head circumference; assess the
anterior fontanel for fullness
e. Protect the sac; cover with a sterile, moist
(normal saline), nonadherent dressing to
maintain the moisture of the sac and
contents, and change the dressing every 2
to 4 hours as prescribed.
f. Placed in a prone position to minimize
tension on the sac and the risk of trauma;
the head is turned to one side for feeding.
g. Change the dressing covering the sac
whenever it becomes soiled because of the
risk of infection; diapering may be
contraindicated until the defect has been
repaired.
h. Use aseptic technique to prevent infection
i. Assess the sac for redness, clear or
purulent drainage, abrasions, irritation, and
signs of infection.
j. Early signs of infection include elevated
temperature (axillary), irritability, lethargy,
and nuchal rigidity.
k. Assess for physical impairments such as
hip and joint deformities.
l. Prepare the child and family for surgery
m. Administer antibiotics as prescribed to
prevent infection
n. Administer anticholinergics to improve
urinary continence and laxatives to achieve
bowel continence in the child, and
antispasmodics to control bladder spasms.
A. Description
a. Reye’s syndrome is acute encephalopathy
that follows a viral illness and is
characterized pathologically by cerebral
edema and fatty changes in the liver.
b. The exact cause is not clear
c. Administration of aspirin is not
recommended for children with varicella or
influenza because of its association with
Reye’s syndrome
d. Acetaminophen (Tylenol) is considered the
medication of choice for pediatric clients.
e. The goal of treatment is to maintain
effective cerebral perfusion and control
increasing ICP.
B. Assessment
a. History of systematic viral illness 4 to 7
days before the onset of symptoms
b. Malaise
c. Nausea and vomiting
d. Progressive neurological deterioration
C. Interventions
a. Assess neurological status
b. Monitor for altered level of consciousness
and signs of increased ICP.
c. Monitor intake and output
d. Provide rest and decrease stimulation in
the environment.
e. Monitor for signs of bleeding and signs of
impaired coagulation, such as a prolonged
bleeding time.
f. Monitor liver function studies.
MENINGITIS
A. Description
a. Meningitis is an infectious process of the
central nervous system caused by bacteria
and viruses that may be acquired as a
primary disease or as a result of
complications of neurosurgery, trauma,
infection of the sinus or ears, or systemic
infections.
b. Diagnosis is made by testing CSF obtained
by lumbar puncture, which shows increase
pressure, cloudy CSF, high protein, and
low glucose.
c. Meningococcal meningitis occurs in
epidemic form and is the only type readily
transmitted by droplet infection from
nasopharyngeal secretions.
d. Viral meningitis is associated with viruses
such as mumps, paramyxovirus,
herpesvirus, and enterovirus.
B. Assessment
a. Signs and symptoms vary, depending on
the type, the age of the child, and the
duration of the preceding illness; there is no
one classic sign of symptom.
b. Fever, chills
c. Vomiting, diarrhea
d. Poor feeding or anorexia
e. Nuchal rigidity
f. Poor or high-pitched cry
g. Altered level of consciousness, such as
lethargy or irritability
h. Bulging anterior fontanel in the infant
i. Kernig’s sign and Brudzinski’s sign in
children and adolescents.
j. Muscle or joint pain
k. Petechila or purpuric rashes
(meningococcal infection)
C. Interventions
a. Provide isolation and maintain it for at least
24 hours after antibiotics are initiated
b. Administer antibiotics as prescribed
c. Perform neurological and cardiovascular
assessment
d. Assess for personality changes and
irritability
e. Monitor intake and output
f. Assess nutritional status
g. Determine close contacts of the child with
meningitis because the contacts will need
prophylactic treatment.
SEIZURE DISORDERS
 A. Description
a. Sudden, transient alterations in brain
function resulting from excessive levels of
electrical activity in the brain
b. Classified as partial or generalized, or
unclassified, depending on the area of the
brain involved
B. Assessment
a. Obtain information from the parents about
the time of onset, precipitating events, and
behaviour before and after the seizure.
b. Determine the child’s history related to
seizures
C. Seizure Precautions
a. Raise the side rails when the child is
sleeping or resting
b. Pad the side rails and other hard objects
c. Place a waterproof mattress or pad on the
bed or crib.
d. Instruct the child to wear or carry medical
identification
e. Instruct the child in precautions to take
during potentially hazardous activities
f. Instruct the child to swim with a companion
g. Instruct the child to use a protective helmet
and padding during bicycle riding,
skateboarding, inline skating.
h. Alert caregivers to the need for any special
precautions
D. Interventions
a. Ensure airway patency
b. Time the seizure episode
c. If the child is standing or sitting, ease the
child down the floor, placing the child in a
side-lying position
d. Place a pillow or folded blanket under the
child’s head; of no bedding is available,
place your own hands under the child’s
head or place the child’s head in your own
lap.
e. Loosen restrictive clothing.
f. Remove eyeglasses from the child if
present.
g. Clear area of any hazards or hard objects.
h. Allow seizure to proceed and end without
interference.
i. If vomiting occurs, turn child to one side as
a unit.
j. Do not restrain the child, place anything in
the child’s mouth, or give any food or
liquids to the child.
k. Prepare to administer medications as
prescribed.
l. Remain with the child until the child fully
recovers.
m. Observe for incontinence, which may have
occurred during the seizure
n. Document the occurrence.
CEREBRAL PALSY
A. Description
a. Cerebral palsy is a disorder characterized
by impaired movement and posture
resulting from an abnormality in the
extrapyramidal or pyramidal motor system
b. The most common clnical type is spastic
cerebral palsy, which represents an upper
motor neuron type of muscle weakness.
B. Assessment
a. Extreme irritability and crying
b. Feeding difficulties
c. Stiff and rigid arms or legs
d. Delayed gross development
e. Abnormal motor performance
f. Alterations of muscle tone
g. Abnormal posturing, such as opisthotonic
(exaggerated arching of the back)
h. Persistence of primitive infantile reflexes
C. Interventions
a. The goal of management is early
recognition and interevention to maximize
the child’s abilities
b. A multidisciplinary team approach is
implemented to meet the many needs of
the child
c. Therapeutic management includes physical
therapy, occupational therapy, speech
therapy, education, and recreation.
d. Assess the child’s developmental level and
intelligence.
e. Encourage early intervention and
participation in school programs.
f. Prepare for using mobilizing devices to help
prevent or reduce deformities.
g. Encourage communication and interaction
with the child on his or her developmental
level rather than chronological age level
h. Provide a safe environment such as by
removing sharp objects, using a protective
helmet if the child falls frequently, and
implementing seizure precautions if
necessary
i. Provide safe, appropriate toys for age and
developmental level
j. Position the child upright after meals
k. Administer medications as prescribed to
decrease spasticity.
l. Surgical interventions are reserved for the
child who does not respond to more
conservative measures or for the child
whose spasticity causes progressive
deformity.
MENTAL RETARDATION
A. Description
a. In mental retardation, the child manifests
subaverage intellectual functioning along
with deficits in adaptive skills.
b. Down syndrome is a congenital condition
that results in moderate to severe
retardation and has been linked to an extra
group G chromosome, chromosome 21
(trisomy 21)
B. Assessment
a. Deficits in cognitive skills and level of
adaptive functioning
b. Delays in fine- and gross-motor skills
c. Speech delays
d. Decreased spontaneous activity
e. Nonresponsivemenss
f. Irritability
g. Poor eye contact during feeding
C. Interventions
a. Medical strategies are focused at correcting
structural deformities and treating
associated behaviours
b. Implement community and educational
services using a multidisciplinary approach
c. Promote care skills as much as possible
d. Assist with communication and
socialization skills
e. Facilitate appropriate playtime
f. Initiate safety precautions as necessary
g. Assist the family with decisions regarding
care
h. Provide information regarding support
services and community agencies
AUTISM
A. Description
a. Autism is a severe mental disorder
beginning in infancy or toddlerhood
b. The disorder is apparent to the parents
before the child is 3 years old
c. It is characterized by impairment in
reciprocal social interaction and in verbal
and nonverbal communication
d. The cause is unknown and the prognosis
may be poor
e. Diagnosis is established based on
symptoms and through the use of
specialized autism assessment tools
f. The disorder also is called infantile autism.
B. Assessment
a. The child experiences a disturbance in the
rate and appearance of physical, social,
and language skills
b. The child experiences abnormal responses
of body sensations
c. The child has abnormal ways of relating to
persons, objects, and events; the child is
self-absorbed and unable to relate to
others.
d. The child has no delusions, hallucinations
or incoherence, and the facies is intelligent
and responsive.
e. The child may play happily alone for hours
but have temper tantrums if interrupted.
f. Language disturbance often includes
repetition of previously heard speech and
reversal of the pronouns “I” and “you”.
 g. If the child can talk, he or she uses speech c. Encourage support groups for parents
not for communication but to repeat words d. Administer prescribed medications; some
or phrases meaninglessly commonly prescribed medications include
h. The child may develop an unusual methylphenidate hydrochloride (Ritalin),
attachement to a significant object and permoline (Cylert), and dextroampethamine
display frequent rocking, spinning twirling, sulphate (Dexedrine)
or other bizarre behaviours. e. Instruct the child and parents regarding
C. Interventions medication administration
a. Determine the child’s routines, habits, and f. Inform the child and parents that positive
preferences and maintain consistency as effects of the medication may be seen
much as possible within 1 to 2 weeks if taken as prescribed.
b. Determine the specific ways in which the
child communicates
c. Facilitate communication through the use of
picture boards
d. Evaluate the child for safety
e. Implement safety precautions as necessary
for self-injurious behaviours such as head
banging
f. Monitor for stress and anxiety
g. Avoid placing demands on the child
h. Initiate referrals to special programs as
required
i. Provide support to parents

ATTENTION-DEFICIT HYPERACTIVITY DISORDER

A. Description
a. Attention-deficit hyperactivity disorder is a
developmental disorder characterized by
developmentally inappropriate degrees of
inattention, overactivity, and impulsivity.
b. The disorder is one of the most common
reasons for referral of children to mental
health services.
c. Childhood problems include lowered
intellectual development, some minor
physical abnormalities, sleeping
disturbances, behavioural or emotional
disorders, and difficulty in social
relationships.
d. Diagnosis is established based on self-
reports, parent and teacher reports, and
psychological assessments.
B. Assessments
a. Fidgets with hands or feet or squirms in the
seat
b. Easily distracted with external or internal
stimuli
c. Difficulty with following through on
instructions
d. Poor attention span
e. Shifting from one uncompleted activity to
another
f. Talking excessively
g. Interrupting or intruding on others
h. Engaging in physically dangerous activities
without considering the possible
consequences
C. Interventions
a. Provide environmental and physical safety
measures
b. Enhance capabilities and self-esteem