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Course: Pediatric Nursing

Topic: Nursing Care of Child with Neurological Disorder Part I

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Module Goals

Learners will be able to:

Define epilepsy
Describe the types of seizures
Identify causes and risk factors associated with seizures
Identify the sign and symptoms of seizures
Describe the management of seizures
Explain the role of the nurse in caring for children with seizures

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Epilepsy

A common condition that affects the brain and causes seizures
May start at any age, but usually starts either in childhood or in individuals over 60

NHS, 2020

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Seizure Disorders

Seizures are not a disease entity they are a symptom of a malfunction that affects the brain
Behavioural changes resulting from abnormal paroxysmal neuronal discharge and are a symptom of an underlying brain problem
The symptoms are related to the part of brain involved:

Altered level of consciousness
Tonic-clonic movements of some or all body parts
Eye movements
Visual, auditory or olfactory disturbance

Government of Canada, 2012

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Seizure Types

Generalized Seizure

Absence seizures:

Impairment of consciousness
Very brief periods of non-distractible staring (average 10 seconds)
Occurs primarily in children (age of first seizure varies from 3-20 years)
Increased or decreased muscle tone may occur as well as automatisms or mild clonic movements
Recovery is rapid

Government of Canada, 2012

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Seizure Types

Generalized Seizure

Primarily generalized tonic-clonic (grand-mal)

Loss of consciousness (without warning preceded by myoclonic jerks)
Clinical features are similar to secondarily generalized partial seizures
Affects both hemispheres of the brain
Characterized by change in level of consciousness
Bilateral motor involvement
Examples: absence seizure or grand mal seizure with tonic-clonic movements of all four limbs

Government of Canada, 2012

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Seizure Types

Simple Partial Seizure

Formerly called focal seizures
No signs and symptoms, may be motor, sensory, autonomic or psychic
Affects only a part of the brain (focal, motor or sensory)

Complex Partial Seizure

Partial seizure with affective or behavioural changes and loss of consciousness
Seizure may occur without warning or with motor, autonomic or psychic symptoms
Seizure is often followed by period of confusion

Government of Canada, 2012

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Seizure Types

Febrile Seizure

The most common type of seizures during childhood

(6 months to 5 years of age)

Associated with temperature > 38°C
No signs or history of underlying seizure disorders
Often familial
High rate associated with roseola, shigellosis and salmonellosis
Involves bilateral tonic-clonic movements
Uncomplicated and benign if seizure is of short duration

(< 5 minutes)

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A child you are caring for on an inpatient pediatric respiratory care unit suddenly develops bilateral tonic-clonic movements that last for 2 minutes.

What are your top priorities for this patient?

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Causes of Seizures

An imbalance of nerve-signaling brain chemicals (neurotransmitters)
Brain tumor
Stroke
Brain damage from illness or injury
High fever

(Johns Hopkins Medicine, 2022)

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Symptoms of Seizures in Children

Staring
Jerking movements of the arms and legs
Stiffening of the body
Loss of consciousness
Breathing problems or stopped breathing
Loss of bowel or bladder control
Falling suddenly for no apparent reason
Appearing confused or in a haze
Nodding head rhythmically, with loss of awareness or consciousness
Periods of rapid eye blinking and staring

Johns Hopkins Medicine, 2022

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Diagnosis of Seizures

Health History
Neurological exam
Blood tests (for problems related to blood glucose and other factors)
Imaging tests (MRI or CT scan)
Electroencephalogram: identifies brain electrical activity
Lumbar puncture (spinal tap):

Measures the pressure in the brain and spinal canal
Examines the cerebral spinal fluid for infection, bleeding in the brain, pressure in the brain and illnesses

Johns Hopkins Medicine, 2022

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

What key points would be part of your health history taking process with a 12 year old child presenting with unexplained episodes of falling down spontaneously?

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Treatment

Goals:

Protect airway
Stabilize cardiorespiratory function
Provide supportive care during seizures
Safety

ABCs (airway, breathing and circulation) are the first priority:

Maintain airway
Suction secretions as necessary
Insert oropharyngeal airway
Assist ventilation as needed by means of Ambu-bag with oxygen

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Treatment (continued)

Adjuvant Therapy:

Oxygen 6-10 L/min by mask or more as necessary (Keep Spo2 > 97%)
Start IV therapy with normal saline

Nonpharmacologic Interventions:

Maintain side-lying position
Maintain warmth
Give nothing by mouth until child has fully recovered

Pharmacologic Interventions

Lorazepam (Ativan), 0.05-0.10 mg/kg IV (max 4 mg per dose); may repeat once in 10 minutes (administer slowly over 5 minutes at a maximum rate of 2 mg/min)

Government of Canada, 2012

Contact info: info@nursesinternational.org

Pharmacologic Intervention:

diazepam (Valium), 0.3 mg/kg IV (maximum 5 mg per dose for child ≤ 5 years old, 10 mg per dose for child > 5 years old); repeat dose in 10 minutes, if necessary, to a maximum of 3 doses (administer slowly over 5 minutes at a maximum rate of 2 mg/min)
If unable to achieve IV access, diazepam and lorazepam can be given effectively by the rectal route.
Use IV solution without dilution and administer by inserting the smallest possible syringe or a small catheter affixed to the end of a syringe (if the dose is less than 5 mg, a tuberculin syringe is ideal):
lorazepam (Ativan), 0.05-0.10 mg/kg IV (maximum 4 mg per dose); may repeat once in 10 minutes if necessary (administer slowly over 5 minutes, at a maximum rate of 2 mg/min)
diazepam (Valium), 0.5 mg/kg per dose PR (maximum dose of 10 mg); may repeat in 10 minutes if necessary, for a total of 3 doses (at a maximum rate of 2 mg/min)

The medication should be placed a distance of 2.5 cm into the rectum, adjacent to the rectal mucosa. The buttocks should be elevated and held together for up to 5 minutes for complete absorption. Two doses may be given, 5-10 minutes apart.

Risks of drug therapy:

Hypotension
Respiratory depression

Monitoring and Follow-Up

Identify focal neurologic deficits
Observe for return to normal level of consciousness
Monitor vital signs, ABCs, pulse oximetry (if available)
Monitor closely for continued seizure activity

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Treatment (continued)

Diazepam and lorazepam may be given by the rectal route if unable to achieve IV access:

Use IV solution without dilution and administer by inserting the smallest possible syringe or a small catheter affixed to the end of a syringe (if the dose is less than 5 mg, a tuberculin syringe is ideal)
The medication should be placed a distance of 2.5 cm into the rectum, adjacent to the rectal mucosa. The buttocks should be elevated and held together for up to 5 minutes for complete absorption. Two doses may be given, 5-10 minutes apart

Government of Canada, 2012

Contact info: info@nursesinternational.org

Pharmacologic Intervention:

diazepam (Valium), 0.3 mg/kg IV (maximum 5 mg per dose for child ≤ 5 years old, 10 mg per dose for child > 5 years old); repeat dose in 10 minutes, if necessary, to a maximum of 3 doses (administer slowly over 5 minutes at a maximum rate of 2 mg/min)
If unable to achieve IV access, diazepam and lorazepam can be given effectively by the rectal route.
Use IV solution without dilution and administer by inserting the smallest possible syringe or a small catheter affixed to the end of a syringe (if the dose is less than 5 mg, a tuberculin syringe is ideal):
lorazepam (Ativan), 0.05-0.10 mg/kg IV (maximum 4 mg per dose); may repeat once in 10 minutes if necessary (administer slowly over 5 minutes, at a maximum rate of 2 mg/min)
diazepam (Valium), 0.5 mg/kg per dose PR (maximum dose of 10 mg); may repeat in 10 minutes if necessary, for a total of 3 doses (at a maximum rate of 2 mg/min)

The medication should be placed a distance of 2.5 cm into the rectum, adjacent to the rectal mucosa. The buttocks should be elevated and held together for up to 5 minutes for complete absorption. Two doses may be given, 5-10 minutes apart.

Risks of drug therapy:

Hypotension
Respiratory depression

Monitoring and Follow-Up

Identify focal neurologic deficits
Observe for return to normal level of consciousness
Monitor vital signs, ABCs, pulse oximetry (if available)
Monitor closely for continued seizure activity

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Treatment (continued)

Risks of drug therapy:

Hypotension
Respiratory depression

Monitoring and Follow-Up

Identify focal neurologic deficits
Observe for return to normal level of consciousness
Monitor vital signs, ABCs, pulse oximetry (if available)
Monitor closely for continued seizure activity
Carefully document the time and description of the seizure

Government of Canada, 2012

Contact info: info@nursesinternational.org

Pharmacologic Intervention:

diazepam (Valium), 0.3 mg/kg IV (maximum 5 mg per dose for child ≤ 5 years old, 10 mg per dose for child > 5 years old); repeat dose in 10 minutes, if necessary, to a maximum of 3 doses (administer slowly over 5 minutes at a maximum rate of 2 mg/min)
If unable to achieve IV access, diazepam and lorazepam can be given effectively by the rectal route.
Use IV solution without dilution and administer by inserting the smallest possible syringe or a small catheter affixed to the end of a syringe (if the dose is less than 5 mg, a tuberculin syringe is ideal):
lorazepam (Ativan), 0.05-0.10 mg/kg IV (maximum 4 mg per dose); may repeat once in 10 minutes if necessary (administer slowly over 5 minutes, at a maximum rate of 2 mg/min)
diazepam (Valium), 0.5 mg/kg per dose PR (maximum dose of 10 mg); may repeat in 10 minutes if necessary, for a total of 3 doses (at a maximum rate of 2 mg/min)

The medication should be placed a distance of 2.5 cm into the rectum, adjacent to the rectal mucosa. The buttocks should be elevated and held together for up to 5 minutes for complete absorption. Two doses may be given, 5-10 minutes apart.

Risks of drug therapy:

Hypotension
Respiratory depression

Monitoring and Follow-Up

Identify focal neurologic deficits
Observe for return to normal level of consciousness
Monitor vital signs, ABCs, pulse oximetry (if available)
Monitor closely for continued seizure activity

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Clients Education

Explain prognosis
Emphasize importance of adhering to medication regimen
Discuss first aid during seizures
Advise supervision during swimming
Advise that the child be treated as other children are treated
Explain possible teratogenic effects of medications (for example, phenytoin) for sexually active females

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Nursing Intervention (continued)

Assessment:

Signs and symptoms of seizures
Observe alteration in behaviors preceding the seizures and characteristics of the episode
Motor effects
Alterations in consciousness

Problem identification

Ineffective tissue perfusion
Anxiety
Self Esteem disturbances

Hockenberry, & Wilson, 2007

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Nursing Intervention (continued)

During the seizure:

Place child in side lying position (Recovery Position)
Remain with child
Remove secretions from mouth
Monitor oxygenation status
Administer Oxygen as needed
Administration of antiepileptic drugs (AEDs)
Monitor side effects of AEDs

Hockenberry, & Wilson, 2007

Northwestern Medicine, 2022

Contact info: info@nursesinternational.org

Resuscitation Council UK ‘Paediatric basic life support Guidelines (2021)’ recommends following steps for putting child in recovery position:

Kneel beside the child and make sure that both legs are straight.
Place the arm nearest to you out at right angles to the body, elbow bent with the hand palm uppermost.
Bring the far arm across the chest, and hold the back of the hand against the child’s cheek nearest to you.
With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground.
Keeping the hand pressed against the cheek, pull on the far leg to roll the child towards you onto their side.
Adjust the upper leg so that both hip and knee are bent at right angles.
Tilt the head back to make sure the airway remains open.
Adjust the hand under the cheek if necessary, to keep the head tilted and facing downwards to allow liquid material to drain from the mouth.
Check breathing regularly (at least every minute).
Ensure the position is stable. In an infant, this may require the support of a small pillow or a rolled-up blanket placed behind their back to maintain the position.

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Nursing Intervention (continued)

Educate family and child about:

Purpose of antiepileptic drugs response, potential side effects
Identify and avoid situations that are known to precipitate a seizure (blinking lights, sleep deprivation)

Educate about seizure first aid:

If child is risk of falling, ease child to floor
Loosen tight and restrictive clothes
Maintain child in the side lying position
Time the seizures
Do not put anything in child’s mouth
Do not attempt to restrain the child

(Hockenberry, & Wilson, 2007; Nationwide Children’s, 2021)

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A parent tells the school nurse that her 8 yr old child had an ear ache and a high fever last night and began shaking a lot and that It seemed more severe than chills as the child seemed to stiffen up at times.

How would the nurse respond?.

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Red Flags

Be aware of school programs or presentations that may have strobe like lights as this may precipitate seizure activity in some children

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

Some cultures attribute spiritual meaning to seizure activity.
The Hmong culture sees it a highly desirable spiritual gift and may not seek or follow through with treatment.

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References:

Belleza, M. (2021). Seizure Disorders. https://nurseslabs.com/seizure-disorders/#:~:text=or%20altered%20consciousness.-,Nursing%20Care%20Planning%20and%20Goals,steps%20to%20correct%20the%20situation

Children Hospital Colorado. (2022). Seizure Safety Precautions for Parents of Kids with Epilepsy. https://www.childrenscolorado.org/doctors-and-departments/departments/neuroscience-institute/resources-for-families/seizure-safety/

Resuscitation Council UK. (2021). Paediatric basic life support Guidelines. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-basic-life-support-guidelines

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References:

Government of Canada. (2012). Clinical Practice Guidelines for for Nurses in Primary Care- Pediatric and Adolescents Care. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-se rvices/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care.html

Guo, L. (n.d.). Seizure Precautions: What Are They, When Are They Used, and More. Osmosis from Elsevier. https://www.osmosis.org/answers/seizure-precautions

Hockenberry, M. J. & Wilson, D. (2007). WONG’S Nursing Care of Infants and Children (8th ed.). Mosby.

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References:

Johns Hopkins Medicine. (2022). Seizure and Epilepsy in children. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/seizures-and-epilepsy-in-children#:~:text=Anything%20that%20interrupts%20the%20normal,this%20is%20diagnosed%20as%20epilepsy.

Nationwide Children’s. (2021). Seizure Safety. https://www.nationwidechildrens.org/specialties/epilepsy-center/seizure-information-for-parents/seizure-safety

Northwestern Medicine. (2022). Do’s and Don'ts of Seizures. https://www.nm.org/healthbeat/healthy-tips/dos-and-donts-of-seizures

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