Neurologic & Neuromuscular

Alterations in Health (Diagnosis)

• Meningitis is inflammation of the meninges covering brain and spinal cord, caused by bacteria, virus, or fungus in the CSF. Viral (aseptic) meningitis is treated supportively. Bacterial (septic) meningitis is contagious and prognosis depends on how fast treatment starts.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Viral: cytomegalovirus, herpes simplex, enterovirus, HIV, arbovirus; more common in summer
• Bacterial organisms: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type B, Escherichia coli
• Since Hib and PCV vaccines, bacterial meningitis has fallen in every age group except infants under 2 months
• Injuries opening a path to CSF — skull fracture, penetrating head wound
• Crowded living conditions
• Bacterial presentation is more severe and life-threatening than viral

Assessment — Expected Findings

• Shared features of viral and bacterial disease: photophobia, vomiting, irritability, headache
• Newborn: well at birth then declines over days; vague findings — poor tone, weak cry, poor suck, feeding refusal, vomiting or diarrhea, fever or hypothermia; neck stays supple, with bulging fontanels and nuchal rigidity appearing late
• 3 months to 2 years: seizures with high-pitched cry, fever, irritability, bulging fontanels, possible nuchal rigidity, poor feeding; Brudzinski and Kernig signs are unreliable at this age
• 2 years through adolescence: seizures often the first sign, nuchal rigidity, positive Brudzinski (neck flexion causes hip/knee flexion), positive Kernig (resistance to extending the flexed leg), fever and chills
• Irritability and restlessness progressing to drowsiness, delirium, stupor, coma
• Petechiae or purpuric rash with meningococcemia; joint involvement with meningococcal and Hib; chronic draining ear with pneumococcal infection

Laboratory Tests

• CBC; blood cultures may be positive even when CSF culture is negative
• Bacterial CSF: cloudy, elevated WBC, elevated protein, decreased glucose, positive Gram stain
• Viral CSF: clear, slightly elevated WBC, normal to slightly elevated protein, normal glucose, negative Gram stain

Diagnostic Procedures

• Lumbar puncture is the definitive test
• Spinal needle into the subarachnoid space at L3-L4 or L4-L5
• Measures CSF pressure and collects fluid for analysis

Nursing Care

• Have the child void before the lumbar puncture
• Apply lidocaine-prilocaine cream 45-60 min beforehand; sedation with fentanyl and midazolam is an option
• Position side-lying with head flexed and knees pulled to chest, hold the position, and use distraction
• Provider cleans the skin, injects local anesthetic, records pressure, and collects 3-5 tubes of CSF
• Apply pressure and an elastic bandage to the site; position after the procedure per facility policy

Medications

• IV antibiotics for bacterial disease; duration set by clinical response and CSF results (normal glucose, negative culture)
• Dexamethasone: not used for viral meningitis; helps early ICP management though not long-term complications; most benefit in reducing neurologic sequelae from Hib

Therapeutic Procedures

Client Education

• Treat upper respiratory infections early and completely
• Keep immunizations current — Hib and PCV at 2, 4, and 6 months with a dose at 12-15 months

Interprofessional Care

Complications

• Increased ICP leading to neurologic dysfunction
• ICP signs in newborns and infants: bulging or tense fontanels, growing head circumference, high-pitched cry, distended scalp veins, irritability, bradycardia, respiratory changes
• ICP signs in children: rising irritability, headache, nausea, vomiting, diplopia, seizures, bradycardia, respiratory changes
• ICP measures: positioning, prevent coughing and straining, dim lights, minimize stimulation
• Hearing loss — arrange audiology evaluation after discharge

Alterations in Health (Diagnosis)

• Seizures are abnormal, involuntary, excessive electrical discharges of brain neurons, classified by type and cause. Focal seizures start in one area; generalized seizures involve the whole brain. Epilepsy is diagnosed after two unprovoked seizures at least 24 hr apart, or one unprovoked seizure within the 10 years following two unprovoked seizures.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Many seizures have no identified cause
• Febrile episode, cerebral edema, intracranial infection or hemorrhage, brain tumor or cyst, anoxia
• Toxins and drugs, lead poisoning, tetanus, Shigella, Salmonella
• Metabolic conditions, electrolyte and glucose abnormalities
• Trauma, congenital defects, prematurity, developmental disability
• Prenatal alcohol exposure and maternal smoking during pregnancy

Assessment — Expected Findings

• Tonic-clonic: abrupt loss of consciousness without aura, usually under 2 min
• Tonic phase: eyes roll up, whole-body tonic contraction with arms flexed and legs/head/neck extended, jaw snaps shut with possible tongue bite, piercing cry, lost swallowing reflex and increased salivation, apnea with cyanosis
• Clonic phase, typically 30-50 seconds and occasionally 30 min or more: violent rhythmic jerking of trunk and extremities, frothing at the mouth, possible urinary and fecal incontinence, gradual slowing to a stop
• Postictal state 30 min to several hours: semiconscious, hard to rouse, confused
• Absence: onset 4-10 years (juvenile form 10-19 years), 5-10 seconds of lost consciousness with a motionless blank stare resembling daydreaming, may drop objects but rarely falls, automatisms such as lip smacking or eyelid twitching, no recall but brief confusion, resumes activity immediately; falling grades are often the first clue
• Myoclonic: brief symmetric or asymmetric muscle contractions of face, trunk, or extremities; no postictal state; consciousness may be preserved
• Atonic/akinetic drop attacks: onset 2-5 years, seconds of lost muscle tone causing a fall, followed by confusion; helmet needed if frequent
• Focal with motor signs: aversive (most common) turns eyes and head away from the focus with or without lost consciousness; Rolandic (Sylvan) tonic-clonic facial movements with salivation, mostly during sleep

Laboratory Tests

• Selected by age, history, and condition: blood glucose, WBC, lead level, toxicology screen, metabolic panel, and chromosomal analysis

Diagnostic Procedures

• EEG records electrical activity and locates the seizure focus; done awake, asleep, and with stimulation or hyperventilation; may run 1 hr to several days, sometimes with video; a normal EEG does not exclude seizures
• MRI gives more detail for malformations, cortical dysplasia, or tumors
• CT detects hemorrhage, infarction, or malformation
• Lumbar puncture measures CSF pressure and identifies infection such as meningitis

Nursing Care

• Seizure precautions for any at-risk child: pad side rails of bed, crib, and wheelchair; clear the bed of hazards; keep suction and oxygen at hand
• During a seizure protect from injury — blanket under the head if on the floor, move furniture away
• Position to keep the airway open and turn side-lying to reduce aspiration risk; be ready to suction
• Loosen tight clothing, remove glasses, give oxygen if needed, stay with the child
• Never restrain the child, force the jaw open, insert an airway or padded tongue blade, or put anything in the mouth
• Record onset, time, and characteristics of the event
• Afterward check breathing, vital signs, head and tongue position, and inspect the mouth for bites; assess for injury
• Let the child rest, then reorient and calm them since agitation and confusion are common

Medications

• Antiepileptics reduce seizure frequency and severity: diazepam, phenytoin, fosphenytoin sodium, carbamazepine, valproic acid, topiramate, lamotrigine, clonazepam
• Drug chosen by age, seizure type, and other medical factors
• Start one drug at a low dose and titrate up until seizures stop; add a second agent if needed
• Febrile seizure: once it ends, lower the fever with acetaminophen or ibuprofen, use a suppository if the child cannot swallow, and dress the child lightly

Therapeutic Procedures

• Brain surgery: removal of tumor, lesion, or hematoma; focal resection of the epileptogenic zone
• Hemispherectomy removes one hemisphere and is reserved for catastrophic intractable epilepsy
• Corpus callosotomy severs the connection between hemispheres
• Vagal nerve stimulator implanted in the left chest wall under general anesthesia with an electrode on the left vagus nerve, programmed for intermittent stimulation; adjunct therapy for partial-onset seizures not controlled by medication

Client Education

• EEG prep: stay still, test is painless, no caffeine for several hours beforehand, sleep may be withheld if ordered, strobe lights or hyperventilation may be used to provoke activity, wash hair before and after with no oils or sprays to clear electrode gel
• Call EMS for apnea, a seizure over 5 min, status epilepticus, unequal pupils afterward, vomiting continuously for 30 min after the event, unresponsiveness to pain or difficulty rousing, a seizure occurring in water, or a first-ever seizure

Interprofessional Care

• School nurse participates in school safety planning, including an individualized education plan or similar program
• Refer to nutrition services when a ketogenic diet is prescribed

Complications

• Status epilepticus: seizure activity lasting 30 min or longer, or repeated seizures without a postictal phase — an emergency
• Maintain airway, give oxygen, obtain IV access, monitor ECG, pulse oximetry, and ABGs
• Load with lorazepam or diazepam, using the buccal, rectal, or nasal route until IV access is available; add fosphenytoin, phenytoin, or levetiracetam if seizures continue
• Support the family, promote optimal development, and make referrals
• Developmental delays

Alterations in Health (Diagnosis)

• Traumatic brain injury results from trauma affecting the brain, surrounding tissue, and vessels, and is graded mild, moderate, or severe by Glasgow Coma Scale. Concussion comes from the brain moving back and forth inside the skull (coup-contrecoup). Contusion or laceration is bruising or tearing of cerebral tissue, usually temporal or frontal, appearing within 12 hr or as late as 3-4 days. Skull fractures follow direct trauma. Hematoma is bleeding between brain and skull.

Health Promotion & Disease Prevention

• Helmets for skateboarding, cycling, ATV and motorcycle riding, skiing, and contact sports
• Seat belts for every ride; car seats installed per manufacturer instructions and law
• Avoid risky behavior such as night cycling without a light, speeding, or driving impaired
• Never shake a baby — it causes head trauma

Assessment — Risk Factors

• Inadequate supervision
• Absent or improper safety practices and misuse of helmets or seat belts
• Contact sports
• Abusive relationships

Assessment — Expected Findings

• History of the event, including dizziness, headache, diplopia, vomiting; amnesia before or after; alcohol or drug use; mechanism (fall, crash, sports); duration of any loss of consciousness is significant
• Concussion: headache is the most common symptom and usually clears in 1-4 weeks; dizziness, vertigo, disrupted sleep, fatigue, nausea, vomiting, photophobia, tinnitus, visual and balance disturbance, temporary trouble with speech, processing, memory, and attention, possible brief loss of consciousness, confusion, lethargy, drowsiness
• Contusion/laceration: loss of consciousness, seizures, speech/vision/hearing problems, external bleeding, skin damage to head, face, neck, headache, double vision
• Subdural hematoma (venous bleed between dura and brain): apnea or breathing difficulty, increasing head circumference, seizures, altered mental status
• Epidural hematoma (arterial bleed between skull and dura): altered consciousness, lethargy, or coma from brain compression; infants show irritability or lethargy, abnormal breathing, bulging anterior fontanel, coma; older children show irritability or drowsiness
• Linear fracture: most common, single line from the impact point, does not cross suture lines
• Depressed fracture: fragments driven inward, misshapen skull, may lacerate dura or penetrate brain
• Comminuted fracture: more than one linear fracture; basilar fracture involves the anterior or posterior skull base

Laboratory Tests

• Usually none for mild TBI; for severe injury or raised ICP obtain blood alcohol and toxicology, CBC with differential, liver function tests, serum electrolytes

Diagnostic Procedures

• Cervical spine x-rays to exclude spinal injury
• Head and neck CT and/or MRI, with or without contrast
• ICP monitoring: expected 5-10 mm Hg, above 20 mm Hg requires action; keep cerebral perfusion pressure above 40 mm Hg (CPP = MAP - ICP)

Nursing Care

• Concussion: rest from physical and cognitive activity — schoolwork, screens, reading, driving — for 24-48 hr, then resume gradually unless symptoms return; keep a regular sleep schedule; OTC NSAIDs for headache; limit physical activity until symptoms resolve
• Moderate to severe TBI: keep the spine immobilized until cord injury is excluded
• Frequent monitoring of vital signs, level of consciousness, pupils, ICP, motor activity, sensation, and verbal response using the Glasgow Coma Scale
• Maintain a patent airway with mechanical ventilation as indicated
• Maintain normothermia

Medications

• Hypertonic saline IV to lower ICP and cerebral edema
• Antiepileptics to prevent or treat seizures
• Acetaminophen for headache, pain, and fever; opioids and benzodiazepines may also be used
• Barbiturates for refractory ICP to reduce cerebral metabolic demand

Therapeutic Procedures

• Subdural drains
• CSF diversion by external ventricular drain or lumbar drain
• Burr hole placement
• Craniotomy removes part of the skull, replaced after edema resolves
• Surgical elevation of depressed fractures

Client Education

Interprofessional Care

• Physical, occupational, recreational, and speech therapy as indicated
• Social services for links to community agencies and schools
• Rehabilitation facilities shorten recovery time

Complications

• Cerebral edema — brain swelling, fatal if untreated; shows as increased ICP, altered cerebral blood flow, tissue hypoxia
• Brain herniation — downward shift of brain tissue; loss of blink and gag reflexes, pupils unreactive to light, Cushing's triad (hypertension, bradycardia, respiratory distress), coma

Alterations in Health (Diagnosis)

• Sensory impairment in children most often involves the eyes and ears, and because vision and hearing drive normal growth and development, early identification matters. Visual impairment spans partial sight through legal blindness and includes myopia, hyperopia, astigmatism, anisometropia, amblyopia, strabismus, cataracts, and glaucoma. Down syndrome, the most common chromosomal abnormality, affects growth and development with both cognitive and sensory impairment.

Health Promotion & Disease Prevention

• Annual vision screening for all children
• Hearing screening for every newborn, repeated at well-child visits when risk factors or concerns exist
• Avoid hazardous noise levels and use ear protection in loud settings

Assessment — Risk Factors

• Prenatal and postnatal conditions: retinopathy of prematurity, trauma, meningitis, postnatal infection
• Perinatal infections: herpes, rubella, syphilis, chlamydia, gonorrhea, toxoplasmosis
• Chronic illness: sickle cell disease, rheumatoid arthritis, retinoblastoma, albinism, Tay-Sachs disease
• Hearing: loud environmental noise, chronic ear infection, ototoxic medications, anatomic malformation, maternal toxic ingestion during pregnancy, perinatal asphyxia or infection
• Hearing: low birth weight, hyperbilirubinemia, family history, Down syndrome, cerebral palsy
• Down syndrome: cause unclear and probably multifactorial; maternal age over 35 years

Assessment — Expected Findings

• Myopia (nearsighted): clear near vision, blurred distance, headaches, eye strain, difficulty reading, poor school performance
• Hyperopia (farsighted): clear distance, blurred near vision; accommodation usually hides it until about age 7
• Astigmatism: uneven refractive curvature so only parts of letters are seen, headache, holds objects close
• Anisometropia: different refractive strength in each eye, often with strabismus and abnormal head position
• Amblyopia: reduced acuity in one eye
• Strabismus: esotropia (inward), exotropia (outward), hypertropia (upward), hypotropia (downward); abnormal corneal light reflex or cover test, misaligned eyes, squinting or frowning, closing one eye, head tilt, headache, dizziness, diplopia, photophobia
• Cataract: gray lens opacity blocking light, decreased acuity, possible peripheral vision loss, nystagmus, strabismus, absent red reflex; infants fail to reach for objects
• Glaucoma: raised intraocular pressure, peripheral vision loss, halos around lights, red eye, epiphora, photophobia, blepharospasm, corneal haziness, buphthalmos, possible pain, red reflex appears gray-green

Laboratory Tests

Diagnostic Procedures

• Visual acuity screening with Snellen letter, tumbling E, or picture/HOTV chart for preschoolers
• Place the child 10-20 feet from the chart depending on age and chart type, wearing glasses if used, both eyes open with one covered
• Read from the bottom up until a line is passed, then top down until a line fails; passing requires 4 of 6 characters correct; repeat with the other eye
• Partial visual impairment is acuity 20/60 to 20/200 (also cited as 20/70 to 20/200)
• Legal blindness means acuity no better than 20/200, or the better eye retaining a visual field of only 20 degrees or less

Nursing Care

• Keep lighting normal to bright for reading, writing, and other close work
• Screen infants and children for visual impairment and identify high-risk children
• Watch for behaviors suggesting reduced or lost vision
• Support optimal development and parent-child attachment
• Remove safety hazards and protect the eyes with helmets and safety glasses

Medications

Therapeutic Procedures

• Cochlear implants for extensive hearing loss — send impulses to the auditory nerve, implanted under the skin with an external component
• Surgery for associated congenital anomalies such as cardiac defects or strabismus

Client Education

• Corrective options: myopia — biconcave lenses, contacts or laser surgery in adolescents; hyperopia — convex lenses or laser surgery; astigmatism — compensating lenses or laser surgery
• Down syndrome: daily moisturizing cream for the skin
• High-fiber diet with fluids to prevent constipation, and calorie monitoring to prevent obesity
• Keep regular health visits, track milestones, and plot growth on Down syndrome-specific charts
• Report spinal cord compression signs: neck pain, motor loss, bladder incontinence, altered sensation
• Assess for atlantoaxial instability — neck pain, weakness, torticollis
• Frequent vision, hearing, and thyroid function testing

Interprofessional Care

• Genetic counseling, social work, home health, school early intervention, and speech, physical, and occupational therapy
• Listen to caregiver concerns and discuss ethical questions about correcting physical defects
• Standard postoperative care emphasizing wound care, respiratory care, and pain management; teach home management and reinforce the plan of care

Complications

• Delayed growth and development — visual and hearing impairment slow speech and motor development, minimized by early detection; encourage self-care and independence, refer to social services, speech, physical, and occupational therapy and teachers, and help the family obtain assistive devices
• Sensory problems in Down syndrome: strabismus, nystagmus, astigmatism, myopia, hyperopia, head tilt, excessive tearing, cataracts; hearing loss from short narrow ear canals, recurrent otitis media, and impacted cerumen
• Frequent respiratory infections from low muscle tone and poor mucus drainage with an underdeveloped nasal bone — keep immunizations current, seek care at the first sign of infection, finish prescribed antibiotics
• Increased incidence of leukemia, thyroid dysfunction, and cardiac defects
• Growth: both height and weight reduced, with weight gain outpacing height and possible excess weight by 36 months
• Sexual development: genitalia may be underdeveloped and delayed; males have lower fertility rates

Alterations in Health (Diagnosis)

• Chronic mobility problems arise from the musculoskeletal system or from disorders along the neural pathway between the cerebral cortex and the neuromuscular junction. Cerebral palsy is a nonprogressive impairment of motor function, muscle control, coordination, and posture that can also alter perception and sensation and bring vision, hearing, and speech impairment, seizures, and cognitive disability; it is congenital or acquired and classified as spastic/pyramidal (up to 80% of cases), dyskinetic/extrapyramidal (10-20%), or ataxic. Spina bifida is a neural tube defect in which the osseous spine fails to close — occulta usually affects the lumbosacral area, is not externally visible, and spares the cord, while cystica shows a protruding sac. Juvenile idiopathic arthritis is a chronic autoimmune inflammation of joints and other tissues where synovial inflammation erodes articular cartilage; it is rarely life-threatening and may remit, but can leave joint deformity and altered function. Its forms are oligoarthritis, polyarthritis with or without rheumatoid factor, systemic, psoriatic, enthesitis-related, and undifferentiated. Muscular dystrophy is a group of inherited disorders causing progressive degeneration of symmetric skeletal muscle groups; Duchenne (pseudohypertrophic) is the most common, X-linked recessive, with onset at 3-5 years, rapid progression, and life expectancy around 30 years.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Cerebral palsy prenatal: maternal malnutrition or drug use, chorioamnionitis, existing brain anomalies, brain anoxia, genetic and chromosomal abnormalities, maternal infection, sepsis, seizures, preeclampsia, placental insufficiency, Rh incompatibility, multiple births, antepartum hemorrhage
• Cerebral palsy perinatal: premature rupture of membranes, long labor, premature birth, low birth weight, meconium aspiration, asphyxia, stroke, bleeding
• Cerebral palsy postnatal: infections including cerebral infections, brain injury, seizures, head trauma such as shaken baby syndrome
• Spina bifida: medications or substances during pregnancy, maternal malnutrition, insufficient folic acid, radiation or chemical exposure, genetic predisposition
• Juvenile idiopathic arthritis: immunogenic susceptibility, environmental triggers, female sex
• Muscular dystrophy: family genetic history

Assessment — Expected Findings

• Cerebral palsy motor signs: gagging or choking with feeding, poor suck, persistent tongue thrust, asymmetric crawl, early hand preference, toe walking
• Cerebral palsy reflexes and tone: persistent primitive reflexes such as Moro or tonic neck, hyperreflexia, rigid posture and extremities, scissoring and extension of the legs, arching back, stiff posture, difficulty diapering
• Spastic cerebral palsy: hypertonicity, increased deep tendon reflexes, clonus, poor control of movement, balance, and posture
• Associated cerebral palsy problems: vision, speech, or hearing impairment, seizures, cognitive impairment, impaired social relationships, and caregiver reports of missed milestones
• Spina bifida occulta: lumbosacral dimpling, port wine angioma nevi, dark hair tufts, subcutaneous lipoma
• Spina bifida cystica: sac protruding midline from the osseous spine, flaccid muscles with flaccid paralysis and absent deep tendon reflexes, no bowel control, constant urine dribbling or overflow, foot contractures, scoliosis or kyphosis
• Juvenile idiopathic arthritis: joint swelling and stiffness worse in the morning or after inactivity, limited mobility, limping gait, fever, rash, delayed growth, fatigue
• Muscular dystrophy: muscle weakness starting in the lower extremities, unsteady waddling gait, lordosis, delayed motor development, frequent falls, learning difficulties

Laboratory Tests

• Maternal alpha-fetoprotein in the second trimester suggests a possible neural tube defect
• Infant blood cultures to identify a causative pathogen when appropriate
• Juvenile idiopathic arthritis: elevated C-reactive protein and erythrocyte sedimentation rate, CBC with differential showing raised WBC especially during flares
• Antinuclear antibodies indicate increased uveitis risk; rheumatoid factor is rarely detected in children
• Muscular dystrophy: blood PCR to detect the dystrophin gene mutation, elevated creatine kinase which can rise before symptoms, and genetic analysis

Diagnostic Procedures

• General movements assessment from birth to 20 weeks post term
• MRI evaluates structures and abnormal areas — keep the child still and sedate if prescribed
• Prenatal ultrasound can visualize the defect; amniocentesis after elevated alpha-fetoprotein detects anencephaly or myelomeningocele; chorionic villus sampling rules out other birth defects and genetic conditions
• After birth: MRI, ultrasonography, and CT of spine and brain, myelography, and spinal x-ray for occulta
• Radiographs give a baseline in juvenile idiopathic arthritis — early films show increased synovial fluid with soft tissue swelling or joint widening, later films show narrowed joint space

Nursing Care

• Individualize care to child and family and arrange hearing and speech evaluations as needed
• Promote independence in self-care and support positive self-image and self-esteem
• Assess family coping, support, and awareness of available resources
• Assess developmental level and monitor milestones, structuring interventions and communication around developmental rather than chronologic age
• Speak directly to the child while including caregivers, and support augmented communication with electronic devices, flash cards, picture boards, or touch-screen computers

Medications

• Intrathecal baclofen through a surgically implanted pump is a centrally acting skeletal muscle relaxant that reduces spasm and severe spasticity in cerebral palsy
• Baclofen adverse effects: muscle weakness, drowsiness, nausea and vomiting, confusion, dizziness, headache, pruritus
• Diazepam is a skeletal muscle relaxant for muscle spasm and severe spasticity
• Botulinum toxin A given IM reduces spasticity in specific muscle groups such as the quadriceps by blocking acetylcholine release, used mainly when spasticity is limited to the lower extremities
• NSAIDs — ibuprofen, naproxen, diclofenac, indomethacin, tolmetin — control pain and inflammation
• Prednisone increases muscle strength

Therapeutic Procedures

• Myelomeningocele sac closure as soon as possible, generally within 24-72 hr of birth, to prevent injury and infection, with hydrocephalus risk afterward
• Preoperatively protect the sac, place the infant prone and unclothed in an incubator or radiant warmer
• Apply a sterile moist nonadherent dressing with sterile 0.9% sodium chloride to the sac, changing every 2 hr; if it dries, add more sterile solution rather than pulling it off
• Inspect the sac closely for leaks, irritation, abrasion, and local infection, and watch for systemic infection signs of fever, irritability, and lethargy
• Orthopedic surgery to correct contractures and spastic deformities, including tendon release
• Neurosurgical dorsal rhizotomy

Client Education

• Watch for expected medication responses and know which adverse effects require a call to the provider
• Never stop a medication without talking to the provider
• Learn pump use, site care, and medication replacement for intrathecal therapy
• Follow the therapeutic plan, nutritional guidelines, feeding schedule and techniques, and medication regimen
• Build in rest periods and developmentally appropriate recreation and stimulation
• Maintain dental hygiene and regular examinations, keep immunizations current
• Understand wound care, ankle-foot orthoses, and pulmonary hygiene techniques if prescribed

Interprofessional Care

• Cerebral palsy team may include neurologist, pulmonologist, speech-language pathologist, dietitian, physical and occupational therapy, and social work depending on severity
• Refer for technical aids that improve coordination, speech, mobility, and independence, including voice-activated wheelchairs
• Physical therapy provides range of motion to strengthen muscles, build endurance, and prevent contractures and deformity, plus orthotic devices such as braces and splints and adaptive equipment such as scooters and wheelchairs
• Spina bifida team: neurosurgeon, urologist, orthopedics, pediatrician, physical and occupational therapy, social worker
• Juvenile idiopathic arthritis team: physical and occupational therapy, ophthalmologist, dentist, rheumatologist, dietitian, social worker, school nurse, counselors, psychologists

Complications

• Aspiration — keep the head elevated, have suction available for copious secretions or swallowing difficulty, use safe feeding techniques, and encourage caregivers to take CPR classes
• Injury risk — raise and pad bed rails and wheelchair arms, secure the child in mobility devices, ensure adequate rest to avoid fatigue-related injury, and use helmets, seat belts, and other safety equipment
• Skin ulceration from prolonged pressure — monitor skin and reposition frequently off bony prominences
• Latex allergy risk with spina bifida, ranging from urticaria to wheezing and anaphylaxis, and linked to banana, avocado, kiwi, and chestnut allergy — test, avoid latex including water toys, pacifiers, and plastic storage bags, teach epinephrine use, and wear an allergy alert bracelet
• Increased ICP from shunt malfunction or hydrocephalus — infants show high-pitched cry, lethargy, vomiting, bulging fontanels, widening sutures, increasing head circumference; children show headache, lethargy, nausea, vomiting, double vision, declining school performance, decreased consciousness, seizures
• For raised ICP prepare for shunt placement or revision, use gentle movements during range of motion, minimize noise and visitors, and manage pain
• Neurogenic bladder with myelomeningocele causing spasm or flaccidity — monitor for dysfunction, infection, and hematuria, give antispasmodics or perform intermittent catheterization, and teach vesicostomy stoma care if present