Neurologic Differences of Infant and Child • • • • INFANT/CHILD Brain 12% NB body wt. Infant: 50 ml CSF Peripheral nerves not myelinated. Primitive reflexes disappear by 6 mo age. ADULT • Brain 2% body wt. • 150 ml. CSF • Myelination fully developed – deficit = injury • Primitive reflexes may reappear with neurologic disease. 1 Causes Neurological Dysfunction • • • • • • • Injury: r/t direct brain tissue Hypoxia Congenital Metabolic derangement Infection Perfusion problem: stroke Brain tumor 2 • • • • • • • Standard Terms for Level of Consciousness Full consciousness Confused Disoriented Lethargic Obtunded Stupor Coma • McKinney et al, 3rd ed. P 1470 3 Glasgow Coma Scale Table 52-1, p. 1469: modified for children –Eye Opening –Verbal Response –Motor Response 4 Causes of Increased ICP • Swelling of brain tissue • Increase in amount of CSF • Increase in amount of blood flow 5 6 Increased Intracranial Pressure- Infant • • • • • • Poor feeding Irritability Restlessness Lethargy Bulging fontanel Increased head circumference • vomiting • Separation of cranial sutures • Distended scalp veins • Eyes deviated downward • Altered pain response • High-pitched cry 7 F Increased ICP - Child • Altered level of consciousness • Mood swings • Headache (esp. am) • Diplopia • Slurred speech • Nausea and vomiting (esp. am) 8 Hydrocephalus • What is it? • Treatment: Shunt –Ventriculoperitoneal (VP) –Ventriculoatrial 9 Postoperative Care • Lie flat – prevent rapid removal of CSF • Don’t lie on suture side • High Risk for: –Shunt malfunction (short-term & long-term) AEB__________. –Infection (long-term) 10 Neural Tube Defects • Definition • Spinal bifida occulta • Spina bifida cystica –Meningocele –Myelomeningocele • Role of Folic Acid as primary prevention • HP 2020 goal 11 Myelomeningocele • • • • Flaccid paralysis Sensory loss Bowel & bladder sphincter Joint deformities 12 Nursing Care: Myelomeningocele • • • • • Check head circumference Fontanels Position Elimination Infection – Pre-op: sterile, moist dressing – Latex precautions • Impaired mobility – Hip & foot alignment 13 Cerebral Palsy • Chronic, nonprogressive disorder of posture & movement • Manifestations vary 14 Causes of CP • prenatal • Intra • postnatal 15 F Clinical Manifestations CP • • • • • Primitive reflexes Delayed development Hypertonia Contractures Often intellectually intact 16 Nursing Diagnoses: CP • • • • • • • Impaired physical mobility Altered growth & development Risk of injury Impaired verbal communication Self-care deficit Altered nutrition Caregiver role strain 17 Care: cerebral palsy • • • • • • Extra calories r/t spasticity Aspiration precautions Multidisciplinary team Prevent developmental delays Maintain a safe environment Control spasticity 18 Surgical Interventions: CP • • • • Surgical release tight muscles & tendon Baclofen Pump Derotation osteotomy Rhizotomy: cutting nerves on affected limbs • Botulinum Toxin A (Botox injections) 19 Intracranial Infections 20 Intracranial Infections • Meningitis: inflammatory process affecting the meninges • Encephalitis: affects the brain • Myelitis: spinal cord • Causes: – Bacterial – Viral (aseptic) – Tuberculosis 21 Bacterial • • • • Haemophilus influenzae Streptococcus pneumoniae Neisseria meningitidis (meningococcal) Frequent cause: infection starting elsewhere 22 Clinical Manifestations: Meningitis • • • • Increased ICP Severe HA Photophobia Nuchal rigidity; opisthotonos (infants) • LP: 23 Bacterial Meningitis: Complications • Compression of cranial nerves – Hearing Loss • • • • • • Brain abscess Seizures Cerebral palsy Learning disorder Attention deficit disorder Paresis (hemi, quad) 24 Nursing Care • Prevention –Immunization –Meds for contacts • Isolation: bacterial • Supportive 25 Supportive Nursing Care • Hydration • Prevent injury –seizure precautions • Minimize increased ICP**: –Quiet, dark environment –Position of comfort –Head/neck in neutral position –Steroid possibly 26 Supportive Nursing Care (cont) • Assessment for deteriorating neuro status • I&O • Manage pain, fever 27 Reye’s Syndrome • Def: acute, toxic encephalopathy w/fatty degeneration of liver • Viral or toxin exposure • Avg age: 6-7 yrs • Association w/ administration of ASA to children w/viral disease 28 Seizure • A sudden, explosive, disorderly discharge of cerebral neurons. • Sudden, transient alteration in brain function • Motor, sensory, autonomic, or psychic clinical manifestations. • Syndrome 29 Patho • Changes in membrane potential group of neurons • Plasma membrane more permeable (more sensitive to triggers) • Spread to adjacent neurons – high level of excitatory neurotransmitters, or low level of inhibitory neurotransmitters 30 Epilepsy • a chronic disorder of recurrent seizures. • A general term for the primary condition that causes seizures. • Primary (AKA Idiopathic) – Genetic predisposition 31 Secondary (acquired) seizures • • • • • Cerebral lesions Cerebral trauma Biochemical disorders Infection Metabolic defects • Congenital malformation • Perinatal injury • Vascular diseases • Drug or alcohol abuse • Degenerative neuro condition 32 Precipitating Factors • • • • • • • Hypoglycemia Fatigue Stress (emotional or physical) Febrile illness Stimulant drugs Withdrawal from depressant drugs Certain environmental stimuli 33 Classification of Seizures • • Partial or generalized Partial – – – Simple Complex Begin locally, can become generalized 34 Generalized Seizures • • • • • • • Bilaterally symmetric Loss of/or impaired consciousness Postictal state Tonic, clonic, or tonic-clonic Absence Infantile spasms Atonic (drop attack) 35 Status Epilepticus • A 2nd, 3rd (or more) seizure before the person has regained consciousness from the proceeding seizure. Or • A single seizure lasting > 5min • Medical emergency 36 Negative Outcome of Seizure • Increased need ATP in brain • Increased O2 consumption • Supplies of O2 & glucose consumed • Cerebral blood flow increases • Severe hypoxia & lactic acidosis 37 Nursing Interventions r/t ‘Potential for Injury’ • • • • Maintain airway Oxygen: “blow-by” Move objects out of way Assess duration, where started, LOC, incontinence 38 Classifications of Anticonvulsant Medications • • • • • • • Hydantoins Barbiturates Succinimides Oxazolidones Benzodiazepines Carbamazepine Valproate 39 Mechanism of Action 1. Suppress sodium influx 2. Suppress calcium influx 3. Increase action of GABA (gamma aminobutyric acid) 40 Medications For SE: Benzodiazapines • Diazepam (Valium), .2mg/kg (10 mg) IV q 15 min. up to 40 mg. – O: 1-5 min IV – Duration: 15 min-1 hr – Give w/NS only • Can also be given rectally, as a gel. 41 Lorazepam (Ativan) • For SE: 0.05-0.1 mg/kg (max 4 mg) IV • Onset: 1-5 min • Duration: 12-24 hr • 2 mg/min • Respiratory depression, hypotension, sedation 42 Clonazepam (Klonipin) • Maintenance – po • Absence, myoclonic seizures 43 Hydantoins • • • • • Phenytoin (Dilantin) IV at 50 mg/min O: 1-2 hr D: 12-24 Cardiac dysrhythmias; hypotension Side effects: confusion, slurred speech, unsteady gait, rash • Long-term po: gingival hyperplasia 44 Fosphenytoin (Cerebyx) • Replacing Dilantin IV • PE (phenytoin equivalents) • Dilute in D5W or NS to 25 mg PE/ml • 150 mg PE/min 45 Barbiturates • • • • Phenobarbital Can be a drip, IVP, or po O: 30-60 min. D: 10-16 h Respiratory depression, hypotension, synergy w/ benzodiazepines • Dizziness, lethargy, confusion 46 Maintenance Seizure Meds • carbamazepine (Tegretol) – Side effects: drowsiness, confusion, HA, – Complications: blood dyscrasia, aplastic anemia • Valproate (Depakene, Depakote) – Side effects: GI, rash drowsiness, HA, tremors – Complications: blood dyscrasias, hepatic failure / hepatitis, stomatitis 47 Miscellaneous • • • • • • • Pregnancy category MgSO4 for eclampsia/preeclampsia Anticonvulsants for other uses Surgical management Drug-drug interaction Ketogenic diet Vagal nerve stimulator 48