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Cerebral Dysfunction Lauren Walker, RN, BSN Georgetown University.

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Presentation on theme: "Cerebral Dysfunction Lauren Walker, RN, BSN Georgetown University."— Presentation transcript:

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2 Cerebral Dysfunction Lauren Walker, RN, BSN Georgetown University

3 Overview Topics Increased Intracranial Pressure Level of Consciousness Cerebral Abnormalities Nervous System Tumors Infections

4 Pediatric Cerebral Dysfunction General Information Children under the age of 2 require special evaluation for neurologic function – Observation of fine and motor reflexes – Pregnancy and delivery history General Assessment – Family History – Health History – Physical Evaluation

5 Abnormal neurologic physical evaluations of infants Size and shape of head Sensory responses Spontaneous activity Symmetry in extremity movement Frequent movement of extremities Skin and hair texture Distinctive facial features High-pitched, piercing cry Abnormal eye movements Inability to suck or swallow Lip smacking Asymmetric facial movements Yawning Muscular activity and coordination Level of development

6 Increased Intracranial Pressure Brain is enclosed in the solid bony cranium Cranium’s total volume: – Brain: 80% – Cerebrospinal fluid (CSF): 10% – Blood: 10% Volume must remain approximately the same at all times Brain is terrible at compensation! Normal ICP 5-10 ICP Video

7 Clinical s/s of Increased ICP Infants Tense and/or bulging fontanel Separated cranial sutures Irritable High-pitched cry Increased occipital circumference Distended scalp veins Changes in feeding Crying when disturbed Setting-sun sign Children Headache Nausea Vomiting Diplopia, blurred vision Seizures Box 28-1, Chapter 28 Wong

8 Clinical s/s of Increased ICP Personality and behavioral signs Irritability, restlessness Indifference, drowsiness Decline in school performance Diminished physical activity and motor performance Increased sleeping Memory loss Inability to follow simple commands Lethargy and drowsiness Late signs Bradycardia Lowered level of consciousness Decreased motor response to commands Decreased sensory response to painful stimuli Alterations in pupil size and reactivity to light Flexion and extension posturing Cheyne-stokes respirations Papilledema Coma Box 28-1, Chapter 28 Wong

9 Level of Consciousness Earliest indicator of improvement or deterioration Determined by observations Physical Assessment – Motor activity, reflexes, vital signs

10 15 points- highest score, unaltered LOC 3 points- lowest score, deep coma esmain/gip/media/images/barclay_glasg ow_comascore2.gif

11 Nursing Management of ICP Positioning Alternating mattresses Avoid causing pain Cluster care Minimize environmental noise Closely monitor nutrition and hydration

12 Nursing Management of Increased ICP Indications for inserting a monitor: – GCS of 8 or below – Deterioration – Judgment from clinical appearance and response Monitors: – Intraventricular catheter – Subarachnoid bolt – Epidural sensor – Anterior fontanel pressure monitor

13 Medications for Altered ICP What is the cause? – Corticosteroids: inflammation – Antibiotics: infectious process – Diuretics: edema – Antiepileptic: seizure activity – Sedation: combativeness – Barbiturates: deep coma

14 Cerebral Malformations Newborn cranial sutures are separated by membranous seams Sutures:Soft areas: - Sagittal-Anterior fontanel -Coronal-Posterior fontanel -Lambdoidal Eight weeks: Posterior fontanel closed Six Months: union of suture lines Eighteen Months: Anterior fontanel closed After 12 years: sutures unable to be separated by increased ICP

15 Hydrocephalus “water on the brain” Imbalance in the production and absorption of CSF in the ventricular system Causes: – Impaired absorption of CSF fluid – Obstruction of flow through ventricle Brain structures become compressed Most cases are from developmental defects

16 Diagnosing Hydrocephalus Time of onset and preexisting lesions – Infants: Head circumferences and neuro signs CT MRI

17 Clinical Manifestations of Hydrocephalus Infancy (early) Infancy (later) Infancy (general) Childhood Abnormal rapid head growth Frontal enlargement IrritableHeadache on awakening Bulging fontanelsDepressed eyesLethargyPapilledema Dilated scalp veins Sun-setting signCries when picked up or rocked strabismus Separated suturesPupils sluggishInfantile reflexes persist Irritable Macewen signChange in LOCLethargy Thinning of skull bones Lower extremity spasticity Confusion/ incoherence Difficult suck and feeding vomiting Box 28-13, chapter 28, Wong

18 Management of Hydrocephalus Direct removal of obstruction Placement of shunt – Ventriculoperitoneal shunt (VP shunt) – Associated with infection and malfunction High success rate with surgically treatment

19 Shunting Shunting Video

20 Family Support Coping is difficult with patents Feel guilty, anxious Uncertain outcome Continue to educate family Include family in patient care Possibility of long term rehabilitation

21 Nervous System Tumors CNS tumors account for 20% of all childhood cancers 3.3 cases per 100,000 occur in kids under 15 years old Difficult to treat No dramatic advancements or improvements seen vs other childhood cancers

22 Brain Tumors Most common solid tumors in children Infratentorial (60%) – Primairly in brain stem or cerebellum – Usually see increased ICP (medulloblastoma, cerebellar astrocytoma, brainstem glioma) Supratentorial – Mainly cerebrum (astrocytoma, hypothalamic tumors, optic pathway tumors)

23 Brain Tumor Diagnostics s/s are related to: – Location – Size of tumor – Child’s age Most common signs: Headache, vomiting s/s are vague and can be overlooked Detected by: – MRI – CT scan Official diagnosis with biopsy from surgery

24 Treatment of Brain Tumors Treatment of choice = total removal of tumor without neurologic damage – Surgery, radiotherapy, chemotherapy Prognosis: – Depends on size, tumor type, extent of disease

25 Nursing Management of Brain Tumors Establish a baseline assessment Vital signs – Look for sudden variations Frequent neurologic assessments Headache? Vomiting? Seizures? Child’s behavior positioning Postoperatively check muscle strength when awake

26 Intracranial Infections Nervous system is limited in ways to respond to an infection Inflammatory process in brain affects: – Meninges (meningitis) – Brain (encephalitis) Meningitis has many origins

27 Bacterial Meningitis Definition: acute inflammation of the meninges and CSF 10-15% of cases are fatal Caused by many bacterial agents – H. Influenzae type b, S. pneumoniae, Neisseria Meningitidis Vascular dissemination or direct implantation Infective Process

28 Clinical Manifestations of Bacterial Meningitis Children and Adolescents (Classic picture) Abrupt onset, rash Fever, chills, headache Alteration in senses Seizures* Irritability/agitation Nuchal rigidity Positive Kernig & Brudzinski signs Infants and Young Children Fever Poor feeding Vomiting Irritable Frequent seizures Bulging fontanel Difficult to evaluate in this age group Box 28-5, Chapter 28 Wong

29 Clinical Manifestations of Bacterial Meningitis Neonates: Specific Signs Very hard to diagnose Well at birth- behaves poorly a few days later Refuses feeds Poor sucking Vomiting/diarrhea Poor tone Lack of movement Weak cry Supple neck Neonates: Nonspecific Signs Hypothermia/fever Jaundice Irritable Drowsiness Seizures Respiratory irregulations cyanosis Box 28-5, Chapter 28 Wong

30 Diagnostic and Therapeutic Management of Bacterial Meningitis Lumbar Puncture Elevated WBC count Decreased Glucose level Considered a medical emergency! Initial management: – Isolation, iv antibiotics, fluids, monitored, treatment of complications

31 Management of Bacterial Meningitis Hydration Quiet, decreased stimulation Side lying position Correct electrolyte imbalance Measure for s/s increased ICP Monitor for complications Prevention: – Vaccines for children starting at 2 months

32 Nonbacterial (aseptic) Meningitis Caused by many viruses! Abrupt or gradual onset Symptoms develop 1-2days after onset s/s vague Diagnosis is based on pt assessment and CSF findings Systematic treatment Nursing care similar to bacterial meningitis

33 Encephalitis Definition: inflammatory process of the CNS which is caused by a variety of organisms – Virus invades CNS or postinfection after a viral disease – Cause in typically unknown

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35 Clinical Findings of Encephalitis Initial findings are nonspecific Evolve to demonstrate neuro s/s – Seizures, abnormal CSF – Mild s/s for a few days, rapid recovery, to fulminating encephalitis with CNS involvement Onset Severe Cases Malaise Fever Headache/Dizziness Lethargy Neck Stiffness Nausea/Vomiting Tremors Speech Difficulties Altered Mental Status High Fever Stupor Seizures Disorientation Spasticity Coma Paralysis

36 Diagnosis and Management of Encephalitis Based on clinical findings CT in late stages Some viruses are found in CSF Hospitalized for observation with supportive treatment Prognosis depends on age, organism, neurologic damage

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