1. 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

2. Causes Neurological Dysfunction Injury: r/t direct brain tissue Hypoxia Congenital Metabolic derangement Infection Perfusion problem: stroke Brain tumor 2

3. Standard Terms for Level of Consciousness Full consciousness Confused Disoriented Lethargic Obtunded Stupor Coma McKinney et al, 3 rd ed. P 1470 3

4. Glasgow Coma Scale Table 52-1, p. 1469: modified for children –Eye Opening –Verbal Response –Motor Response 4

5. Causes of Increased ICP Swelling of brain tissue Increase in amount of CSF Increase in amount of blood flow 5

6. 6

7. 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 F 7

8. Increased ICP - Child Altered level of consciousness Mood swings Headache (esp. am) Diplopia Slurred speech Nausea and vomiting (esp. am) 8

9. Hydrocephalus What is it? Treatment: Shunt –Ventriculoperitoneal (VP) –Ventriculoatrial 9

10. 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

11. Neural Tube Defects Definition Spinal bifida occulta Spina bifida cystica –Meningocele –Myelomeningocele Role of Folic Acid as primary prevention HP 2020 goal 11

12. Myelomeningocele Flaccid paralysis Sensory loss Bowel & bladder sphincter Joint deformities 12

13. Nursing Care: Myelomeningocele Check head circumference Fontanels Position Elimination Infection –Pre-op: sterile, moist dressing –Latex precautions Impaired mobility –Hip & foot alignment 13

14. Cerebral Palsy Chronic, nonprogressive disorder of posture & movement Manifestations vary 14

15. Causes of CP prenatal Intra postnatal F 15

16. Clinical Manifestations CP Primitive reflexes Delayed development Hypertonia Contractures Often intellectually intact 16

17. Nursing Diagnoses: CP Impaired physical mobility Altered growth & development Risk of injury Impaired verbal communication Self-care deficit Altered nutrition Caregiver role strain 17

18. Care: cerebral palsy Extra calories r/t spasticity Aspiration precautions Multidisciplinary team Prevent developmental delays Maintain a safe environment Control spasticity 18

19. Surgical Interventions: CP Surgical release tight muscles & tendon Baclofen Pump Derotation osteotomy Rhizotomy: cutting nerves on affected limbs Botulinum Toxin A (Botox injections) 19

20. Intracranial Infections 20

21. Intracranial Infections Meningitis: inflammatory process affecting the meninges Encephalitis: affects the brain Myelitis: spinal cord Causes: –Bacterial –Viral (aseptic) –Tuberculosis 21

22. Bacterial Haemophilus influenzae Streptococcus pneumoniae Neisseria meningitidis (meningococcal) Frequent cause: infection starting elsewhere 22

23. Clinical Manifestations: Meningitis Increased ICP Severe HA Photophobia Nuchal rigidity; opisthotonos (infants) LP: 23

24. Bacterial Meningitis: Complications Compression of cranial nerves –Hearing Loss Brain abscess Seizures Cerebral palsy Learning disorder Attention deficit disorder Paresis (hemi, quad) 24

25. Nursing Care Prevention –Immunization –Meds for contacts Isolation: bacterial Supportive 25

26. 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

27. Supportive Nursing Care (cont) Assessment for deteriorating neuro status I & O Manage pain, fever 27

28. 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

29. Seizure A sudden, explosive, disorderly discharge of cerebral neurons. Sudden, transient alteration in brain function Motor, sensory, autonomic, or psychic clinical manifestations. Syndrome 29

30. 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

31. Epilepsy a chronic disorder of recurrent seizures. A general term for the primary condition that causes seizures. Primary (AKA Idiopathic) –Genetic predisposition 31

32. 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

33. Precipitating Factors Hypoglycemia Fatigue Stress (emotional or physical) Febrile illness Stimulant drugs Withdrawal from depressant drugs Certain environmental stimuli 33

34. Classification of Seizures Partial or generalized Partial –Simple –Complex –Begin locally, can become generalized 34

35. Generalized Seizures Bilaterally symmetric Loss of/or impaired consciousness Postictal state Tonic, clonic, or tonic-clonic Absence Infantile spasms Atonic (drop attack) 35

36. Status Epilepticus A 2 nd, 3 rd (or more) seizure before the person has regained consciousness from the proceeding seizure. Or A single seizure lasting > 5min Medical emergency 36

37. Negative Outcome of Seizure Increased need ATP in brain Increased O 2 consumption Supplies of O 2 & glucose consumed Cerebral blood flow increases Severe hypoxia & lactic acidosis 37

38. Nursing Interventions r/t ‘Potential for Injury’ Maintain airway Oxygen: “blow-by” Move objects out of way Assess duration, where started, LOC, incontinence 38

39. Classifications of Anticonvulsant Medications Hydantoins Barbiturates Succinimides Oxazolidones Benzodiazepines Carbamazepine Valproate 39

40. Mechanism of Action 1.Suppress sodium influx 2.Suppress calcium influx 3.Increase action of GABA (gamma aminobutyric acid) 40

41. 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

42. 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

43. Clonazepam (Klonipin) Maintenance – po Absence, myoclonic seizures 43

44. 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

45. Fosphenytoin (Cerebyx) Replacing Dilantin IV PE (phenytoin equivalents) Dilute in D5W or NS to 25 mg PE/ml 150 mg PE/min 45

46. 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

47. 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

48. Miscellaneous Pregnancy category MgSO 4 for eclampsia/preeclampsia Anticonvulsants for other uses Surgical management Drug-drug interaction Ketogenic diet Vagal nerve stimulator 48