neurologic differences of infant and child infant/child brain 12% nb body wt. infant: 50 ml csf...
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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.
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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
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Causes of Increased ICP
• Swelling of brain tissue• Increase in amount of CSF• Increase in amount of blood flow
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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
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)
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Neural Tube Defects
• Definition• Spinal bifida occulta• Spina bifida cystica
–Meningocele–Myelomeningocele
• Role of Folic Acid as primary prevention• HP 2020 goal
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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
F
15
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)
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Intracranial Infections
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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
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Clinical Manifestations: Meningitis
• Increased ICP• Severe HA• Photophobia• Nuchal rigidity; opisthotonos
(infants)• LP:
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Bacterial Meningitis: Complications• Compression of cranial nerves
– Hearing Loss
• Brain abscess• Seizures• Cerebral palsy• Learning disorder• Attention deficit disorder• Paresis (hemi, quad)
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Nursing Care• Prevention
–Immunization–Meds for contacts
• Isolation: bacterial• Supportive
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Supportive Nursing Care• Hydration • Prevent injury
–seizure precautions• Minimize increased ICP**:
–Quiet, dark environment–Position of comfort–Head/neck in neutral position–Steroid possibly
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Supportive Nursing Care (cont)
• Assessment for deteriorating neuro status
• I & O• Manage pain, fever
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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
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Seizure
• A sudden, explosive, disorderly discharge of cerebral neurons.
• Sudden, transient alteration in brain function
• Motor, sensory, autonomic, or psychic clinical manifestations.
• Syndrome
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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
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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
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Classification of Seizures
• Partial or generalized• Partial
– Simple– Complex– Begin locally, can become
generalized
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Generalized Seizures
• Bilaterally symmetric• Loss of/or impaired consciousness• Postictal state• Tonic, clonic, or tonic-clonic• Absence• Infantile spasms• Atonic (drop attack)
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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
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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
MedicationsFor 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
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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, confusion46
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
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