Chapter 16 Intracranial Regulation/ Neurologic Disorder

Epilepsy is defined as having any of the following conditions

-two or more unprovoked seizures, which occur more than 24 hours apart -one unprovoked seizure and a chance of further seizures the same as the general recurrence risk after two unprovoked seizures happening over the next 10 years -Diagnosis of an epilepsy syndrome

Causes of nonaccidental head trauma

-violent shaking: Shaken baby syndrome -blows to the head -intentional cranial impacts against the wall, furniture, or the floor

Nursing management for sever brain injury

*ABC -assess neuro status frequently -elevate head to 30 degrees if no neck injury -keep head midline to promote venous drainage -*minimal stimulation -monitor vital signs, I&O, and ICP -skin care and range of motion -enteral nutrition within 72 hours (past the pylorus)

Interventions for Status Epilepticus*

*Airway management: respiratory depression or apnea may occur due to medication side effects -suction excess secretions - administer oxygen -monitor vital signs and neurological status - establish intravenous access - if hypoglycemic administer glucose - additional medications

Bacterial meningitis

*inflammation of the meninges - newborns and infants at greatest risk -higher morbidity and mortality than viral meningitis -common bacterial causes -often secondary to URI

Risk factors for Epilepsy

- Family history of seizures - Any complications during the prenatal, perinatal, or postnatal periods -changes in developmental status or delays in developmental milestones -any recent illness, fever, trauma, or toxin exposure

What are the components of a concussion that is Grade 2?

- transient confusion with post traumatic amnesia -no loss of consciousness -mental status abnormalities last great than or equal to 15 minutes

Myelodysplasia (aka Spina Bifida): Pre-op Nursing care*

-*Cover sac with sterile dressing (warm saline) - monitor for CSF leakage\ - * Place infant in prone position with knees sligthtly flexed - open warmer or incubator -monitor for signs of infection - Feed with head turned to one side - *Avoid latex products - Assess bowel, bladder function

Causes of acute stroke in children

-Congenital or acquired heart disease -sickle cell -infection -coagulopathies -vascular malformation (AVm) -trauma -malignancy

Bacterial meningitis signs and symptoms in infants

-Fever, changes in feeding pattern, vomiting, diarrhea, *anterior fontanel bulging or flat, *difficult to console, alert restless, lethargic or irritable

Moderate brain injury consists of:

-Glasgow coma scale: 9-12 -loss of consciousness - headache, nausea and vomiting -amnesia for 1- 24 hours

What is the primary problem resulting from near drowning?

-Hypoxic- ischemic brain injury -Anoxia: leads to cerebral edema and increased ICP, resulting in secondary cerebral injury - Time: 5-10= less neuro impairment 25 mins or longer= severe impairment of death Interventions: immediate CPR, 100% O2, rewarming

Viral meningitis: Treatment

-Labs and cultures (blood urine and cerebrospinal fluid) - *IV antibiotics until cultures are negative treating as bacterial meningitis until proven otherwise -symptoms last 3-10 days -neurologic deficits are uncommon

Hydrocephalus: Nursing care

-Measure head circumference daily -Observe for signs of increased ICP -Neurologic assessment -Signs of shunt malfunction -Positioning: usually supine- head of bed is raised gradually

Myelodysplasia: Post-op Nursing care

-Monitor for wound healing -Monitor for signs of infection -*Monitor for signs of hydrocephalus, increased ICP -Place in prone or side lying position -*Measure head circumference daily -assess intake and output -avoid latex products

Define Arteriovenous Malformation (AVM)

-abnormal development of blood vessels -usually diagnosed once a problem has occurred -hemorrhage can lead to significant neurologic sequela

What are the components of a concussion that is Grade 3?

-any loss of consciousness seconds or minutes -dizziness may last for more than 6 weeks

Bacterial meningitis signs and symptoms: children

-fever, *confusion, delirium, irritable, lethargic, vomiting, muscle or joint pain, hemorrhagic rash (*meningococcal meningitis) -Meningeal irritation: headache, photophobia, nuchal rigidity or back pain - child may rest in the opisthotonic position

Sever brain injury consists of:

-glasgow coma scale of less than 8 -prolonged period of consciousness -signs of increased ICP -amnesia for more than 24 hours

Bacterial meningitis: Nursing management

-medical emergency -labs and culture (blood, urine, cerebrospinal fluid) -IV antibiotics -steroids, anticonvulsants, antipyretics -IV fluid, fluid resuscitation -may be left with severe neurologic defecits

Define Hydrocephalus

-not a specific illness but results from underlying brain disorders -CSF accumulates within the ventricular system and causes the ventricles to enlarge and increases in ICF to occur

Reye syndrome S&S

-sever and continual vomiting -changes in mental status -lethargy -irritability -confusion -hyperreflexia

What are the components of a concussion that is Grade 1?

-transient confusion -no loss of consciousness - no post traumatic amnesia -mental status abnormalities last ,15 minutes -resolves without complication over 7-10 days

Five states of Consciousness

1. Full consciousness: the child is awake and alert, is oriented to time, place and person, exhibits age appropriate behaviors 2. Confusion: disorientation exists, the child may be alert but responds inappropriately to questions 3. obtunded: the child has limited responses to the environment and falls asleep unless stimulation is provided 4. stupor: the child only responds to vigourous stimulation 5. Coma: the child cannot be aroused, even with painful stimuli

External ventricular drainage (EVD)

A catheter is temporarily placed in the ventricle and CSF is drained in a closed system to an external reservoir

Birth trauma

Results from prolonged or abrupt labor, abnormal or difficult presentation, mechanical assistance

The nurse is caring for an infant with myelomeningocele following surgical repair. What is an important nursing assessment?

Assess the surgical site for cerebral spinal fluid leakage and symptoms of infection

Where do children younger than 1 ofter drown?

Bathtubs, buckets, or toilets

Common places for older children to drown?

Bodies of fresh water

Reye syndrome

Brain swelling, liver failure, and death with hours if not treated, cause is unknown may be related to using salicylates

The nurse is assisting with testing on a child suspected of having a neural tube defect. What diagnostic test would confirm this condition?

Computer tomography- CT scan

Define Anencephaly

Defect in brain development resulting in small or missing brain hemispheres, skull, and scalp, incompatible with life, stillborn or die within a few days

Anticovulsants: Benzodiazepines**

Diazepam and lorazepam (the go to medications for emergency seizures) -administer IV push medication very slowly into the IV entry site closest to the child's body (if you don't do it there it will take a long time for medication to get to them) - monitor for hypotension, tachycardia, and respiratory depression

Ketogenic Diet

Diet involving high intake of fats, adequate protein, and a very low intake of carbohydrates, resulting in a ketosis state, child is kept in a mild state of dehydration, used for the prevention and control of seizures

A child has been diagnosed with epilepsy and is on daily phenytoin (Dilantin). What education should you provide?

Educate about good dental health

Signs and symptoms of shunt infection

Elevated vital signs poor feeding vomiting decreased responsiveness seizure activity signs of local inflammation along the shunt tract

Glasgow Coma Scale: Child Criteria

Eye Opening 4 Spontaneous opening 3 To loud noise 2 To pain 1 No response Verbal Response 5 Smiles, coos, cries, to appropriate stimuli 4 Irritable, cries 3 Cries to pain 2 Moans to pain 1 No response Motor response 6 Spontaneous movement 5 Purposeful, localizes pain 4 Withdrawal to pain 3 Flexor posturing 2 Extensor posturing 1 No response

Glasgow Coma Scale: Older child or Adult criteria

Eye opening 4 Spontaneous 3 To verbal stimuli 2 To pain 1 No response Verbal Response 5 Oriented X3 4 Confused 3 Inappropriate words or verbal response 2 Incomprehensible words 1 No response Motor Response 6 Spontaneous movement 5 purposeful, localizes pain 4 withdraws to pain 3 Flexor posturing 2 Extensor posturing 1 No response

Define Encephalocele

Failure of the neural tube to close and brian and meninges protrude through a skull defect, surgical repair for protection of brain tissue

Sudden presence of fixed or dilated you should first do what?

Immediately report

Alterations in motor function may indicate certain neurologic problems such as?

Increased Intra cranial pressure, head injury, and cerebral infections

Encephalitis

Inflammation of the brain -meninges may be inflamed as well -viruses most common cause: herpes simplex 1, measles, mumps, chickenpox, rabies, west nile -happens most in infants less than 1 year of age

Viral meningitis

Inflammatory response of meninges -most common cause is enterovirus, coxsackievirus -child not as ill appearig as child with bacterial meningitis

Head circumference

Is measured around the child's head a the largest area, may indicate microcephaly, and a larger normal may indicate hydrocephalus

Common anticonvulsants used in children

Keppra and topamax

Electroencephalogram (EEG)

Measures electrical activity of the brain

What should you do if clear liquid is draining from the ears or nose?

Notify physician this is indicative of leaking CSF

Common places for adolescents to drown?

Often related to risk taking behavior: alcohol/drug use while swimming, cliff jumping etc.

Define Craniosynostosis

Premature closure of cranial sutures -distorted skull appearance -outcomes good with surgery -post-op management: Pain management, Watching H&H due to large blood loss, strict I&O, fever is normal, swelling can be profound (eyelids may evert)

Status Epilepsy *

Seizure lasts more than 20 minutes OR Series of small seizures during which consciousness is not regained - Because the seizures last so long children get a lot of medication to stop the seizing, it is important to check their airway

Epilepsy

Seizure lasts seconds to minutes

Which consideration would be most important in planning nursing care for an infant following surgical insertion of a ventriculoperitoneal shunt:?

The infant is placed in a flat, supine position immediately after surgery.

Chiari Malformation

Type I: deformity is usually a result of the cerebellar tonsils displacing into the upper cervical canal Type II: deformity results from the cerebellum, the medulla oblongata, and the fourth ventricle displacing into the cervical canal resulting in an obstruction of the CSF and causing hydrocephalus

External Ventricular Drain big safety issue

Unless the drain and the ear are lined up the drain should be turned off because the CSF fluid could drain at a faster rate

Febrile seizures

Usually seen in children younger than 5 years, associated with a fever usually related to a viral illness, usually benign but frightening for parent and child, can be a sign of meningitis or sepsis

Why would we place a Shunt?

a catheter is placed in the ventricle to pass the CSF to the peritoneal cavity, atrium of the heart of pleural spaced (ventriculoperitoneal shunts are common) -Used for hydrocephalus, and increased ICP -Monitor for s&s of increased ICP, neurologic status, LOC and VS, s&s of infections

Common places for 1-4 year olds to drown?

artificial pools, bodies of fresh water, hot tubs, toilets, water filled buckets

Positional plagiocephaly

asymmetry in head shape without fused sutures, caused by laying child on back too much (gravitational forces)

Intraventricular hemorrhage (IVH)

bleeding into the ventricles (of the brain)

Periventicular hemorrhage (PVH)

bleeding near the ventricles

Mild brain injury consists of:

closed head injury -no loss or consciousness -normal behavior after injury - healthy prior to injury

cephalohematoma

collection of blood between skull and periosteum

Head Injuries: Subdural hematoma

collection of blood between the dura and cerebrum (underneath the dura mater)

head injuries: epidural hematoma

collection of blood located outside the dura within the skull (forms above the dura mater)

tonic-clonic (grand mal)

extremely common generalized seizures, most dramatic seizure type, loss of consciousness

Early signs of ICP (intracranial pressure)

headache, vomiting (possibly projectile)*, blurred vision, dizziness, decreased pulse and RR, increased BP, pupil reaction decreased, changes in LOC*, irritable, seizure activity*, bulging fontanels, wide sutures and increased head circumference, high pitched cry

Assessment of dysfunction in children includes:

health history, physical examination, laboratory and diagnostic testing

Patho of epilepsy

imbalance of excitatory and inhibitory mechanisms in the brain causing the neurons to either fire when they are not supposed to or not fire when they should

myoclonic

involves motor cortex of the brain, sudden brief massive muscle jerks that may involve whole body or one body part

Virl meningitis: S&S

irritable, lethargic, fever, headache, photophobia, upper respiratory symptoms, stiff neck, seizures are rare

late signs of ICP

lowered LOC, decreased motor and sensory responses, bradycardia, irregular respirations, decerebrate or decorticate posturing, fixed and dilated pupils*

Long term Management of seizures*

monotherapy medications: successful in 60% of children -Ketogenic diet - Family teaching: *management at of seizure at home school, important to give medications as prescribed, blood levels may be needed to monitor anticonvulsant dosing

Computed tomography (CT)

noninvasive x-ray study that looks at tissue density structures

Decerebrate posturing

occurs with damage at the level of the brain stem, rigid muscle tone occurs, extremities extended and pronated

Decorticate posturing

occurs with damage of the cerebral cortex, rigid muscle tone occurs, extremities flexed

atonic

often referred to as "drop attacks", sudden loss of muscle tone, sudden drop of the head regain consciousness within a few seconds to a minute

Clonic seizure

presents with repeated jerking movements

tonic seizure

presents with stiffening of the muscles typically the back, legs, arms, consciousness usually preserved

status epilepticus

prolonged or clustered seizures where consciousness does not return between seizures,

What categories can neurologic disorders be divided into?

structural disorders, seizure disorders, infectious disorders, blood flow disruption disorders, chronic disorders, and trauma to the neurologic system

Define Nystagmus

sunset appearance of the eyes (eyes are half covered by bottom eyelid) sign of ICP

What make up the central nervous system?

the brain and spinal cord

What does intracranial regulation refer to?

the process that affects equilibrium within the brain and therefore neurologic function

Common signs of stroke in children

weakness on one side or hemiplegia, facial droop, slurred speech, speech deficits, seizures, headaches, lethargy