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

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Standard Terms for Level of Consciousness

• Full consciousness• Confused• Disoriented• Lethargic• Obtunded• Stupor• Coma

• McKinney et al, 3rd ed. P 14703

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

F7

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

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Hydrocephalus

• What is it?

• Treatment: Shunt–Ventriculoperitoneal (VP)–Ventriculoatrial

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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

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Nursing Care: Myelomeningocele• Check head circumference• Fontanels • Position • Elimination• Infection

–Pre-op: sterile, moist dressing–Latex precautions

• Impaired mobility–Hip & foot alignment

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Cerebral Palsy

• Chronic, nonprogressive disorder of posture & movement

• Manifestations vary

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Causes of CP

• prenatal

• Intra

• postnatal

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

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

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

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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

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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

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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

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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

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Nursing Interventions r/t ‘Potential for Injury’

• Maintain airway• Oxygen: “blow-by”• Move objects out of way• Assess duration, where started,

LOC, incontinence

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Classifications of Anticonvulsant Medications

• Hydantoins• Barbiturates• Succinimides• Oxazolidones• Benzodiazepines • Carbamazepine• Valproate 39

Mechanism of Action

1. Suppress sodium influx2. Suppress calcium influx3. Increase action of GABA (gamma

aminobutyric acid)

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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.

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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

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Clonazepam (Klonipin)

• Maintenance – po• Absence, myoclonic seizures

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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

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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

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