Transcript The Brain - Pediatric Nursing

The Child With Altered Neurologic
Status
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
The Brain
Differences in Children
Biological Differences





At birth, brain is 25% of adult size
By age 5, brain is 90% of adult size
CSF is 5 ml in a neonate and 150 ml in adult
Myelinization is complete by puberty
Spinal cord terminates at L3 in infant
Developmental Differences



Handedness before age 1-year may be associated with
focal lesion.
Reflexes present at birth disappear by 1 year.
Neurological assessment of the child is limited to their
developmental level.
Neurologic Assessment

Level of consciousness

What stimuli is needed?

What is quality of the response?

What is length of response?
Levels of Consciousness

Confusion


Delirium



Disorientation to time, place, or person
Characterized by confusion, fear, agitation, hyperactivity, or
anxiety
Stupor = response to vigorous stimuli only
Coma = severely diminished response
Glasgow Coma Scale


Designed as a standardized assessment of the patient with
disturbed consciousness.
The lower the score at time of admission the poorer the
outcomes.
Pupil Changes
Fixed and dilated pupil(s) is neuro emergency
Pupil Changes




Pin point pupils suggest narcotic overdose.
Midpoint fixed pupils suggest structural damage in the
midbrain.
Dilated or large pupils indicate severe anoxia or
overdose.
One pupil fixed and dilated suggests herniation of the the
temporal lobe.
CT Scan
Non-invasive
three dimensional
look at normal and
abnormal structures.
Brain Tumor
CT Scan
MRI
Brain Scan
Injection of tiny amounts
of radioactive isotope
to measure tissue uptake.
Lumbar Puncture
Side lying position for LP
Lumbar Puncture
Insertion of spinal
needle into
subarachnoid space
between the lower
lumbar vertebrae.
Analysis of CSF
Cerebral Spinal Fluid






Normal CSF
Clear odorless
WBC’s 0 – 5
Protein 15 to 45
Glucose 50 – 80
Pressure 50 to 180






Abnormal CSF
Turbid, cloudy
WBC’s 1000 – 2000
Protein 100 – 500
Glucose lower than blood
sugar
Pressure 180 or greater
Intracranial Pressure


The head is a closed box
Total volume inside brain
V brain + V blood + V CSF + V other = Constant
Volume of Brain

Brain volume can increase with:




Edema
Blood flow
Bleed within the brain
Tumor
Volume of Cerebrospinal Fluid
Vital Sign Changes
Increase in
Blood Pressure
Cushing Triad
Decrease in Pulse
Altered Respiratory
pattern
Vital Signs


Pulse rate decreases as ICP increases
Respirations: rate, quality, and characteristic change


Initially slow as ICP rises rate becomes rapid and noisy leading
to apnea
Blood pressure rises slowly / late sign is widening pulse
pressure
Assessment






Glasgow coma scale
Pupil size
LOC
Vital signs
Accurate I & O
Minimize metabolic demands

Fever, pain, seizures
Multidisciplinary Interventions

Controlled hyperventilation

Evacuation of hematoma

Correction of CSF increase

Steroids / dexamethasone

Correction of coagulopathies
Alterations in Neurologic Status

Seizures: a paroxysmal , uncontrolled
episode of behavior that results from an
abnormal electrical discharge from the
brain.
Effect on Child

Altered responsiveness

Altered sensation or perception

Altered movements, mobility or muscle tone
Classification of Seizures

Partial




No loss of consciousness
Symptoms depend on what area of the brain is involved
Often presents as a staring episode or slight twitching of eyes and
drooling
Generalized



Tonic-clonic
Sudden loss of muscle tone
Eye blinking, altered awareness, mouth, or facial movement
Status Epilepticus



Seizures lasting more than 30 minutes
Serial seizures without return to baseline
Medical emergency
Febrile Seizures





Occurs in 2 to 5% of all children
6 months to 3 years of age
Occur in association with a febrile illness
The younger the child the more likely they are to reoccur
Treatment: none unless additional seizures
Documentation






When seizures began
Duration
Warning signs
Clinical characteristics
Level of consciousness
Signs and symptoms when seizures stop
Interventions





Remain calm and stay with child
Protect child from injury
Provide time for child to recover
Reassure and provide support to child and others
Document
Diagnostic Tests


Febrile seizure – clinical diagnosis based on history
Seizures





EEG
LP
Electrolytes
MRI
Medications

Dilantin causes overgrowth of gum tissue
Anencephaly
Absence of brain tissue
above a rudimentary
brain stem and basal
ganglia.
Anencephaly Diagnostic Tests





Prenatal ultra-sound
Elevated alpha fetal protein
Multiple anomalies
Incompatible with life
Heart transplant donors
Multidisciplinary Interventions





Supportive care
Genetic and psychological counseling
Organ donation
Grief therapy
Sustained extra uterine life impossible
Spina Bifida Cystica

Incomplete fusion of one or more vertebral laminae,
resulting in an external protrusion of the spinal tissue.

5 per 10,000 births

Other anomalies
Focused History





Poor maternal nutrition
Maternal age
Pregnancy history
Birth order
Socioeconomic status
Diagnosis
Ultrasound
Elevated AFP
95% survival rate
Meningomyelocele / Meningocele
Bowden & Greenberg
Myelomeningocele

A protruding saclike structure
containing meninges, spinal fluid and
neural tissue.
Myelomeningocele
Assessment at Birth


Size, level, nature of tissue covering
Nerve involvement


Lower limbs / bowel and bladder function
Monitor for signs of hydrocephalus



Head circumference
Leakage of CSF
Cranial sutures
Immediate Interventions

Protect from injury and infection

Rupture of the sac can lead to death

Sterile moist dressing on sac until surgery

Position to prevent pressure on back
Goals of Surgery

Provide a normal anatomic barrier

Control Infection

Control hydrocephaly
Community Care





Bladder and bowel problems
Latex allergies: due to in and out catheterization
Problems with self-esteem
Orthopedic management
Schooling based on IQ
Hydrocephalus



Greek meaning water on the brain
Dilation of the ventricles
Two primary causes:


Congenital .5 to 1%
Acquired:

Lesion, tumors, infection, intracranial bleed, myelomeningocele
Hydrocephalus
Head Circumference
Hydrocephalus
Bulging anterior fontanelle
Eyes deviated downward
“Setting” Sun sign
Bates: Physical Assessment
Transillumination of Skull
Advanced cases of
Hydrocephaly produces
a glow of light over
the entire cranium.
Bates: Physical Assessment
Severe Hydrocephalus
Assessment

Bulging fontanels

Split sutures
Increasing head circumference
Prominent scalp veins
Sunset eyes
Irritability – high pitched cry
Poor feed
The older child will complain of headache






Interventions
Placement of shunt to
drain CSF from the
ventricles to another
part of the body.
Assessment of Shunt






Vomiting
Headache
Irritability
Fever
Redness along shunt line
Fluid around shunt valve
Microcephaly
Reduction in
brain size
Radiology.uchs.edu
Microcephaly

TORCH infections in the mother

Cocaine use by mother during pregnancy

Autosomal dominant transmission

Reduction of blood supply at birth
Infectious Process

Bacterial meningitis

Pyrogenic or purulent infection that
involves the pia mater and arachnoid mater
layers of the meninges.
Infection of Meninges
Pathogens

Under 2 months :E-coli, Group B streptococcus, Listeria,
Haemophilus influenza type B, and Streptococcus
pneumonia

Beyond neonate: Strep, Haemophilus, Neisseria.
Focused Health History








Otitis
Sinusitis
Mastoiditis
Post skull fracture
Meningocele
PROM
Premature infant
Sepsis / bacteremia
Clinical Manifestations






Poor feeding
Hypothermia / hyperthermia
Irritability
Apnea
Bulging fontanel
Look sick
Assessment

Older Child






High fever
Headache
Nuchal rigidity / stiff neck
+ Kernigs = inability to extend legs
+ Brudzinski sign = flexion of hips when neck is flexed
Purple rash (check for blanching)
Kernig Sign

The test for Kernig sign is done by having the person lie
supine (flat on the back), flex the thigh so that it is at a
right angle to the trunk, and completely extend the leg at
the knee joint. If the leg cannot be completely extended
due to pain, this is Kernig sign.
Kernig Sign
Brudzinski Sign

Severe neck stiffness causes a patient's hips and knees to
flex when the neck is flexed.
Brudzinski Sign
Septic Looking
Ball & Bindler
Purple Rash
Bowden & Greenberg
Characteristic purpuric lesions of meningococcal meningitis.
Diagnostic Tests

+ Spinal fluid

+ Blood Culture
Multidisciplinary Interventions

IV antibiotics

Dexamethasone to decrease meningeal inflammation and
hearing loss

Monitor Gentamycin blood levels
Interventions







Droplet precautions
Isolation X 24 hours
Vital signs
Neuro checks / palpate fontanel
Monitor fluids to prevent fluid overload
Head circumference
Pain management / quiet environment
Droplet Protection

If patient is a rule out meningitis the nurse should wear a
mask when helping with diagnostic tests.
Outcomes

Unfavorable outcomes





Young age
Delay in treatment
Coma
Focal neurologic signs
Poor clinical course
Community Care



BAER hearing test in hospital and 3 to 6 months later
Developmental testing
Watch for learning disabilities
Subdural Hematoma



Shear force injury created by impact can cause tearing of
bridging vessels.
Falls, assaults, MVA, Shaken Baby Syndrome.
Children under 1 year
Subdural Hematoma
Bridging Veins
Clinical Manifestations






LOC
Vomiting
Headache
Retinal hemorrhages
Pupil on side injury fixed and dilated
Seizures
Retinal Hemorrhages
Normal retinal
Retinal hemorrhage
Subdural Hematoma
CT scan to confirm diagnosis
Subdural tap
50% die
75% seizures
Skull Fractures
Depressed Skull Fracture
Six-year
old hit by
auto while
riding his
bike.
Depressed Skull Fracture

Part of the skull is actually sunken in from trauma.

May occur with or without a cut in the scalp.

Surgical intervention is needed to correct the deformity.
Basilar Skull Fracture





Most serious type of skull fracture.
Involves a break in the bone at the base of the skull.
Child has bruises around their eyes and a bruise behind
the ear.
May have clear fluid draining from their nose or ears.
Need close observation in hospital.
Battle’s Sign
Battle’s Sign