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
developedâ 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 1470
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Glasgow Coma Scale
Table 52-1, p. 1469: modified for childrenâEye OpeningâVerbal ResponseâMotor 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
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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: ShuntâVentriculoperitoneal (VP)âVentriculoatrial
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Postoperative Care
⢠Lie flat â prevent rapid removal of CSF
⢠Donât lie on suture side⢠High Risk for:
âShunt malfunction (short-term & long-term) AEB__________.
âInfection (long-term)
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Neural Tube Defects
⢠Definition⢠Spinal bifida occulta⢠Spina bifida cystica
âMeningoceleâMyelomeningocele
⢠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
âPre-op: sterile, moist dressingâLatex precautions
⢠Impaired mobilityâHip & 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
F
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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:
âBacterialâViral (aseptic)âTuberculosis
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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
â Hearing Loss
⢠Brain abscess⢠Seizures⢠Cerebral palsy⢠Learning disorder⢠Attention deficit disorder⢠Paresis (hemi, quad)
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Nursing Care⢠Prevention
âImmunizationâMeds for contacts
⢠Isolation: bacterial⢠Supportive
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Supportive Nursing Care⢠Hydration ⢠Prevent injury
âseizure precautions⢠Minimize increased ICP**:
âQuiet, dark environmentâPosition of comfortâHead/neck in neutral positionâSteroid possibly
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Supportive Nursing Care (cont)
⢠Assessment for deteriorating neuro status
⢠I & O⢠Manage pain, fever
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Reyeâs 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
âhigh 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)âGenetic 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
â Simpleâ Complexâ 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 âPotential for Injuryâ
⢠Maintain airway⢠Oxygen: âblow-byâ⢠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 influx
2. Suppress calcium influx
3. 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.â O: 1-5 min IV â Duration: 15 min-1 hrâ 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 â 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)âSide effects: drowsiness, confusion, HA,âComplications: blood dyscrasia, aplastic
anemia⢠Valproate (Depakene, Depakote)
âSide effects: GI, rash drowsiness, HA, tremors
âComplications: 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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