What are the s/s of ICP?
Headache, N/V, diplopia, blurred vision, seizures
What are the late s/s of ICP?
Bradycardia, lowered LOC, Decreased motor response to command, and painful stimuli, alterations in pupil size and reactivity, d/d posturing, coma, cheyne-stokes respirations, coma, doll's head manuever (move head side to side...eyes go in same place...wit
What is the treatment for bacterial and septic meningitis?
Requires hospitalization
Need isolation precautions
Antibiotics Needed ASAP before death
Fever: control it. Give tylenol, motrin...
Maintain hydration and ventilation...watch for Increased ICP.
Control any type of seizures, anemias
Difference between subdural and epidural hematoma?
:
Name the different types of seizures.
:
What is hydrocephalus?
:
What are the different types of LOC?
:
What are the different types of head trauma?
:
Reye's syndrome?
:
Brain and spinal cord develop at
3 to 4 weeks gestation.
Why do kids have higher risk of skull fractures?
Bone development...
Sutures and fontanels close early or late
Cause brain damage
Myelinization
Increase of nerve impulses
Kids head is a
4th of their body size. The adults is an 8th.
Neuro hx
Family hx
Moms pregnancy
PMH
Sudden movements/alterations
ha, NV, Double Vision, incontinence, unusual behavior
LOC
is one of the FIRST things we can tell about neuro disorders.
Name types of LOC
obtunded, etc...look up...
Physical assessment includes
LOC, VS, CN, motor funciton, relfexes, sensory function, ICP
Decerebrate posturing
Damage to the spinal cord..."MIDBRAIN.
Decorticate posturing
Damage to the cerebral cortex
Physical assessment for infants
size and shape of head is very important.
Symmetry in movement
Does the kid have any twitching movements?
High pitched crying can be
increased ICP or ...something else she said...I didn't get it...
I.ICP s/s
Tense of bulging fontanel
Separated sutures
Macewen sign positive
irritability
high pitched cry
increased hc
distended scalp veins
changes in feeding
crying when disturbed
What is MACEWEN sign?
if you percuss and get a resonant sound..its positive and means increased ICP
Behavioral signs of ICP
Decline in school performance..
Diminished phys. activity and motor performance
Memory Loss
Inability to follow simple commands.
ICP management may include
drains...keep an eye on posture: Want them straight midline and HOB 15 to 30 degrees. No turning side to side. Hyperoxygenate patients and perform suctionsing.
Altered LOC
2 components: Alertness and cognitive power
Alertness
An arousal-waking state, including the ability to response to stimuli
Cognitive Power
Ability to process stimuli and produce verbal and motor responses
Full consciousness is
awake and alert; oriented x3
Confusion is
Impaired decision making
Disorientation
to time and place. decreased LOC
Lethargy
sluggish speech, drowsy, spontaneous movement
How we check LOC
Glascow coma scale
Glascow Coma Scale (look at pg 1143)
Eye Opening
Verbal Response
Best Motor Response
Know that the higher the # the better the LOC
Stupor means
deep sleep: painful stimuli required to wake up...like sternal rub
Coma
no motor or verbal repsonse
Persistent Veg. State
The permanent loss of the cerebral cortex function
Seizures
caused by malfunctions of the brains electric system
Two types of seizures
Epileptic
NON-Epi.
Epilepsy
Un-provoked...
can be idiopathic or acquired (family hx)
more common in the first 2 years of life
Two types of EPILLEPTIC
Partial: one part of the brain
Generalized: electrical disturbance all over brain usually causes loss of consciousness.
Simple Partial seizures
numbness tingling, prickling, pain
usually last 10 to 20 seconds..
remains conscious
NO-Post ictal state
clonic or tonic movements
Complex partial
Preceding auras
Impaired LOC during event
Stare, become limp, do repetitive movements like pick at bedsheets, etc..
inability to respond to enviornment
positive post ictal state
confusion or amnesia may be prolonged
Generalized: Tonic Clonic: know this one forsure!
Formerly grandmal seizure
lasts 10 to 20 seconds during TONIC phase
Immediated Loss of Consciousness
Entire body involvement
Periods of apnea: May turn blue
Increased salivation and loss of swallowing reflex
May bite tongue
Clonic Phase
Violent jerking
Dont respond to touch
Incontient
LAST 30 seconds to 30 minutes
May foam at mouth
Clonic Tonic Postictal
Appears to relax, difficult to arouse, poor coordination, impaired fine motor skills, visual/speech difficulty, N/V, no recollection of event
Seizure concern
Bring them to the floor. Safety most important. Never never restrain a child with a seizure. Dont use tongue blade. If vomiting or foaming...dont suction...turn on their side.
Absence Seizures
Blank stare, brief loss of consciousness, abrupt onset, do have amnesia after episode, have lip smacking, twitching of eyelids and face, slight hand movements
ATONIC seizures
DROP TO GROUND SUDDENTLY.
Myoclonic Seizures
Sudden brief contractions of muscle group...occur singly or repetitively. no postictal state. may/may not lose consc.
Infantile Spasm
Possible sudden contractions..flushed pale or cyanotic...may be preceded by giglling or cry...eyes may roll upward
AGAIN...PAY ATTENTION TO
CLONIC TONIC.
To dx a seizure know these two things
1. Determine the type of seizure
2. Determine the cause
Detailed hx of seizures
PRE-PERI-NEONATAL HX
Description of seizure
Postictal behavior: Did they remember or not remember??
Record length of seizures
Did they turn blue? Apneic?
Recurrent? Did they fall recently, bicycle accident, flashing lights, loud sounds?
Dx tests for seizures
CBC, WBC, Blood or CSF analysis, LP, Skull radiographs, CT, EEG.
Therapuetic Goal
Control or reduce frequency
Medications (Dont have to know meds for the test)
Main thing to know: Will be having blood drawn regularly to test levels of drugs...Ex: Ck Dilantin levels
Status Epilepticus
THE BIG ONE
Continuous seizure which lasts more than 30 minutes
Does NOT regain premoribid level of consciousness
Tx of status epilepticus
ABCS
HYDRATION
IV VALIUM
PHENOBARB
RECTAL ATIVAN
Nursing management of status epl.
Describe seizure, onset, movement, face, eyes, resp effort, incontinence, observe posictal
Febrile Seizure: know this one!
Most common
less than 15 minutes
core rapidly increases to 39 C.
Postictal state: Drowsy
Fever doesn't respond to Tylenol...baths, etc
INTERVENTIONS: keep safe.
Neonatal seizure
during first 4 weeks of life
due to immaturity of brain
postictal adverse affects on brain...neurological, behavioral or motor affects
Management for Neonatal seizures
chart 37.4
Adequate ventilation
correcting metabolic disturbances
may have normal EEG. see tachycardia and elevated BP.
Anticonvulsive therapy
Neural tube defects
anacephaly
encephalocele
spina bifida
Structural defects
Microcephaly
Arnold-Chairi
Hydrocephalus
Intracranial arteriovenous malformation
Craniosynsotosis
Microcephaly
More than 3 deviations below normal
Failure of the brain to develop
Results in mental retardation
Small head, normal face, lose wrinkled scalp
No tx available. Be supportive and educate.
Arnold-Chari
Type 1 and Type 2
Type 2 is most common...most a/w meningocele and hydrocephalus...Will be tested over...Leading cause of death in children with open neural tube defects. REQUIRE SURGERY.
Arnold-Chiari
Weak cry, stridor, apnea, GI dist.
Hydrocephalus
most frequently seen disorder
imbalance in production and absorption of CSF in ventricular system.
2 types of hydroceph.
1. nonobstructive: impaired absorption
2. obstuctive: blockage of CSF to ventricles
Can be either congenital or acquired.
Dx tests of hydrocephalus
Change in LOC. positive Mecewen sign.
CT, MRIs...
Treatments: VP shunt
VP shunt: KNOW THIS SLIDE
Complications can be infection or malfunction of shunt
Child will have to go back to surgery for revisions throughout life.
PRIORITY: RECOGNIZE INFECTION: VS, WBC, TEMP
POOR FEEDING, VOM, DECREASED RESPONSIVENESS, SEIZURE ACTIVITY, SHUNT TRACT REDNESS/SWE
VP definition:
is cathedar that diverts flow of CSF....Look up better definition...
Taking care of pt pre-VP shunt
Monitor ICP. Advancing condition. Adequate nutrition...No scalp IVs.
Post VP shunt
Neuro checks, LOC, VS, Abdominal distention because it goes to periotenum...aren't absorbing CSF correctly, monitor for infection, watch diaper placement so you dont interupt shunt.
Nursing management VP shunt
Care plan: Ineffective cerebral tissue perfusion
Support child and family.
AVM: Intracranial Arterio.venous Malformation ****
is when the artery and vein communicate with one another...which causes issues with blood clots...
Rare congential disorders
****
Most common cause of hemorrhagic stroke in infants
*****
Some never cause problems...some lead to death.
What are we going to do for AVM?
Treat aggressively with surgery...embolization of vessels...radiosurgery involved...focus radiation on AVM. Nursing assessment: Watch for intracranial hemorrhage...vision problems...paralysis...speech problems...h/a.
DX thru imaging procedures with a dye.
Craniosynostosis
Premature closure of sutures...Brain cant grow...starts to change shape of head...Types page 1169 table 36.5
Nursing Assessment for Cranio.synostosis
Present at birth...Palpable bony ridge..Need xray studies which will show the sutures are closed.
Tx: Surgically release sutures.
Nursing management: H&H, pain management, fever, hemorrhage, infection and swelling...watch these!
Positional plagio.cephaly
You'll see flat on one side..bulging on the other side due to unfused sutures...
See due to laying on back...flattening out head...
Tx is basic. Reposition. Avoid use of carseats..Molding helmets...Place towel on affected side. No surgery needed.
Infectious Disorder
Bacterial Meningitis
Aseptic Meningitis
Encephalitis
Reye's Syndrome
Botulism
Rabies...
Bacterial Meningitis
Acute inflammation of the meninges and the CNS
BM
can lead to death.
occurs 1 to 5 months of age.
Causes at different ages: table 1170
Causes of BMeningitis
Causes inflammation, swelling, purulent exudates, and tissue damage to the brain...Occurs as secondary infection
Direct introduction can occur if there is an unsterile LP, skull fracture, neurosurgical interventions can cause Bmeningitis.
Tx for Bacterial Meningitis: PAY ATTENTION
Requires hospitalization
Need isolation precautions
Antibiotics Needed ASAP before death
Fever: control it. Give tylenol, motrin...
Maintain hydration and ventilation...watch for Increased ICP.
Control any type of seizures, anemias.
How does Bacterial Meningitis get dx?
LP to determine CSF (give demerol, fentanyl, versed, EMLA cream)
Blood culture
Nose/throat culture
S/S of bacterial mengitis
Fever, chills, HA, vomiting, stiff neck, photophobia, irritability, lethargy, rash, drowsiness, muscle rigidity, seizures
positive Kergigs Sign: pg 1172: flex legs at hip...extend knee upward...pain down vertebral column
positive Brudzinski's sign: pull n
Infants with bacterial meningtis
weak cry, poor sucking and feeding
Pay attention to this slide: How are we going to take care of BACTERIAL MENINGITIS pts?
Vaccinations at 2 months old...Influenza, Pnuemococcal.
Post exposure shot they can get...
Initiate ABX ASAP.
Temp of environment
VS, neuro checks, isolation, HC, NPO, Long-term IV therapy
Opisthon.tonic posituring: Which head and neck is hyperextended to
Aspectic Meningitis
Most common type in children less than 5 years old.
Use to be called viral meningitis
Can be a/w measles, mumps, herpes, leukemia
S/S of aspecic meningitis
are the same as bacterial.
Dx of aseptic meningitis
Based on clnical signs and CSF findings: Do culture and sensitivity
Important to distinguish between viral and bacterial.
TX: Isolation until confirmed.
Treat symptoms
Encephalitis is
the inflammatory process of the CNS that produces altered function of the various portions of the brain and spinal cord.
Encephalitis is caused by
protozoan, bacterial, fungal or viral causes. Most are VIRAL.
Direct invasion of the CNS by virus.. Herpes..West Nile
Post infectious involves CNS
Assessment of Encephalitis
Fever, flu-like, altered LOC, HA, lethargy, drowsiness, generalized weakness, seizures, neuro exam reveals changes in sensorium: more sensory issues
DOES NOT HAVE POSITIVE KERNIGS SIGN IN ENCEPHALITIS
DX of encephalitis
LP, MRI, CT AND EEG
Nursing management of encephalitis
educate for prevention
important to get immunizations
Treatment of Encephalitis
Same as meningitis
Reyes syndrome
Acute NON-inflam encephalopathy..
affects under 15 years of age who are recovering from like chicken pox...triggered by use of aspirins...
Reyes s/s
severe and continual vomiting
changes in mental status
lethargy
confusion
hyperrelfexia
disordered hepatic function
using aspirins within 3 weeks of start of viral illness
Pay attention! How do you dx reyes?
Elevated AST and ALTs.
Elevated ammonia levels which tells liver has been compromised.
Management of Reyes: early dx, maintain ICP, safety measures due to seizures, monitor fluid status, teach parents not to use salicytates,
Head truama
is the most common cause of death and diability in children
CCommon types of head trauma
table 37.7
Types of head injuries
Acceleration: Head is still...something hits it.
Coup: point of impact Countrecoup: result of brain recoil
Deceleration: Head hits still object.
Deformation: Can cause sheering stress which tear small arteriers and causes hemmorhages.
Nursing assess of head trauma
very detailed hx of event
physical exam: ABCs, stabalize head and neck...dont move them till r/o head trauma, neurologic function, S/S ICP
Lab and DX tests: head and neck x-ray, CT, MRI
Nursing management of head trauma
Check pupils. If fixed or sluggish at all, neurological complications exist.
Nursing management: Mild to Moderate Head trauma
Page 1179 37.2
Tell caregive to watch pt to watch for 24 hours...wake up ever 2 hours...watch behaviors...any kind of changes--need to seek medical attention.
Severe head injuries
need intenstive care: WATCH ABCs
LOC, PUPIL RESPONSES, S/S of I.ICP, monitor for seizures, administer sedation.
Keep parents involved in child's care. Involve social work due to guilt. Include Rehab. PREVENTION IS THE KEY.
Cerebral traumas
Concussions
Contusions/Laceration
Fractures
Epidural Hematoma
Subdural Hematoma
Concussions
a traumatically induced alteration in mental status
MOST COMMON TYPE OF INJURY
Hallmark sign: Confusion and amnesia
TX: Mild: Go home.
Contustions/Lacerations
visible bruising and tearing of cerebral tissue
petechial hemorrhage at coup.
Little lesions at countercoup or opposite side of injury
Fractures include PG 1107 table
Linear fractures: Simple break in skull
Commonly a/w overlying hematoma or soft tissue swelling
Depressed fracture
bone is locally broken...ping pong fracture...surgically elevate bones to ellivate brain pressure
Basilar Fracture :PAY ATTENTION
S/S are CSF rhinorrhea and otorhea
Battle sign: Bleeding behind ears.
Racoon Eyes: Orbital bruising: black eyes
INCREASED RISK OF INFECTION!!!
Compound Fractures
Open fractures: splintering of bone...require surgery possibly.
Diastatic (growing) fractures: observation required...traumatic separation of sutures...
Epidural Hematoma
blood accumulates between the DURA and SKULL.
Epidural
Bleeding is usually arterial. Can have respir. and hear impairment. Watch for V/HA/lethargy.
TX: surgical evacuation and cauterization of artery..may see drain in place
Do Neuro checks, pupil reactions, LOC
Pay ATTENTION: Subdural Hematoma
Bleeding between DURA and CEREBRUM.
Subdural Hematoma
Due to shaken baby, or birth trauma
changes in LOC, Pupils, Neuro checks, Increased ICP
Can occur within ---------------- missed this part....
Intracranial Hemorrhage Assessment
Cushings Triad:
Hypertension
Widening Pulse Pressure
Bradycardia
Unequal pupils, fixed pupils
Bleeding from nose or ears that tests positive for glucose means CSF fluid...which means HIGH RISK OF INFECTION.
CT SCAN WITHOUT CONTRAST TO SHOW BLEEDING.
Nonaccidental Head Trauma
Most common cause of death and morbidity of infancy.
Some a**hole inentionally harms the child.
Nursing assessment for abuse
Have parent explain injury.
Note discrepancies.
Report child abuse.
s/s poor feeding, v, ftt, difficulty arousing, bradycardia, apnea, bulging fontanels, seizures, decreased LOC
Nursing Management for Nonaccidentals
SEE CHART Pg 1181 37.3
Main topic: Tips to calm a crying baby.
Teach parents how to deal with stress.
Drowning
Drowning is defined as death from asphyxia while submerged with or without aspiration of fluids
Near Drowning
WONT BE TESTED. ;)
Cerebral vascular disorders
disruption of blood flow to the brain which affects neuro function.
Strokes
Ischemic
Hemmorhagic
Ischemic Stroke
More common than hemorrhagic due to the risk factors:
VSD, ASD, aortic stenosis.
Coagulation abnormalities
Sickle Cell
Infections such as meningitis
Atrial disection
Genetic Disorders
N2K: Hemorrhagic Stroke
Vascular malformations
aneurysms
coumadin therapy
malignancies
trauma
phrombo.cyto.penia
leukemia
Nursing Assessment for hemorrhagic stroke
unilateral weakness, slurred speech, speech deficts, facial drooping...assess neuro status, increase mobility, provide adequate nutrition and hydration, encourage self care, rehab, provide support and education.
What are the s/s of ICP?
Headache, N/V, diplopia, blurred vision, seizures
What are the late s/s of ICP?
Bradycardia, lowered LOC, Decreased motor response to command, and painful stimuli, alterations in pupil size and reactivity, d/d posturing, coma, cheyne-stokes respirations, coma, doll's head manuever (move head side to side...eyes go in same place...wit
What is the treatment for bacterial and septic meningitis?
Requires hospitalization
Need isolation precautions
Antibiotics Needed ASAP before death
Fever: control it. Give tylenol, motrin...
Maintain hydration and ventilation...watch for Increased ICP.
Control any type of seizures, anemias
Difference between subdural and epidural hematoma?
:
Name the different types of seizures.
:
What is hydrocephalus?
:
What are the different types of LOC?
:
What are the different types of head trauma?
:
Reye's syndrome?
:
Brain and spinal cord develop at
3 to 4 weeks gestation.
Why do kids have higher risk of skull fractures?
Bone development...
Sutures and fontanels close early or late
Cause brain damage
Myelinization
Increase of nerve impulses
Kids head is a
4th of their body size. The adults is an 8th.
Neuro hx
Family hx
Moms pregnancy
PMH
Sudden movements/alterations
ha, NV, Double Vision, incontinence, unusual behavior
LOC
is one of the FIRST things we can tell about neuro disorders.
Name types of LOC
obtunded, etc...look up...
Physical assessment includes
LOC, VS, CN, motor funciton, relfexes, sensory function, ICP
Decerebrate posturing
Damage to the spinal cord..."MIDBRAIN.
Decorticate posturing
Damage to the cerebral cortex
Physical assessment for infants
size and shape of head is very important.
Symmetry in movement
Does the kid have any twitching movements?
High pitched crying can be
increased ICP or ...something else she said...I didn't get it...
I.ICP s/s
Tense of bulging fontanel
Separated sutures
Macewen sign positive
irritability
high pitched cry
increased hc
distended scalp veins
changes in feeding
crying when disturbed
What is MACEWEN sign?
if you percuss and get a resonant sound..its positive and means increased ICP
Behavioral signs of ICP
Decline in school performance..
Diminished phys. activity and motor performance
Memory Loss
Inability to follow simple commands.
ICP management may include
drains...keep an eye on posture: Want them straight midline and HOB 15 to 30 degrees. No turning side to side. Hyperoxygenate patients and perform suctionsing.
Altered LOC
2 components: Alertness and cognitive power
Alertness
An arousal-waking state, including the ability to response to stimuli
Cognitive Power
Ability to process stimuli and produce verbal and motor responses
Full consciousness is
awake and alert; oriented x3
Confusion is
Impaired decision making
Disorientation
to time and place. decreased LOC
Lethargy
sluggish speech, drowsy, spontaneous movement
How we check LOC
Glascow coma scale
Glascow Coma Scale (look at pg 1143)
Eye Opening
Verbal Response
Best Motor Response
Know that the higher the # the better the LOC
Stupor means
deep sleep: painful stimuli required to wake up...like sternal rub
Coma
no motor or verbal repsonse
Persistent Veg. State
The permanent loss of the cerebral cortex function
Seizures
caused by malfunctions of the brains electric system
Two types of seizures
Epileptic
NON-Epi.
Epilepsy
Un-provoked...
can be idiopathic or acquired (family hx)
more common in the first 2 years of life
Two types of EPILLEPTIC
Partial: one part of the brain
Generalized: electrical disturbance all over brain usually causes loss of consciousness.
Simple Partial seizures
numbness tingling, prickling, pain
usually last 10 to 20 seconds..
remains conscious
NO-Post ictal state
clonic or tonic movements
Complex partial
Preceding auras
Impaired LOC during event
Stare, become limp, do repetitive movements like pick at bedsheets, etc..
inability to respond to enviornment
positive post ictal state
confusion or amnesia may be prolonged
Generalized: Tonic Clonic: know this one forsure!
Formerly grandmal seizure
lasts 10 to 20 seconds during TONIC phase
Immediated Loss of Consciousness
Entire body involvement
Periods of apnea: May turn blue
Increased salivation and loss of swallowing reflex
May bite tongue
Clonic Phase
Violent jerking
Dont respond to touch
Incontient
LAST 30 seconds to 30 minutes
May foam at mouth
Clonic Tonic Postictal
Appears to relax, difficult to arouse, poor coordination, impaired fine motor skills, visual/speech difficulty, N/V, no recollection of event
Seizure concern
Bring them to the floor. Safety most important. Never never restrain a child with a seizure. Dont use tongue blade. If vomiting or foaming...dont suction...turn on their side.
Absence Seizures
Blank stare, brief loss of consciousness, abrupt onset, do have amnesia after episode, have lip smacking, twitching of eyelids and face, slight hand movements
ATONIC seizures
DROP TO GROUND SUDDENTLY.
Myoclonic Seizures
Sudden brief contractions of muscle group...occur singly or repetitively. no postictal state. may/may not lose consc.
Infantile Spasm
Possible sudden contractions..flushed pale or cyanotic...may be preceded by giglling or cry...eyes may roll upward
AGAIN...PAY ATTENTION TO
CLONIC TONIC.
To dx a seizure know these two things
1. Determine the type of seizure
2. Determine the cause
Detailed hx of seizures
PRE-PERI-NEONATAL HX
Description of seizure
Postictal behavior: Did they remember or not remember??
Record length of seizures
Did they turn blue? Apneic?
Recurrent? Did they fall recently, bicycle accident, flashing lights, loud sounds?
Dx tests for seizures
CBC, WBC, Blood or CSF analysis, LP, Skull radiographs, CT, EEG.
Therapuetic Goal
Control or reduce frequency
Medications (Dont have to know meds for the test)
Main thing to know: Will be having blood drawn regularly to test levels of drugs...Ex: Ck Dilantin levels
Status Epilepticus
THE BIG ONE
Continuous seizure which lasts more than 30 minutes
Does NOT regain premoribid level of consciousness
Tx of status epilepticus
ABCS
HYDRATION
IV VALIUM
PHENOBARB
RECTAL ATIVAN
Nursing management of status epl.
Describe seizure, onset, movement, face, eyes, resp effort, incontinence, observe posictal
Febrile Seizure: know this one!
Most common
less than 15 minutes
core rapidly increases to 39 C.
Postictal state: Drowsy
Fever doesn't respond to Tylenol...baths, etc
INTERVENTIONS: keep safe.
Neonatal seizure
during first 4 weeks of life
due to immaturity of brain
postictal adverse affects on brain...neurological, behavioral or motor affects
Management for Neonatal seizures
chart 37.4
Adequate ventilation
correcting metabolic disturbances
may have normal EEG. see tachycardia and elevated BP.
Anticonvulsive therapy
Neural tube defects
anacephaly
encephalocele
spina bifida
Structural defects
Microcephaly
Arnold-Chairi
Hydrocephalus
Intracranial arteriovenous malformation
Craniosynsotosis
Microcephaly
More than 3 deviations below normal
Failure of the brain to develop
Results in mental retardation
Small head, normal face, lose wrinkled scalp
No tx available. Be supportive and educate.
Arnold-Chari
Type 1 and Type 2
Type 2 is most common...most a/w meningocele and hydrocephalus...Will be tested over...Leading cause of death in children with open neural tube defects. REQUIRE SURGERY.
Arnold-Chiari
Weak cry, stridor, apnea, GI dist.
Hydrocephalus
most frequently seen disorder
imbalance in production and absorption of CSF in ventricular system.
2 types of hydroceph.
1. nonobstructive: impaired absorption
2. obstuctive: blockage of CSF to ventricles
Can be either congenital or acquired.
Dx tests of hydrocephalus
Change in LOC. positive Mecewen sign.
CT, MRIs...
Treatments: VP shunt
VP shunt: KNOW THIS SLIDE
Complications can be infection or malfunction of shunt
Child will have to go back to surgery for revisions throughout life.
PRIORITY: RECOGNIZE INFECTION: VS, WBC, TEMP
POOR FEEDING, VOM, DECREASED RESPONSIVENESS, SEIZURE ACTIVITY, SHUNT TRACT REDNESS/SWE
VP definition:
is cathedar that diverts flow of CSF....Look up better definition...
Taking care of pt pre-VP shunt
Monitor ICP. Advancing condition. Adequate nutrition...No scalp IVs.
Post VP shunt
Neuro checks, LOC, VS, Abdominal distention because it goes to periotenum...aren't absorbing CSF correctly, monitor for infection, watch diaper placement so you dont interupt shunt.
Nursing management VP shunt
Care plan: Ineffective cerebral tissue perfusion
Support child and family.
AVM: Intracranial Arterio.venous Malformation ****
is when the artery and vein communicate with one another...which causes issues with blood clots...
Rare congential disorders
****
Most common cause of hemorrhagic stroke in infants
*****
Some never cause problems...some lead to death.
What are we going to do for AVM?
Treat aggressively with surgery...embolization of vessels...radiosurgery involved...focus radiation on AVM. Nursing assessment: Watch for intracranial hemorrhage...vision problems...paralysis...speech problems...h/a.
DX thru imaging procedures with a dye.
Craniosynostosis
Premature closure of sutures...Brain cant grow...starts to change shape of head...Types page 1169 table 36.5
Nursing Assessment for Cranio.synostosis
Present at birth...Palpable bony ridge..Need xray studies which will show the sutures are closed.
Tx: Surgically release sutures.
Nursing management: H&H, pain management, fever, hemorrhage, infection and swelling...watch these!
Positional plagio.cephaly
You'll see flat on one side..bulging on the other side due to unfused sutures...
See due to laying on back...flattening out head...
Tx is basic. Reposition. Avoid use of carseats..Molding helmets...Place towel on affected side. No surgery needed.
Infectious Disorder
Bacterial Meningitis
Aseptic Meningitis
Encephalitis
Reye's Syndrome
Botulism
Rabies...
Bacterial Meningitis
Acute inflammation of the meninges and the CNS
BM
can lead to death.
occurs 1 to 5 months of age.
Causes at different ages: table 1170
Causes of BMeningitis
Causes inflammation, swelling, purulent exudates, and tissue damage to the brain...Occurs as secondary infection
Direct introduction can occur if there is an unsterile LP, skull fracture, neurosurgical interventions can cause Bmeningitis.
Tx for Bacterial Meningitis: PAY ATTENTION
Requires hospitalization
Need isolation precautions
Antibiotics Needed ASAP before death
Fever: control it. Give tylenol, motrin...
Maintain hydration and ventilation...watch for Increased ICP.
Control any type of seizures, anemias.
How does Bacterial Meningitis get dx?
LP to determine CSF (give demerol, fentanyl, versed, EMLA cream)
Blood culture
Nose/throat culture
S/S of bacterial mengitis
Fever, chills, HA, vomiting, stiff neck, photophobia, irritability, lethargy, rash, drowsiness, muscle rigidity, seizures
positive Kergigs Sign: pg 1172: flex legs at hip...extend knee upward...pain down vertebral column
positive Brudzinski's sign: pull n
Infants with bacterial meningtis
weak cry, poor sucking and feeding
Pay attention to this slide: How are we going to take care of BACTERIAL MENINGITIS pts?
Vaccinations at 2 months old...Influenza, Pnuemococcal.
Post exposure shot they can get...
Initiate ABX ASAP.
Temp of environment
VS, neuro checks, isolation, HC, NPO, Long-term IV therapy
Opisthon.tonic posituring: Which head and neck is hyperextended to
Aspectic Meningitis
Most common type in children less than 5 years old.
Use to be called viral meningitis
Can be a/w measles, mumps, herpes, leukemia
S/S of aspecic meningitis
are the same as bacterial.
Dx of aseptic meningitis
Based on clnical signs and CSF findings: Do culture and sensitivity
Important to distinguish between viral and bacterial.
TX: Isolation until confirmed.
Treat symptoms
Encephalitis is
the inflammatory process of the CNS that produces altered function of the various portions of the brain and spinal cord.
Encephalitis is caused by
protozoan, bacterial, fungal or viral causes. Most are VIRAL.
Direct invasion of the CNS by virus.. Herpes..West Nile
Post infectious involves CNS
Assessment of Encephalitis
Fever, flu-like, altered LOC, HA, lethargy, drowsiness, generalized weakness, seizures, neuro exam reveals changes in sensorium: more sensory issues
DOES NOT HAVE POSITIVE KERNIGS SIGN IN ENCEPHALITIS
DX of encephalitis
LP, MRI, CT AND EEG
Nursing management of encephalitis
educate for prevention
important to get immunizations
Treatment of Encephalitis
Same as meningitis
Reyes syndrome
Acute NON-inflam encephalopathy..
affects under 15 years of age who are recovering from like chicken pox...triggered by use of aspirins...
Reyes s/s
severe and continual vomiting
changes in mental status
lethargy
confusion
hyperrelfexia
disordered hepatic function
using aspirins within 3 weeks of start of viral illness
Pay attention! How do you dx reyes?
Elevated AST and ALTs.
Elevated ammonia levels which tells liver has been compromised.
Management of Reyes: early dx, maintain ICP, safety measures due to seizures, monitor fluid status, teach parents not to use salicytates,
Head truama
is the most common cause of death and diability in children
CCommon types of head trauma
table 37.7
Types of head injuries
Acceleration: Head is still...something hits it.
Coup: point of impact Countrecoup: result of brain recoil
Deceleration: Head hits still object.
Deformation: Can cause sheering stress which tear small arteriers and causes hemmorhages.
Nursing assess of head trauma
very detailed hx of event
physical exam: ABCs, stabalize head and neck...dont move them till r/o head trauma, neurologic function, S/S ICP
Lab and DX tests: head and neck x-ray, CT, MRI
Nursing management of head trauma
Check pupils. If fixed or sluggish at all, neurological complications exist.
Nursing management: Mild to Moderate Head trauma
Page 1179 37.2
Tell caregive to watch pt to watch for 24 hours...wake up ever 2 hours...watch behaviors...any kind of changes--need to seek medical attention.
Severe head injuries
need intenstive care: WATCH ABCs
LOC, PUPIL RESPONSES, S/S of I.ICP, monitor for seizures, administer sedation.
Keep parents involved in child's care. Involve social work due to guilt. Include Rehab. PREVENTION IS THE KEY.
Cerebral traumas
Concussions
Contusions/Laceration
Fractures
Epidural Hematoma
Subdural Hematoma
Concussions
a traumatically induced alteration in mental status
MOST COMMON TYPE OF INJURY
Hallmark sign: Confusion and amnesia
TX: Mild: Go home.
Contustions/Lacerations
visible bruising and tearing of cerebral tissue
petechial hemorrhage at coup.
Little lesions at countercoup or opposite side of injury
Fractures include PG 1107 table
Linear fractures: Simple break in skull
Commonly a/w overlying hematoma or soft tissue swelling
Depressed fracture
bone is locally broken...ping pong fracture...surgically elevate bones to ellivate brain pressure
Basilar Fracture :PAY ATTENTION
S/S are CSF rhinorrhea and otorhea
Battle sign: Bleeding behind ears.
Racoon Eyes: Orbital bruising: black eyes
INCREASED RISK OF INFECTION!!!
Compound Fractures
Open fractures: splintering of bone...require surgery possibly.
Diastatic (growing) fractures: observation required...traumatic separation of sutures...
Epidural Hematoma
blood accumulates between the DURA and SKULL.
Epidural
Bleeding is usually arterial. Can have respir. and hear impairment. Watch for V/HA/lethargy.
TX: surgical evacuation and cauterization of artery..may see drain in place
Do Neuro checks, pupil reactions, LOC
Pay ATTENTION: Subdural Hematoma
Bleeding between DURA and CEREBRUM.
Subdural Hematoma
Due to shaken baby, or birth trauma
changes in LOC, Pupils, Neuro checks, Increased ICP
Can occur within ---------------- missed this part....
Intracranial Hemorrhage Assessment
Cushings Triad:
Hypertension
Widening Pulse Pressure
Bradycardia
Unequal pupils, fixed pupils
Bleeding from nose or ears that tests positive for glucose means CSF fluid...which means HIGH RISK OF INFECTION.
CT SCAN WITHOUT CONTRAST TO SHOW BLEEDING.
Nonaccidental Head Trauma
Most common cause of death and morbidity of infancy.
Some a**hole inentionally harms the child.
Nursing assessment for abuse
Have parent explain injury.
Note discrepancies.
Report child abuse.
s/s poor feeding, v, ftt, difficulty arousing, bradycardia, apnea, bulging fontanels, seizures, decreased LOC
Nursing Management for Nonaccidentals
SEE CHART Pg 1181 37.3
Main topic: Tips to calm a crying baby.
Teach parents how to deal with stress.
Drowning
Drowning is defined as death from asphyxia while submerged with or without aspiration of fluids
Near Drowning
WONT BE TESTED. ;)
Cerebral vascular disorders
disruption of blood flow to the brain which affects neuro function.
Strokes
Ischemic
Hemmorhagic
Ischemic Stroke
More common than hemorrhagic due to the risk factors:
VSD, ASD, aortic stenosis.
Coagulation abnormalities
Sickle Cell
Infections such as meningitis
Atrial disection
Genetic Disorders
N2K: Hemorrhagic Stroke
Vascular malformations
aneurysms
coumadin therapy
malignancies
trauma
phrombo.cyto.penia
leukemia
Nursing Assessment for hemorrhagic stroke
unilateral weakness, slurred speech, speech deficts, facial drooping...assess neuro status, increase mobility, provide adequate nutrition and hydration, encourage self care, rehab, provide support and education.