NSG 217: Intracranial Regulation & Infection

Intracranial Regulation General Aspects

• Children < 2 require special evaluation 

  • Unable to respond to directions

• Infants

  • Information for neuro obtained thru observation of spontaneous & elicited reflex responses

  • As the infant matures—reflexes are replaced by purposeful movement

  • Reappearance of reflexes indicate a pathologic condition

    • If the child had their reflexes at birth and then the reflexes went away as they should through the life span, and then all of a sudden they reappear, that could indicate that there's something going on intracranially and they're gonna probably need further testing.

  
  

  • through indirect measurement, check those reflexes, and see are they there if they are, should they still be there? If they shouldn't still be there, then that could suggest that there is a neurological issue going on.

• Delay or deviation from expected milestones helps Identify high-risk infants/children

• Assessment

  • Family history

    • Whenever they come in and you're suspecting that there might be issues with the intracranial regulation, you want to make sure you get a family history. 


    • So is there any neurological history in the family? And if so, what is it? When did it appear? 
How has it been treated? Did it go away on its own? Those sorts of things.

  • Health history

    • Maternal health history (pregnancy & delivery)

      • babies don’t have much of a health history so we’re going to look at the moms

      • Was there any complications during pregnancy? 
Were there any issues during the birthing process?

  • Physical evaluation of infant/child

• Most information about the status of the brain is obtained by indirect measurement

  • There's so much about the brain that we don't know. 
So most of what we're gonna find out about intracranial regulation is going to be through indirect observation.

    • So watching the child, talking to the parents, finding out from the parents that they have deviated from their baseline or from their norm

      
      

      
      

• Importance of milestones

  • Babies may not be able to follow directions, so how will we know their A&O status?

    • we measure their milestones

      • Have they met them? Are they where they need to be? Were they late reaching them?

        
        
        

• Will not be oriented x3?? What is normal--milestones

  
  
  

• if you have too much pressure because you have too many fluids or things like that, you can have issues like strokes and other things, and if for whatever reason, your cerebral spinal fluid is low and you have low intracranial pressures, you can have things like seizures and episodes of fainting and things of that nature.

Neurological Assessment

• Anatomy and Physiology differences

  • Infants

    • Head size

    • Cranial bones 

    • Fontanels 

    • Suture lines

• Head is large in proportion to the rest of the body and neck muscles are poorly developed – Increases risk for SBS

  • In addition, they have those weak neck muscles, so they can't do a great job of holding their head up, secondary to that. They are at risk for shaken baby syndrome.

  • we can also see intracranial regulation issues with shaken baby syndrome

  • you're definitely going to want to check some scans of the brain to see what, if any damage has been done.
    

    
    

• The skull expands until 2 years of age. Infants have excessive spinal mobility.

  
  

  
  

• Cranial bones not completely ossified placing the infant at greater risk for injury resulting from trauma.

  • that does put them at a greater risk for injury, resulting from trauma.

    
    

    
    

• Fontanels are spaces of connective tissue covering the brain at the junction of skull bones.

  • So they have an anterior and posterior fontanel. And basically that's just an open area. There's nothing protecting the brain in those areas. 
So we need to be very careful about protecting those areas.

    
    

• Suture lines are completely ossified by 12 years of age.

Neurological Assessment Continued

• Baseline neurologic information

  • through parents and your own assessment

• Observation

  • most of what we're going to end yet is going to be through indirect measurement, it’s going to be from watching them.

• Health History

• Developmental Milestones

  • how we would know a child’s A&O status

• Physical Assessment

  • Fontanels for infant

    • you want to make sure that you're assessing the fontanels specifically the anterior fontanel, because they can tell you, like, if it's bulging, that means that there's excessive fluid in the cranial cavity and If it's, dipped in, that means that there's not enough food, which could mean that they’re dehydrated

• Family History

• LOC is the earliest indicator of IICP

  • Deterioration or improvement

• Important to establish an accurate baseline of neurologic information. – this is why it is important to complete your assessment early in your shift

  
  
  

• Most information about infant and young children is gained by observation.

  
  
  

• Detailed health history to identify causes of alteration in neurologic status

  
  

• Infant physical assessment

  • Size and shape of the head

  • Reflexes

  • Symmetry of movements

    • might be at risk for stroke if pressures too high

  • Cry

    • there is a neurological cry. It is dubbed the cry of the cat

    • It's very high pitched

  • Level of development

• Glasgow coma scale (chart to follow)

  
  

• Pupil response Normal response is to constrict to light bilaterally. 

  
  

• bilateral fixed and dilated or very sluggish 0 poor sign-brain herniation from increased ICP

  • problematic. This probably means that there's a herniations somewhere in the brain that was secondary to that increased intracranial pressure.

    
    

• Vital signs should be monitored for any changes-can indicate increased ICP (will talk about on next slide)

Nursing Assessment

• Vital Signs

  • Cushing’s Triad – Widened pulse pressure, Bradycardia, Irregular RR, Bradypnea

• Skin—examined for signs of trauma 

• Eyes—pupil check “fixed and dilated”

• Motor Function

• Posturing

• Reflexes

  • Specifically Moro and Tonic Neck

• What is widened pulse pressure?  Increasing gap between systolic and diastolic

  
  

  
  

• Posturing Flexion & extension posturing (decebrate and decorticate)

  
  
  

• Infant reflexes: key: Moro, tonic neck and withdrawal reflexes 

  
  
  

• Moro: The startle reflex observed in normal infants from birth through the first few months, consisting of abduction and extension of all extremities, followed by flexion and abduction of the extremities. 

  
  
  

• Tonic neck: fencing reflex – head turns to arm/leg that is extended and other side is flexed.

  
  
  

• Positive babinski is significant in >18mo – toes fan out

Nursing Assessment: Glasgow Coma Scale

• Many different variations

  
  

• Glasgow coma scale total score is 15. Lowest score is 3. total neurologic unresponsiveness.

  
  

• Age appropriate responses/keep in mind stranger

  
  

• Alert responsive to parents, coos, cuddles, smiles

  Verbal responsive to verbal stimuli

  
  

• Pain responsive to painful stimuli ONLY

  
  

• Unresponsive to painful stimuli

  
  

Altered Levels of Consciousness

• Level of consciousness is the MOST IMPORTANT indicator of neurologic dysfunction

  •  WHY?

• LOC is earliest indicator of neurologic issues

• Full Consciousness - Alertness-ability to react to stimuli.

  
  

• Unconsciousness - Inability of the brain to respond to stimuli. Depressed cerebral function

  
  

• Lethargy- limited spontaneous movement, sluggish speech

  
  

• Obtunded limited response to the environment, arousable with stimulation

  
  

• Stupor response to vigorous stimuli only

  
  

• Coma severely diminished response. No motor or verbal response to painful stimuli

  
  

• Persistent vegetative state – permanent loss of cerebral cortex function

• This is very subjective!! Paint clearest picture possible

Altered Levels of Consciousness Causes

• Causes

  • Trauma

  • Infection

  • Poisoning

  • VP shunt malfunction

  • Seizures

  • Tumors

  • Hypoxia

  • Congenital structural defect of the brain

Altered Level of Consciousness Clinical Manifestations

• Clinical Manifestations

  • Restlessness

  • Fussy

  • Pupil changes

  • Irritability

  • Posturing

  • Increased ICP

Posturing

• Decorticate-characterized by rigid flexion associated with lesions above the brainstem in the corticospinal tracts.

  
  

• Decerebrate characterized by rigid extension  associated with lesions of the brainstem.

  
  
  

• Posturing may not be evident when the child is quiet----elicited by stimuli (usually painful stim)

Increased ICP

• Normal pressure: 5-15 mmHg

  
  
  

  
  

• The brain is well protected within the skull---but vulnerable to changes in pressure

  
  
  

  
  

• Early signs-VS and LOC can be slight, need to be aware of any changes. Pulse ox change can be your first sign.   

  
  
  

  
  

• In infants-bulging fontanels and high-pitched cry

Increased ICP ~ Early (Infants)

• Infants:

  • Tense, bulging fontanel

  • Separated cranial sutures

  • Irritability and restlessness

  • Drowsiness

  • Increased sleeping

  • High-pitched cry

  • Increased fronto-occipital circumference

  • Distended scalp veins

  • Poor feeding

  • Crying when disturbed

  • Setting-sun sign

Increased ICP ~ Early (Children)

• Children:

  • Headache

  • Nausea

  • Forceful vomiting

  • Diplopia, blurred vision

  • Seizures

  • Indifference, drowsiness

  • Decline in school performance

  • Diminished physical activity and motor performance

  • Increased sleeping

  • Inability to follow simple commands

  • Lethargy

Late Signs Of IICP Infants & Children

• Bradycardia

• Decreased motor response to command

• Decreased sensory response to painful stimuli

• Alterations in pupil size and reactivity

• Extension or flexion posturing

• Cheyne-Stokes respirations

• Papilledema

• Papilledema – swelling of optic disc

• Decreased consciousness

• Coma

If you see any of these symptoms in children consider that the child is in severe distress

Special Diagnostic Tests

• Laboratory

  • Blood sugar

  • Lytes, BUN, Cr

  • Toxicology

  • Ammonia level

  • CBC

  • Blood cultures

• EEG

  • EEG- identifies  damaged or nonfunctioning areas of the brain

• LP

  • LP not In presence of IICP----herniation

• CT

• MRI

  • CT Scan, PET scan, MRI to detect lesions, structural abnormalities, vascular malfunction or edema. 

• Intracranial pressure monitoring. 

  
  

• Skull x-rays detect fractures or bone malformations.

Lumbar Puncture

• Lumbar puncture collects cerebrospinal fluid for testing and measures CSF---definitive diagnosis

  
  
  

• Contraindicated in patients with increased ICP or infected skin over puncture site.

  
  
  

• LP the holder is the most important person, stabilizes the spine for person performing LP---sedation!!

  
  
  

• Other Diagnostics include: Glasgow coma scale. Lab tests CBC electrolytes Blood culture, Toxicology 

Nursing Considerations

• Maintain airway

• Perform routine care

• Provide adequate nutrition

• Provide skin care

• Perform ROM activities

• Provide sensory stimulation

• Provide family support and education

• Routine Care- bed bath, oral care, artificial tears

  
  

  
  

• Frequent Nero checks, ICP monitoring. Pupil checks, Vital signs

  
  

  
  

• Emergency measures are directed toward ensuring airway, treatment of shock & reduction of ICP

Intracranial Pressure Monitoring

Nursing Diagnoses

• Ineffective breathing pattern

• Risk for aspiration

• Risk for impaired skin integrity

• Impaired Verbal Communication

• Interrupted family process

Structural Defects: Hydrocephelus

• Imbalance of CSF in the ventricular system.

  • Congenital

    • Developmental malformation 

  • Acquired

    • Infection

    • Trauma

• An imbalance in the production and absorption of CSF in the ventricular system. 

  
  

• CSF accumulates causing an increase of pressure within the ventricle which leads to dilatation of the ventricles.

• Hydrocephalus is the body’s response to an imbalance between the production and absorption of CSF leading to an increase in the volume of CSF.

Communicating Hydrocephalus

• Communicating  (Non-obstructive)

  • Impaired absorption 

  • Caused by:

    • Neural Tube Defects

    • Neonatal Meningitis

    • Trauma

    • Tumor 

    • Chiara Malformation

• Communicating (non-obstructive) – Flow of CSF is blocked after it exits the ventricles. CSF can still flow between ventricles.

Noncommunicating Hydrocephalus

• Noncommunicating (obstructive)

  • Obstructive

    • Subarachnoid hemmorhage

• Noncommunicating (obstructive) – CSF is blocked in the ventricular system. Most common type in children

Hydrocephalus: Clinical Manifestations in Infants

• Infants

• Early Signs

  • Infants-increased head circumference

  • Bulging fontanels

  • Irritability 

  • Dilated scalp veins 

  
  

• Late Signs

  • Frontal bossing

  • Sluggish pupils

  • Setting-sun sign

  
  

• General 

  • Difficulty swallowing or feeding

  • Cardiopulmonary depression

  • Shrill, high-pitched cry

Hydrocephalus: Clinical Manifestations in Children

Children

• Headache

• Irritability, lethargy.

• Altered level of consciousness

• Personality changes

• Alterations in motor development

• Signs of ICP

Hydrocephalus Nursing Interventions

• Measure and mark head circumference – also done with brain tumor

  
  
  

  
  

• Scalp veins may appear dilated and prominent.

  
  
  

  
  

• Sunsetting eyes are when the sclera is visible above the iris.

  
  
  

  
  

• Increased tone or hyperreflexia

  
  
  

  
  

• Decreased LOC

  
  
  

  
  

• Distortion of the brainstem may result in vital sign changes like bradycardia, hypertension and altered respiratory rate.

  
  
  

  
  

• IICP signs and symptoms – Teach these to parents/care givers

Hydrocephalus-Diagnostics

• Neurological Assessment

  • Including HC that is increasing in growth chart

  • Mark the location of tape  measure for serial measurements

• Neuro-Imaging studies:

  • CT Scan

  • MRI

• Infant-measure head circumference

  Childhood-increased ICP

  
  

  
  

• Left—hydroceph right –normal scan 

Therapeutic Management

• Surgery

  • Ventriculoperitoneal (VP) shunt

  • Ventriculoartial (VA) shunt

• Goal: 

  • Relief of the hydrocephalus

  • Treatment of complications

  • Management of problems related to the effect of the disorder on psychomotor development

• Shunt- catheter is placed into one of the lateral ventricles, usually the right and the distal end is placed in the peritoneal cavity (VP) or right atrium (AV). 

  
  

  
  

• The catheter has a flush pump and a one-directional flow valve . When the pressure exceeds a certain value the valve opens. When pressures decreases the valve closes (preventing backflow).

  
  
  

Shunt Complications

• Shunt Complications

  • Infection

    • Most serious complication

    • Need for external ventricular device (EVD)

• Mechanical failure

  • Blockage

  • Kinking

  • Valve breakdown

• When patient has an infection of the shunt, the infected shunt is removed and an EVD is placed to drain the CSF outside of the body. 

  
  

  
  

• EVD’s positioned at the level of the external auditory meatus for optimal drainage of CSF fluid. 

  
  

  
  

• A new shunt is placed when the infection is cleared up.

  
  
  

• Mechanical failure can sometimes be repaired without removal, but if removal is required, a new one can be placed immediately because no infection is present.

Nursing Care Management

• Neurologic Assessment

  • ICP concerns 

    • Teach parents for home care s & sx

• Postoperative care 

  • Provide skin care

  • Nutritional needs

  • Do Not Place on Operate side

    • HOB will be FLAT

  • Observe for abdominal distention

• Monitor Intake and Output

• Provide family support

• Why are we observing for abdominal distention? CSF may cause peritionitis or a postop ileus as a complication of catheter placement.

Hydrocephalus Nursing Diagnoses

• Risk for infection

• Impaired physical mobility

• Risk for caregiver role strain

• Anxiety

• Risk for delayed development

Febrile Seizure

• Febrile Seizure

  • One of the most common neurologic issues of childhood

  • Seen between 1 months and 5 years

    • Peak incidence before18 months

  • Sudden rise in temperature >38 C

  • Runs in families

  • Generalized tonic-clonic movements

• Can occur with both viral and bacterial infections.

  
  
  

• Cause is uncertain – believe it is because the temp rises so quickly

  
  
  

• Children who have multiple 4 or > febrile seizures are at greater risk for developing a seizure disorder like epilepsy

  
  
  

• Lower seizure threshold may explain why infants have them most frequently

Febrile Seizures Diagnostics

• Diagnostics

  • Lumbar puncture

  • Lab work

  • Neuro imaging if other s/s

  • Does not need EEG

Febrile Seizures Management & Nursing Considerations

• Management

  • Antipyretics

• Nursing Considerations

  • Family teaching

  • Seizure precautions

• Children with febrile seizures do not need to be put on anti-seizures medications. 

  
  

  
  

• They need antipyretics such as Acetaminophen or Ibuprofen and family teaching---may be given rectal valium. 
  
  

  
  

• What are seizure precautions?  KEEP THEM SAFE

  
  
  

Otitis Media

• Infection

• Pathophysiology & Etiology

  • Peak incidence-6-20 months of age

  • Occurs more frequently in:

    • Males

    • American Indians & Alaska Native children

    • Children in day care

    • Children exposed to second hand smoke

    • Children  who use a pacifier several hours/day 

    • Children with cleft defects

    • Children with Down Syndrome

• Inflammation of the middle ear - one of the most common childhood illnesses

  
  
  

• Eustachian tubes – shorter, straighter, and more open in infants – thus more easily obstructed

  
  
  

• Why second hand smoke - passive smoking increases by prolonging inflammatory response

  
  
  

• Highest in winter months—usually proceeded by a viral URI (RSV and influenza)

  
  
  

• Function of the eustachian tube: 

  • protection of middle ear from secretions of the nasopharynx

  • drainage of secretions from middle ear to nasopharynx

  • equalization of pressure via ventilation of the middle ear

Otitis Media Clinical Manifestations

• Ear pain-pulling at the ear

• May have diarrhea, vomiting

• May have fever

• Irritability & acting out (signs of hearing loss)

• Night awakenings with crying due to increase pressure when prone or supine

• Drainage

Otitis Media Diagnosis & Therapeutic Management

• Diagnosis

  • Direct & careful visualization of Tympanic Membrane

  
  

• Therapeutic Management:

  • Pharmacologic

    • High dose oral Amoxicillin drug of choice

      • Length of Abx therapy

        • 10-14 days for severe AOM

        • 5-7 days for mild/moderate infection in children > 6 years

          
          

    • Ibuprofen or acetaminophen for pain relief

  
  

  • Surgical

    • Myringotomy—surgical incision of the eardrum – allows drainage of fluid and relief of pressure

      
      
      

Myringotomy with Tube Insertion

• Not done as frequently as they used to be

Nursing Care Management Otitis Media

• Relieve pain

• Prevent Complications or Recurrence

  • Proper use of antibiotics

  • Hold upright for feeds

  • No second hand smoke

• Education

• Emotional Support

  • Child & Family

• Non-pharmacological pain relief – positioning, warm compress

  
  

• Pharmacological treatment – acetaminophen in all ages, ibuprofen 6 months and older – discuss with physician

Meningitis

• Pathophysiology

  • Inflammation of the meninges: 

    • Bacterial

    • Viral (aseptic)

  
  

  • Occurs secondary to other infections:

    • otitis media

    • Sinusitis

    • Pharyngitis

    • Cellulitis

    • Pneumonia

    • TB

    • septic arthritis

    • brain trauma

    • neurosurgical procedures

  
  

  • Infectious agent spreads to CSF and enters the subarachnoid space

• Infants <2 month—group B strep passed from the mom to the infant during the birth process.

  
  
  

• Meningococcal in adolescents. 

  • What has helped change the epidemiology of bacterial meningitis??? Hib vaccine (haemophilus influenza b – not associated with virus that causes the flu) today almost eradicated in countries where vaccine is given

  
  
  

• Viral meningitis

  • Increased number of blood cells and protein in CSF

  • Enterovirus-80% of all viral meningitis

  • Child does not appear as ill as child with bacterial meningitis

Bacterial Meningitis Clinical Manifestations & Diagnostics

• Bacterial Meningitis

  
  

  • Clinical Manifestations

    • Increased irritability and lethargy

    • Headache

    • Nuchal rigidity

    • Fever

    • + Kernig and Brudzinski signs

  
  

  • Diagnostics

    • Lumbar puncture

    • Blood cultures

• Older children may be sick for several days with URI or GI illness.

  
  

• May have photophobia.

  
  

• Nuchal rigidity-resistance to neck flexion. 

  
  

• Symptoms may progress to seizures, altered LOC, hydrocephalus

  
  

• **Priority is to get LP and blood cultures ASAP Before Abx therapy is started. 

Viral Meningitis Clinical Manifestations & Diagnostics

• Viral Meningitis

  
  

  • Clinical Manifestations

    • Usually febrile

    • Irritable and lethargic

    • Headache

    • Maculopapular rash

    • + Kernig and Brudzinski signs

  
  

  • Diagnostics

    • Lumbar puncture

    • Blood cultures

• Older children may be sick for several days with URI or GI illness.

  
  

• May have photophobia.

  
  

• Symptoms may progress to seizures, altered LOC, hydrocephalus

  
  

• **Priority is to get LP and blood cultures ASAP Before Abx therapy is started. 

Therapeutic Management

• Medical Emergency

  • PICU

• Isolation precautions

  • Respiratory for 24 hours after appropriate treatment has been started

• Antibiotic therapy

• Corticosteroids-reduce neurological sequalae

  • eg. hearing loss

• Maintain hydration

  • prevent cerebral edema

• Respiratory isolation is needed secondary to the mode of transmission of meningitis – mask, gown, gloves

Therapeutic Management Continued

• Maintain quiet environment

  • Minimize environmental stimuli 

• Reduce the ICP 

• Management of systemic shock

  • Monitor I & O

• Control seizures

• Control temperatures

• Management of pain

• Treatment of complications

  • blindness, deafness, paralysis, learning problems/cognitive challenges

• Care is determined by severity of sx

Meningitis Nursing Considerations

• Nursing Considerations

  • Neurologic Assessment

  • Quiet Environment

  • Positioning

  • Monitor response to antibiotic therapy

  • Prevention

  • Provide family support and education

• **Watch for changes in behavior – this is an early sign of increased ICP in children

  
  

• Management for Meningitis is antibiotic therapy until CSF and blood cultures are received. 

  • If viral meningitis antibiotics are discontinued. 

  
  

• Bacterial continues antibiotic therapy.  Bacterial meningitis patients are treated in the PICU. 

  • Treat any complications.  

  • Administer antipyretics as needed. 

  
  

• Keep the room dark and quiet. Strict I and O. Seizure Precautions.

  
  

• What Nursing Diagnoses are most appropriate for a child with meningitis?