Nursing care with an alteration in intracranial regulation/Neurological disorders

whats included in a Pediatric neurological assessment

thorough health history is critical, always look before touching, LOC, fontanel and suture assessment if appropriate, head circumference measurement if appropriate, pupil assessment, movement and posture, monitoring for sign of increased ICP

when does the anterior fontanel close

12-18 months

when does the posterior fontanel close

2-3 months

if a fontanel is extremely full what could that tell you

increased ICP

if a fontanel is sunken in what could that tell you

baby is dehydrated

what are some causes of increased ICP

brain tumor, head trauma, hematoma, infection, hydrocephalus

what are early signs of ICP

headache, vomiting, blurred/double vision, dizziness, decreased pulse, increased BP, pupils sluggish/unequal, sunset eyes, irritable, seizure activity, bulging/tense fontanel, wide sutures, increased head circumference, dilated scalp veins, high- pitched cry

what are late sign of increased ICP

lowered LOC, bradycardia, Cheyne-Stokes reparations, decerebrate/decorticate posturing, fixed/dilated pupils, Cushing’s triad (widening pulse pressures, bradycardia, irregular respirations)

nursing management for increased ICP

ABC’s, elevate HOB, strict I/O, daily weight, fluid restriction, monitor electrolyte balance, reduce agitation, can give mannitol which is an osmotic diuretic, 3% hypertonic saline

what is a neural tube defect

failure of neural tube to close by 4th week of gestation

causes of neural tube defects

folic acid deficiency, previous neural tube defect, drug use, genetics

how can we prevent neural tube defects

400mcg folic acid daily, higher does for women with history of neural tube defects about 600mcg

what are some neural tube defects

anencephaly, encephalocele

what is anencephaly

small or missing Brian hemispheres, skull, and scalp, born without a forebrain and cerebrum, remaining brain tissue may be exposed, incompatible with life most are stillborn or die within hours, days, weeks

whats an encephalocele

protrusion of the Brain and meninges through a skull deficit, often accompanied by craniofacial abnormalities, hydrocephalus, microcephaly, visual problems, developmental delay, and seizures, prognosis will depend on size and involvement of other brain structures

explain surgical repair for encephalocele

placement of tissue back into skull and removal of sac possible VP stunt placement to correct hydrocephalus corrective repair of any craniofacial abnormalities

nursing care for encephalocele

monitor for hydrocephalus, increased ICP

what is microcephaly

defined as HC greater than 3 standard deviations below the mean for the age and sec of the infant, generally results in intellectual disability, can be congenital or acquired

how can microcephaly be congenital

happens in utero abnormal development, chromosomal abnormalities or exposure to infection such as rubella, toxoplasmosis, CMV

how can microcephaly be acquired

something happens after birth such as severe malnutrition, perinatal infections or anoxic events in infancy

treatment for microcephaly

none just supportive care

what is positional plagiocephaly

asymmetry in head shape without fused suture, result of cranial molding and flattening of the occiput safe sleep position can cause this or torticollis shortening sternocleidomastoid muscle causing head to be turned

how can we prevent positional plagiocephaly

daily tummy time, alternate head position during sleep

how do we treat positional plagiocephaly

PT and customized helmet to reshape the skull

what is hydrocephalus

imbalance between production and absorption of CSF, leads to increase in CSF circulating volume increasing ICP, complication of many neurologic conditions meaning it’s a result of something else

what is non obstructive hydrocephalus

flow of CSF is blocked after it exits the ventricles defective absorption

what is obstructive hydrocephalus

flow of CSF is blocked within the ventricular system

clinical manifestation of hydrocephalus

signs and symptoms of increased ICP, increasing HC, sunsetting eyes, bulging fontanels, separating suture, irritability, change in LOC, poor feeding, N/V/HA

what are diagnostics for hydrocephalus

CT and/or MRI

treatment for hydrocephalus

surgical correction of structural deformities, remove or bypass obstruction, possible placement of VP or VA shunt

Hydrocephalus shunt care

place on opposite side of shunt incision, keep incision clean, dry, and intact, keep salt to prevent rapid reduction of CSF, monitor for shunt failure (still have signs of increased ICP) and infection

hydrocephalus shunt complications

shunt malfunction surgery to replace shunt or shunt infections surgery to externalize shunt EVD: external ventricular drain, IV antibiotics

nursing management for EVD

make sure you read your orders, make sure all connections are open, regularly check the drip chamber, clamp the drain in the event of child movement after movement rezero and open clamp back up, accurately document volume and color every hour, if amount is significantly increasing notify provider, child may be taking antibiotics make sure, inline with Tracis of the ear normally but check your order

what is meningitis

inflammation of the meninges of brain and spinal cord can be caused by a bacterial or viral infection in the CSF

what are the viral viruses that can cause menitigis

CMV, HSV, enterovirus, HIV

what bacterial viruses can cause meningitis

meningococcal, pneumococcal H flu, E.coli

which types of meningitis is worse bacterial or viral

bacterial

clinical manifestation of meningitis

fever, irritability then progresses to lethargy, drowsiness, stupor, headache, photophobia, full bulging fontanel, poor feeding, vomiting, meningeal irritation (Nuchal Rigidity, Kernig’s, and brudzinski’s sign), signs of increased ICP, infant resting in opisthotonic position, petechiae or purpuric type of rash with meningococcal infection, chronic ear drainage with pneumococcal infection, arthralgia with mengococcal and Hib infections

meningitis diagnostics

blood cultures, CBC, CRP/ESR, CT and/or MRI, CSF analysis via LP (informed consent, cream on back for 30 minutes for numbing, hold child during procedure by should and hip pt is almost rolled into a ball on their side)

what are bacterial meningitis labs going to look like

cloudy, increased WBC, increased protein, decreased glucose, positive gram stain

what are viral meningitis labs going to look like

clear, slightly increased WBC, normal to slightly elevated protein, normal glucose, negative gram stain

meningitis treatment

droplet isolation, monitor VS frequently, fever management, I/O, assess neuro status frequently, look for s/s of increased ICP, pain assessment, decrease environmental stimuli, antibiotic up to 10 days, also maybe have corticosteroids (dexamethasone), or antivirals

what is reye syndrome

rare disease that affects young children recovering from a viral illness is a reaction that is triggered by the use of salicylates (aspirin) that are used to treat viral infection it affects the liver and brain causing liver dysfunction and cerebral edema

clinical manifestations with reye syndrome

sever profuse vomiting, change in mental status, irritability, combativeness, delirium, seizures

reye syndrome diagnostics

elevated liver enzymes, elevated blood ammonia levels, cognation times can be prolonged, liver biopsy, lumbar puncture to r/o meningitis

reye syndrome treatment

hydrating but watching for cerebral edema, same treatment as increased ICP (ABC’s, elevate HOB, strict I/O, daily weight, fluid restriction, monitor electrolyte balance, reduce agitation, can give mannitol which is an osmotic diuretic, 3% hypertonic saline), monitor and prevent bleeding episodes, assess and treat pain, seizure precautions, education on not giving kids aspirin

define concussion

traumatic injury to the Brian that alters the way the brain functions

define contussion

bruising of the cerebral tissue

define laceration with head trauma

tearing of the cerebral tissue

define skull frature

direct trauma to skull many types

define linear skull fracture

most common single fracture at point of impact do not cross suture lines

define depressed skull fracture

broken bone fragments pushing inward, blunt trauma a hammer for example

define comminuted skull fractures

more than one linear fracture following intense impact could have been a car accident

define basilar skull fractures

fracture of bones at base of skull

what are risks for pediatric abusive head trauma

inconsolable crying child, more common in male caregivers, unwanted pregnancy or child

what is the cause of pediatric abusive head trauma

vigorous shaking, intentional blow to head, intentional dropping

what can be the outcomes of pediatric abusive head trauma

skull fractures, intracranial bleeding, retinal hemorrhage, subdural hematoma, cerebral edema, if not death then may have long term consequences

what are clinical manifestations of head trauma

loss of consciousness how long, minor injury you can see confusion, vomiting, pallor, irritability, lethargy, drowsiness, when there is a profession of injury you can see marked changes in vitals altered mental status , increase in agitation, in severe injury you will see increased ICP, decoricate/decerebrate posturing

what are some clinical manifestation of depressed skull fracture and basilar skull fractures

depressed skull fractures skull appears misshapen, in basilar skull fracture blood over mastoid process and/or around orbits, leakage of CSF from nose

head trauma labs and diagnostics

ABG’s, CBC, blood alcohol and toxicology screen, liver function tests, cervical spine x-rays, CT and/or MRI, EEG, ICP measurement

Nursing care for head injury

stabilizing of spine, ABC’s important making sure you have a patent airway, mechanical ventilation, keep sats >95%, frequent and thorough near assessment, monitor for seizures, monitor I&O, electrolytes, decrease stimulation, pain management

what meds are we giving for nursing management of head trauma

mannitol, anti epileptics, analgesics

what are complications you will see in head traumas

epidural hematoma, subdural hematoma, cerebral edema and brain herniation

what is an epidural hematoma

bleeding between dura and skull typically arterial and developed rapidly

what are some clinical manifestation of an epidural hematoma

short periods of unconsciousness followed by a normal period for several hours, lethargy, coma, vomiting due to compression of the brainw

what is the treatment for an epidural hematoma

removal of accumulated blood and/or ligation of torn artery

what is a subdural hematoma

bleeding between the dura and the arachnoid membrane typically venous can be because of birth trauma, falls, or violent shaking

what are some clinical manifestation of a subdural hematoma

irritability, vomiting, increased HC, lethargy, anemia, seizures, coma

what is the treatment for a subdural hematoma

self resolving or drains/subdural tap

what is cerebral edema

24-72 hours post trauma there is an increase in ICP, they will get worse before they get better

what is a brain herniation

its a downward shift of brain tissue cause loss of blink reflex, gag reflex, pupils dilated and fixed, cushing traid

how can we prevent head traumas

seat belts, helmets, shaken baby and child abuse prevention, car seat compliance w

what is a seizure

abnormal, involuntary, excessive electrical discharges within the brain

what are the types of seizures

unclassified, generalized, partial/focal

what falls under an unclassified seizure

febrile, infantile spasms, neonatal seizures w

what falls under a generalized seizure

tonic-clonic, myoclonic, atonic

what falls under a partial/focal seizure

simple partial with either motor or sensory manifestations. complex partial

what is a febrile seizure

associated with sudden spike in temp as high as 102-104 lasts 15-20 second

treatment for febrile seizure

acetaminophen or ibuprofen, light clothing, tepid bath

what is a infantile spams

rare disorder peak between 3-7 month, sudden brief symmetric muscle contractions, can occur as single even or in cluster

what is a neonatal seizure

most times are focal (coming from a certain part of the brain), first 4 weeks of life, there is an underlying cause (hypoxic ischemic encephalopathy, metabolic disorders, infection, cerebral infarction) so treat that a seizures will most likely stop

what is our job as a nurse when it comes to seizures

document exactly what we saw, what did the movements look like, how long did it last, what happen before and after

what is a tonic clonic seizure

onset without warning tonic phase 10-20 sec, clonic phase 30-50 seconds, postictal state

what is an absence (petit mal) seizure

abrupt onset offset, blank stare motionless, affects schoolwork which is often first indicator, can drop items being help, unable to recall, no postictal phase

what is a myoclonic seizure

variety of seizure episodes, symmetric or asymmetric, brief contraction of muscle groups, can involved only the face and trunk or one or more extremities, no postictal state, may not lose consciousness

what is an atonic seizure

“drop attacks” onset between 2-5 years old, loss of tone which often causes falls, period of confusion follows, if frequent should wear helmet

seizure labs and diagnostics

lead level, WBC, blood glucose, metabolic panel, chromosomal analysis, toxicology screen, EEG, CT and/or MRI, lumbar puncture

seizure treatment

seizure precautions (pads, suction, O2), during seizure (protect airway take time, protect head, call for help, and watch behavior) post seizure care, medications such as abortive treatments, preventative maintenance meds, miscellaneous treatments w

what are the abortive meds we use for seizure

Lorazepam 1st line IV, midazolam IV or intranasal, diazepam rectal home med

client education for seizure meds

takes meds at the same time every day, dosage will need to be increased as child grows, therapeutic drug levels to be monitored, never stop abruptly, wean very slow

what are the preventative seizure medications

Levetiracetam (Keppra), Topiramate (Topamax), Lamotrigine (Lamictal), Oxcarbazepine (Trileptal), Valproic Acid (Depakote), Lacosamide (Vimpat), Phenytoin (Dilantin), Fosphenytion (Cerebyx), Phenobarbital

MISC seizure treatments

ketogenic diet (high fat low CHO), vagal nerve stimulator, removal of tumor/lesion, focal resection, hemispherectomy, corpus callosotomy