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Cerebral Dysfunction

Cerebral Dysfunction. Lauren Walker, RN, BSN Georgetown University. Overview Topics. Increased Intracranial Pressure Level of Consciousness Cerebral Abnormalities Nervous System Tumors Infections . Pediatric Cerebral Dysfunction General Information.

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Cerebral Dysfunction

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  1. Cerebral Dysfunction Lauren Walker, RN, BSN Georgetown University

  2. Overview Topics • Increased Intracranial Pressure • Level of Consciousness • Cerebral Abnormalities • Nervous System Tumors • Infections

  3. Pediatric Cerebral DysfunctionGeneral Information • Children under the age of 2 require special evaluation for neurologic function • Observation of fine and motor reflexes • Pregnancy and delivery history • General Assessment • Family History • Health History • Physical Evaluation

  4. Abnormal neurologic physical evaluations of infants High-pitched, piercing cry Abnormal eye movements Inability to suck or swallow Lip smacking Asymmetric facial movements Yawning Muscular activity and coordination Level of development • Size and shape of head • Sensory responses • Spontaneous activity • Symmetry in extremity movement • Frequent movement of extremities • Skin and hair texture • Distinctive facial features

  5. Increased Intracranial Pressure • Brain is enclosed in the solid bony cranium • Cranium’s total volume: • Brain: 80% • Cerebrospinal fluid (CSF): 10% • Blood: 10% • Volume must remain approximately the same at all times • Brain is terrible at compensation! • Normal ICP 5-10 ICP Video

  6. Clinical s/s of Increased ICP Infants Children Headache Nausea Vomiting Diplopia, blurred vision Seizures • Tense and/or bulging fontanel • Separated cranial sutures • Irritable • High-pitched cry • Increased occipital circumference • Distended scalp veins • Changes in feeding • Crying when disturbed • Setting-sun sign Box 28-1, Chapter 28 Wong

  7. Clinical s/s of Increased ICP Personality and behavioral signs Late signs Bradycardia Lowered level of consciousness Decreased motor response to commands Decreased sensory response to painful stimuli Alterations in pupil size and reactivity to light Flexion and extension posturing Cheyne-stokes respirations Papilledema Coma • Irritability, restlessness • Indifference, drowsiness • Decline in school performance • Diminished physical activity and motor performance • Increased sleeping • Memory loss • Inability to follow simple commands • Lethargy and drowsiness Box 28-1, Chapter 28 Wong

  8. Level of Consciousness Earliest indicator of improvement or deterioration • Determined by observations • Physical Assessment • Motor activity, reflexes, vital signs

  9. http://www.eguidelines.co.uk/eguidelinesmain/gip/media/images/barclay_glasgow_comascore2.gifhttp://www.eguidelines.co.uk/eguidelinesmain/gip/media/images/barclay_glasgow_comascore2.gif 15 points- highest score, unaltered LOC 3 points- lowest score, deep coma

  10. Nursing Management of ICP • Positioning • Alternating mattresses • Avoid causing pain • Cluster care • Minimize environmental noise • Closely monitor nutrition and hydration

  11. Nursing Management of Increased ICP • Indications for inserting a monitor: • GCS of 8 or below • Deterioration • Judgment from clinical appearance and response • Monitors: • Intraventricular catheter • Subarachnoid bolt • Epidural sensor • Anterior fontanel pressure monitor

  12. Medications for Altered ICP • What is the cause? • Corticosteroids: inflammation • Antibiotics: infectious process • Diuretics: edema • Antiepileptic: seizure activity • Sedation: combativeness • Barbiturates: deep coma

  13. Cerebral Malformations • Newborn cranial sutures are separated by membranous seams Sutures: Soft areas: -Sagittal -Anterior fontanel -Coronal -Posterior fontanel -Lambdoidal

  14. Hydrocephalus“water on the brain” • Imbalance in the production and absorption of CSF in the ventricular system • Causes: • Impaired absorption of CSF fluid • Obstruction of flow through ventricle • Brain structures become compressed • Most cases are from developmental defects

  15. Diagnosing Hydrocephalus • Time of onset and preexisting lesions • Infants: Head circumferences and neuro signs • CT • MRI

  16. Clinical Manifestations of Hydrocephalus Box 28-13, chapter 28, Wong

  17. Management of Hydrocephalus • Direct removal of obstruction • Placement of shunt • Ventriculoperitoneal shunt (VP shunt) • Associated with infection and malfunction High success rate with surgically treatment

  18. Shunting Shunting Video

  19. Family Support • Coping is difficult with patents • Feel guilty, anxious • Uncertain outcome • Continue to educate family • Include family in patient care • Possibility of long term rehabilitation

  20. Nervous System Tumors • CNS tumors account for 20% of all childhood cancers • 3.3 cases per 100,000 occur in kids under 15 years old • Difficult to treat • No dramatic advancements or improvements seen vs other childhood cancers

  21. Brain Tumors • Most common solid tumors in children • Infratentorial (60%) • Primairly in brain stem or cerebellum • Usually see increased ICP (medulloblastoma, cerebellarastrocytoma, brainstem glioma) • Supratentorial • Mainly cerebrum (astrocytoma, hypothalamic tumors, optic pathway tumors)

  22. Brain Tumor Diagnostics • s/s are related to: • Location • Size of tumor • Child’s age • Most common signs: Headache, vomiting • s/s are vague and can be overlooked • Detected by: • MRI • CT scan • Official diagnosis with biopsy from surgery

  23. Treatment of Brain Tumors • Treatment of choice = total removal of tumor without neurologic damage • Surgery, radiotherapy, chemotherapy • Prognosis: • Depends on size, tumor type, extent of disease

  24. Nursing Management of Brain Tumors • Establish a baseline assessment • Vital signs • Look for sudden variations • Frequent neurologic assessments • Headache? Vomiting? Seizures? • Child’s behavior • positioning • Postoperatively check muscle strength when awake

  25. Intracranial Infections • Nervous system is limited in ways to respond to an infection • Inflammatory process in brain affects: • Meninges (meningitis) • Brain (encephalitis) • Meningitis has many origins

  26. Bacterial Meningitis • Definition: acute inflammation of the meninges and CSF • 10-15% of cases are fatal • Caused by many bacterial agents • H. Influenzae type b, S. pneumoniae, NeisseriaMeningitidis • Vascular dissemination or direct implantation • Infective Process

  27. Clinical Manifestations of Bacterial Meningitis Children and Adolescents (Classic picture) Infants and Young Children Fever Poor feeding Vomiting Irritable Frequent seizures Bulging fontanel Difficult to evaluate in this age group • Abrupt onset, rash • Fever, chills, headache • Alteration in senses • Seizures* • Irritability/agitation • Nuchal rigidity • Positive Kernig & • Brudzinski signs Box 28-5, Chapter 28 Wong

  28. Clinical Manifestations of Bacterial Meningitis Neonates: Specific Signs Neonates: Nonspecific Signs Hypothermia/fever Jaundice Irritable Drowsiness Seizures Respiratory irregulations cyanosis • Very hard to diagnose • Well at birth- behaves poorly a few days later • Refuses feeds • Poor sucking • Vomiting/diarrhea • Poor tone • Lack of movement • Weak cry • Supple neck Box 28-5, Chapter 28 Wong

  29. Diagnostic and Therapeutic Management of Bacterial Meningitis • Lumbar Puncture • Elevated WBC count • Decreased Glucose level • Considered a medical emergency! • Initial management: • Isolation, iv antibiotics, fluids, monitored, treatment of complications

  30. Management of Bacterial Meningitis • Hydration • Quiet, decreased stimulation • Side lying position • Correct electrolyte imbalance • Measure for s/s increased ICP • Monitor for complications • Prevention: • Vaccines for children starting at 2 months

  31. Nonbacterial (aseptic) Meningitis • Caused by many viruses! • Abrupt or gradual onset • Symptoms develop 1-2days after onset • s/s vague • Diagnosis is based on pt assessment and CSF findings • Systematic treatment • Nursing care similar to bacterial meningitis

  32. Encephalitis • Definition: inflammatory process of the CNS which is caused by a variety of organisms • Virus invades CNS or postinfection after a viral disease • Cause in typically unknown

  33. Clinical Findings of Encephalitis • Initial findings are nonspecific • Evolve to demonstrate neuro s/s • Seizures, abnormal CSF • Mild s/s for a few days, rapid recovery, to fulminating encephalitis with CNS involvement

  34. Diagnosis and Management of Encephalitis • Based on clinical findings • CT in late stages • Some viruses are found in CSF • Hospitalized for observation with supportive treatment • Prognosis depends on age, organism, neurologic damage

  35. http://www.youtube.com/watch?v=8tf5VewEfGs http://www.youtube.com/watch?v=Qmym2iFVNw8&feature=related

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