Neurologic Differences of Infant and Child

1. 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 developed deficit = injury Primitive reflexes may reappear with neurologic disease.

2. Causes Neurological Dysfunction Injury: r/t direct brain tissue Hypoxia Congenital Metabolic derangement Infection Perfusion problem: stroke Brain tumor

3. Standard Terms for Level of Consciousness Full consciousness Confused Disoriented Lethargic Obtunded Stupor Coma McKinney et al, 3rd ed. P 1470

4. Glasgow Coma Scale Table 52-1, p. 1469: modified for children Eye Opening Verbal Response Motor Response

5. Causes of Increased ICP Swelling of brain tissue Increase in amount of CSF Increase in amount of blood flow

7. 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

8. Increased ICP - Child Altered level of consciousness Mood swings Headache (esp. am) Diplopia Slurred speech Nausea and vomiting (esp. am)

9. Hydrocephalus What is it? Treatment: Shunt Ventriculoperitoneal (VP) Ventriculoatrial

10. Postoperative Care Lie flat – prevent rapid removal of CSF Don’t lie on suture side High Risk for: Shunt malfunction (short-term & long-term) AEB__________. Infection (long-term)

11. Neural Tube Defects • Definition • Spinal bifida occulta • Spina bifida cystica • Meningocele • Myelomeningocele • Role of Folic Acid as primary prevention • HP 2020 goal

12. Myelomeningocele Flaccid paralysis Sensory loss Bowel & bladder sphincter Joint deformities

13. Nursing Care: Myelomeningocele Check head circumference Fontanels Position Elimination Infection Pre-op: sterile, moist dressing Latex precautions Impaired mobility Hip & foot alignment

14. Cerebral Palsy Chronic, nonprogressive disorder of posture & movement Manifestations vary

15. Causes of CP prenatal Intra postnatal F

16. Clinical Manifestations CP Primitive reflexes Delayed development Hypertonia Contractures Often intellectually intact

17. Nursing Diagnoses: CP Impaired physical mobility Altered growth & development Risk of injury Impaired verbal communication Self-care deficit Altered nutrition Caregiver role strain

18. Care: cerebral palsy Extra calories r/t spasticity Aspiration precautions Multidisciplinary team Prevent developmental delays Maintain a safe environment Control spasticity

19. Surgical Interventions: CP Surgical release tight muscles & tendon Baclofen Pump Derotation osteotomy Rhizotomy: cutting nerves on affected limbs Botulinum Toxin A (Botox injections)

20. Intracranial Infections

21. Intracranial Infections Meningitis: inflammatory process affecting the meninges Encephalitis: affects the brain Myelitis: spinal cord Causes: Bacterial Viral (aseptic) Tuberculosis

22. Bacterial Haemophilus influenzae Streptococcus pneumoniae Neisseria meningitidis (meningococcal) Frequent cause: infection starting elsewhere

23. Clinical Manifestations: Meningitis Increased ICP Severe HA Photophobia Nuchal rigidity; opisthotonos (infants) LP:

24. Bacterial Meningitis: Complications Compression of cranial nerves Hearing Loss Brain abscess Seizures Cerebral palsy Learning disorder Attention deficit disorder Paresis (hemi, quad)

25. Nursing Care Prevention Immunization Meds for contacts Isolation: bacterial Supportive

26. Supportive Nursing Care Hydration Prevent injury seizure precautions Minimize increased ICP**: Quiet, dark environment Position of comfort Head/neck in neutral position Steroid possibly

27. Supportive Nursing Care (cont) Assessment for deteriorating neuro status I & O Manage pain, fever

28. Reye’s 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

29. Seizure A sudden, explosive, disorderly discharge of cerebral neurons. Sudden, transient alteration in brain function Motor, sensory, autonomic, or psychic clinical manifestations. Syndrome

30. Patho Changes in membrane potential group of neurons Plasma membrane more permeable (more sensitive to triggers) Spread to adjacent neurons high level of excitatory neurotransmitters, or low level of inhibitory neurotransmitters

31. Epilepsy a chronic disorder of recurrent seizures. A general term for the primary condition that causes seizures. Primary (AKA Idiopathic) Genetic predisposition

32. 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

33. Precipitating Factors Hypoglycemia Fatigue Stress (emotional or physical) Febrile illness Stimulant drugs Withdrawal from depressant drugs Certain environmental stimuli

34. Classification of Seizures Partial or generalized Partial Simple Complex Begin locally, can become generalized

35. Generalized Seizures Bilaterally symmetric Loss of/or impaired consciousness Postictal state Tonic, clonic, or tonic-clonic Absence Infantile spasms Atonic (drop attack)

36. 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

37. 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

38. Nursing Interventions r/t ‘Potential for Injury’ Maintain airway Oxygen: “blow-by” Move objects out of way Assess duration, where started, LOC, incontinence

39. Classifications of Anticonvulsant Medications Hydantoins Barbiturates Succinimides Oxazolidones Benzodiazepines Carbamazepine Valproate

40. Mechanism of Action Suppress sodium influx Suppress calcium influx Increase action of GABA (gamma aminobutyric acid)

41. Medications For SE: Benzodiazapines Diazepam (Valium), .2mg/kg (10 mg) IV q 15 min. up to 40 mg. O: 1-5 min IV Duration: 15 min-1 hr Give w/NS only Can also be given rectally, as a gel.

42. 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

43. Clonazepam (Klonipin) Maintenance – po Absence, myoclonic seizures

44. 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

45. Fosphenytoin (Cerebyx) Replacing Dilantin IV PE (phenytoin equivalents) Dilute in D5W or NS to 25 mg PE/ml 150 mg PE/min

46. 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, confusion

47. Maintenance Seizure Meds carbamazepine (Tegretol) Side effects: drowsiness, confusion, HA, Complications: blood dyscrasia, aplastic anemia Valproate (Depakene, Depakote) Side effects: GI, rash drowsiness, HA, tremors Complications: blood dyscrasias, hepatic failure / hepatitis, stomatitis

48. Miscellaneous Pregnancy category MgSO4 for eclampsia/preeclampsia Anticonvulsants for other uses Surgical management Drug-drug interaction Ketogenic diet Vagal nerve stimulator