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Neurologic Disorders

Neurologic Disorders. Jan Bazner-Chandler CPNP, CNS, MSN, RN. The Brain . Differences in Children. Biological Differences. Fibrous union of suture lines and interlocking of edges occurs by 6 months solid union requires approximately 12 years. Biological Differences.

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Neurologic Disorders

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  1. Neurologic Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN

  2. The Brain

  3. Differences in Children

  4. Biological Differences • Fibrous union of suture lines and interlocking of edges occurs by 6 months solid union requires approximately 12 years.

  5. Biological Differences • At birth, brain is 25% of adult size • By age 5, brain is 90% of adult size • CSF is 5 ml in a neonate and 150 ml in adult • Myelinization is complete by puberty • Spinal cord terminates at L3 in infant

  6. Developmental Differences • Handedness before age 1-year may be associated with focal lesion. • Reflexes present at birth disappear by 1 year. • Neurological assessment of the child is limited to their developmental level.

  7. Neurologic Exam • Level of consciousness • What stimuli is needed? • What is quality of the response? • What is length of response? • Most important indicator of neurologic function

  8. Levels of Consciousness • Confusion • Disorientation to time, place, or person • Delirium • Characterized by confusion, fear, agitation, hyperactivity, or anxiety • Stupor = response to vigorous stimuli only • Coma = severely diminished response

  9. Glasgow Coma Scale • Designed as a standardized assessment of the patient with disturbed consciousness. • The lower the score at time of admission the poorer the outcomes.

  10. Pupil Changes Fixed and dilated pupil(s) is neuro emergency Whaley & Wong

  11. Pupil Changes • Pin point pupils suggest narcotic overdose. • Midpoint fixed pupils suggest structural damage in the midbrain. • Dilated or large pupils indicate severe anoxia or overdose. • One pupil fixed and dilated suggests herniation of the the temporal lobe.

  12. Decoritate posturing Decerebrate posturing Whaley & Wong

  13. CT Scan Non-invasive three dimensional look at normal and abnormal structures.

  14. MRI Image body tissue or organs in action.

  15. Brain Tumor CT Scan MRI

  16. Brain Scan Injection of tiny amounts of radioactive isotope to measure tissue uptake.

  17. Lumbar Puncture Side lying position for LP

  18. Lumbar Puncture Insertion of spinal needle into subarachnoid space between the lower lumbar vertebrae. Waley & Wong Modified sitting position for LP

  19. Normal CSF Clear odorless WBC’s 0 – 5 Protein 15 to 45 Glucose 50 – 80 Pressure 50 to 180 Abnormal CSF Turbid, cloudy WBC’s 1000 – 2000 Protein 100 – 500 Glucose lower than blood sugar Pressure 180 or greater Cerebral Spinal Fluid

  20. Intracranial Pressure • The head is a closed box • Total volume inside brain V brain + V blood + V CSF + V other = Constant

  21. Volume of Brain • Brain volume can increase with: • Edema • Blood flow • Bleed within the brain • Tumor

  22. Volume of Cerebrospinal Fluid

  23. Volume - Other Medlib.utah.edu Ventricular bleed in a 28 week neonate

  24. Vital Sign Changes Increase in Blood Pressure Cushing Triad Altered Respiratory pattern Decrease in Pulse

  25. Vital Signs • Pulse rate decreases as ICP increases • Respirations: rate, quality, and characteristic change • Initially slow as ICP rises rate becomes rapid and noisy leading to apnea • Blood pressure rises slowly / late sign is widening pulse pressure

  26. Nursing Assessment • Glasgow coma scale • Pupil size • LOC • Vital signs • Accurate I & O • Minimize metabolic demands • Fever, pain, seizures

  27. Medical Management • Controlled hyperventilation • Evacuation of hematoma • Correction of CSF increase • Steroids / dexamethasone • Correction of coagulopathies

  28. Keep Kids Safe Children.com

  29. Alterations in Neurologic Status • Seizures: a paroxysmal , uncontrolled episode of behavior that results from an abnormal electrical discharge from the brain.

  30. Effect on Child • Altered responsiveness • Altered sensation or perception • Altered movements, mobility or muscle tone

  31. Classification of Seizures • Partial • No loss of consciousness • Symptoms depend on what area of the brain is involved • Often presents as a staring episode or slight twitching of eyes and drooling • Generalized • Tonic-clonic • Sudden loss of muscle tone • Eye blinking, alter awareness, mouth, or facial movement

  32. Status Epilepticus • Seizures lasting more than 30 seconds • Serial seizures without return to baseline • Medical emergency

  33. Febrile Seizures • Occurs in 2 to 5% of all children • 6 months to 6-years of age • The younger the child the more likely they are to re-occur • Familial tendency • Treatment: phenobarbital or diazepam (only if second febrile seizure)

  34. Documentation • When seizures began • Duration • Warning signs • Clinical characteristics • Level of consciousness • Signs and symptoms when seizures stops

  35. Interventions • Remain calm and stay with child • Protect child from injury • Provide time for child to recover • Reassure and provide support to child and others • Document

  36. Diagnostic Tests • Febrile seizure: Lumbar puncture • Seizures • EEG • Electrolytes • MRI • Medications • Dilantin causes overgrowth of gum tissue

  37. Ancephaly Absence of brain tissue above a rudimentary brain stem and basal ganglia. med.utah.edu

  38. Ancephaly Diagnostic Tests • Prenatal ultra-sound • Elevated alpha fetal protein • Multiple anomalies • Incompatible with life • Heart transplant donors

  39. Interventions • Supportive care • Genetic and psychological counseling • Organ donation • Grief therapy • Sustained extra uterine life impossible

  40. Spina Bifida Cystica • Incomplete fusion of one or more vertebral laminae, resulting in an external protrusion of the spinal tissue. • 5 per 10,000 births • Other anomalies

  41. Contributing factors • Poor maternal nutrition • Maternal age • Pregnancy history • Birth order • Socioeconomic status

  42. Diagnosis Ultrasound Elevated AFP 95% survival rate med.utah.edu

  43. Myelomeningocele

  44. Spina Bifida Bowden & Greenberg

  45. Myelomeningocele • A protruding saclike structure containing meninges, spinal fluid and neural tissue.

  46. Assessment at Birth • Size, level, nature of tissue covering • Nerve involvement • Lower limbs / bowel and bladder function • Degree of hydrocephalus • Head circumference • Leakage of CSF • Cranial sutures

  47. Interventions • Protect from injury and infection • Rupture of the sac can lead to death • Sterile moist dressing on sac until surgery • Position to prevent pressure on back

  48. Goals of Surgery • Control infection • Provide a normal anatomic barrier • Provide a normal anatomic barrier • Control hydrocephaly

  49. Outcomes • Bladder and bowel problems • Latex allergies: due to in and out catheterization • Problems with self-esteem • Orthopedic management • Schooling based on IQ

  50. Hydrocephalus • Greek meaning water on the brain • Dilation of the ventricles • Two primary causes: • Congenital .5 to 1% • Acquired: • Lesion, tumors, infection, intracranial bleed, myelomeningocele

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