neurologic differences of infant and child
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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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.
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Causes Neurological Dysfunction• Injury: r/t direct brain tissue• Hypoxia• Congenital• Metabolic derangement• Infection • Perfusion problem: stroke• Brain tumor
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Standard Terms for Level of Consciousness
• Full consciousness• Confused• Disoriented• Lethargic• Obtunded• Stupor• Coma
• McKinney et al, 3rd ed. P 14703
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Glasgow Coma Scale
Table 52-1, p. 1469: modified for children–Eye Opening–Verbal Response–Motor Response
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Causes of Increased ICP
• Swelling of brain tissue• Increase in amount of CSF• Increase in amount of blood flow
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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
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Increased ICP - Child• Altered level of consciousness• Mood swings• Headache (esp. am)• Diplopia• Slurred speech • Nausea and vomiting (esp. am)
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Hydrocephalus
• What is it?
• Treatment: Shunt–Ventriculoperitoneal (VP)–Ventriculoatrial
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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)
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Neural Tube Defects
• Definition• Spinal bifida occulta• Spina bifida cystica
–Meningocele–Myelomeningocele
• Role of Folic Acid as primary prevention• HP 2020 goal
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Myelomeningocele
• Flaccid paralysis• Sensory loss• Bowel & bladder sphincter • Joint deformities
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Nursing Care: Myelomeningocele• Check head circumference• Fontanels • Position • Elimination• Infection
–Pre-op: sterile, moist dressing–Latex precautions
• Impaired mobility–Hip & foot alignment
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Cerebral Palsy
• Chronic, nonprogressive disorder of posture & movement
• Manifestations vary
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Causes of CP
• prenatal
• Intra
• postnatal
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Clinical Manifestations CP• Primitive reflexes• Delayed development• Hypertonia• Contractures• Often intellectually intact
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Nursing Diagnoses: CP• Impaired physical mobility • Altered growth & development • Risk of injury• Impaired verbal communication • Self-care deficit• Altered nutrition• Caregiver role strain
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Care: cerebral palsy• Extra calories r/t spasticity • Aspiration precautions• Multidisciplinary team• Prevent developmental delays• Maintain a safe environment• Control spasticity
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Surgical Interventions: CP
• Surgical release tight muscles & tendon• Baclofen Pump• Derotation osteotomy• Rhizotomy: cutting nerves on affected
limbs• Botulinum Toxin A (Botox injections)
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Intracranial Infections
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Intracranial Infections• Meningitis: inflammatory process
affecting the meninges• Encephalitis: affects the brain• Myelitis: spinal cord• Causes:
–Bacterial–Viral (aseptic)–Tuberculosis
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Bacterial
• Haemophilus influenzae• Streptococcus pneumoniae• Neisseria meningitidis (meningococcal)• Frequent cause: infection starting
elsewhere
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Clinical Manifestations: Meningitis
• Increased ICP• Severe HA• Photophobia• Nuchal rigidity; opisthotonos
(infants)• LP:
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Bacterial Meningitis: Complications• Compression of cranial nerves
– Hearing Loss• Brain abscess• Seizures• Cerebral palsy• Learning disorder• Attention deficit disorder• Paresis (hemi, quad)
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Nursing Care• Prevention
–Immunization–Meds for contacts
• Isolation: bacterial• Supportive
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Supportive Nursing Care• Hydration • Prevent injury
–seizure precautions• Minimize increased ICP**:
–Quiet, dark environment–Position of comfort–Head/neck in neutral position–Steroid possibly
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Supportive Nursing Care (cont)
• Assessment for deteriorating neuro status
• I & O• Manage pain, fever
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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
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Seizure
• A sudden, explosive, disorderly discharge of cerebral neurons.
• Sudden, transient alteration in brain function
• Motor, sensory, autonomic, or psychic clinical manifestations.
• Syndrome
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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
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Epilepsy
• a chronic disorder of recurrent seizures.
• A general term for the primary condition that causes seizures.
• Primary (AKA Idiopathic)–Genetic predisposition
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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
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Precipitating Factors• Hypoglycemia• Fatigue• Stress (emotional or physical)• Febrile illness• Stimulant drugs• Withdrawal from depressant drugs• Certain environmental stimuli
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Classification of Seizures
• Partial or generalized• Partial
– Simple– Complex– Begin locally, can become
generalized
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Generalized Seizures
• Bilaterally symmetric• Loss of/or impaired consciousness• Postictal state• Tonic, clonic, or tonic-clonic• Absence• Infantile spasms• Atonic (drop attack)
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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
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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
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Nursing Interventions r/t ‘Potential for Injury’
• Maintain airway• Oxygen: “blow-by”• Move objects out of way• Assess duration, where started,
LOC, incontinence
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Classifications of Anticonvulsant Medications
• Hydantoins• Barbiturates• Succinimides• Oxazolidones• Benzodiazepines • Carbamazepine• Valproate 39
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Mechanism of Action
1. Suppress sodium influx2. Suppress calcium influx3. Increase action of GABA (gamma
aminobutyric acid)
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MedicationsFor 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.
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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
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Clonazepam (Klonipin)
• Maintenance – po• Absence, myoclonic seizures
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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
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Fosphenytoin (Cerebyx)
• Replacing Dilantin IV• PE (phenytoin equivalents)• Dilute in D5W or NS to 25 mg
PE/ml• 150 mg PE/min
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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, confusion46
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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 47
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Miscellaneous
• Pregnancy category• MgSO4 for eclampsia/preeclampsia• Anticonvulsants for other uses• Surgical management• Drug-drug interaction• Ketogenic diet• Vagal nerve stimulator
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