Cerebral Dysfunction Lauren Walker, RN, BSN - PowerPoint Presentation

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Cerebral Dysfunction

Lauren Walker, RN, BSNGeorgetown University

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Overview Topics

Increased Intracranial PressureLevel of ConsciousnessCerebral AbnormalitiesNervous System Tumors

Infections

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Pediatric Cerebral Dysfunction

General 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

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Abnormal neurologic physical evaluations of infants

Size and shape of headSensory responsesSpontaneous activitySymmetry in extremity movement

Frequent movement of extremities

Skin and hair texture

Distinctive facial features

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

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Increased Intracranial Pressure

Brain is enclosed in the solid bony craniumCranium’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

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Clinical s/s of Increased ICP

Infants

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

Children

Headache

NauseaVomitingDiplopia, blurred visionSeizures

Box 28-1, Chapter 28 Wong

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Clinical s/s of Increased ICP

Personality and behavioral signs

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

Late signs

Bradycardia

Lowered level of consciousness

Decreased motor response to commandsDecreased sensory response to painful stimuliAlterations in pupil size and reactivity to light

Flexion and extension posturingCheyne-stokes respirationsPapilledema

Coma

Box 28-1, Chapter 28 Wong

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Level of Consciousness

Earliest indicator of improvement or deteriorationDetermined by observationsPhysical Assessment

Motor activity, reflexes, vital signs

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15 points- highest score, unaltered LOC

3 points- lowest score, deep coma

http://www.eguidelines.co.uk/eguidelinesmain/gip/media/images/barclay_glasgow_comascore2.gif

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Nursing Management of ICP

PositioningAlternating mattressesAvoid causing painCluster care

Minimize environmental noise

Closely monitor nutrition and hydration

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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

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Medications for Altered ICP

What is the cause?Corticosteroids: inflammation

Antibiotics: infectious process

Diuretics: edema

Antiepileptic: seizure activity

Sedation: combativeness

Barbiturates: deep coma

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Cerebral Malformations

Newborn cranial sutures are separated by membranous seamsSutures: Soft areas: -Sagittal

-Anterior fontanel

-Coronal -Posterior fontanel

-

Lambdoidal

Eight weeks:

Posterior fontanel closed

Six Months

:

union of suture lines

Eighteen Months

: Anterior fontanel closed

After

12 years

: sutures unable to be separated by increased ICP

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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

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Diagnosing Hydrocephalus

Time of onset and preexisting lesionsInfants: Head circumferences and neuro signsCT

MRI

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Clinical Manifestations of Hydrocephalus

Infancy (early)

Infancy (later)

Infancy

(general)

Childhood

Abnormal

rapid head growth

Frontal enlargement

Irritable

Headache on awakening

Bulging fontanels

Depressed eyes

Lethargy

Papilledema

Dilated scalp veins

Sun-setting sign

Cries when

picked up or rocked

strabismus

Separated sutures

Pupils sluggish

Infantile reflexes persist

Irritable

Macewen

sign

Change in LOC

Lethargy

Thinning of skull bones

Lower extremity spasticity

Confusion/ incoherence

Difficult

suck and feeding

vomiting

Box 28-13, chapter 28, Wong

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Management of Hydrocephalus

Direct removal of obstructionPlacement of shuntVentriculoperitoneal shunt (VP shunt)

Associated with infection and malfunction

High success rate with surgically treatment

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Shunting

Shunting Video

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Family Support

Coping is difficult with patentsFeel guilty, anxiousUncertain outcomeContinue to educate familyInclude family in patient care

Possibility of long term rehabilitation

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Nervous System Tumors

CNS tumors account for 20% of all childhood cancers3.3 cases per 100,000 occur in kids under 15 years old

Difficult to treat

No dramatic advancements or improvements seen

vs

other childhood cancers

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Brain Tumors

Most common solid tumors in childrenInfratentorial

(60%)

Primairly

in brain stem or cerebellum

Usually see increased ICP

(

medulloblastoma

,

cerebellar

astrocytoma

, brainstem glioma)SupratentorialMainly cerebrum(

astrocytoma, hypothalamic tumors, optic pathway tumors)

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Brain Tumor Diagnostics

s/s are related to:LocationSize 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

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Treatment of Brain Tumors

Treatment of choice = total removal of tumor without neurologic damageSurgery, radiotherapy, chemotherapyPrognosis:

Depends on size, tumor type, extent of disease

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Nursing Management of Brain Tumors

Establish a baseline assessmentVital signsLook for sudden variations

Frequent neurologic assessments

Headache? Vomiting? Seizures?

Child’s behavior

positioning

Postoperatively check muscle strength when awake

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Intracranial Infections

Nervous system is limited in ways to respond to an infectionInflammatory process in brain affects:

Meninges

(meningitis)

Brain (encephalitis)

Meningitis has many origins

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Bacterial Meningitis

Definition: acute inflammation of the meninges and CSF10-15% of cases are fatal

Caused by many bacterial agents

H.

Influenzae

type b, S.

pneumoniae

,

Neisseria

Meningitidis

Vascular dissemination or direct implantation

Infective Process

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Clinical Manifestations of

Bacterial MeningitisChildren and Adolescents

(Classic picture)

Abrupt onset, rash

Fever, chills, headache

Alteration in senses

Seizures*

Irritability/agitation

Nuchal

rigidity

Positive

Kernig

&Brudzinski signs

Infants and Young Children

FeverPoor feedingVomitingIrritable

Frequent seizures

Bulging fontanel

Difficult to evaluate in this age group

Box 28-5, Chapter 28 Wong

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Clinical Manifestations of

Bacterial MeningitisNeonates: Specific Signs

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

Neonates: Nonspecific Signs

Hypothermia/fever

JaundiceIrritableDrowsiness

SeizuresRespiratory irregulationscyanosis

Box 28-5, Chapter 28 Wong

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Diagnostic and Therapeutic Management of Bacterial Meningitis

Lumbar PunctureElevated WBC countDecreased Glucose levelConsidered a medical emergency!

Initial management:

Isolation, iv antibiotics, fluids, monitored, treatment of complications

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Management of Bacterial Meningitis

HydrationQuiet, decreased stimulationSide lying position

Correct electrolyte imbalance

Measure for s/s increased ICP

Monitor for complications

Prevention:

Vaccines for children starting at 2 months

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Nonbacterial (aseptic) Meningitis

Caused by many viruses!Abrupt or gradual onsetSymptoms develop 1-2days after onsets/s vague

Diagnosis is based on pt assessment and CSF findings

Systematic treatment

Nursing care similar to bacterial meningitis

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Encephalitis

Definition: inflammatory process of the CNS which is caused by a variety of organismsVirus invades CNS or postinfection

after a viral disease

Cause in typically unknown

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Clinical Findings of Encephalitis

Initial findings are nonspecificEvolve to demonstrate neuro s/s

Seizures, abnormal CSF

Mild s/s for a few days, rapid recovery, to fulminating encephalitis with CNS involvement

Onset

Severe Cases

Malaise

Fever

Headache/Dizziness

Lethargy

Neck Stiffness

Nausea/Vomiting

Tremors

Speech Difficulties

Altered Mental StatusHigh FeverStupor

Seizures

Disorientation

Spasticity

Coma

Paralysis

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Diagnosis and Management of Encephalitis

Based on clinical findings CT in late stagesSome viruses are found in CSF

Hospitalized for observation with supportive treatment

Prognosis depends on age, organism, neurologic damage

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http://www.youtube.com/watch?v=8tf5VewEfGs

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