Chapter 32 The Child with Cerebral Dysfunction Copyright
Chapter 32 The Child with Cerebral Dysfunction Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved.
Development of the Neuro System Grow proportionately (vs. rapid) after birth Brain growth reflected in head circumference Cerebral blood flow and oxygen consumption twice that of adults Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 2
Central Nervous System Brain coverings Ø Brain Ø Ø Ø Three membranes Cerebral hemispheres Basal ganglia Brainstem Cerebral Blood Flow Ø Ø Ø Autoregulation Oxygen Blood-brain barrier Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 3
Increased Intracranial Pressure Etiologies Clinical manifestations Ø Ø Ø Infants Children Adolescents Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 4
Evaluation of Neurologic Status Assessment Ø Ø History Physical Exam • Head • Activity strength and coordination • Reflex activity • Sensory responses • Alertness/behavior • Vital Signs • Skin • Eyes (pupils) Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 5
Evaluation (Cont. ) Motor function and posturing Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 6
Altered Level of Consciousness Etiology Earliest indicator of neurologic status Coma assessment Ø Glasgow Coma Scale (GCS) Irreversible coma Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 7
GCS Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 8
Diagnostic Procedures Blood testing Ø Include drug testing Lumbar puncture or tap Electroencephalogram (EEG) Auditory and visual evoked potential tests CT and MRI Nuclear brain scan Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 9
Care of an Unconscious Child Careful observation, recording, and evaluation of changes Direct measures to ensure patent airway, breathing, and circulation Stabilization of the spine Treating shock Reducing ICP Thermoregulation Pain assessment Protection of skin Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 10
Care of an Unconscious Child Respiratory management Intracranial pressure monitoring Nutritional support Hydration—adjusting fluids carefully Medications Thermoregulation Elimination Stimulation and support of skin, joints, limbs Family support Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 11
Head Injury Unintentional injury is the number one health risk for children and leading cause of death in children >1 year. Etiology: Ø Ø Ø Falls MVA Bicycle injury Pathophysiology Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 12
Types of Closed Head Injuries Concussion Contusion and laceration Fractures Epidural hematoma Subdural hematoma Other hemorrhagic lesions Ø Ø Ø Subarachnoid Cerebral edema Posttraumatic syndrome Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 13
Therapeutic Management of CHI Initial assessment Ø Ø ABCs Neurologic exam Testing based on history and exam Support to child and family IV fluid Sedation is usually withheld but headache is controlled Surgical therapy Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 14
Nursing Care of CHI Frequent assessments Bedrest with head of bed slightly elevated and head in midline position Seizure precautions Sedation and pain management Limit stimulation Documentation Family support Plan for healing process and rehab Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 15
Submersion Injuries Highest mortality in children 0 -4 years Pathophysiology Clinical manifestations Ø Based on water temperature, length of submersion, type of water Therapeutic management Nursing care management Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 16
Intracranial Infections Bacterial meningitis Ø Ø Ø Etiology Pathophysiology Clinical manifestations • Most children have sudden onset headache, fever, vomiting, and severe headache with irritability • Infants may have fever or hypothermia, poor feeding, and bulging fontanel • Complications Ø Ø Diagnostic testing Therapeutic management Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 17
Nursing Care Management of Intracranial Infections Establish isolation Careful and frequent assessment Atraumatic care Ø Ø Lumbar puncture Establish IVF and nourishment Limit stimulation Provision of medications Prevention and prophylaxis Family support Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 18
Cerebral Infections Nonbacterial (aseptic) meningitis Tuberculous meningitis Brain abscess Encephalitis Rabies Reye’s syndrome HIV encephalopathy Ø Ø Pathophysiology Clinical manifestations Therapeutic management Nursing care management Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 19
Neuromuscular Dysfunction Terms to understand Ø Ø Ø Myopathy Upper motor neurons Lower motor neurons Motor unit Pyramidal Extrapyramidal Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 20
Classification and Diagnosis Upper motor neuron lesions Ø Ø Ø Weakness/spasticity Increased DTRs and abnormal superficial reflexes Primarily cerebral palsy Lower motor neuron lesions Ø Ø Ø Weakness, atrophy of skeletal muscles, hypotonia Usually symmetric Gradual or sudden onset indicates causation Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 21
Seizures and Epilepsy: two or more unprovoked seizures Classification of seizures Partial • Single • Complex Ø Generalized Ø Atonic and akinetic Ø Etiology and Incidence Pathophysiology Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 22
Seizure types Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 23
Seizures and Epilepsy Diagnostic evaluation Ø Ø History and assessment Testing: EEG, sleep study, video Therapeutic management Control seizures, reduce frequency and severity Drug therapy • Complications • Combination therapy Ø Ketogenic diet Ø Vagus nerve stimulation Ø Surgical therapy Ø Ø Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 24
Status Epilepticus Seizure lasting >30 minutes Nursing care management: Ø Ø Ø Maintain patent airway Ensure safety Assessment, documentation Diazepam administration (buccal, nasal, rectal, IV) Support family Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 25
Nursing Care Management Seizure precautions, prevent injury Long-term care and support to child and family Education and anticipatory guidance Medication compliance and administration Prevention of triggers Nutritional support (vitamin D and folic acid) School plans to ensure safety and medication Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 26
Headache Assessment Ø Offers clues to etiology Types Ø Ø Acute recurrent (migraine) Chronic progressive Chronic nonprogressive Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 27
Migraine Pathophysiology Classification Clinical manifestations Therapeutic management Nursing management Ø Ø Ø Triggers Sleep Nutrition Stress Treatment adherence Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 28
Cerebral Malformation Hydrocephalus Pathophysiology Clinical manifestations • Infancy • Childhood Ø Diagnostic evaluation • HC measurement • Assessment of neurologic status • CT or MRI Ø Ø Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 29
Hydrocephalus Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 30
Hydrocephalus (Cont. ) Therapeutic management Medical management • Medications Ø Surgical treatment • Ventriculoperitoneal Ø shunt (VP) • Complications Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 31
Hydrocephalus (Cont. ) Nursing care management: Careful observation • Measurement of head circumference • Fontanels and suture line assessment • Behavioral changes • HA, N/V, irritability Ø Pre-op care Ø Post-op care Ø Family support Ø Long-term care Ø Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc. , an imprint of Elsevier Inc. All rights reserved. 32
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