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The Child With Altered Neurologic Status Jan Bazner-Chandler CPNP, CNS, MSN, RN The Brain Differences in Children 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 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. Neurologic Assessment Level of consciousness What stimuli is needed? What is quality of the response? What is length of response? Levels of Consciousness Confusion Delirium Disorientation to time, place, or person Characterized by confusion, fear, agitation, hyperactivity, or anxiety Stupor = response to vigorous stimuli only Coma = severely diminished response 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. Pupil Changes Fixed and dilated pupil(s) is neuro emergency 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. CT Scan Non-invasive three dimensional look at normal and abnormal structures. Brain Tumor CT Scan MRI Brain Scan Injection of tiny amounts of radioactive isotope to measure tissue uptake. Lumbar Puncture Side lying position for LP Lumbar Puncture Insertion of spinal needle into subarachnoid space between the lower lumbar vertebrae. Analysis of CSF Cerebral Spinal Fluid 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 Intracranial Pressure The head is a closed box Total volume inside brain V brain + V blood + V CSF + V other = Constant Volume of Brain Brain volume can increase with: Edema Blood flow Bleed within the brain Tumor Volume of Cerebrospinal Fluid Vital Sign Changes Increase in Blood Pressure Cushing Triad Decrease in Pulse Altered Respiratory pattern 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 Assessment Glasgow coma scale Pupil size LOC Vital signs Accurate I & O Minimize metabolic demands Fever, pain, seizures Multidisciplinary Interventions Controlled hyperventilation Evacuation of hematoma Correction of CSF increase Steroids / dexamethasone Correction of coagulopathies Alterations in Neurologic Status Seizures: a paroxysmal , uncontrolled episode of behavior that results from an abnormal electrical discharge from the brain. Effect on Child Altered responsiveness Altered sensation or perception Altered movements, mobility or muscle tone 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, altered awareness, mouth, or facial movement Status Epilepticus Seizures lasting more than 30 minutes Serial seizures without return to baseline Medical emergency Febrile Seizures Occurs in 2 to 5% of all children 6 months to 3 years of age Occur in association with a febrile illness The younger the child the more likely they are to reoccur Treatment: none unless additional seizures Documentation When seizures began Duration Warning signs Clinical characteristics Level of consciousness Signs and symptoms when seizures stop 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 Diagnostic Tests Febrile seizure – clinical diagnosis based on history Seizures EEG LP Electrolytes MRI Medications Dilantin causes overgrowth of gum tissue Anencephaly Absence of brain tissue above a rudimentary brain stem and basal ganglia. Anencephaly Diagnostic Tests Prenatal ultra-sound Elevated alpha fetal protein Multiple anomalies Incompatible with life Heart transplant donors Multidisciplinary Interventions Supportive care Genetic and psychological counseling Organ donation Grief therapy Sustained extra uterine life impossible 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 Focused History Poor maternal nutrition Maternal age Pregnancy history Birth order Socioeconomic status Diagnosis Ultrasound Elevated AFP 95% survival rate Meningomyelocele / Meningocele Bowden & Greenberg Myelomeningocele A protruding saclike structure containing meninges, spinal fluid and neural tissue. Myelomeningocele Assessment at Birth Size, level, nature of tissue covering Nerve involvement Lower limbs / bowel and bladder function Monitor for signs of hydrocephalus Head circumference Leakage of CSF Cranial sutures Immediate 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 Goals of Surgery Provide a normal anatomic barrier Control Infection Control hydrocephaly Community Care Bladder and bowel problems Latex allergies: due to in and out catheterization Problems with self-esteem Orthopedic management Schooling based on IQ 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 Hydrocephalus Head Circumference Hydrocephalus Bulging anterior fontanelle Eyes deviated downward “Setting” Sun sign Bates: Physical Assessment Transillumination of Skull Advanced cases of Hydrocephaly produces a glow of light over the entire cranium. Bates: Physical Assessment Severe Hydrocephalus Assessment Bulging fontanels Split sutures Increasing head circumference Prominent scalp veins Sunset eyes Irritability – high pitched cry Poor feed The older child will complain of headache Interventions Placement of shunt to drain CSF from the ventricles to another part of the body. Assessment of Shunt Vomiting Headache Irritability Fever Redness along shunt line Fluid around shunt valve Microcephaly Reduction in brain size Radiology.uchs.edu Microcephaly TORCH infections in the mother Cocaine use by mother during pregnancy Autosomal dominant transmission Reduction of blood supply at birth Infectious Process Bacterial meningitis Pyrogenic or purulent infection that involves the pia mater and arachnoid mater layers of the meninges. Infection of Meninges Pathogens Under 2 months :E-coli, Group B streptococcus, Listeria, Haemophilus influenza type B, and Streptococcus pneumonia Beyond neonate: Strep, Haemophilus, Neisseria. Focused Health History Otitis Sinusitis Mastoiditis Post skull fracture Meningocele PROM Premature infant Sepsis / bacteremia Clinical Manifestations Poor feeding Hypothermia / hyperthermia Irritability Apnea Bulging fontanel Look sick Assessment Older Child High fever Headache Nuchal rigidity / stiff neck + Kernigs = inability to extend legs + Brudzinski sign = flexion of hips when neck is flexed Purple rash (check for blanching) Kernig Sign The test for Kernig sign is done by having the person lie supine (flat on the back), flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint. If the leg cannot be completely extended due to pain, this is Kernig sign. Kernig Sign Brudzinski Sign Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed. Brudzinski Sign Septic Looking Ball & Bindler Purple Rash Bowden & Greenberg Characteristic purpuric lesions of meningococcal meningitis. Diagnostic Tests + Spinal fluid + Blood Culture Multidisciplinary Interventions IV antibiotics Dexamethasone to decrease meningeal inflammation and hearing loss Monitor Gentamycin blood levels Interventions Droplet precautions Isolation X 24 hours Vital signs Neuro checks / palpate fontanel Monitor fluids to prevent fluid overload Head circumference Pain management / quiet environment Droplet Protection If patient is a rule out meningitis the nurse should wear a mask when helping with diagnostic tests. Outcomes Unfavorable outcomes Young age Delay in treatment Coma Focal neurologic signs Poor clinical course Community Care BAER hearing test in hospital and 3 to 6 months later Developmental testing Watch for learning disabilities Subdural Hematoma Shear force injury created by impact can cause tearing of bridging vessels. Falls, assaults, MVA, Shaken Baby Syndrome. Children under 1 year Subdural Hematoma Bridging Veins Clinical Manifestations LOC Vomiting Headache Retinal hemorrhages Pupil on side injury fixed and dilated Seizures Retinal Hemorrhages Normal retinal Retinal hemorrhage Subdural Hematoma CT scan to confirm diagnosis Subdural tap 50% die 75% seizures Skull Fractures Depressed Skull Fracture Six-year old hit by auto while riding his bike. Depressed Skull Fracture Part of the skull is actually sunken in from trauma. May occur with or without a cut in the scalp. Surgical intervention is needed to correct the deformity. Basilar Skull Fracture Most serious type of skull fracture. Involves a break in the bone at the base of the skull. Child has bruises around their eyes and a bruise behind the ear. May have clear fluid draining from their nose or ears. Need close observation in hospital. Battle’s Sign Battle’s Sign