Cerebral Dysfunction Flashcards
What are the 6 steps for degeration of LOC?
- Irritable but consolable
- Irritable and inconsolable
- Lethargic when left alone
- Needs more stimulation to wake up
- No response to touch
- No response to pain
Re: LOC, define Lethargic
- Drowsy but awakens with stimulation, slow to answer questions
Re: LOC, define Obtunded
- Difficult to arouse, falls back to sleep in the absence of stimulation
Re: LOC, define Stuporous
Needs painful stimulus to arouse, only response might be to withdraw from the painful stimulus
Re: LOC, define Comatose
No purposeful movement or response (May still have reflexes intact)
Child with increased ICP exhibits changes in motor function. _____ movement will decrease, and _____ posturing may be observed
- Purposeful
- abnormal
Describe Decorticate posturing.
- Flexion, or decorticate posturing, refers to flexion of upper extremities with elbows and wrists pulled up toward chin and extension of lower extremities.
- Plantar flexion of feet may also be observed.
- This type of posturing implies an injury to cerebral hemispheres.
Describe Decerebrate posturing.
- Extension, or decerebrate posturing, involves extension of upper extremities with internal rotation of upper arm and wrist.
- Lower extremities will extend, with some internal rotation noted at knees and feet.
Trauma results from physical forces from acceleration, deceleration or deformation.
Describe Coup vs Contrecoup
- Coup- bruising at the point of impact – “head hits window”
- Contrecoup- bruising at an alternate location – “brain hits back of head”
What is a basilar fracture and what are its s/s?
- Basilar Skull Fracture (back of head trauma)
- “Raccoon Eyes”
- Hemotympanum
- blood in the middle ear
What are the three components to head trauma?
- Primary
- The contusion or injury
- Secondary
- ICP as a result
- Hematoma
- Epidural - blood accumulates between the epidura and the skull
What is “Cushing’s Triad”?
- A response to increased ICP
- Decreased HR
- Increased BP
- Irregular breathing
- This is a really late sign
- We want to catch it early
What is the result of unchecked ICP?
- Cerebral herniation
- Pressure forces the brain out the skull hole
What are the early s/s of increased ICP in children?
- Headache,
- vomiting without nausea,
- blurred vision,
- seizures,
- decreased LOC
What are the early s/s of increased ICP in infants?
- Tense or bulging fontanel,
- high-pitched cry,
- changes in feeding,
- vomiting,
- irritability (which is a decrease in LOC)
What are the late s/s of increased ICP in infants and children?
- Cushings Triad
- Bradycardia,
- irregular breathing,
- widening pulse pressure,
- alteration in pupil size or reactivity,
- coma
What are our priorities for ICP?
- Continual neural assessments!
- Protect from injury
- Medications/fluids
- Family education
Treatment for ICP?
- Abx if bacterial cause of ICP
- Antiseizure if they’re seizing
- Corticosteroids to reduce cerebral edema
- Diuretic to decrease fluid
- Restrict fluid
- Watch I/O fluids
- Only hypertonic solutions
- Hypotonic will cross blood/brain barrier and increase ICP
What is our family education for ICP?
- Watch for these things to know if you need to come in
- Fever, vomiting, dizziness, blurred vision, loss of movement, slurred speech, seizures
What is hydrocephalus?
- Brain is making too much CSF or not allowing it to drain
- Either way, the result is too much CSF in head
Treatment for hydrocephalus?
- Externalized Ventricular Drain (EVD)
- Ventriculoperitoneal Shunt (VP Shunt)
- Ventriculoarial Shunt (VA Shunt)
Whay do we raise and lower the EVD bag and what is the result of doing so?
- Bag is raised or lowered to control how much CSF is desired to be drained
- Low position, more drains
- Higher position, less drains
Where do the VP and VA shunts drain to?
- VP Shunt - leads to peritoneal cavity
- VA shunt- leads to atrial cavity
Nursing Care for a Child s/p VP Shunt Placement
- Continually monitor LOC
- Monitor for s/s infection
- Incision site care
Key points of VP Shunt Malfunction and Infection
- AN EMERGENCY!
- Signs and symptoms of VP shunt malfunction are the same as for increased ICP
- VP shunt infection-
- Shunt malfunction will also occur in most cases
- Add fever and abdominal pain to increased ICP s/s
Nursing actions for VP shunt malfunction?
- HOB up – head of bed
- Seizure precautions
- Side rails up
- Clear area around pt
- Call MD
- Stay with the patient
- If fever/abdominal pain: prepare for IV abx
How is epilepsy dx’d?
- w/ two or more unprovoked seizures with no precipitating s/s
How is epilepsy manged?
- Multi-drug treatment
- Ketogenic diet
How is the drug treatment for epilepsy developed?
- Start with one drug and increase dose over time until we get the desired effect
- If sfx, we’ll back off dose until sfx are gone, but still need to make up for what we just took away, so…
- We add a second drug and increase dose until desired effect (no seizures)
What does the ketogenic diet consist of for epileptics?
- Normal protein, high fat, low carb
- Puts them in ketogenic state where body burns fat for glucose
What are some triggers for seizures?
- Sudden loud sound
- Fatigue
- Dehydration
- Flashes of light/ rapid changes in light/dark
- Extreme/abrupt temperature changes
Sometimes, HCP wants to see the seizure on the monitors, to do this, they’ll ask the parents to…
- keep the child up all night and then admit in the morning.
- Hope is they’re so tired it triggers the seizure so that the right med/procedures can be developed from there
What are absence seizures?
A seizure where the pt just checks out for a few seconds and then just comes right back to normal
What is the continuing medication management over time for epilepsy/seizures?
- Monitor therapeutic levels
- Increase dosage as child grows
- Add second medication ONLY if needed
- Avoid abrupt discontinuation—gradual dose reduction
- Family to keep Diastat (rectal diazepam) available at all times
What are the considerations for Diastat use?
- If seizure lasts more than 5 mins, then this is used to stop the seizure
- If < then 5 and typical for the child, don’t use and family will keep track of episodes
- Educate family to TAKE THE CAP off before they stick it up their kid’s ass!
- If used, you’ll need to take kid to HCP for f/u
If children are seizure free for more than 2 years, the HCP may try to reduce their dose over about 3 months to see if they’ve outgrown their seizures. What is the key thing to remember about timing before doing this?
It must be done before or well after puberty to due to hormonal chaos
What are febrile seizures?
- seziures triggered by fever
- usually of >102°
- occur between 6 months and 3 years of age
- Febrile seizures do not cause any problems
Treatment for febrile seizures, while in hospital?
Pt will be given IV or rectal diazepam
What is the family teaching regarding febrile seizures?
- Febrile seizures are scary but benign
- There are no studies that show that attempts to lower temperature will prevent sz
- If seizure lasts more than five minutes call 911
- Safety
True or False
Tylenol can be used to treat fever and avoid febrile seizures.
- False
- If its gonna happen, its gonna happen regardless of Tylenol
What is our nursing care for the child with a seizure disorder?
- Protect from injury
- Know what happens for the individual child
- Medicate (if applicable)
- Family educaion
What is Meningitis and why is it life threatening?
- It is an inflammation of the meniges around the brain and spinal cord
- inflammation can be baterial or viral
- may also be caused by some medications
- Its proximity to the brain and spinal cord is why it is life threatening
If there is ICP present with meningitis, do we do the LP? why or why not?
- Thats a big fat NO!
- It can cause cererbral herniation
If we can’t do the LP for meningitis, what is our alternate course of action?
Assume its bacterial and administer abx
What are the long term complications of meningitis?
- Deafness
- Seizure disorder
- Hydrocephalus
- Cognitive Deficits
What is the treatment for meningitis?
- Rapid admin of antibiotics
If petechiae is present with meningitis, what does it indicate and what are our immediate actions?
- Sure sign that menengitis is caused by the neisseria bacteria
- Only form that can be transmitted by droplets
- Get into proper gear precautions
- Get the abx
- Treat quickly or it can turn into meningocoxemia - which leads to sepsis
What is the tx for Viral (Aseptic) Meningitis?
- Treatment is just manage s/s and sequelae
- Sequelae = whatever happens after
- Sometimes given anti-virals
What is encephalitis?
- “Inflammation of the brain”
- Most often caused by viral infection
What is the treatment for encephalitis?
Treatment is supportive and the same as with any child with decreased LOC or meningitis
What are some causes of encephalitis?
Rabies, HSV, ebstein barr, varicella, mesquito virus, measles/mumps
Long term considerations for encephalitis?
- Even if s/s are controlled, the condition can have devatating effects
- There will be rehab to do, could have severe brain injuries that will take a lot of work to fix
- Long term f/u to take care of this
What is responsible for the dramatic decline of bacterial meningitis?
The Hib (Haemophilus influenzae type B) vaccine in 1990
What are two things that can be triggered when you have CNS trauma or illness and what are the key points of each?
- SIADH
- Oversecretion of ADH
- Fluid retention and hypotonicity
- Decreased sodium levels
- Diabetes Insipidus
- Posterior pituitary hypofunction
- Under Secretion of ADH
- Uncontrolled diuresis
