cerebral dysfunction Flashcards
dev differences
expandable skull
great blood volume
bbb more permeable
small epidural space = fewer hemorrhages
bulging fontanelles = increasing ICP (compensate until they decline rapidly)
more blood flow and oxygen consumption than adults
thinner and softer brain tissue
assessment
history
posturing
decerebrate = arms extended, wrists flexed back, arched back
decorticate = elbows bent and brought to chest
increased ICP - causes
tumor/lesions, hemorrhage, edema of cerebral tissue, accumulation of CSF in ventricles
increased ICP cm - children
HA, blurred vision, diplopia, pupils sluggish to light, seizure, n, forceful v, lethargy, increased sleeping, declining school performance, declining motor function (change in gait)
increased ICP cm - infants
tense bulging fontanelles
separated cranial suture
macewen (cracked pot) sign
irritable
high pitch cry, catlike
increased head circumference
distended scalp veins
feeding change
cry when held or rocked
setting sun eyes
taught shiny skin over scalp
late S of ICP
significant decrease in LOC
decreased motor response to command
decreased sensory response to pain
fixed and dilated pupils
decerebrate/decorticate posturing
cushings triad
nc - unconscious child
emergent
ASSESS - subtle cues
ABCs, stabilized spine, treat shock, reduce ICP
nc - unconscious child
ongoing
freq neuro assessment
LOC, pupillary reaction, VS
pain management -
nc - unconscious child
pain signs
HR, BP
resp, ICP, nutrition and hydration, elimination, thermoregulation, positioning, hygiene, meds, stimulation, fam support
hydrocephalus
too much fluid in ventricles
obstruction or not draining correctly
same s/s as ICP
hydrocephalus tm
- relieve pressure - VP shunt drains to peritoneal cavity
extra is left to uncoil with growth - treat cause
- treat complications
- promote psychomotor dev
VP/VA shunt nc - preop
prevent breakdown of scalp, infection, damage to spinal cord
monitor for increased ICP
promote nutrition
keep eyes moist
prep child and fam for procedures
VP/VA shunt nc - post op
bed rest with minimal handling (flat, no P on shunted side), later = elevate HOB 15-30
monitor: VS, neuro, abd distention, s/s infection
comfort, discharge teaching (s/s of increased ICP, s/s of infection), record dev milestones
VP shunt complications - infection
shunt removed, external ventricular drain inserted and connected to collection bag
close monitoring of EVD, IV abx for several weeks, new shunt placed once CSF is clear of infection
VP shunt complications - malfunction
new shunt insertion via surgery
can happen bc growth (doesnt uncoil correctly), tubing disconnects or kinks
EVDs
EVDs nc
dont turn side to side (increase ICP)
keep HOB 15-30
drainage level with tragus (or surgeons order)
assess CSF output every hour
dont change dressing
sudden increase or decrease in CSF output or poor waveform = all stopcocks in correct direction, cords plugged in, thorough and quick assess, call surgeon
TBI
scalp, skull, meninges, brain
result of mechanical force
TBI scalp laceration
superficial, will bleed alot
TBI skull fracture
linear = single crack
depressed = several fragments and pushes inwards
basilar
TBI - basilar skull fracture
break in base of skull, close to brainstem = serious
higher risk of secondary infection (meningitis, no invasive - no suction, high alert for fever, nothing up the nose)
raccoon eyes and battle sign, CSF leakage possible (nose and ears)
concussion
alteration in mental status with or without loss of consciousness - immediately after blow to head
diagnosed with rule out
concussion cm
confusion and amnesia!!
HA, dizzy, difficulty concentrating, vision change, sensitive to light and noise, n, drowsy, tinnitus, irritable, loss of consciousness, hyperexcitability
concussion - when to seek treatment
infant, lost consciousness, wont stop crying, head and neck pain, repeated v, difficult to awaken, difficult to console, change in gait, unusual behavior, bleeding from nose/mouth, watery glucose discharge from nose or ears
TBI - tm
ABCs, stabilized neck and spine, freq neuro and vs, hypertonic solution (mannitol, hypertonic saline = draw fluid into vasculature and away from brain), IV steroids to decrease inflam and edema
TBI - complications
TBI S of progression
mental status change, mounting agitation, dev of focal lateral neuro s (posturing, one eye changes), marked change in VS, cushing reflex, S of brainstem involvement
meningitis
inflam of meninges in brain and spinal cord
less with abx and vaccines
bacterial = bad, permanent damage
viral = vanishing, not as bad
meningitis cm
poor suck and feed, apnea, weak cry, nvd, tense fontanelle, jaundice, fever, increased irritability, high pitch cry, seizures, HA, petechial or purpural racsh, altered sensorium, opisthotonos, kernig’s sign, nuchal rigidity (brudzinski’s)
meningitis tm
diagnose: LP = increased WBC (cloudy), P, protein, decreased glucose, + culture
meds: abx if bacterial or until cultures return, anticonvulsants, antipyretics
treat F+E imbalance
meningitis nc
isolation first! collect specimens, then abx ASAP
prevent complications, seizure precautions and neuro checks, prevent increase in ICP, hydration and nutrition, support
monitor for septic shock, circulatory collapse, dilutional hypoNa, long term sequelae
prevention
encephalitis
inflammation usually caused by HSV1
encephalitis cm
non specific, fever, altered mental status, possible seizures
can resemble meningitis, lasts few days, complete recovery or severe CNS involvement or death
encephalitis tm
diagnose: cm and organism ID, ct scan may show hemorrhagic area, blood samples
hospitalized for observation
supportive care
encephalitis nc
same as unconscious child and meningitis
reyes syndrome
encephalopathy with hepatic dysfunction
no aspirin with flu/cold/varicella
epilepsy
abnormal electrical impulses in brain
2+ seizure episodes not caused by reversible med conditions
febrile seizure
> 101, 6 mo - 5 yrs, w/o epilepsy, CNS infection, or met abn
febrile seizure tm
> 5min = call EMS
meds = rescue sedative (rectal diazepam or intranasal midazolam)
epilepsy tm
- antiepileptic drugs (start with 1, may need multiple)
- keto diet (high fat, low carb, supplement with vits)
- vagus nerve stimulator -device under skin, use magnet?
- surgery
keto diet
epilepsy nc - during seizure
- observe (eye movement, LOC, uni/bilateral movement, duration)
- protect - lower bed, protect head, turn on side, NPO, dont restrain
- VS, oxygen if <90%
- > 5 min = rescue sedatives
- call hcp and monitor
epilespy nc - long term
educate caregivers (rescue meds - always have and admin)
avoid triggers (sress, sleep deprivation, flickering lights)
safety (dont bathe/swim alone, helmet, no open flames, avoid climbing tall heights)
support - balance autonomy and safety
