Cerebral Dysfunction
Lauren Walker, RN, BSN
Georgetown University
Overview Topics
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Increased Intracranial Pressure
Level of Consciousness
Cerebral Abnormalities
Nervous System Tumors
Infections
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
Abnormal neurologic physical
evaluations of infants
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Size and shape of head
Sensory responses
Spontaneous activity
Symmetry in extremity
movement
• Frequent movement of
extremities
• Skin and hair texture
• Distinctive facial features
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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
Increased Intracranial Pressure
• Brain is enclosed in the solid bony cranium
• Cranium’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
Clinical s/s of Increased ICP
Infants
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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
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Children
Headache
Nausea
Vomiting
Diplopia, blurred vision
Seizures
Box 28-1,
Chapter 28 Wong
Clinical s/s of Increased ICP
Personality and behavioral signs
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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
commands
• Decreased sensory response to
painful stimuli
• Alterations in pupil size and
reactivity to light
• Flexion and extension posturing
• Cheyne-stokes respirations
• Papilledema
• Coma
Box 28-1, Chapter
28 Wong
Level of Consciousness
Earliest indicator of improvement or
deterioration
• Determined by observations
• Physical 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/eguidelin
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Nursing Management of ICP
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Positioning
Alternating mattresses
Avoid causing pain
Cluster care
Minimize environmental noise
Closely monitor nutrition and hydration
Nursing Management of Increased ICP
• Indications for inserting a monitor:
– GCS of 8 or below
– Deterioration
– Judgment from clinical appearance and response
• Monitors:
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Intraventricular catheter
Subarachnoid bolt
Epidural sensor
Anterior fontanel pressure monitor
Medications for Altered ICP
• What is the cause?
– Corticosteroids: inflammation
– Antibiotics: infectious process
– Diuretics: edema
– Antiepileptic: seizure activity
– Sedation: combativeness
– Barbiturates: deep coma
Cerebral Malformations
• Newborn cranial sutures are separated by
membranous seams
Sutures:
Soft areas:
-Sagittal
-Anterior fontanel
-Coronal
-Lambdoidal
-Posterior fontanel
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
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
Diagnosing Hydrocephalus
• Time of onset and preexisting lesions
– Infants: Head circumferences and neuro signs
• CT
• MRI
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 strabismus
up or rocked
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
Management of Hydrocephalus
• Direct removal of obstruction
• Placement of shunt
– Ventriculoperitoneal shunt (VP shunt)
– Associated with infection and malfunction
High success rate with surgically treatment
Shunting
Shunting Video
Family Support
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Coping is difficult with patents
Feel guilty, anxious
Uncertain outcome
Continue to educate family
Include family in patient care
Possibility of long term rehabilitation
Nervous System Tumors
• CNS tumors account for 20% of all childhood
cancers
• 3.3 cases per 100,000 occur in kids under 15
years old
• Difficult to treat
• No dramatic advancements or improvements
seen vs other childhood cancers
Brain Tumors
• Most common solid tumors in children
• Infratentorial (60%)
– Primairly in brain stem or cerebellum
– Usually see increased ICP
(medulloblastoma, cerebellar astrocytoma, brainstem glioma)
• Supratentorial
– Mainly cerebrum
(astrocytoma, hypothalamic tumors, optic pathway tumors)
Brain Tumor Diagnostics
• s/s are related to:
– Location
– Size 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
Treatment of Brain Tumors
• Treatment of choice = total removal of tumor
without neurologic damage
– Surgery, radiotherapy, chemotherapy
• Prognosis:
– Depends on size, tumor type, extent of disease
Nursing Management of Brain Tumors
• Establish a baseline assessment
• Vital signs
– Look for sudden variations
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Frequent neurologic assessments
Headache? Vomiting? Seizures?
Child’s behavior
positioning
Postoperatively check muscle strength when
awake
Intracranial Infections
• Nervous system is limited in ways to respond
to an infection
• Inflammatory process in brain affects:
– Meninges (meningitis)
– Brain (encephalitis)
• Meningitis has many origins
Bacterial Meningitis
• Definition: acute inflammation of the
meninges and CSF
• 10-15% of cases are fatal
• Caused by many bacterial agents
– H. Influenzae type b, S. pneumoniae, Neisseria Meningitidis
• Vascular dissemination or direct implantation
• Infective Process
Clinical Manifestations of
Bacterial Meningitis
Children and Adolescents
(Classic picture)
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Abrupt onset, rash
Fever, chills, headache
Alteration in senses
Seizures*
Irritability/agitation
Nuchal rigidity
Positive Kernig &
Brudzinski signs
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Infants and Young Children
Fever
Poor feeding
Vomiting
Irritable
Frequent seizures
Bulging fontanel
Difficult to evaluate in this
age group
Box 28-5, Chapter 28 Wong
Clinical Manifestations of
Bacterial Meningitis
Neonates: 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
• Jaundice
• Irritable
• Drowsiness
• Seizures
• Respiratory irregulations
• cyanosis
Box 28-5, Chapter 28 Wong
Diagnostic and Therapeutic
Management of Bacterial Meningitis
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Lumbar Puncture
Elevated WBC count
Decreased Glucose level
Considered a medical emergency!
Initial management:
– Isolation, iv antibiotics, fluids, monitored,
treatment of complications
Management of Bacterial Meningitis
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Hydration
Quiet, decreased stimulation
Side lying position
Correct electrolyte imbalance
Measure for s/s increased ICP
Monitor for complications
• Prevention:
– Vaccines for children starting at 2 months
Nonbacterial (aseptic) Meningitis
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Caused by many viruses!
Abrupt or gradual onset
Symptoms develop 1-2days after onset
s/s vague
Diagnosis is based on pt assessment and CSF
findings
• Systematic treatment
• Nursing care similar to bacterial meningitis
Encephalitis
• Definition: inflammatory process of the CNS
which is caused by a variety of organisms
– Virus invades CNS or postinfection after a viral
disease
– Cause in typically unknown
Clinical Findings of Encephalitis
• Initial findings are nonspecific
• Evolve to demonstrate neuro s/s
– Seizures, abnormal CSF
– Mild s/s for a few days, rapid recovery, to
fulminating encephalitis with CNS involvement
Onset
Malaise
Fever
Headache/Dizziness
Lethargy
Neck Stiffness
Nausea/Vomiting
Tremors
Speech Difficulties
Altered Mental Status
Severe Cases
High Fever
Stupor
Seizures
Disorientation
Spasticity
Coma
Paralysis
Diagnosis and Management of
Encephalitis
• Based on clinical findings
• CT in late stages
• Some viruses are found in CSF
• Hospitalized for observation with supportive
treatment
• Prognosis depends on age, organism,
neurologic damage
• http://www.youtube.com/watch?v=8tf5VewEf
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