Neurologic Differences of Infant and
Child
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INFANT/CHILD
Brain 12% NB body
wt.
Infant: 50 ml CSF
Peripheral nerves not
myelinated.
Primitive reflexes
disappear by 6 mo
age.
ADULT
• Brain 2% body wt.
• 150 ml. CSF
• Myelination fully
developed
– deficit = injury
• Primitive reflexes
may reappear with
neurologic disease.
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Causes Neurological Dysfunction
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Injury: r/t direct brain tissue
Hypoxia
Congenital
Metabolic derangement
Infection
Perfusion problem: stroke
Brain tumor
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Standard Terms for Level of
Consciousness
Full consciousness
Confused
Disoriented
Lethargic
Obtunded
Stupor
Coma
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McKinney et al, 3rd ed. P 1470
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Glasgow Coma Scale
Table 52-1, p. 1469: modified for
children
–Eye Opening
–Verbal Response
–Motor Response
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Causes of Increased ICP
• Swelling of brain tissue
• Increase in amount of CSF
• Increase in amount of blood flow
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Increased Intracranial Pressure- Infant
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Poor feeding
Irritability
Restlessness
Lethargy
Bulging fontanel
Increased head
circumference
• vomiting
• Separation of
cranial sutures
• Distended scalp
veins
• Eyes deviated
downward
• Altered pain
response
• High-pitched cry
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Increased ICP - Child
• Altered level of consciousness
• Mood swings
• Headache (esp. am)
• Diplopia
• Slurred speech
• Nausea and vomiting (esp. am)
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Hydrocephalus
• What is it?
• Treatment: Shunt
–Ventriculoperitoneal (VP)
–Ventriculoatrial
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Postoperative Care
• Lie flat – prevent rapid removal of
CSF
• Don’t lie on suture side
• High Risk for:
–Shunt malfunction (short-term &
long-term) AEB__________.
–Infection (long-term)
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Neural Tube Defects
• Definition
• Spinal bifida occulta
• Spina bifida cystica
–Meningocele
–Myelomeningocele
• Role of Folic Acid as primary prevention
• HP 2020 goal
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Myelomeningocele
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Flaccid paralysis
Sensory loss
Bowel & bladder sphincter
Joint deformities
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Nursing Care: Myelomeningocele
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Check head circumference
Fontanels
Position
Elimination
Infection
– Pre-op: sterile, moist dressing
– Latex precautions
• Impaired mobility
– Hip & foot alignment
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Cerebral Palsy
• Chronic, nonprogressive disorder
of posture & movement
• Manifestations vary
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Causes of CP
• prenatal
• Intra
• postnatal
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Clinical Manifestations CP
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Primitive reflexes
Delayed development
Hypertonia
Contractures
Often intellectually intact
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Nursing Diagnoses: CP
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Impaired physical mobility
Altered growth & development
Risk of injury
Impaired verbal communication
Self-care deficit
Altered nutrition
Caregiver role strain
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Care: cerebral palsy
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Extra calories r/t spasticity
Aspiration precautions
Multidisciplinary team
Prevent developmental delays
Maintain a safe environment
Control spasticity
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Surgical Interventions: CP
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Surgical release tight muscles & tendon
Baclofen Pump
Derotation osteotomy
Rhizotomy: cutting nerves on affected
limbs
• Botulinum Toxin A (Botox injections)
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Intracranial Infections
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Intracranial Infections
• Meningitis: inflammatory process
affecting the meninges
• Encephalitis: affects the brain
• Myelitis: spinal cord
• Causes:
– Bacterial
– Viral (aseptic)
– Tuberculosis
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Bacterial
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Haemophilus influenzae
Streptococcus pneumoniae
Neisseria meningitidis (meningococcal)
Frequent cause: infection starting
elsewhere
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Clinical Manifestations: Meningitis
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Increased ICP
Severe HA
Photophobia
Nuchal rigidity; opisthotonos
(infants)
• LP:
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Bacterial Meningitis: Complications
• Compression of cranial nerves
– Hearing Loss
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Brain abscess
Seizures
Cerebral palsy
Learning disorder
Attention deficit disorder
Paresis (hemi, quad)
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Nursing Care
• Prevention
–Immunization
–Meds for contacts
• Isolation: bacterial
• Supportive
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Supportive Nursing Care
• Hydration
• Prevent injury
–seizure precautions
• Minimize increased ICP**:
–Quiet, dark environment
–Position of comfort
–Head/neck in neutral position
–Steroid possibly
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Supportive Nursing Care (cont)
• Assessment for deteriorating
neuro status
• I&O
• Manage pain, fever
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Reye’s Syndrome
• Def: acute, toxic encephalopathy
w/fatty degeneration of liver
• Viral or toxin exposure
• Avg age: 6-7 yrs
• Association w/ administration of
ASA to children w/viral disease
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Seizure
• A sudden, explosive, disorderly
discharge of cerebral neurons.
• Sudden, transient alteration in brain
function
• Motor, sensory, autonomic, or
psychic clinical manifestations.
• Syndrome
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Patho
• Changes in membrane potential group
of neurons
• Plasma membrane more permeable
(more sensitive to triggers)
• Spread to adjacent neurons
– high level of excitatory
neurotransmitters, or low level of
inhibitory neurotransmitters
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Epilepsy
• a chronic disorder of recurrent
seizures.
• A general term for the primary
condition that causes seizures.
• Primary (AKA Idiopathic)
– Genetic predisposition
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Secondary (acquired) seizures
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Cerebral lesions
Cerebral trauma
Biochemical disorders
Infection
Metabolic defects
• Congenital
malformation
• Perinatal injury
• Vascular diseases
• Drug or alcohol abuse
• Degenerative neuro
condition
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Precipitating Factors
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Hypoglycemia
Fatigue
Stress (emotional or physical)
Febrile illness
Stimulant drugs
Withdrawal from depressant drugs
Certain environmental stimuli
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Classification of Seizures
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Partial or generalized
Partial
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Simple
Complex
Begin locally, can become
generalized
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Generalized Seizures
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Bilaterally symmetric
Loss of/or impaired consciousness
Postictal state
Tonic, clonic, or tonic-clonic
Absence
Infantile spasms
Atonic (drop attack)
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Status Epilepticus
• A 2nd, 3rd (or more) seizure before the
person has regained consciousness
from the proceeding seizure.
Or
• A single seizure lasting > 5min
• Medical emergency
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Negative Outcome of Seizure
• Increased need ATP in brain
• Increased O2 consumption
• Supplies of O2 & glucose
consumed
• Cerebral blood flow increases
• Severe hypoxia & lactic acidosis
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Nursing Interventions r/t ‘Potential
for Injury’
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Maintain airway
Oxygen: “blow-by”
Move objects out of way
Assess duration, where started,
LOC, incontinence
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Classifications of Anticonvulsant
Medications
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Hydantoins
Barbiturates
Succinimides
Oxazolidones
Benzodiazepines
Carbamazepine
Valproate
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Mechanism of Action
1. Suppress sodium influx
2. Suppress calcium influx
3. Increase action of GABA (gamma
aminobutyric acid)
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Medications
For SE: Benzodiazapines
• Diazepam (Valium), .2mg/kg (10 mg) IV q
15 min. up to 40 mg.
– O: 1-5 min IV
– Duration: 15 min-1 hr
– Give w/NS only
• Can also be given rectally, as a gel.
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Lorazepam (Ativan)
• For SE: 0.05-0.1 mg/kg (max 4 mg)
IV
• Onset: 1-5 min
• Duration: 12-24 hr
• 2 mg/min
• Respiratory depression,
hypotension, sedation
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Clonazepam (Klonipin)
• Maintenance – po
• Absence, myoclonic seizures
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Hydantoins
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Phenytoin (Dilantin)
IV at 50 mg/min
O: 1-2 hr D: 12-24
Cardiac dysrhythmias; hypotension
Side effects: confusion, slurred speech,
unsteady gait, rash
• Long-term po: gingival hyperplasia
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Fosphenytoin (Cerebyx)
• Replacing Dilantin IV
• PE (phenytoin equivalents)
• Dilute in D5W or NS to 25 mg
PE/ml
• 150 mg PE/min
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Barbiturates
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Phenobarbital
Can be a drip, IVP, or po
O: 30-60 min. D: 10-16 h
Respiratory depression,
hypotension, synergy w/
benzodiazepines
• Dizziness, lethargy, confusion
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Maintenance Seizure Meds
• carbamazepine (Tegretol)
– Side effects: drowsiness, confusion, HA,
– Complications: blood dyscrasia, aplastic
anemia
• Valproate (Depakene, Depakote)
– Side effects: GI, rash drowsiness, HA,
tremors
– Complications: blood dyscrasias,
hepatic failure / hepatitis, stomatitis 47
Miscellaneous
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Pregnancy category
MgSO4 for eclampsia/preeclampsia
Anticonvulsants for other uses
Surgical management
Drug-drug interaction
Ketogenic diet
Vagal nerve stimulator
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