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The Child With Altered Neurologic Status

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

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The Child With Altered Neurologic Status

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  1. The Child With Altered Neurologic Status Jan Bazner-Chandler CPNP, CNS, MSN, RN

  2. The Brain

  3. Differences in Children

  4. 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

  5. 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.

  6. Neurologic Assessment • Level of consciousness • What stimuli is needed? • What is quality of the response? • What is length of response?

  7. Levels of Consciousness • Confusion • Disorientation to time, place, or person • Delirium • Characterized by confusion, fear, agitation, hyperactivity, or anxiety • Stupor = response to vigorous stimuli only • Coma = severely diminished response

  8. 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.

  9. Pupil Changes Fixed and dilated pupil(s) is neuro emergency

  10. 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.

  11. CT Scan Non-invasive three dimensional look at normal and abnormal structures.

  12. Brain Tumor CT Scan MRI

  13. Brain Scan Injection of tiny amounts of radioactive isotope to measure tissue uptake.

  14. Lumbar Puncture Side lying position for LP

  15. Lumbar Puncture Insertion of spinal needle into subarachnoid space between the lower lumbar vertebrae.

  16. Analysis of CSF

  17. 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

  18. Intracranial Pressure • The head is a closed box • Total volume inside brain V brain + V blood + V CSF + V other = Constant

  19. Volume of Brain • Brain volume can increase with: • Edema • Blood flow • Bleed within the brain • Tumor

  20. Volume of Cerebrospinal Fluid

  21. Vital Sign Changes Increase in Blood Pressure Cushing Triad Altered Respiratory pattern Decrease in Pulse

  22. 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

  23. Assessment • Glasgow coma scale • Pupil size • LOC • Vital signs • Accurate I & O • Minimize metabolic demands • Fever, pain, seizures

  24. Multidisciplinary Interventions • Controlled hyperventilation • Evacuation of hematoma • Correction of CSF increase • Steroids / dexamethasone • Correction of coagulopathies

  25. Alterations in Neurologic Status • Seizures: a paroxysmal , uncontrolled episode of behavior that results from an abnormal electrical discharge from the brain.

  26. Effect on Child • Altered responsiveness • Altered sensation or perception • Altered movements, mobility or muscle tone

  27. 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

  28. Status Epilepticus • Seizures lasting more than 30 minutes • Serial seizures without return to baseline • Medical emergency

  29. 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 re-occur • Treatment: none unless additional seizures

  30. Documentation • When seizures began • Duration • Warning signs • Clinical characteristics • Level of consciousness • Signs and symptoms when seizures stop

  31. 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

  32. Diagnostic Tests • Febrile seizure – clinical diagnosis based on history • Seizures • EEG • LP • Electrolytes • MRI • Medications • Dilantin causes overgrowth of gum tissue

  33. Anencephaly Absence of brain tissue above a rudimentary brain stem and basal ganglia.

  34. Anencephaly Diagnostic Tests • Prenatal ultra-sound • Elevated alpha fetal protein • Multiple anomalies • Incompatible with life • Heart transplant donors

  35. Multidisciplinary Interventions • Supportive care • Genetic and psychological counseling • Organ donation • Grief therapy • Sustained extra uterine life impossible

  36. 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

  37. Focused History • Poor maternal nutrition • Maternal age • Pregnancy history • Birth order • Socioeconomic status

  38. Diagnosis Ultrasound Elevated AFP 95% survival rate

  39. Meningomyelocele / Meningocele Bowden & Greenberg

  40. Myelomeningocele • A protruding saclike structure containing meninges, spinal fluid and neural tissue.

  41. Myelomeningocele

  42. 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

  43. 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

  44. Goals of Surgery • Provide a normal anatomic barrier • Control Infection • Control hydrocephaly

  45. Community Care • Bladder and bowel problems • Latex allergies: due to in and out catheterization • Problems with self-esteem • Orthopedic management • Schooling based on IQ

  46. 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

  47. Hydrocephalus

  48. Head Circumference

  49. Hydrocephalus Bulging anterior fontanelle Eyes deviated downward “Setting” Sun sign Bates: Physical Assessment

  50. Transillumination of Skull Advanced cases of Hydrocephaly produces a glow of light over the entire cranium. Bates: Physical Assessment

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