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Increased Intracranial Increased Intracranial Pressure (Pressure (IICP)CP)
What is it? Increased ICP results from a
disturbance in the auto-regulation of the pressure exerted by the blood, brain, cerebrospinal fluid, and other space-occupying fluid/mass within the central nervous system.
Increased ICP is defined as pressure sustained at 20 mm Hg or higher.
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Increased Intracranial Pressure
Overproduction or malabsorption of CSF
Space occupying lesion – tumor, hematoma
Head Trauma Infection
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Clinical Manifestations: Infant
Irritability and restlessness; high-pitched cry
Full to bulging fontanels; Increase in FOC
Poor feeding, poor sucking
Prominence of frontal portion of the skull with
distension of superficial scalp veins
Nuchal rigidity
Nonreactive; unequal pupils
Seizures (late sign)
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Clinical Manifestations: Child
Headache
Visual disturbances - diplopia
Nausea and Vomiting
Dizziness or vertigo
Irritability, lethargy, mood swings
Ataxia, lower extremity spasticity
Nuchal rigidity Deterioration in school performance, or cognitive
ability
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Severe Manifestations of IICP Widened pulse pressure Bradycardia Irregular respirations Abnormal Posturing
Decorticate (rigid flexion-upper arms extension of legs)
Decerebrate (rigid extension- arms with internal rotation of arms and wrists)
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Diagnosis Blood studies
CT or MRI
EEG
Lumbar puncture – may or may not be done
Why?
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What is the purpose of the following?
Medications Corticosteroid (Decadron)
Osmotic diuretic (Mannitol)
Sedation
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Nursing Care
Try to keep coughing, sneezing, vomiting to a minimum
When burping infant do not put pressure on the jugular vein
Monitor IV rate administration Place child in semi-fowlers position Monitor VS, Neuro VS, behavior Assess for increases in ICP Assess I&O, Maintain optimal hydration Decrease stimuli, decrease pain or crying with
activities Organize care, Educate parents
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Ask Yourself
What B/P would indicate a neurological problem?
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Review
What emergency equipment should the nurse have on
hand at all times for a child with IICP?
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Critical Thinking
What would you expect as a first sign of IICP in an infant?
What would you expect as an initial sign of IICP in a 10 year old child?
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What is the difference?
Spina Bifida
Meningocele:
Myelomeningocele:
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What nutritional supplement is encouraged for women during
childbearing age?
Why?
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Clinical Manifestations:
Visualization of the defect
Motor sensory, reflex and sphincter abnormalities
Flaccid paralysis of legs- absent sensation and reflexes, or spasticity
Malformation
Abnormalities in bladder and bowel function
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Diagnostic Tests:
Prenatal detection Ultrasound Alpha-fetoprotein
Following Birth: NB assessment X-ray of spine X-ray of skull
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Prevention of _____ to the sac preoperatively
Prevention of _________.
How are these goals accomplished?
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Nursing Intervention Keep sac moist & sterile Meticulous skin care Protect from feces or urine Maintain NB in prone position with
legs in abduction Keep in isolette
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Post-Op Nursing Interventions
Assess surgical site
Monitor VS and neuro VS
Institute latex precautions
Encourage contact with parents/care
givers
Positioning
Skin Care
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Nursing Interventions cont... Antibiotic therapy
Prevent UTI
Education
Emphasize the normal, positive abilities of the child
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Critical Thinking Would you expect a 5-year-old with
repaired meningomyelocele to have bladder/bowel sphincter control?
Which type of neural tube defect is most likely to have no outward signs or symptoms?
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Etiology and Pathophysiology:
Imbalance between the production and
absorption of cerebral spinal fluid
causing Accumulation of fluid
in the ventricles
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Clinical Manifestations
Infants
1. Increase in FOC
2. Frontal enlargement or bossing
3. Head larger than face
4. Translucent skin
5. Wide palpable suture lines
6. Bulging Fontanels
7. Eyes -wide bridge between
8. Behavior changes
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Clinical Manifestations
Children:
1. Depressed eyes; strabismus
2. “Setting Sun” Eyes
3. Pupils sluggish, with unequal response to
light
4. Headache with nausea and vomiting that
may be projectile
5. S & S of IICP
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Diagnostic Tests
MRI/ CT scan
Skull X-ray
FOC
Transillumination
**lumbar puncture very dangerous and usually NOT done
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Goal of treatment Prevent further CSF accumulation Reduce disability and death
Bypass the blockage and drain the fluid from
the ventricles to an area where it may be reabsorbed into the circulation
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Interventions: Surgical
Ventricular endoscopy or laser Shunting to bypass the point of obstruction
by shunting the fluid to another point of absorption
Atrioventricular
Ventricular peritoneal
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What are the main Complications of Shunts
I____________
B___________
S___________
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Nursing Interventions
Monitor VS and neurological status Assess functioning of the shunt Assess operative site Assess for infection Positioning of the patient Activity of patient Promote nutrition Avoid constipation Education
Wear helmet
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Critical Thinking What is the most important assessment
data on a infant who has just had a shunt placement for hydrocephalus?
What is the most important teaching for the parents or caregivers?
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Cerebral Palsy (CP)What is wrong?
What is it associated with? Preterm Birth asphyxia Low Apgar Poor feeder Weak cry as a newborn Shaken baby syndrome Intrauterine anoxia – placental perfusion decreased
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AssessmentDetermining diagnosis or extent of involvement in
an infant can be difficult –may be recognizable only when child is older and attempts more complex motor skills, such as walking
Jittery (easily startled) Weak cry (difficult to comfort) Experience difficulty with eating (muscle control
of tongue and swallow reflex) Uncoordinated or involuntary movements
(twitching and spasticity) Abnormal newborn reflexes – prolonged
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Assessment Alterations in muscle tone
Abnormal resistance Keeps legs extended or crossed Rigid and unbending
Abnormal posture Do not crawl on knees, scoot on back When try to walk, walk with toes first as
in plantar flexion Scissoring and extension (legs feet in
plantar flexion) Persistent fetal position (>5 months)
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Diagnostic Tests:
EEG, CT, or MRI
Electrolyte levels and metabolic workup
Neurologic examination
Developmental assessment
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Nursing Care Prevent injury and provide safety
Maintain Mobility and Prevent disuse
Maintain nutrition
Maximize Communication ability
Maintain Growth and Development
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Complications
Increased incidence of respiratory infection
Muscle contractures
Skin breakdown
Injury
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Shaken Baby Syndrome
The subdural vessels are torn as the brain moves within the skull, as the brain moves over the skull floor bruising occurs, and the brain stem my become herniated with direct trauma
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Shaken Baby Syndrome
Maintain airway to prevent hypoxia and further brain damage
Nurse must report to child protective service
Nursing care of a child with a brain injury is similar to care of child with IIP
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When is the child most likely to exhibit signs of an subdural hematoma?
What additional organ may have hemorrhages in the child with shaken baby syndrome?
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Seizures What are they?
Brief convulsive behavior caused by abnormal discharge of neurons.
The result of these discharges is involuntary contraction of muscles
When numerous nerve cells fire abnormally at the same time, a seizure may result.
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Clinical Manifestations of General Seizure/ Tonic - Clonic
Onset is abrupt. Usually less than 5 minutes duration
Tonic Phase: - Usually lasts 10-20 seconds
- Child loses consciousness- Jaw clenches shut, abdomen and chest become
rigid and may emit a cry or grunt as air is forced through the taut diaphragm.
- Pale- Eyes roll upward or deviate to one side.- Arms flexed; legs, head, neck extended- increased salivation and loss of swallowing
reflex
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Clinical Manifestations of General Seizure/ Tonic - Clonic
Clonic Phase Violent jerky movements as the trunk and
extremities undergo rhythmic contraction and relaxation
Respirations are irregular and may have stridor May foam at the mouth Incontinent of urine and feces
Afterwards Drowsy and sleep afterwards
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Diagnostic Tests
EEG CT, MRI Lumbar puncture CBC Metabolic screen for glucose, phosphorus
and lead levels
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Goal of Care:Maintain Patent Airway
Ensure SafetyAdminister medications
Emotional support
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What Preventive Measures does the nurse Provide?
Padded side rails, helmets to protect head O2 Setup and Suction equipment at bedside Rectal /tympanic temperatures Interventions during a seizure:
1. Remain Calm2. Clear environment and make safe3. Maintain airway4. Do not attempt to restrain5. Turn to side6. Stay at the bedside and call out/emergency
button for a nurse to assist you immediately
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How does the nurse maintain the airway during a seizure
Roll to the side Loosen clothing around neck Do NOT place anything in the mouth
during a seizure May give oxygen
**Do not put fingers in the patient’s mouth
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What is the priority intervention following a seizure?
Notify primary care provider
Provide emotional support
Reposition, provide for sleep and rest
Reorient to what has happened
Document
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Seizure Medications Phenobarbital
Carbamazephine – (Tegretol)
Phenytoin – (Dilantin)
Diazepam – (Valium) – used mainly for status epilepticus
** Know nursing implications for each
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Meningitis
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Bacterial Meningitis
potentially FatalCaused by:
Streptococcus Neisseria meningitides E coli
What is it? Bacteria enters blood stream, CS fluid, and
brain causing an inflammatory response. Body sends WBC and they accumulate over surface of brain causing purulent exudates
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Viral Meningitis
Same signs and symptoms, may be milder and self-limiting.
Usually lasts a few days
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Assessment
Infants: Fever (not always present) Lethargy Alterations in sleep and feeding habits Fussy and irritable Nuchal rigidity (late sign) Bulging fontanel High pitched cry
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Assessment:
Childhood & Adolescence Hyperthermia S&S of IICP Nausea and vomiting Headache Seizures Photophobia
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Signs of Meningeal Irritation Headache Photophobia Nuchal Rigidy Opisthotonic position
Positive Kernig’s sign
Postive Brudzinski’s sign
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Diagnostic Tests:
Lumbar Puncture
Serum Glucose Level
Blood Cultures
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Therapeutic Interventions Mediation Therapy
AntibioticsAmpicillinClaforan Rocephin
Dexamethasone
Antipyretics
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Nursing Care Place on Respiratory Isolation until on antibiotics
for 24 hours
Assess vital signs and behavior Antibiotic therapy Monitor lab values Strict I&O Monitor FOC Bedrest – do not flex neck Comforting – they are very irritable
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Trisomy 21- the most common chromosomal abnormality resulting in mild
to profound intellectual Disability
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Down syndrome
Clinical Manifestations: Congenital anomalies – cardiac and GI tract Flat facial features, nose broad and flat Low set ears Upward slanting eyes Prominent epicanthial folds Short hands with simian crease Hypotonia Neck short with extra fat pad Usually sterile
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Health Promotion
How does the nurse promote health of the child with Down’s syndrome? Initial assessment of newborn Parental perception (focus on the
positive) Initiate long-term assistance
SpeechOccupationalNutritionalFinancial assistance