Hockenberry: Wongs Nursing Care of Infants and Children, 10th Edition

Chapter 32: The Child with Cerebral Dysfunction

Key Points - Print

Level of consciousness is the most important indicator of neurologic health. Various levels
include full consciousness, confusion, disorientation, lethargy, obtundation, stupor, coma, and
persistent vegetative state.
An altered state of consciousness may be the outcome of several processes that affect the
central nervous system (CNS). Impaired neurologic function can result from a direct or
indirect cause. Some altered states, such as the diffuse changes observed in encephalitis, are
directly related to cerebral insult. Others are the result of dysfunction in other organs or
processes. For example, biochemical changes can impair neurologic function without
morphologic findings, as in hypoglycemia.
Respiratory effectiveness is the primary concern in the care of an unconscious child, and
establishment of an adequate airway is always the first priority. Carbon dioxide has a potent
vasodilating effect and will increase cerebral blood flow and intracranial pressure (ICP).
Cerebral hypoxia at normal body temperature that lasts longer than 4 minutes nearly always
causes irreversible brain damage.
The purpose of the neurologic examination is to establish an accurate, objective baseline of
neurologic information. Complete neurologic examination includes level of consciousness;
posture; motor, sensory, cranial nerve, and reflex testing; and vital signs.
Nursing care of an unconscious child focuses on ensuring respiratory management;
performing neurologic assessment; monitoring ICP; supplying adequate nutrition and
hydration; administering drug therapy as indicated; regulating temperature; promoting
elimination, hygienic care, proper positioning, exercise, and stimulation; and providing
family support.
Head injury is a pathologic process involving the scalp, skull, meninges, or brain as a result
of mechanical force. The most common head injury is concussion, which is defined as an
alteration in mental status with or without loss of consciousness. Fractures resulting from
head injuries may be classified as linear, comminuted, depressed, open, basilar, and growing
fractures.
Epidural (extradural) hematoma is a hemorrhage into the space between the dura and the
skull. As the hematoma enlarges, the dura is stripped from the skull; this accumulation of
blood results in a mass effect on the brain, forcing the underlying brain contents downward
and inward as it expands.
A subdural hemorrhage is bleeding between the dura and the arachnoid membrane, which
overlies the brain and the subarachnoid space. The hemorrhage may be from two sources, (1)
tearing of the veins that bridge the subdural space and (2) hemorrhage from the cortex of the
brain caused by direct brain trauma. Subdural hematomas are much more common than
epidural hematomas and occur most often in infancy, with a peak incidence between 0 to 4
months of age.
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Key Points - Print 32-2

Some degree of cerebral edema is expected after craniocerebral trauma. Cerebral edema
peaks at 24 to 72 hours after injury and may account for changes in a childs neurologic
status. Cerebral edema associated with traumatic brain injury may be a result of two different
mechanisms, cytotoxic edema or vasogenic edema.
Postconcussion syndrome is a sequela to brain injury with or without loss of consciousness.
It is a symptom complex that includes at least three of the following symptoms: headaches,
dizziness, light sensitivity, fatigue, nausea, irritability, restlessness, difficulty concentrating,
and memory impairment. The symptoms develop within days of the injury and resolve within
3 months.
Primary head injury involves features that occur at the time of trauma, including fractured
skull, contusions, intracranial hematoma, and diffuse injury. Secondary complications include
hypoxic brain damage, increased ICP, infection, cerebral edema, and posttraumatic
syndromes. Young childrens response to head injury is different from the response of older
children and adults because of the following features: larger head size; expandable skull;
larger blood volume to the brain; small subdural spaces; and thinner, softer brain tissue.
Submersion injury is a major cause of unintentional injury-related death in children ages 1
to 19 years. The term near-drowning is no longer used; instead, the term submersion injury
should be used up until the time of drowning-related death. Submersion injury can take place
in any body of water, and potential sites of drowning are important to consider for
preventative education.
All children who have a submersion injury should be admitted to the hospital for observation.
Although many patients do not appear to have sustained adverse effects from the event,
complications (e.g., respiratory compromise, cerebral edema) may occur 24 hours after the
incident.
Meningitis can be caused by a variety of organisms, but the three main types are (1) bacterial,
or pyogenic, caused by pus-forming bacteria, especially meningococci and pneumococci; (2)
viral, or aseptic, caused by a wide variety of viral agents; and (3) tuberculous, caused by the
tuberculin bacillus. The majority of children with acute febrile encephalopathy have either
bacterial meningitis or viral meningitis as the underlying cause.
Bacterial meningitis is an acute inflammation of the meninges and cerebrospinal fluid.
Acute bacterial meningitis is a medical emergency that requires early recognition and
immediate therapy to prevent death and avoid residual disabilities. The child is isolated from
other children, usually in an intensive care unit for close observation. An intravenous (IV)
infusion is started to facilitate administration of antimicrobial agents, fluids, antiepileptic
drugs, and blood, if needed. The child is placed in respiratory isolation.
Many different viruses cause aseptic meningitis. The onset may be abrupt or gradual. The
initial manifestations are headache, fever, photophobia, and nuchal rigidity. Diagnosis is
based on clinical features and cerebral spinal fluid findings. Treatment is primarily
symptomatic.
Encephalitis is an inflammatory process of the CNS that is caused by a variety of organisms,
including bacteria, spirochetes, fungi, protozoa, helminths, and viruses. Most infections are

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Key Points - Print 32-3

associated with viruses and may result from direct invasion of the CNS by a virus or from
involvement of the CNS after viral disease.
Patients suspected of having encephalitis are hospitalized promptly for observation, including
ICP monitoring. Treatment is primarily supportive and includes conscientious nursing care,
control of cerebral manifestations, and adequate nutrition and hydration, with observations
and management as for other cerebral disorders.
Reye syndrome (RS) is a disorder defined as a metabolic encephalopathy associated with
other organ involvement. It is characterized by fever, profoundly impaired consciousness,
and disordered hepatic function. The most important aspects of successful management of a
child with RS are early diagnosis and aggressive therapy. Cerebral edema with increased ICP
represents the most immediate threat to life. Recovery from RS is rapid and usually without
sequelae if the diagnosis was made and therapy implemented early.
Epilepsy is a condition characterized by two or more unprovoked seizures and can be caused
by a variety of pathologic processes in the brain. Seizures are a symptom of an underlying
disease process. A single seizure event should not be classified as epilepsy and is generally
not treated with long-term antiepileptic drugs.
Seizures are caused by excessive and disorderly neuronal discharges in the brain. The
manifestation of seizures depends on the region of the brain in which they originate and may
include unconsciousness or altered consciousness; involuntary movements; and changes in
perception, behaviors, sensations, and posture.
Regardless of the etiologic factor or type of seizure, the basic mechanism is the same.
Abnormal electrical discharges (1) may arise from central areas in the brain that affect
consciousness; (2) may be restricted to one area of the cerebral cortex, producing
manifestations characteristic of that particular anatomic focus; or (3) may begin in a localized
area of the cortex and spread to other portions of the brain; if sufficiently extensive, this
produces generalized seizure activity.
Partial seizures are categorized as simple (meaning without associated impairment of
consciousness) or complex (with impaired consciousness); both types may become
generalized. Partial seizures may arise from any area of the cerebral cortex, but the frontal,
temporal, and parietal lobes are most often affected and are characterized by localized motor
symptoms; somatosensory, psychic, or autonomic symptoms; or a combination of these.
Partial seizures exhibit manifestations related to where they occur in the brain. A clear
description of the seizure (ictal state) by an eyewitness is a valuable aid in localizing the
brain area involved. In addition to the initial event, the circumstances that precipitated the
episode are important to note. The postictal state (the period after a seizure) may be varied.
The child may be drowsy, be uncoordinated, have transient aphasia or confusion, and display
some sensory or motor impairment. Weakness, hypotonia, or inactivity of a body part may
indicate an epileptogenic focus in the corresponding contralateral cortical region.
Generalized seizures are categorized as tonic-clonic, absence, myoclonic, and West
syndrome (infantile spasms). Loss of consciousness and impairment of motor function occur
from the outset of generalized seizures.

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Key Points - Print 32-4

The generalized tonic-clonic seizure, formerly known as grand mal, is the most dramatic of
all seizure manifestations of childhood. The seizure usually occurs without warning and
consists of two distinct phases, tonic and clonic.
Absence seizures, formerly called petit mal or lapses, are generalized seizures. They have a
sudden onset and are characterized by a brief loss of consciousness, a blank stare, and
automatisms.
Establishing a diagnosis is critical for establishing a prognosis and planning the proper
treatment. The process of diagnosis in a child suspected of having epilepsy includes (1)
determining whether epilepsy or seizures exist and not an alternative diagnosis and (2)
defining the underlying cause, if possible. The goals of treatment of seizure disorders are to
control the seizures or to reduce their frequency and severity, discover and correct the cause
when possible, and help the child live as normal a life as possible.
Status epilepticus is a continuous seizure that lasts more than 30 minutes or a series of
seizures from which the child does not regain a premorbid level of consciousness. The initial
treatment is directed toward support and maintenance of vital functions including the ABCs
(airway, breathing, and circulation) of life support, administering oxygen, and gaining IV
access followed by administration of antiepileptic agents.
Febrile seizures are the most common type of childhood seizure. Antiepileptic prophylaxis
therapy is not indicated for children with simple febrile seizures.
Headaches are a common complaint of children and are associated with different pathologic
conditions, including extracranial disease, intracranial disease, vascular abnormalities,
psychogenic disorders, or a combination of these.
Migraine headaches occur in children as well as adults. Typical symptoms include nausea,
vomiting, and abdominal pain, which are relieved by sleep. Migraine headaches are managed
with general measures (education, a headache diary to identify and eliminate precipitating
factors, and documented response to treatment), abortive treatment, and prophylactic
treatment. At the onset of the headache, the child should rest or sleep in a quiet, dark room
when feasible. Migraine therapy, if administered early in the course of the headache, may
provide rapid relief. Acetaminophen or ibuprofen is often effective if given early.
Hydrocephalus is a group of conditions resulting from disturbances in the dynamics of
cerebral circulation and cerebrospinal fluid (CSF) caused by either (1) impaired absorption of
CSF fluid (nonobstructive or communicating hydrocephalus) or (2) obstruction to the flow of
CSF through the ventricular system (obstructive or noncommunicating hydrocephalus).
Surgical treatment is the therapy of choice in almost all cases of hydrocephalus; however,
most children require a shunt to promote CSF drainage.

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