Hockenberry: Wongs Essentials of Pediatric Nursing, 9th Edition

Chapter 28: The Child with Cerebral Dysfunction

Key Point Summaries

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 the 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 the unconscious child focuses on ensuring respiratory management;
performing neurologic assessment; monitoring ICP; supplying adequate nutrition and
hydration; providing drug therapy; 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. Fractures resulting from head injuries may be classified as
depressed, compound, basilar, and diastatic.
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 at
6 months.
Some degree of cerebral edema is expected after craniocerebral trauma and often

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Key Point Summaries 28-2

accompanies any of the previously mentioned disorders. 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.
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.
The young childs response to head injury is different from 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 14 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.
All children who have a submersion injury should be admitted to the hospital for
observation. Although many patients do not appear to have suffered adverse effects from the
event, complications (e.g., respiratory compromise, cerebral edema) may occur 24 hours after
the incident.
The signs and symptoms of brain tumors are directly related to their anatomic location
and size and to some extent the childs age. For instance, in infants whose sutures are still
open, a bulging fontanel indicates hydrocephalus. Head circumference measurements allow
for detection of increased head size. Even in older children, clinical manifestations may be
nonspecific. However, the most common symptoms of infratentorial brain tumors are
headache, especially on awakening, and vomiting that is not related to feeding.
Diagnosis of a brain tumor is based on presenting clinical signs and diagnostic imaging.
Treatment may involve the use of surgery, radiotherapy, and chemotherapy. All three may or
may not be used, depending on the type of tumor.
Neuroblastoma is the most common extracranial solid tumor of childhood and the most
common cancer diagnosed in infancy. The signs and symptoms of neuroblastoma depend on
the location and stage of the disease.
Neuroblastoma is a silent tumor. In more than 70% of cases, diagnosis is made after
metastasis occurs, with the first signs caused by involvement in the nonprimary site, usually
the lymph nodes, bone marrow, skeletal system, skin, or liver. 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, pneumococci, and group B streptococci; (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.
Nursing care of the child with meningitis includes administering antibiotics, taking isolation
precautions, removing environmental stimuli, ensuring correct positioning, monitoring vital

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Key Point Summaries 28-3

signs, administering intravenous (IV) therapy, promoting adequate fluid and nutritional
status, and providing supportive care to the family.
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 IV infusion is
started to facilitate administration of antimicrobial agents, fluids, antiepileptic drugs, and
blood, if needed. The child is placed on a cardiac monitor and in respiratory isolation.
Routine immunization of infants with Haemophilus influenzae type b and pneumococcal
conjugate vaccines has reduced the incidence of bacterial meningitis.
Many different viruses cause aseptic meningitis. The onset may be abrupt or gradual. The
initial manifestations are headache, fever, malaise, and gastrointestinal symptoms. Signs of
meningeal irritation develop 1 or 2 days after the onset of illness. Onset is more insidious in
infants and toddlers. Signs and symptoms are vague and are often thought to be associated
with a minor illness.
Encephalitis is an inflammatory process of the CNS that is caused by a variety of
organisms, including bacteria, spirochetes, fungi, protozoa, helminths, and viruses.
Encephalitis 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.
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 characteristic organ involvement. It is characterized by fever, profoundly impaired
consciousness, and disordered hepatic function.
The most important aspect of successful management of the child with RS is 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.
A seizure is a symptom of an underlying pathologic condition and may be manifested by
sensory-hallucinatory phenomena, motor effects, sensorimotor effects, or loss of
consciousness. 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

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Key Point Summaries 28-4

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. The initial event may provide the best clue for assessing the type of
seizure and its localization. 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. Document neurologic changes. 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, atonic and akinetic,
myoclonic, and infantile spasms. The generalized tonic-clonic seizure, formerly known as
grand mal, is the most dramatic of all seizure manifestations of childhood.
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 goal of treatment of seizure disorders is 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. Long-term care of the child with recurrent seizure disorders
includes physical care and education on the importance of drug therapy and problems related
to emotional aspects of the disorder.
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.
Febrile seizures are the most common type of childhood seizure. Long-term antiepileptic
therapy is usually not required 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 the above.
Migraine headaches occur in children as well as in adults. Typical symptoms include
nausea, vomiting, and abdominal pain, which are relieved by sleep. Toddlers may be seen
with episodic pallor, decreased activity, and vomiting. The onset of a migraine headache in a

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Key Point Summaries 28-5

young child is typically in the afternoon and may be bifrontal, temporal, and bilateral or
unilateral. Children may vomit repetitively during a migraine headache.
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.

All Elsevier items and derived items 2013, 2009, Mosby, Inc., an imprint of Elsevier Inc.