Causes Hydrocephalus Other manifestations - High pitch cry - irritability tremors - poor sucking Cushing's reflex - late sign

of increased ICP. Cushing's response is a late sign of ICP and consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in the respiratory rate and pattern. Cushing's response is usually apparent just before or when the brainstem herniates. T = increased PR = decreased RR= decreased Bp = systolic bp increased / N Diastolic blood pressure Widened pulse pressure (eg. 140/80 = 60 100/70 = 30 ) Diagnostics 1. Ultrasound 2. CT scan 3. MRI 4. Transillumination - bright light (flash light) against the skull filled with fluid; darkened room 5. Skull X-ray - shows seperated suture line 1. Acetazolamide (Diamox) - promotes excretion of fluid 2. Surgery * VP - shunt (Ventriculo Peritoneal shunt) - threading of polyethylene catheter under the skin from ventricles to peritoneum. Fluid is absorb in the peritoneum with a valve. It should be replaced as child grows old. *Monitoring of input and output after VP shunt to prevent fluid overload thus increasing ICP * high pitch cry is a sign of shunt complication/malfunction which indicate increased ICP * increased in head circumference indicate VP shunt malfunction *A fever may be an indication of an infection of the shunt, which is the primary concern in the postoperative period related to a shunt insertion. *Atrioventricular shunt - ventricles to the right atrium of the heart.

Post operative care 1. Position: Supine with head turned to unoperative side (to prevent obstruction to the flow of CSF) After 48 hours slight head elevation (30 degrees) - to prevent rapid decompression cause by CSF flow w/c can lead to possible tearing of cerebral arteries. 2. Assess for sign of VP malfunction 3. Assess signs and symptoms of hydrocephalus 4. Assess for signs of meningitis B- rudzinki sign O-pisthotonus K- ernig's sign N- uchal rigidity CSF cloudy decreased CHO, protein, increased wbc 5. Assess for sign of increased ICP Increased Intracranial pressure (ICP) Birth Trauma (0-15 mmhg - normal ICP) Head trauma Infection Brain Tumor Guillain Barre Syndrome - ascending paralysis Management: 1. Avoid coughing sneezing and vomitting 2. When bubling an infant do not pressure on the jugular vein 3.Monitor Intravenous fluid - Overhydration increases ICP 4. Semi- fowlers position (30 degrees) 5. Dexamethasone (Decadron) - for cerebral edema 6. Mannitol - shifting of fluid from interstitial to intravenous 7. Ventricular tap maybe necessary 8. Measuring head circumference for signs of hydrocephalus Monroe Kellis Hypothesis Increased in 3 brain compartment = increased ICP 1. Brain mass (semi-solid) 2. Blood 3. CSF

B. Anencephaly - absence of cerebral hemisphere - survive for only days due to no cerebral function C. Microcephaly * Brain gowth is slow * Maybe caused by infection ( rubella, Cytomegalo virus or toxoplasmosis ) * Malnutrition or Anoxia in an early infancy normal life depends on the extent of restriction of brain growth * Cognitively challenged (MR) D. Craniosynostosis * normal brain growth but with premature fusion of sutures * decreased head circumference - increased ICP Tx ; surgery brain growth normal Seizure - involuntary contraction of muscle caused by electrical discharge Epilepsy *Chronic seizure now known as Recurrent Seizure Causes * Idiopathic * Infection * Trauma * Tumor growth Categories 1. Partial Seizure - one area of the brain is involved 2. Generalized seizure - involves the entire brain with loss of conciousness Febrile Seizure - associated with high fever (38.9 - 40) Common among: * Preschool * Age 5 mos - 5y/o * As late as 7 years old or as early as 3 mos 9 and above - not common; with organic cause

* show tonic - clonic which last for 15-20 seconds with normal EEG training * During seizure decreased blood flow in the brain = Oxygen administration (Independent Nursing Action) Management 1. After seizure, sponge child with tepid water to decreased fever 2.Do not put the child into the bath tub 3. No cold water or alcohol 4. After seizure no oral medication - because child is drowsy to prevent aspiration 5. If sponging is not successful put wash cloth on child's fore head, axillary and groin areas 6. Bring the child to the hospital with light clothes 7.Suctioning may be required during a seizure to remove secretions that obstruct the airway. 8. Padded crib sides will protect the child from injury during seizure activity. 9. Do not restraint during seizure * Do not use ice - because extreme cooling may lead to shock * Do not use alcohol - because alcohol can be absorb in the skin *Seizure disorder - abrupt cessation of medication can cause status epilepticus Prevention 1. Give acetaminophen 2. Bring to the hospital if with fever for proper diagnosis Reye's Syndrome (brain, liver involved) - multisystem injury due to viral infection with administration of Aspirin during viral illness most commonly varicella and influenza Fatty degeneration in the liver Ammonia is not converted to urea Hypoalbuminemia (protein maintains osmotic pressure) Hyperammonemia Progressive Edema Crosses blood brain barrier

Encephalopathy Seizure Coma

Manifestation : Categorized by stages to determine the progression of disease Stage I *sudden onset of persistent vomiting * fatigue * weakness * listlessness (restlessness) Stage II * confusion * disorientation * change in personality behavior Stage III * decorticate * Coma * Seizure Stage IV * decerebrate - abnormal extension of the upper extremities with internal rotation of the upper arm and wrist and extension of the lower extremities with some internal rotation. * deep coma * fixed pupil Stage V * loss of reflexes * respiratory arrest * death Stage I - II * responds to stimuli * lethargy delirium or possible combativeness

Stage III - IV * unresponsive with deepening coma Diagnostic Test: a. Elevated liver enzyme - ALT (SGPT) - AST (SGOT) b. Elevated serum ammonia c. Decreased blood glucose (D5050) - Normal glucose level 50 to 60/80 mg/dL for infants, 60 to100 mg/dL for a child, and 70 to 105 mg/dL for an adolescent. d. Increased BUN e. Increased serum amylase f. Increased wbc Management 1. Head Elevation ( 30 degrees ) 2. Hydration 3. Prevent increased ICP - p 4. Prevent seizure 5. No aspirin, No acetaminophen (hepatotoxic) 6.Cerebral edema is a progressive part of the disease process of Reye's syndrome. A major component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue as well as neuron responses. Lead Poisoning Lead interfere with rbc by blocking the incorporation of Fe in the hgb Lead Encephalitis (most serious complication, lead can cross brain blood barrier) Hypochromic, microcytic Kidney Destruction Lethargy 2 successive blood cell level > 10mcg/dl blood lead level

anemia Impulsiveness difficulties

(dec. blood flow to the kidney) Learning Glucosuria (maybe + in pregnant) Proteinuria ( possible edema) Phosphates

* Without iron low O2 carrying capacity * Block by lead * hypochromic - low hemoglobin content * microcytic - size of rbc is little Sources A. Paint chips B. Paint dust C. Home glazed pottery D. Fumes from burning battery Diagnostic Test 1. Free Erythrocyte Protoporphysin Test - linked with iron to form hemoglobin - finger stick test increased 2. X- ray of the abdomen - reveal paint chips Management * Check the child's skin and eyes everyday of yellow discoloration can indicate presence of liver complication * If vomiting occurs in Reye's syndrome -may indicates cerebral edema and it is a sign of increased ICP * Decreasing environmental stimuli provide rest and decrease stress on the brain *Observe for signs of increased ICP 1. Monitor blood lead level 1. 10 - 15 mcg/dl - rescreen to confirm the level

2. > 15 mcg/dl - remove the child from lead environment 3. > 20 mcg/dl - oral chelating agents (succimer) 4. > 45 mcg/dl - chelating agents ( Dimercaprol/ BAL and Edetate Calcium Disodium) *Chelation - remove the lead from soft tissue, bones and eliminated in the urine * Succimer Oral * Calcium EDTA (Edetate Calcium Disodium) *Dimercaprol * Calcium EDTA - IM to large muscle painful combine with 0.5 ml procaine calicum is also removed : Monitor BUN (Blood Urea Nitrogen) - Ca EDTA is neurotoxic Monitor for serum calcium Monitor Intake and output Dimercaprol (BAL) - remove lead from rbc - can cause severe toxicity, use only for severe cases Penicillamine ( Cuprimine ) - given orally after BAL or EDTA - monitor blood count. renal and liver function test (nephrotoxicity- BUN, hepatotoxicity - ALT, AST) - 3-6 months Mental Retardation - an intelligence of < 70 (IQ) with an onset before 8y/o Normal IQ ??? Classifications 1. Mild MR IQ : 50-70 ; Mental age 7-12 y/o Educable and can go to school Can learn social and commuincation skills up to grade 6 As adults; can achieve social and vocational skills e.g. weaving Can live independently but needs guidance when under stress 2. Moderate MR IQ 35 - 55 ; Mental age 2-7 y/o Trainable can learn to talk and communication Can learn academic skills up to grade 2

Needs supervision Can travel alone to familiar places 3. Severe MR IQ: 20 - 40 With minimal speech and little or no communicative sppech With poor motor development During school years can be learned to talk and be trained in basic hygiene and dressing skill and constant supervision for safety 4. Profound MR IQ < 20 thinks like an infant Can't be trained Preschool period : shows minimal capacity for sensorimotor functioning Needs highly structured environment Supervision: safety Causes 1. Genetic (Down's Syndrome) 2. Endocrine Imbalance (PKU) phenylketonuria 3. Trauma 4. Anoxia 5. Infections 6. Malnutrition Nursing Intervention Obtain history of home routine especially for profound Plan nursing Intervention based on child's level of development Assist parents in helping the child Learn new activities : Relaxation Repetition Reinforcement Provide safety Cerebral Palsy * Non progressive, non communicable brain injury due to cerebral anoxia which affects the motor and speech center * Idiopathic but sometimes associated with cerebral anoxia - affecting motor and speech center * a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system.

Causes A. Asphyxia during labor and delivery * most common cause related with medical malpractice * leaving the child in birth canal for too long * failure to recognize and treat symptoms following delivery * Cord coil / cord prolapse * failure to perform a cesarean section in presence of fetal distress * not responding to the change in Fetal heart tone B. Insufficient O2 reaching the fetus * impaired placental function * early placental separation ; abruptio placenta C. Infections during pregnancy : * Rubella ( german measles ) * CMV ( Cytomegalo virus ) * Herpes * Toxoplasmosis D. Severe Jaundice * Increased bilirubin in the blood Increased bilirubin Crosses BBB Coat Brain Kernicterus - low blood flow in the brain causing brain damage leading to cerebral palsy E. Blood Clotting Disorder * Cerebral Hemorrhage 1. Spastic - most common type - damage in the cortical motor area (pyramidal tract) - fine versatile movement Abnormal strong clonus of some muscle groups d/t tight muscle in the hips and legs Scissoring

* increase muscle tone and stretch reflexes * toe walking is common * muscle stiffness and jerky movements * difficulty in walking * legs turn inward and cross at knees * increased spasm when touched 2. Athetoid / Dsykinetic - damage in the (extrapyramidal tract)- gross skeletal muscle movement and basal ganglia Involuntary uncoordinated, uncontrollable movement of muscle group * with tremors and lack of active movement(athetoid type) * Entire body is affected * Fluctuations in muscle tone (too tight or too lose) * Difficulty in learning to control their bodies well enough to sit / walk * Muscle of face and tongue can be affected ( sucking, swallowing and speech defecit ) * Worm like movement 3. Ataxic * cerebellar involvement (balance disturbance and coordination) * Unsteady gait : feet apart * difficulty in motion that require precise coordination * low muscle tone * shakiness when trying to handle/ hold small objects 4. Mixed Type * combination of spastic and athetoid or others * damage to the extrapyramidal and pyramidal areas of the brain * tight muscle tone and involuntary movement Clinical Manifestations * Depends o the area of the brain damage A. Child > 2 mos old who : *has difficulty controlling her head when picked up ( head lag diminished at 2 mos) * had stiff legs that cross or scissor when picked up B. Child > 6 mos old who reaches only one hand while keeping the other on the

fist Normal * @ 6mos holds the feeding bottle independently * @ 7 mos thumb index finger grasp C. Child > 10 mos old who crawls by pushing off with one hand and leg while dragging the opposite hand and leg Normal * @ 9 mos creep and crawl * @ 10 mos putting self to stand * @ 11 mos stand with support D. Child > 12 mos old who *cannot crawl @ 9 mos creep and crawl * cannot stand without support @ 12 mos walk with support @ 15 mos walk without support Other Manifestations : * Delay motor development * Muscle weakness * Ataxia * Rigidity Spasm Tremor * paralysis * seizure Diagnostic Test 1. Persistence of primitive reflexes * moro reflex, sucking, rooting * normal in younger infants * dissapear by 6-12 mos 2. Developmental Delay 3. CT scan/ MRI/ Blood testing * identify the cause of CP by ruling out the (+) toxins infectious process Medical Management

Drugs * To ease spasticity or to reduced abnormal movement * route??? IM * Botulinum toxin (Botox) - directly to spastic muscle - last for several months Baclofen * moderate to severe spasticity * implanted under the skin to deliver antispasmodic effect Dantrolene (Dantrium) Diazepam (Valium) Dilantin * To prevent convulsion * S/E G - um swelling, hyperplasial bleeding H - airy tongue A - taxia N - sytagmus GI upset Vitamin D deficiency The adolescent is advised to contact the physician if oily skin or acne becomes problematic. Birth control pills may be less effective when the client is taking antiepileptic medication. B. Surgery Selective Dorsal Rhizotomy * Identification and cutting of the nerve fibers at the base of the spine that contributes to spasticity * Permanently reduces spasticity which improves ability to sit, stand and walk * Recommended for children with severe spasticity who have not well responded to treatment Nursing Management Nsg dx. Imbalance nutrition less than body requirements r/t to impaired oral motor control * Provide safe environment

* Encourage and assist development of motor skills * Encourage and assist development of skills for self care and self feeding * Maximize the assets * Prevent aspiration * feed upright * provide bite size food * place the food at the back of the tongue * Re-educate the muscle * provide finger foods * practice lifting an empty cup * nose finger pointing coordination * toys appropriate for developmental level and age Criteria for toy selection * compatibility * Usability * Safety Physical Therapy * Improves motor skills (sitting/walking) * Improves muscle strenght * Prevent contractures (common complication) * Speech therapy - improves speech