Increased Intracranial Pressure

The brain, tightly enclosed in the solid bony cranium, is well protected but highly vulnerable to pressure that may accumulate within the enclosure (Fig. 28-1). The cranium’s total volume—brain (80%), cerebrospinal fluid (CSF) (10%), and blood (10%)—must remain approximately the same at all times. A change in the proportional volume of one of these components (e.g., increase or decrease in intracranial blood) must be accompanied by a compensatory change in another. In this way, the volume and pressure normally remain constant. Examples of compensatory changes are reduction in blood volume, decrease in CSF production, increase in CSF absorption, or shrinkage of brain mass by displacement of intracellular and extracellular fluid. Children with open fontanels compensate by skull expansion and widened sutures. However, at any age, the capacity for spatial compensation is limited. An increase in ICP may be caused by tumors or other space-occupying lesions, accumulation of fluid within the ventricular system, bleeding, or edema of cerebral tissues. When compensation is exhausted, any further increase in the cranium’s volume will result in a rapid rise in ICP.

Animation—Brain Anatomy; Brain Lobes

Early signs and symptoms of increased ICP are often subtle and assume many patterns (Box 28-1). As pressure increases, signs and symptoms become more pronounced, and the level of consciousness (LOC) deteriorates.

Altered States of Consciousness

Consciousness implies awareness—the ability to respond to sensory stimuli and have subjective experiences. There are two components of consciousness: alertness, an arousal-waking state, including the ability to respond to stimuli, and cognitive power, including the ability to process stimuli and produce verbal and motor responses.

An altered state of consciousness usually refers to varying states of unconsciousness that may be momentary or may extend for hours, for days, or indefinitely. Unconsciousness is depressed cerebral function—the inability to respond to sensory stimuli and have subjective experiences. Coma is defined as a state of unconsciousness from which the patient cannot be aroused even with powerful stimuli.

Coma Assessment

Several scales have been devised in an attempt to standardize the description and interpretation of the degree of depressed consciousness. The most popular of these is the Glasgow Coma Scale (GCS), which consists of a three-part assessment: eye opening, verbal response, and motor response (Fig. 28-2). Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient’s LOC. A person with an unaltered LOC would score the highest, 15; a score of 8 or below is generally accepted as a definition of coma; and the lowest score, 3, indicates deep coma. A decrease in the GCS score indicates a deterioration of the patient’s condition. In 1987, major medical and legal societies developed specific guidelines for the determination of brain death among children of all ages (Mathur, Peterson, Stadtier, and others, 2008).

General Aspects

Children younger than 2 years of age require special evaluation because they are unable to respond to directions designed to elicit specific neurologic responses. Early neurologic responses in infants are primarily reflexive; these responses are gradually replaced by meaningful movement in the characteristic cephalocaudal direction of development. This evidence of progressive maturation reflects more extensive myelinization and changes in neurochemical and electrophysiologic properties.

Most information about infants and small children is gained by observing their spontaneous and elicited reflex responses as they develop increasingly complex motor skills and by eliciting progressively sophisticated communicative and adaptive behaviors. Delay or deviation from expected milestones helps identify high-risk children. Persistence or reappearance of reflexes that normally disappear indicates a pathologic condition. In evaluating an infant or young child, it is also important to obtain the pregnancy and delivery history to determine the possible impact of intrauterine environmental influences known to affect the orderly maturation of the central nervous system (CNS). These influences include maternal infections, cigarette or alcohol consumption, drug use, toxin exposure, trauma, and metabolic insults.

General aspects of assessment that provide clues to the etiology of dysfunction include:

Neurologic Examination

The purpose of the neurologic examination is to establish an accurate, objective baseline of neurologic information. It is essential that the neurologic examination be documented in a fashion that can be reproduced by others. This allows for a comparison of the findings so the observer can detect subtle changes in the neurologic status that might not otherwise be evident. Descriptions of behaviors should be simple, objective, and easily interpreted: “Drowsy but awake and conversationally rational/oriented”; “Sleepy but arousable with vigorous physical stimuli. Pressure to nail base of right hand results in upper extremity flexion/lower extremity extension.”

Animation—Cervical Nerve Examination

Eyes

Pupil size and reactivity are assessed (Fig. 28-3; see also Fig. 28-2). Pinpoint pupils are commonly observed in poisoning, such as opiate or barbiturate poisoning, and in brainstem dysfunction. Widely dilated and reactive pupils are often seen after seizures and may involve only one side. Dilated pupils may also be caused by eye trauma. Widely dilated and fixed pupils suggest paralysis of cranial nerve III secondary to pressure from herniation of the brain through the tentorium. A unilateral fixed pupil usually suggests a lesion on the same side. If pupils are fixed bilaterally for more than 5 minutes, brainstem damage is usually implied. Dilated and nonreactive pupils are also seen in hypothermia, anoxia, ischemia, poisoning with atropine-like substances, or prior instillation of mydriatic drugs.

 Nursing Alert

The sudden appearance of a fixed and dilated pupil(s) is a neurologic emergency.

The description of eye movements should indicate whether one or both eyes are involved and how the reaction was elicited. The parents should be asked about preexisting strabismus, which will cause the eyes to appear normal under compromise. Posttraumatic strabismus indicates cranial nerve VI damage.

Special tests, usually performed by qualified persons, include:

Doll’s head maneuver—Elicited by rotating the child’s head quickly to one side and then to the other. Conjugate (paired or working together) movement of the eyes in the direction opposite to the head rotation is normal. Absence of this response suggests dysfunction of the brainstem or oculomotor nerve (cranial nerve III).

 Nursing Alert

Any tests that require head movement are not attempted until after cervical spine injury has been ruled out.

Caloric test, or oculovestibular response—Elicited with the child’s head up (head of bed is elevated 30 degrees) by irrigating the external auditory canal with 10 ml of ice water for 20 seconds, which normally causes conjugate movement of the eyes toward the side of stimulation. This movement is lost when the pontine centers are impaired, thus providing important information in assessment of the comatose patient.

 Nursing Alert

The caloric test is painful and is never performed on a child who is awake or on an individual with a ruptured tympanic membrane.

Funduscopic examination—Reveals additional clues. Papilledema will not be evident early in the course of unconsciousness because it takes 24 to 48 hours to develop, if it develops at all. Papilledema is characterized by optic disc swelling, indistinct optic disc margins, hemorrhage, tortuosity of vessels, and absence of venous pulsations. The presence of preretinal (subhyaloid) hemorrhages in children is almost invariably a result of acute trauma with intracranial bleeding, usually subarachnoid or subdural hemorrhage.

Posturing

Primitive postural reflexes emerge as cortical control over motor function is lost in brain dysfunction. These reflexes are evident in posturing and motor movements directly related to the area of the brain involved. Posturing reflects a balance between the lower exciting and the higher inhibiting influences and strong muscles overcoming weaker ones. Decorticate or flexion posturing (Fig. 28-4, A) is seen with severe dysfunction of the cerebral cortex or with lesions to corticospinal tracts above the brainstem. Typical posturing includes rigid flexion with the arms held tightly to the body; flexed elbows, wrists, and fingers; plantar flexed feet; legs extended and internally rotated; and possibly the presence of fine tremors or intense stiffness. Decerebrate posture or extension posturing (see Fig. 28-4, B) is a sign of dysfunction at the level of the midbrain or lesions to the brainstem. It is characterized by rigid extension and pronation of the arms and legs, flexed wrists and fingers, a clenched jaw, an extended neck, and possibly an arched back. Unilateral decerebrate posture is often caused by tentorial herniation.

Posturing may not be evident when the child is quiet but can usually be elicited by applying painful stimuli, such as a blunt object pressed on the base of the nail. Nurses should avoid applying thumb pressure to the supraorbital region of the frontal bone (risk of orbital damage). Noxious stimuli (e.g., suctioning) will elicit a response, as may turning or touching. When the nurse is describing posturing, the stimulus needed to provoke the response is as important as the reaction.

Special Diagnostic Procedures

Numerous diagnostic procedures are used for the assessment of cerebral function. Laboratory tests that may help delineate the cause of unconsciousness include blood glucose, urea nitrogen, and electrolyte (pH, sodium, potassium, chloride, calcium, and bicarbonate) tests; blood ammonia levels; clotting studies, hematocrit, and a complete blood count; liver function tests; blood cultures if there is fever; and urine toxicology screen and blood lead levels if clinically indicated.

An electroencephalogram (EEG) may provide important information. For example, generalized random, slow activity suggests suppressed cortical function, and localized slow activity suggests a space-occupying issue such as a hematoma, tumor, or infectious process. A flat tracing is one of the criteria used as evidence of brain death.

Examination of spinal fluid is performed when toxic encephalopathy or infection is suspected. Lumbar puncture is ordinarily delayed if intracranial hemorrhage is suspected and is contraindicated in the presence of ICP because of the potential for tentorial herniation.

Auditory and visual evoked potentials are sometimes used in neurologic evaluation of infants and very young children. Visual evoked potentials are useful in evaluating visual abnormalities from the retina to the visual cortex, and brainstem auditory evoked potentials are useful for assessing hearing acuity and brainstem function. Both are particularly useful for detecting demyelinating disease and neoplasms.

Highly sophisticated tests are carried out with specialized equipment. Two imaging techniques, computed tomography (CT) and magnetic resonance imaging (MRI), assist in diagnosis by scanning both soft tissues and solid matter. Most of these tests are outlined in Table 28-1. Because such tests can be threatening to children, the nurse needs to prepare patients for the tests and provide support and reassurance during the tests (see Preparation for Diagnostic and Therapeutic Procedures, Chapter 22). Children who are old enough to understand require careful explanation of the procedure, reason for the procedure, what they will experience, and how they can help. School-age children usually appreciate a more detailed description of why contrast material is injected. The importance of lying still for tests needs to be stressed. Children unfamiliar with the machines can be shown a picture beforehand.

TABLE 28-1

NEUROLOGIC DIAGNOSTIC PROCEDURES

TEST	DESCRIPTION	PURPOSE	COMMENTS
LP	Spinal needle is inserted between L3–L4 or L4–L5 vertebral spaces into subarachnoid space; CSF pressure is measured, and sample is collected.	Diagnostic—Measures spinal fluid pressure, obtains CSF for laboratory analysis Therapeutic—Injection of medication	Contraindicated in patients with increased ICP or infected skin over puncture site.
Subdural tap	Needle is inserted into anterior fontanel or coronal suture (midline to pupil).	Helps rule out subdural effusions Removes CSF to relieve pressure	Place infant in semi-erect position after subdural tap to minimize leakage from site; prevent child from crying if possible. Check site frequently for evidence of leakage.
Ventricular puncture	Needle is inserted into lateral ventricle via coronal suture (midline to pupil).	Removes CSF to relieve pressure	Risk of intracerebral or ventricular hemorrhage.
EEG	EEG records changes in electrical potential of brain. Electrodes are placed at various points to assess electrical function in a particular area. Impulses are recorded by electromagnetic pen or digitally.	Detects spikes, or bursts of electrical activity that indicate the potential for seizures Used to determine brain death	Patient should remain quiet during procedure; may require sedation. Minimize external stimuli during procedure.
Nuclear brain scan	Radioisotope is injected intravenously and then counted and recorded after fixed time intervals. Radioisotope accumulates in areas where blood–brain barrier is defective.	Identifies focal brain lesions (e.g., tumors, abscesses) Positive uptake of material with encephalitis and subdural hematoma Visualizes CSF pathways	Requires IV access; patient may require sedation. In normal children or noncommunicating hydrocephalus, no retrograde filling of ventricles occurs. Areas of concentrated uptake of material are termed hot spots.
Endocephalography	Pulses of ultrasonic waves are beamed through head; echoes from reflecting surfaces are recorded graphically.	Identifies shifts in midline structures from their normal positions as a result of intracranial lesions May show ventricular dilation	Simple, safe, rapid procedure. Fontanel must be patent.
RTUS	Similar to CT but uses ultrasound instead of ionizing radiation.	Allows high-resolution anatomic visualization in variety of imaging planes	Produces images similar to CT scan. Especially useful in neonatal CNS problems. Anterior fontanel must be patent.
Radiography	Skull films are taken from different views—lateral, posterolateral, axial (submentoventricular), half-axial.	Shows fractures, dislocations, spreading suture lines, craniosynostosis Shows degenerative changes, bone erosion, calcifications	Simple, noninvasive procedure.
CT scan	Pinpoint x-ray beam is directed on horizontal or vertical plane to provide series of images that are fed into computer and assembled in image displayed on video screen. CT uses ionizing radiation.	Visualizes horizontal and vertical cross section of brain in three planes (axial, coronal, sagittal) Distinguishes density of various intracranial tissues and structures—congenital abnormalities, hemorrhage, tumors, demyelinating and inflammatory processes, calcification	Requires IV access if contrast agent is used. Patient may require sedation. Rapid.
MRI	MRI produces radiofrequency emissions from elements (e.g., hydrogen, phosphorus), which are converted to visual images by computer.	Permits visualization of morphologic feature of target structures Permits tissue discrimination unavailable with many techniques	MRI is noninvasive procedure except when IV contrast agent is used. No exposure to radiation occurs. Patient may require sedation. Parent or attendant can remain in room with child. MRI does not visualize bone detail or calcifications. No metal can be present in scanner.
PET	PET involves IV injection of positron-emitting radionucleotide; local concentrations are detected and transformed into visual display by computer.	Detects and measures blood volume and flow in brain, metabolic activity, and biochemical changes within tissue	Requires lengthy period of immobility. Minimum exposure to radiation occurs. Patient may require sedation.
DSA	Contrast dye is injected intravenously; computer “subtracts” all tissues without contrast medium, leaving clear image of contrast medium in vessels studied.	Visualizes vasculature of target tissue Visualizes finite vascular abnormalities	Safe alternative to angiography. Patient must remain still during procedure; may require sedation.
SPECT	Involves IV injection of photon-emitting radionuclide; radionuclides are absorbed by healthy tissue at different rate than by diseased or necrotic tissue; data are transferred to computer that converts image to film.	Provides information regarding blood flow to tissues; analyzing blood flow to organ may help determine how well it is functioning	Requires lengthy period of immobility. Minimum exposure to radiation occurs. Patient may require sedation.

Animation—Blood Flow to the Brain

CNS, Central nervous system; CSF, cerebrospinal fluid; CT, computed tomography; DSA, digital subtraction angiography; EEG, electroencephalography; ICP, intracranial pressure; IV, intravenous; LP, lumbar puncture; MRI, magnetic resonance imaging; PET, positron emission tomography; RTUS, real-time ultrasonography; SPECT, single-photon emission computed tomography.

Although radiographic examinations are not painful, the machinery is often so frightening in appearance that the child protests because of anxiety. This is especially true of CT and MRI, both of which require that the child’s head be placed within a special immobilizing device. Chin and cheek pads are sometimes used to prevent the slightest head movement, and straps are applied to the body to prevent a slight change in body position. The nurse can explain these events to a frightened child by comparing them to an astronaut’s preparation for a space flight. It is important to emphasize to the child that at no time is the procedure painful.

The nurse should not expect cooperation from a young child. Sedation may be required. Many different agents are currently used for sedation of children undergoing neurologic diagnostic procedures. Chloral hydrate, pentobarbital, or benzodiazepines have been used for decades as short-term sedative agents and remain safe methods of pediatric outpatient sedation (Mason, 2008). Chloral hydrate and pentobarbital have no analgesic proprieties but can provide successful sedation for nonpainful procedures such as CT and MRI (Mason, 2008). In recent years, propofol has been used as a sedation agent for diagnostic procedures because of its short induction and recovery time, but this medication should be used with caution because it can cause respiratory depression and apnea with little warning (Machata, Willschke, Kabon, and others, 2008; Mason, 2008). (See Pain Management, Chapter 7.)

Physical preparation for the diagnostic test may involve administration of a sedative. If so, children should be helped through the preparation and administration and assured that someone will remain with them (if possible). Children need continual support and reinforcement during procedures in which they remain conscious. Vital signs and physiologic responses to the procedure are monitored throughout. Many diagnostic procedures performed on an outpatient basis require sedation, and children need recovery time and observation. The nurse should review written instructions with parents if the child is discharged after a procedure. Children who have undergone a procedure with a general anesthetic require postanesthesia care, including positioning, to prevent aspiration of secretions and frequent assessment of the vital signs and LOC. In addition, other neurologic functions such as pupillary responses, motor strength, and movement are tested at regular intervals. Any surgical wound resulting from the test is checked for bleeding, CSF leakage, and other complications. Children who undergo repeated subdural taps should have their hematocrit monitored to detect excessive blood loss from the procedure.

Respiratory Management

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 (CBF) and ICP. Cerebral hypoxia that lasts longer than 4 minutes nearly always causes irreversible brain damage.

Children in lighter states of coma may be able to cough and swallow, but those in deeper states are unable to handle secretions, which tend to pool in the throat and pharynx. Dysfunction of cranial nerves IX and X places the child at risk for aspiration and cardiac arrest; therefore, the child is positioned to prevent aspiration of secretions, and the stomach is emptied to reduce the likelihood of vomiting. In infants, blockage of air passages from secretions can happen in seconds. In addition, upper airway obstruction from laryngospasm is a frequent complication in comatose children.

An oral airway can be used for children who have a temporary loss of consciousness, such as after a contusion, seizure, or anesthesia. For children who remain unconscious for a longer time, a nasotracheal or orotracheal tube is inserted to maintain the open airway and facilitate removal of secretions. Endotracheal intubation should be considered in children with a GCS score of less than 8, evidence of herniation, apnea, or inability to maintain an airway (Sankhyan, Raju, Sharma, and other, 2010). A tracheostomy is performed in cases in which laryngoscopy for introduction of an endotracheal tube would be difficult or for a child who needs long-term ventilatory support. Suctioning is used only as needed to clear the airway, exerting care to prevent increasing ICP. Respiratory status is observed and evaluated regularly. Signs of respiratory distress may be an indication for ventilatory assistance.

When the respiratory center is involved, mechanical ventilation is usually indicated (see Chapter 22). Blood gas analysis is performed regularly, and oxygen is administered as indicated. Moderately severe hypoxia and respiratory acidosis are often present but not always evident from clinical manifestations. Hyperventilation frequently accompanies unconsciousness and may lead to respiratory alkalosis, or it may represent the body’s attempt to compensate for metabolic acidosis. Therefore, blood gas and pH determinations are essential guides for therapy. Chest physiotherapy is carried out on a regular basis, and the child’s position is changed at least every 2 hours to prevent pulmonary complications.

Intracranial Pressure Monitoring

An acute rise in ICP can cause secondary brain injury (Singhi and Tiwari, 2009), and management of the child with increased ICP is a complex and important task. ICP monitoring is used to guide therapy to reduce ICP and provides information on intracranial compliance, cerebrovascular status, and cerebral perfusion (Sankhyan, Raju, Sharma, and other, 2010). Nonetheless, ICP monitoring is an invasive procedure that has associated risks, including infection, hemorrhage, malfunction, and obstruction (Singhi and Tiwari, 2009). Indications for inserting an ICP monitor are as follows:

Animation—Cerebral Perfusion

Four major types of ICP monitors are

Direct ventricular pressure measurement with an intraventricular catheter remains the gold standard of ICP monitoring (Singhi and Tiwari, 2009). Subarachnoid and epidural monitoring can be used when a catheter cannot be cannulated in the ventricle, but they often must be replaced after several days because of measurement drift (Singhi and Tiwari, 2009). Transducers for both ventricular and subarachnoid monitoring should be set up without the use of a flush device.

Placement of the intraventricular catheter and subarachnoid bolt occurs through a burr hole in the skull. The intraventricular method involves introduction of a catheter into the lateral ventricle on the nondominant side, if known. The subarachnoid bolt involves placement of a bolt in the subarachnoid space, and the epidural sensor involves placement of a sensor between the dura and the skull. The intraventricular catheter has the advantage of providing a means for recalibration when measurement drift occurs, but both the catheter and the bolt can be used for therapeutic CSF drainage to reduce pressure. A drainage bag attached to the system is kept at the level of the ventricles and can be lowered to decrease ICP (see Critical Thinking Case Study).

Placement of the subarachnoid bolt is not adjusted by anyone except the neurosurgeon who placed the device. The neurosurgeon is notified if a satisfactory waveform on the ICP monitoring is not observed.

An epidural sensor provides a readout of the ICP with a stopcock assembly and transducer. Although less invasive, ICP measurements may be inconsistent. In infants, a fontanel transducer can be used to detect impulses from a pressure sensor and convert them to electrical energy. The electrical energy is then converted to visible waves or numeric readings on an oscilloscope. ICP measurement from the anterior fontanel is noninvasive but may prove to be inaccurate if the equipment is poorly placed or inconsistently recalibrated.

Intracranial pressure can be increased by instillation of solutions; therefore, antibiotics are administered systemically if a positive CSF culture is obtained. CSF is a body fluid; therefore, standard precautions are implemented according to hospital policy (see Infection Control, Chapter 22).

Nurses caring for patients with intracranial monitoring devices must be acquainted with the system, assist with insertion, interpret the monitor readings, and be able to distinguish between danger signals and mechanical dysfunction.

For sustained ICP elevations greater than 20 to 25 mm Hg, several medical measures are available. Osmotic diuretics may provide rapid relief in emergency situations. Although their effect is transient, lasting only about 6 hours, they can be lifesaving in emergencies. These substances are rapidly excreted by the kidneys and carry with them large quantities of sodium and water. Mannitol (or sometimes urea) administered intravenously is the drug most frequently used for rapid reduction and can lower ICP in 1 to 5 minutes. The infusion is generally given slowly but may be pushed rapidly in cases of herniation or impending herniation. Hypertonic saline in concentrations of 3% to 23% have been shown to reduce ICP by its osmotic force and can be beneficial for hypovolemic and hypotensive patients by increasing intravascular volume and blood pressure (Singhi and Tiwari, 2009). Adrenocorticosteroids are not recommended for cerebral edema secondary to head trauma. PaCO₂ should be maintained at 25 to 30 mm Hg to produce vasoconstriction, which reduces CSF, thereby decreasing ICP, but this effect is sustained only 11 to 20 hours because the CSF equilibrates to the new PaCO₂ level (Singhi and Tiwari, 2009).

Nutrition and Hydration

In the unconscious child, fluids and calories are supplied initially by the IV route (see Chapter 22). An IV infusion is started early, and the type of fluid administered is determined by the patient’s general condition. Fluid therapy requires careful monitoring and adjustment based on neurologic signs and electrolyte determinations. The goal of fluid therapy is euvolemia. Often, comatose children are unable to cope with the same amounts of fluid they could tolerate when they are healthy, and overhydration must be avoided to prevent fatal cerebral edema. When cerebral edema is a threat, fluids may be restricted to reduce the chance of fluid overload. Skin and mucous membranes are examined for signs of dehydration. Observation for signs of altered fluid balance related to abnormal pituitary secretions is a part of nursing care.

Long-term nutrition is provided with a balanced formula via a nasogastric or gastrostomy tube. Most children have continuous feedings, but if bolus feedings are used, the tube is rinsed with water after each feeding. Avoid overfeeding to prevent vomiting and the risk of aspiration.

Medications

The cause of unconsciousness determines specific drug therapies. Children with infectious processes are given antibiotics appropriate to the disease and the infecting organism. Corticosteroids are prescribed for inflammatory conditions and edema. Cerebral edema is an indication for osmotherapy. Sedatives or antiepileptics are prescribed for seizure activity (see p. 960).

Deep coma induced by administration of barbiturates is controversial in the management of ICP. Barbiturates are currently reserved for the reduction of increased ICP when all else has failed. Barbiturates decrease the cerebral metabolic rate for oxygen and protect the brain during times of reduced cerebral perfusion pressure. Barbiturate coma requires extensive monitoring, cardiovascular and respiratory support, and ICP monitoring to assess response to therapy. Paralyzing agents such as pancuronium also may be needed to aid in performing diagnostic tests, improving effectiveness of therapy, and reducing risks of secondary complications. Elevation of ICP or heart rate of patients who are being given paralyzing agents or are under sedation may indicate the need for another dose of either or both medications.

Thermoregulation

Hyperthermia often accompanies cerebral dysfunction; if it is present, measures are implemented to reduce the temperature to prevent brain damage and to reduce metabolic demands generated by the increased body temperature. Antipyretic agents are usually ineffective with hyperthermia as a result of traumatic brain injury; therefore, external cooling should be used (Badjatia, 2009). External cooling consists of evaporation (sponge baths), conduction (ice packs, cooling blankets), convection (fans), and radiation (skin exposure) (Badjatia, 2009). Laboratory tests and other methods are used in an attempt to determine the cause of the hyperthermia.

Elimination

A urinary catheter is usually inserted in the acute phase, although diapers may be used and weighed to record urinary output. The child who formerly had bowel and bladder control is generally incontinent. If the child remains comatose for a long period, the indwelling catheter may be removed, and periodic bladder emptying can be accomplished by intermittent catheterization. Stool softeners are usually sufficient to maintain bowel function, but suppositories or enemas may be needed occasionally for adequate elimination and to prevent fecal impaction. The passage of liquid stool after a period of no bowel activity is usually a sign of an impaction. To avoid this preventable problem, daily recording of bowel activity is essential.

Hygienic Care

Routine measures for cleansing and maintaining skin integrity are an integral part of nursing care of the unconscious child (see Maintaining Healthy Skin, Chapter 22).

Mouth care is performed at least twice daily because the mouth tends to become dry or coated with mucus. The teeth are carefully brushed with a soft toothbrush or cleaned with gauze saturated with saline. Commercially prepared cleansing devices, such as Toothettes, are convenient for cleansing the mouth and teeth. Lips are coated with ointment or other preparations to protect them from drying, cracking, or blistering.

Unconscious children are susceptible to eye irritation. The corneal reflexes are absent; therefore, the eyes are easily irritated or damaged by linen, dust, or other substances that may come in contact with them. Excessive dryness results from incomplete closure of the eyes or decreased secretions, especially if the child is undergoing osmotherapy to reduce or prevent cerebral edema.

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