2 Neuro Flashcards
Layers of the brain (inner to outer)
Pia mater
Arachnoid
Dura
Nervous system is complete at birth but its what
Immature (waiting on myelinization)
Cranial bones and vertebrae are what
Not fully ossified
Immature muscles/ligaments (why we sit rearseated)
Risk for fx and head injuries
Peds neuro assessment
8
Health hx (birth hx)
Look before touching
Loc
Fontanel/suture assessment (until 3)
Head circumference measurement (until 3)
Pupil assessment
Movement/posture (primitive vs protective reflex)
-decorticate/decerebrate (also need to know reflexes
Signs of increased ICP
Peds GCS differences
For best response to auditory and verbal stimulus
There is seperate sections for over 2 and under 2
-under 2 is less verbal and more observations like crying
Decorticate vs decerebrate
Decorticate (toward the core you get more score on GCS) -not as bad
-flexed
Decerebrate:
-extention (worse)
Increased ICP
3 components
What causes it (5)
Increased pressure exerted by: brain/CSF/blood
Causes:
-brain tumor
-head trauma
-hematoma
-hydrocephalus
-infection
Increased ICP
Early signs
Non head related:9
Head related: 6
HA
Vomiting
Blurred/double vision
Dizziness
Decreased pulse
Increased BP
Irritable
Seizure activity
High pitched cry (sounds like a kitten)
Head related:
Bulging/tense fontanel
Wide sutures
Increased head circumference
Dilated scalp veins
Pupils sluggish/unequal
Sunset eyes
Increased ICP
Late signs (5)
Lowered loc
Bradycardia
Cheyne-stokes resp
Decerebrate/decorticate posturing
Fixed/dilated pupils
Cushings triad (increased ICP)
Bradycardia
Cheyne-stokes resp
Widening pulse pressures (systolic/dialstolic get further apart)
Is pulsating fontanel normally?
Yes
Increased ICP
Nursing management
ABC’s
Elevate HOB 30 minimum
Strict I/O, DW, fluid restrictions
Monitor electrolyte balance
Reduce agitation (less noise/visitors)
Increased ICP
Meds
Mannitol (osmotic diuretic)
3% hypertonic saline
These temporarily fix issue need to fix actual problem
Neural tube defects (anencephaly, encephalocele)
What is it
Causes (4)
Failure of neural tube to close by 4th week of gestation
Causes:
-folic acid deficiency
-previous neural tube defect
-drug use
-genetics
Neural tube defects (anencephaly, encephalocele)
Preventions
400 mcg folic acid daily
Higher dose for women with hx of neural tube defect
Anencephaly
-what does it look like
-born without what
-is it compatible with life?
Small or missing brain hemispheres, skull, scalp
Born without a forebrain and cerebrum
Remaining rain tissue may be exposed
Incompatible with life
Encephalocele
What does it look like
Prognosis depends on what
Often accompanied by (6)
Protrusion of the brain and meninges thru a skull deficit
Prgnosis depend on size of encephalocele and involvement of other brain structures
Accompanied by:
Craniofacial abnormalities
Hydrocephalus
Microcephaly
Visual problems
Developmental delay
Seizures
Encephalocele
Surgical repair
Nursing care
Sx:
-placement of tissue back into skull and removal of sac
-VP(ventriculoperitonial shunt) placed to correct hydrocephalus
-corrective repair of any craniofacial abnormalities
Nursing:
-monitor for hydrocephalus
-increased ICP
Hydrocephalus
Too much CSF on brain
Microcephaly
Define?
Congenital vs acquired
Results in?
Tx
Defined as hc greater than 3 standard deviations below the mean for the age and sex of the infant
Generally resuts in intellectual disability
No tx (just support)
Congential microcephaly
Abnormal development
Chromosomal abdnormalities
Exposure to infection (rubella, toxoplasmosis, CMV)
Acquired microcephaly
Severe malnutrition
Perinatal infections
Anoxic events in infancy
Positional plagiocephaly
What happens
Result of what (4)
Asymmetry in head shape without fused suture
Result of:
-cranial molding
-flattening of the occiput
-safe sleep position
-torticollis (neck muscles cause them turn to 1 side)
Positional plagiocephaly
Prevention
Tx
P:
-daily tummy time
-alternate head position during sleep
Tx:
PT
Customized helmet to reshape the skull
Hydrocephalus
What is it
Leads to what
Imbalance between production and absorption CSF
Leads to:
Increase in CSF circulating volume—>increased ICP
Hydrocephalus
Nonobstructive vs obstructive
Nonobstructive:
-flow of CSF blocked AFTER it exits the ventricles
-defective absorption
Obstructive:
-flow of CSF blocked WITHIN the ventricular system
Hydrocephalus
S/s
S/s of increased ICP:
Increased HC
Bulging fontanels/seperating sutures (when young)
Irritability/change loc
N/V/HA
Sunsetting eyes
Poor feeding
Hydrocephalus
Tx
Surgical correction of structural deformities
Remove or bypass obstruction
VP(ventroperitonel) or VA(ventriculoatrial) shunt
Hydrocephalus
Shunt care
Place on opposite side of shunt incision
Keep (clean/dry/intact) (no wet cloths=infection)
Keep flat to prevent rapid reduction of CSF
Monitor for shunt failure (doesnt work), infection
Hydrocephalus
Shunt complications
Shunt malfunction: sx to replace shunt
Shunt infection:
-Sx to externalize shunt
-EVD: external ventricular drain
-IV abx
Where do we want the lazer on EVD?
Head Too high will cause what
Monitor how often
At the tragus of ear
Too high will drain too fast
Every hour
Meningitis
What is it
Causes
Which is more life threatening
Inflammation of meninges (in brain/spinal cord)
Bacterial or viral infection in CSF
Viral: many types (CMV/HSV/enterovirus/HIV)
Bacterial: meningococcal/pheumococcal/H. Flu (Hib), E.coli
Bacterial is more life threatening
Meningitis
S/s
3 unique
3 vague
Meningeal irritation signs (3)
S/s of increased ICP :vomiting, HA, bulging font.
Infant resting in opisthotonic position
Irritability then progresses to drowsiness/stupor
Fever
Poor feeding (younger kids)
photophobia (older kids can vocalize)
Meningeal irritation:
-nuchal rigidity
-kernigs sign
-brudzinskis sign
Brudzinskis sign
Vs
Kernigs sign
B:
-pull neck = involuntary flexing of knees and hips
K:
-hip at 90degree angle
-cant fully straighten leg
Meningitis
Complications
(Clinical manifestations) what infection causes it
meningococcal:(bacterial)
-Petechiae/purpuric type rash
Pneumococcal:
-Chronic ear drainage
Meingococcal and Hib infection:
-Arthralgias
Meningitis diagnotics
Blood culture
CBC (WBCs)
CRP/ESR (inflammation)
CT/MRI
CSF analysis via LP
Meningitis
Bacterial vs viral CSF
Color
WBC
Proteins
Glucose
Gram stain
Bacterial:
Color: cloudy
WBC: elevated
Proteins: elevated
Glucose: decreased (bacteria eating it)
Gram stain: positive
Viral:
Color: clear
WBC: elevated
Proteins: normal or elevated
Glucose: normal
Gram stain: negative
Lumbar punctures for peds
Position
How to decrease pain
What to do after
Fetal lying position
Pain:
-topical numbing cream
-sucrose water, fetanyl, versed
Lay flat for several hours after to prevent spinal HA
Meningitis tx
Precaution
Monitor what (3)
Assess (2)
Manage what
Decrease what
Droplet isolation
Monitor: VS, I/O (UOP), s/s of increased ICP
Assess: nuro status, pain
Manage fever
Decrease environmental stimuli
Meningitis
Meds example
Antivirals?
Abx (up to 10days)
Corticosteroids: dexamethason
Antivirals:
-maybe before we know if its bacterial. But usually let viral meningitis run its course
Reye syndrome
Affects who usually
Found to be a reaction that is triggered by what
Primarily affects what
Affects young children recovering from a viral illness
Triggered by use of salicylates to treat viral infections
(ASA)
Affects: liver/brain
-liver dysfunction
-cerebral edema
Reye syndrome
S/s (4)
Neuro s/s d/t liver d/t build up of ammonium
Severe Vomiting
Change in mental status (confusion/delirium)
Irritability/combativeness
Seizures
Reye syndrome
Diagnostics
(5)
Wanna rule out what?
Elevated liver enzymes (ALT/AST)
Elevated blood ammonia levels
Coagulation times can prolong
Liver biopsy
LP: CSF analysis to rule out meningitis
Reye syndrome
Tx
Hydrate whilte preventing cerebral edema
Decrease stimulants like increased ICP
Monitor/prevent bleeding episodes
Implement sz precautions
Meds:
Mannitol
Head trauma: key terms
Concussion
Contusion
Laceration
Skull fractures
Concussion:
-traumatic injury to the brain that alters the way the brain functions
Contusion:
-bruising of the cerebral tissue
Laceration:
-tearing of cerebral tissue
Skull fractures:
-direct trauma to skull (will cover types)
Skull fracture types:
Linear
Depressed
Comminuted fractures
Basilar fractures
Linear: most common
- single fx at point of impact
-do not cross suture lines
Depressed:
-broken bone fragment pushing inward
-blunt trauma (hammer)
Comminuted fractures:
-more than one linear fx following intense impact
Basilar fractures:
-fracture of bones at base of skull
Peds abusive head trauma:
More common in what gender
Between what ages
Risks
Males
3- 8 months
Risks:
-inconsolable/ crying child
-male caregiver
-unwanted pregnancy/child
Peds abusive head trauma: severe child abuse
Caused by 3
Outcomes 6
Caused:
-vigoreous shaking
-intentional blow to head
-intentional dropping
Outcomes:
-skull fx
-intercranial bleeding
-retinal hemorrhage
-subdural hematoma
-cerebral edema
-if not death then may have long-term consequences
Head trauma clinical manifestation
minor 6
Progressive 3
Severe 2
Loss of consciousness (need to know how long)
Minor injury:
-confusion, vomiting, pallor, irritability, lethary, drowsiness
Progression of injury:
-marked changes in vital, AMS, increased agitation
Severe injury:
-increased ICP, decorticate/decerebrate posturing
Head trauma: clinical manifestations
Palpitation allows us to determine
What do we see and feel?
Depressed vs basilar skull fx
Dont do what with fx
Depressed skull fx:
Skull appears misshapen
Basilar skull fx:
Blood over mastoid process and/or around orbitis, leakage of CSF from nose.
Dont put anything in nose if have a fx
Head trauma: Labs and diagnostics
Think other causes to rule out neuro status
ABGs
CBC: h&h, ply, RBC, reticulocytes
Blood alcohol and toxicology screen
Liver function test (bilirubin/ammonia) affects neuro
Cervical spine x-ray
CT/MRI
EEG
ICP measurement
Head injury : nursing care
Stabilize spine
ABCs: airway, mechanical ventilation, sats 95%+
Through neuro assessment
Monitor I&O, electrolyte balance
Decrease stimulation
Manage pain: analgesics
Mannitol, antiepileptics
Complications: epidural hematoma
Bleeding
Typically
Bleeding between dura and skull
typically arterial
Complications: epidural hematoma
Clinical manifestations
Short period of unconsciousness followed by a normal period for several hours
Lethargy/coma/vomiting due to compression of the brain
Complications: epidural hematoma
Treatment
Removal of accuulated blood
Ligation of torn artery
Complications: subdural hematoma
Bleeding
Typically
Could be a result of what
Bleeding between the dura and the arachnoid membrane
Typically venous
Could be d/t:
-birth trauma
-falls
-violent shaking
Complications: subdural hematoma
Clinical manifestations
Tx
CM:
-irritability, anemia, sz
-Increased HC
-lethargy,coma, vomiting
Tx:
-self-resolving or drains/subdural tap
(same as epidural hematoma)
Complications
Cerebral edema
Brain herniation
-what is it
-s/s 3
Cerebral edema:
doesnt happen fast (worse before it gets better)
-24-72 hours post trauma
-increased ICP
Brain herniation:
-downward shift of brain tissue
-loss of blink reflex, gag reflex
-pupil dilated and fixed (big and dont react)
-cushings triad (widen pulse pressure, bradycardia, irregular respirations)
Health promotion and disease prevention
Seat belts
Helmets
Shaken baby and child abuse prevention
Car seat compliance ( rear facing until 2 )
Seizure: types
Unclassified
Generalized
Partial/focal
Unclassified:
-febrile, infantile spasms, neonatal seziures
Generalized: (not specific part of brain)
-tonic-clonic, absence , myoclonic, atonic
Partial/focal: (specific part of brain)
Simple partial with either motor or sensory manifestations complex partial.
Unclassified: febrile seizures
Associeted with what
Duration
Tx
Associated with sudden spike in temp as high as 102-104F
Duration: 15-20 seconds
Tx:
acetaminophen or ibuprofen
Light clothing
Tepid bath
Unclassified: infantile spasms
Peak onset
S/s
How many events
Peak onset: 3-7 months
Sudden, brief, symmetric muscle contractions
Can occur as single event or in clusters
Unclassified: neonatal seizures
Most times are what type
When your likely to get it
Associeted with underlying causes 4
Tx
Mostly focal
1st 4 weeks of life
Causes:
-hypoxic ischemic encephalopathy
-metabolic disorder
-infection/sepsis
-cerebral infarction
Tx: tx the cause
Generalized: tonic-clonic
Most prevalent of all seizures
Onset is without what
Tonic phase duration
Clonic phase duration
State after all phases
Onset without warning
Tonic phase: 10-20 secs
Clonic phase: 30-50 secs (can last 30 min or longer)
Postictal phase
Tonic phase
Clonic phase
Postictal state
T:
Piercing cry, pallor
Stiffening of body and limbs (back arching)
C:
Salivary frothing
Eye blinking
Clonic jerks of limbs, body, and head
P:
Limbs and body limp
Generalized: absence
Aka
S/s
What is first indicator
Is there a postictal phase?
Aka: petit mal
Affects schoolwork 1st indication
S/s:
-abrupt onset/offset
-blank stare, motionless
-can drop items being held
-unable to call (come out of it on their own)
No postictal phase (come back as if nothing happened)
Generalized: myoclonic
S/s:4
Postictal phase?
S/s
-Symmetric or asymmetric ( one sided or both)
-Brief contractions of muscle groups
-Can involve only the face and trunk or one or more extremities
-may lose consciousness
No postictal phase
Generalized: atonic
Aka
Onset what ages
S/s
If frequent child should do what.
Aka: drop attacks
Onset at age 2-5 y/o
S/s:
-loss of tone which can cause a fall
-period of confusion follows
If frequent: child should wear helmet
Partial : simple partial and complex partial
Simple partial: with motor manifestations
Simple partial with sensory manifestations
Complex partial
Seizures: labs and diagnostics
9
6 unique
3 easy
Lead level: blood levels
Blood glucose (r/o low sugar)
Metabolic panel
Chromosomal analysis
Toxicology screen
Lumbar puncture (r/o meningitis)
WBC
EEG
CT/MRI
Seizure tx
During vs after
Suctioning
Sz Precautions
During:
Nurse worried about safety/their head/ timing event/ watch CR monitor/ recovery position
Post sz:
Monitor/notify provider
Can suction around mouth but not in mouth during sz
Sz med types
Abortivet tx
Preventative/maintance meds
Miscellaneous tx
Sz: abortive meds
Lorazepam (ativan):
-1st line drug
-route: IV
Midazolam (versed)
-route: IV or intranasal (good when dont have a IV)
Diazepam (diastat)
-route: rectal
Home med (good for taking home by parents)
Sz preventative meds
What it does
Single med intitiated how
When can additional meds be added
Decrease incidence and severity of sz
Single med intitially at:
Low dose
Gradually increased until sz are controlled
Additional meds can be added to achieve control
Sz preventative meds
Client education
When to take
Dosage when growing
What we need to monitor
Never stop how
Wean how
Take med at same time everyday
Dosage will need to be increased as the child grows
Therapeutic drug levels need to be monitored
Never stop taking abruptly
Wean very slow
Sz misc tx
Ketogenic diet:
-high fat, protien/low carbs
Vagal nerve stimulation (stim. Stops sz)
Removal of tumor/lesion
Focal resection (remove specific tissue causing issue)
Hemispherectomy (remove whole hemisphere)
Corpus callostomy (separate te the 2 hemispheres)
