Alterations in Neurological Function Flashcards
Development of size of brain from birth
Birth: 1/4 of adult size
9 months: size has doubled
5-7: close to full weight
7-10: full weight
What age does the skull expand until?
2
CSF in infant vs adult
50ml vs 130-150ml
Nervous system __________ but _________ at birth
Complete but immature
Infants are born with all the _______ they will ever have
Nerve cells
What type of injury are infants at high risk for?
High cervical spine (C1-C2)
Myelination is incomplete until age
4
Development/Myelination proceeds in the
cephalocaudal direction
Head proportion infant vs adult
Infant: head proportionally large
Neck muscle consideration infant
poorly developed
Neck muscle consideration infant
poorly developed
Cranial bone consideration infant
thin, not well developed, unfused sutures, expands until age 2
prone to brain injury and skull fracture with falls
Infants have _____ spinal mobility
excessive
Describe the muscles, joint capsules and ligaments of the cervical spine of infant
immature, wedge-shaped, cartilaginous, incomplete ossification
What may cause infant/child to not respond when doing neuro assessment/alter GCS score?
deep sleep
unfamiliar voices
sedation
7 General Points of Neuro Assessment
- LOC/GCS
- Head Circumference
- Vital Signs
- Cranial Nerve Function
- Pupil Function
- Reflexes
- Signs of ICP
Cushing’s Triad
Signs of acute elevation of ICP
- bradycardia
- widening pulse pressure (difference in systolic and diastolic)
- irregular respirations
Early ICP signs
- headache
- repetitive vomiting
- visual disturbances
- slight VS changes
- slight LOC changes
- seizures
Considerations of ICP assessment in infants
Cannot verbalize: headache, visual disturbances, LOC changes
Assess:
- bulging fontanelles
- increased head circumference
- irritability/high pitched cry
- dilated scalp veins
- widening sutures
Late signs of increases ICP
- significant decrease in LOC
- decreased motor/sensory responce
- bradycardia
- irregular respirations
- posturing
- fixed/dilated pupils
Posturing is a ___________
Very late and serious sign of alterations in neuro status/increased ICP
Decorticate posturing
Flexor - abnormal flexion of the arms with extension of the legs
Decerebrate posturing
Arms and legs being help straight out, toes pointed downward, and head/neck being arched backward
What is the most important indicator of neurologic dysfunction?
level of consciousness
How can you describe LOC?
Conscious (alertness and cognition) or unconscious
Alertness
ability to react
Cognition
processing of data/response
Meningitis definition
Inflammation of the meninges
Most common infectious process affecting CNS
Meningitis
Many of the bacteria or viruses that can cause meningitis are:
fairly common and are more often associated with other everyday illnesses.
Where does meningitis usually originate?
Any source: skin, GI, GU
Most common: respiratory
Most common symptoms of meningitis
Fever, headache, lethargy, irritability, confusion
Manifestation of meningitis in younger children
o Bulging fontanelles
o poor feeding or sucking
o high pitched/different cry
o lethargy
o hypothermia
o apnea,
o seizures
o rash
o irritability
o inconsolable crying.
Manifestations of meningitis in older children
o a headache
o photophobia (eye sensitivity to light)
o stiff neck
o Skin rashes
Brudzinski’s sign and Kernig’s signs are signs of
Meningitis
Brudzinski’s sign
Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.
Kernig’s sign
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Bacterial meningitis comparison to viral
- less common
- more serious/life threatening
Bacterial Meningitis Incidence
Common in very young and very old
Teenagers have more risk because of time spent in close contact with peers
Viral meningitis incidence
More common in children
Meningitis cause birth-3 months (neonatal)
GBS and E.Coli
Meningitis cause 3mon-6years
o Neisseria meningitis (meningococcal)
o Haemophilus Influenza Type B
o Streptococcus pneumoniae (pneumococcus)
Vaccine preventable
Older children and adolescent meningitis cause
o Streptococcus pneumoniae (pneumococcus)
o Meningococcal Meningitis
Vaccine preventable
Aseptic Meningitis
Any type that isn’t bacterial
Bacteria do not grow in cultures of the cerebrospinal fluid
Aseptic meningitis is characterized by
headache, fever, and inflammation
Viral meningitis is relatively ________ and far less ______ than bacterial meningitis
common
serious
Treatment for viral meningitis is
symptomatic and supportive
If a patient presents with signs of meningitis, what is the immediate management?
Lumbar puncture, bloodwork and begin antibiotics immediately because of how serious, if suspected. If bloodwork returns viral then antibiotics stop
Diagnosis of meningitis
- lumbar puncture
- bloodwork
- prevention
WBC in meningitis
increased in LP and BW
Glucose in LP for meningitis
decrease
Protein in LP for meningitis
increased
Appearance of CSF in LP for meningitis
cloudy r/t presence of proteins
Encephalitis defintion
inflammation of the brain, but it usually refers to brain inflammation caused by an infection or toxin which results in edema and neurological dysfunction.
True or false: encephalitis is a common disease
False: rare disease that only occurs in approximately 0.5 per 100,000 individuals
Symptoms of encephalitis
- Severe headache
- Fever
- Nausea and vomiting
- Stiff neck
- Dizziness
- Ataxia
- Convulsions (seizures)
- Sensory disturbances
- Drowsiness
- Coma
Causes of encephalitis
- Herpes Simplex Virus (HSV)
- Ticks
- Mosquitoes
- Measles, mumps, chickenpox, rubella (German measles) - (MMR Preventable) and mononucleosis.
Untreated infants with HSV encephalitis have a _____ mortality rate
85%
Early treatment of HSV encephalitis decreases mortality rate by
50%
Prevention of neonatal HSV
- c section
- contact drainage
- secretion precautions
- oral acyclovir or valacyclovir during in the last few weeks of pregnancy to women with a history of genital HSV may prevent recurrences at the time of delivery and decrease the need for cesarean delivery.
Encephalitis diagnosis
- CT/MRI
- EEG
- LP
- BW
Treatment of Encephalitis
Prevention and Symptom Management
- antivirals
- corticosteroids to reduce inflammation
- anticonvulsants PRN symptom management
- antipyretics PRN symptom management
How can you prevent Encephalitis
cannot be prevented except to try to prevent the illnesses that may lead to it.
o Prevent mosquito and tick bites
o Immunization.
Seizure
an involuntary contraction of muscle caused by abnormal electrical brain discharges.
Status Epilepticus
Prolonged and clustered seizures in which consciousness does not return between seizures
Intractable seizures
Seizures that continue to occur even with optimal medication management.
Epilepsy
reoccurring seizures that have no immediate underlying cause or an underlying problem that cannot be corrected
Seizures often result from
acute brain insults such as trauma or infection
Peak incidence of seizures
neonatal period and infancy.
what percent of childrenin NICU will have seizures
1.5-5%
Primary causes of seizures in NICU
Rx for hemorrhage and ICP
Classification of seizures
- Partial/Focal: simple v complex
- Generalized: absence v atonic v myoclonic v tonic clonic
Partial Seizure
electrical disturbance is limited to a specific area of one cerebral hemisphere (side of the brain).
* Partial seizures may spread to cause a generalized seizure
Simple Partial Seizure (4 components)
- no LOC change
- motor twitch
- autonomic response (increase HR, sweating, pupil dilation)
- sensory symptoms (alteration to taste, smell)
Complex Partial Seizures (5 components)
- impaired LOC
- altered mental status
- unilateral tonic clonic movement
- period of confusion, lethargy, sleep following
- difficult to control
Generalized Seizure
affect both cerebral hemispheres (sides of the brain) from the beginning of the seizure.
impair consciousness, either briefly or for a longer period of time
Absence Seizures
are lapses of awareness, sometimes with staring, that begin and end abruptly, lasting only a few seconds.
Is there a warning sign or after effect with absence seizures?
No
Onset of absence seizures
Uncommon before age 5
How long do absence seizures last
less than 30 seconds
Frequency of absence seizures
Frequent attacks: (50-100/day), interferes with school and learning.
Atonic seizures
produce an abrupt loss of muscle tone. They produce head drops, loss of posture, or sudden collapse.
Child loses consciousness.
Myoclonic seizures
rapid, brief contractions of bodily muscles, which usually occur at the same time on both sides of the body.
Occasionally, they involve one arm or a foot, sudden jerks or clumsiness.
Child may or may not lose consciousness.
Loss of consciousness myoclonic vs atonic
Atonic: lose consciousness
Myoclonic: may or may not lose consciousness
Most common and best known type of generalized seizure
Tonic Clonic
Tonic vs Clonic phase of tonic clonic seizure
o Tonic phase: begin with stiffening of the limbs followed by
o Clonic phase: jerking of the limbs and face
Onset of infantile spasms
3-12 months
Do infantile spasms alter consciousness
May occur with altered consciousness
Occurence of infantile spasms
5-150 a day
True or false infantile spasms decrease with intensity and duration over time
False they increase
6 causes of seizures
- fever
- genetics
- cerebral lesions
- progressive brain disease (rare)
- head trauma
- infections
Diagnosis r/t seizures
MRI
CT
EEG
Videos/description from parents and family
Use of MRI/CT for seizure diagnostic
diagnose cause - infection v trauma
Consideration of EEG for seizure diagnosis
where the seizure is occurring in brain – not always able to obtain when seizure is occurring
Rescue Agents for Status Epilepticus
Benzodiazepine
intranasal midazolam or rectal diazepam
Medication treatment following seizure activity
Phenobarbitol: rescue agent - not always first choice
Tegretol/Carbamazepine: management of various seizure types, particularly focal and generalized tonic-clonic seizures
Dilantin/Phenytoin: long term prevention/control of epilepsy
Who is a ketogenic diet used for in seizure treatment
under age 8 years with myoclonic and absence seizures.
Describe ketogenic diet
90%fat, adequate protein and low intake of carbohydrates.
What is an extra-temporal cortical resection?
resection of the brain tissue that contains a seizure focus.
What is the most common extratemporal site for seizures
frontal lobe
What is a functional hemispherectomy?
One hemisphere is removed, corpus callosum cut, disconnecting communication between the 2 hemispheres to prevent the spread of seizures to functional side
What is cannabis used for in pediatric epilepsy
Drug resistant epilepsy
6 Nursing Diagnosis for Seizure Management
- Ineffective breathing Pattern – AIRWAY #1
- Risk for inadequate oxygen exchange.
- Risk for injury
- Risk for Aspiration
- Ineffective therapeutic regimen management.
- Potential for inadequate cerebral perfusion
6 Nursing Interventions for Seizure Management
- Maximize airway
- Oxygen
- Safety-suction
- Medication
- Monitor electrolytes (lowering of sodium following protocol to assure it does not cause)
- Maintain nutrition and fluid balance
Spina Bifida
any congenital defect involving insufficient closure of the spine.
When does spina bifida occur?
- Is a neural tube defect that occurs during the first month of pregnancy.
3 most common types of spina bifida
- myelomeningocele
- meningocele
- occulta
Myeolmeningocele
Most common and severe type of spina bifida
Spinal cord and nerves protrude through back
Meningocele
Spinal cord does not protrude, only meninges
Occulta
Hidden spina bifida, small gap in spine but no opening or sac
Myelomeningocele (most serious) accounts for about ____ of all cases of spina bifida and may affect as many as ____________
75%
1 out of every 800 infants.
Main cause of neural tube defects
Folate deficiency
Secondary to maternal folate deficiency, what other factor could cause fetal folate deficiency?
maternal inability to metabolize folate caused by genetic predisposition
4 Symptoms of Spina Bifida
- partial/complete paralysis/loss of sensation of the legs
- loss of bladder/bowel control depending on level of the spine
- hydrocephalus
- Sac like protrusion
What places a child with spina bifida at increased rx for latex allergy
Frequent self catherizations
Spina Bifida Diagnosis
- neuro exam
- BW
- prenatal US
- amniocentesis
What would the neuro exam of a child with spina bifida show?
indicate loss of neurologic functions below the defect.
What would the BW of a women carrying a child with spina bifida show?
Eighty-five percent of women carrying a fetus with spina bifida will show elevated maternal serum alpha fetoprotein.
What is the treatment of spina bifida?
early surgical repair - fetal spina bifida surgery
When is fetal spina bifida surgery completed?
Prenatal repair of myelomeningocele is performed between 19 and 25 weeks’ gestation.
Research shows that fetal spina bifida surgery does what 3 things:
- reduces need for shunt
- improves mobility
- improves odds child will walk
Risk associated with fetal spina bifida surgery
preterm birth resulting in immediate fetal death or preterm labor and delivery due to stimulation of uterus later on
Antiseizure medications should be _________ rather than ________
tapered slowly
stopped suddenly
Medications used for active seizure
Midazolam, Lorazepam
Why does hydrocephalus develop?
an imbalance between the production and absorption of cerebral spinal fluid (CSF).
In hydrocephalus, what does CSF build up cause?
abnormal enlargement of the ventricles in the brain.
What are kids with hydrocephalus commonly in the hospital for?
shunt malfunctions or infection
Signs and Symptoms of Hydrocephalus
- An unusually large head (only for kids up to 3 because after that sutures have fused)
- A rapid increase in the size of the head
- Bulging anterior fontanel
- Vomiting (because of increased pressure)
- Sleepiness
- Irritability
- Seizures
- Eyes fixed downward (sunsetting of the eyes)
- Blurred or double vision
2 Types/Causes of Hydrocephalus
- Obstructive/Non Communicating
- Nonobstructive/Communicating
Obstructive Hydrocephalus
results from an obstruction within the ventricular system of the brain that prevents CSF from flowing or “communicating” within the brain.
o Ex. Tumor, abnormal bone structures
Non-obstructive Hydrocephalus
results from problems with the production or absorption of CSF; inability to absorb
Treatment of Hydrocephalus
re-establish the balance between CSF production and reabsorption.
o lumbar puncture
o Shunt insertion
o Tumor removal
3 Complications of VP Shunts
- mechanical failure
- shunt infection
- blocked shunt
Mechanical failure of a shunt results in
Alterations in amount of CSF (over or under drainage) from blockage of catheter or failure of valve system
Infection of VP shunt leads to need for
External shunt utilized to brain infected fluid NOT into peritoneal cavity
How is shunt infection treated
Vancomycin directly into brain
A blocked shunt leads to ______. How is it diagnosed?
Increased ICP
MRI/CT/LP
blocking can happen at various levels throughout shunt
4 Key components of care of external ventricular device shunt
- clamp every time
- maintained at level of ventricles
- sterile technique
- measure CSF output Q1h
What is vancomycin used to treat?
Treatment of patients with Infections due to MRSA, Meningitis, endocarditis, osteomyelitis.
Infections associated with CVLs, VP shunts vascular grafts and prosthetic heart valves.
Ativan Class, Action, Side Effects
Class: Benzodiazepine.
Action: Enhances the effect of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, in the central nervous system. This results in calming effects.
drowsiness, dizziness, and the potential for dependence or withdrawal symptoms with long-term use.
Phenobarbital Class, Action, Side Effects
Class: Barbiturate.
Action: Enhances the action of GABA, leading to increased chloride ion influx, which inhibits neuronal activity. It also has anticonvulsant properties.
sedation, dizziness, respiratory depression (at high doses), and the risk of dependence.
Dilantin class, action, side effects
Class: Hydantoin.
Action: Stabilizes neuronal membranes by inhibiting sodium influx during depolarization. This helps prevent repetitive firing of neurons.
Side effects may include gingival hyperplasia, drowsiness, dizziness, and, at high levels, potential for toxicity (such as ataxia and nystagmus).
Tegretol class, action, side effects
Class: Anticonvulsant.
Action: Blocks voltage-gated sodium channels, reducing the excitability of neurons. It also has mood-stabilizing properties.
Side effects may include dizziness, drowsiness, and, in some cases, skin reactions (e.g., Stevens-Johnson syndrome). Blood counts and liver function should be monitored.
Valproic Acid class, action, side effects
Class: Anticonvulsant.
Action: Increases GABA levels, blocks sodium channels, and may inhibit certain excitatory neurotransmitters. It has broad-spectrum anticonvulsant effects.
Side effects may include weight gain, gastrointestinal disturbances, and, rarely, hepatotoxicity. It may also cause sedation and hair loss.
