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Pediatrics > ALTERATIONS IN PEDIATRIC NEUROLOGIC FUNCTIONS > Flashcards

ALTERATIONS IN PEDIATRIC NEUROLOGIC FUNCTIONS Flashcards

1
Q

BASIC STRUCTURES OF THE NEUROLOGIC SYSTEM

A
  • brain
  • spinal cord
  • nerves
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2
Q

DEVELOPMENTAL CONSIDERATIONS

A
  • nervous system complete but immature at birth
  • infant born with all nerves he or she will have
  • myelination of nerves incomplete until age 4 yrs
  1. progresses in a cephalocaudal direction
  2. responisible for progressive development of fine and gross motor skills
  3. need fat in diet for myelin
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3
Q

PEDIATRIC DIFFERENCES AND RISKS

A
  • head is “top heavy”
  • neck muscles weak
  • thin cranial bones
  • excessive spinal mobility
  • immature muscles and ligaments or cervical spine
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4
Q

PEDIATRIC DIFFERENCES: FONTANELS

A

How are fontanels useful in assessment?

  • bulging
  • sunken
  • pulsating
  • flat and soft
  • closes early
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5
Q

LEVEL OF CONSCIOUSNESS(LOC)

A
  • most important indicator of neurologic dysfunction

- conscious= awareness of stimuli

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6
Q

ALTERED LEVELS OF CONSCIOUSNESS

A
  • confusion
  • delirium
  • lethargy
  • stupor
  • coma
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7
Q

DETERIORATION OF LOC: A SEQUENTIAL PATTERN

A
  1. awake and alert- responds appropriately
  2. slight disorientation to time, place,or person (confusion)
  3. restless,fussy,or irritable (delirium)
  4. profound slumber, responds to loud commands, painful stimuli(lethargy)
  5. non- purposeful response to moderate stimulation -decorticate or decerebrate posturing (stupor)
  6. No response (coma)
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8
Q

CAUSES OF ALTERED LOC

A

-infection of brain and meninges #1 cause in children
-other causes
trauma
hypoxia
poisoning
seizures
DKA
electrolyte or acid base imbalance
congenital structural defects

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9
Q

PEDIATRIC GLASGOW COMA SCALE

A
  • three part assessment
  • eyes
  • verbal response
  • motor response
  • score of 15= unaltered LOC
  • score of 3= extremely decreased LOC (worst possible score on the scale)
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10
Q

ALTERED LOC

A

any of causes of altered LOC can result in:

  • increased intracranial pressure(ICP): force exerted by brain tissue, CSF, blood
  • decreased cerebral perfusion pressure (CPP): amount of pressure needed to perfuse brain
  • increase ICP can lead to decreased CPP
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11
Q

PEDIATRIC NEURO ASSESSMENT GUIDLINES

A 
LOC
Vitals
Pain
Cognition 
Head 
Eyes
Neck
Posture/movements 
reflexes
cranial nerves
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12
Q

BACTERIAL MENINGITIS

A
  • inflammation of the meninges
  • newborns and infants at greatest risk
  • higher morbidity and mortality than viral meningitis
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13
Q

ETIOLOGY MENINGITIS

A

NEWBORNS TO AGE ONE MONTH:

  • group B streptococcus
  • E.coli
  • listeria monocytogenes

OVER 1 MONTH OF AGE :

  • streptococcus pneumonaie most common
  • Neisseria meningitis
  • haemophilus influenza type B

-decreased incidence following Hib, pneumoccacal and meningoccal vaccine

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14
Q

PATHOPHYSIOLOGY

A
  • often secondary to OM,sinusitis, pharyngitis, cellulitis , pneumonia or brain trauma
  • bacteria enter bloodstream “bacteremia”
  • bacteria cross “ blood brain barrier” and enter CNS
  • inflammation occurs- WBC’s accumulate and cover brain with purulent exudate
  • brain swells, can lead to increased ICP and hydrocephalus
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15
Q

CLINICAL MANIFESTATIONS OF MENINGITIS

A

classic triad

  • fever
  • nuchal rigidity
  • headache or change in mental status
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16
Q

CLINICAL MANIFESTATIONS NEONATES

A

Nonspecific

  • fever or hypothermia
  • poor feeding/poor suck
  • vomiting or diarrhea
  • fontanel bulging
  • irritable or lethargic, weak cry
  • poor tone
  • seizures
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17
Q

INFANTS AND YOUNG CHILDREN

A
  • fever
  • vomiting
  • nuchal rigidity
  • opisthotones
  • bulging fontanel
  • irritable or lethargic
  • difficult to console
  • high pitched cry
  • seizures
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18
Q

OLDER CHILDREN AND ADOLESCENTS

A
  • classic signs: fever,headache,nuchial rigidity
  • photophobia,opisthotonos
  • positive kernig and brudzinski signs
  • confusion,delirium,irritable,lethargic
  • vomiting
  • petechial rash
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19
Q

DIAGNOSIS

A

-based on history, clinical presentation and labs

  • lumbar puncture(LP)- definitive diagnostic test
    WBC’s increased,increased protein, low glucose
    Gram stain and culture and sensitivity
  • CBC’s ,blood cultures, serum electrolytes and clotting factors, UA with C&S
  • CT scan for increased ICP or suspected brain abscess
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20
Q

TREATMENT

A

-antibiotics administered as soon as blood ,LP,urine obtained , IV antibiotics for 7-21 days

ampicillin
cefotaxime(claforan)
ceftriaxone (rocephin)
penicillin G
vancomycin 
aminoglygocides
  • may be changed when culture results available
  • contacts may need prophylactic antibiotics- cipro,or rifampin
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21
Q

TREATMENT MENINGITIS

A
  • NPO -IVF (2/3 maintenance initially)
  • treat increased ICP with mannitol and furosemide
  • treat seizures
  • treat shock to maintain CPP
  • treat fever/isolation
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22
Q

NURSING MANAGEMENT

A

-monitor VS, LOC, pupils, neuroo status , I and O’s, labs,ICP, CPP

  • assist with LP
    position after LP:supine to prevent headache

-seizure precautions

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23
Q

NURSING MANAGMENT

A
  • antibiotics ,antipyretics
  • measure head circumference
  • promote comfort and quiet environment with minimal stimulation -reduce noise,light
  • isolate for first 24-48 hours
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24
Q

SEQUELAE (complications)

A

most common - 8th cranial nerve -hearing loss

  • seizures
  • hydrocephalus
  • developmental delay
  • learning problems severe -septic shock,stroke, death
  • EBP: study indicates that heparin and aspirin may discourage stroke in pediatric
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25
Q

PREVENTATVE MEASURES

A
  • HIB vaccine
  • pneumococcal vaccine
  • meningococcal vaccine
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26
Q

MICROCEPHALY

A
  • small brain
  • head below 3rd percentile
  • due to :

fetal insult such as rubella,zika,
genetic disorder
chromosomal
insult during infancy

-assoiciated with DD

27
Q

HYDROCEPHALUS

A
  • water on the brain -imbalance B/W production and absorption of CSF
  • body produces 500mls CSF/day
  • CSF cushions brain from injury ,delivers nutrients , remove waste and maintains normal ICP

circulates throughout ventricular system
absorbed within the subrarachnoid spaces

28
Q

HYDROCEHALUS

A
  • non-communicating - most common
  • caused by obstruction to flow of CSF thrpugh ventricular system -ventricles enlarge
  • infection
  • hemorrhage
  • tumor
  • congenital defect
29
Q

ETIOLOGY /PATHO

A
  • congenital or acquired
  • congenital- present at birth ,may not be apparent ,may be assocoaited eith other CNS abnormalities (spina bifida)
  • acquired may result of illness (tumor) or trauma
30
Q

CLINICAL MANIFESTATIONS

A

vary with age of the child

Infant- rapidly increasing head circumfrance , decreased LOC, vomiting,irritablity, sunset eyes , bulging fontanel, distended scalp veins,bossing of frontal skull

older child- signs of increased intracranial pressure,headache in AM with vomiting, ataxia, strabismus

31
Q

DIAGNOSIS

A 
prenatally-ultrasound 
clinical manifestations after birth 
head circumference
CT scan MRI
U/S of head of infant- open fontanel
32
Q

CLINICAL THERAPY

A
  • removal of obstruction
  • creating a new CSF pathway to divert excess CSF (VP shunt)
  • treatment of complications
  • manage problems related to pdychomotor development
33
Q

VP SHUNT COMPLICATIONS

A
  • infection
  • malfunction- blockage or kinking of tube
  • increased ICP
  • worsening neurological status/altered LOC
34
Q

HYDROCEPHALUS : NURSING CARE

A
  • measure head circumference (infants)
  • observe for signs of increased ICP -may indicate shunt malfunction
  • positioning usually supine: head of bed is raised gradually (post-op)
  • provide emotional support to child, parents
  • teaching about medications,signs of shunt malfunction
35
Q

NEURAL TUBE DEFECTS

A
  • neural tube is structure in embryo that becomes CNS brain and spinal cord
  • neural tube fused by 28th day of gestation
  • if neural tube does not fuse properly , a NTD forms at open location
36
Q

NTD’S

A

SPINA BIFIDA OCCUITA
spinal cord not completely fused, but does not protrude -tuft of hair or sacral dimple seen

SPINA BIFIDA CYSTICA (two types)
1. meningocele- fluid filled sac protrudes from back,but spinal cord in normal position

  1. meningomyelocele- fluid filled sac with spinal cord
37
Q

ETIOLOGY /PATHO

A

causes
-50% or more =folic acid deficiency
other cases =multifactorial -environmental,chemical,medications,genetic,maternal obesity

38
Q

PRENATAL DIAGNOSIS

A
  • amniocentesis- elevated alpha-fetoprotein in amniotic fluid -16 to 18 weeks gestation
  • uterine ultrasound
39
Q

PREVENTION

A

-Folic acid supplementation -0.4mg/day
if history of NTD -4 mg /day
in 1998 FDA fortifies grain creals with folic acid
begin at preconception

40
Q

SPINA BIFIDA OCCULTA

A

-mildest form of spina bifida
- usually no problem with nervous system
- skin indicators
sacral dimple
port wine nevus
sacral tufts of dark hair
sacral lipoma

41
Q

SPINA BIFIDA CYSTICA

A

DEFINITION
visible defect with external saclike protrusion

Two Types:

  1. meningocele- sac contains meninges and spinal fluid but no neural elements
    - spinal cord in normal position
    - no neurologic deficits
42
Q

MYELOMENINGOCELE

A

-sac contains meninges,spinal fluid, and nerves

  • it defect below 2nd lumbar vertebra
  • flaccid paralysis of lower extremeties
  • sensory deficit
  • orthopedic braces,walkers,crutches, and wheelchairs
  • bladder and bowel sphincters may be affected
43
Q

CLINICAL THERAPY

A
  • prevent infection of sac
  • assessment of neurologic and associated anomalies
  • early closure in 24-48hrs after birth (prevent stretching of other nerve roots and further damage)
  • hydrocephalus- VP shunt placement
  • braces to support joint mobility
  • neurogenic bladder- clean intermittent catheterization Q 3-4 hours
44
Q

NURSING MANAGEMENT

A
  • cover sac with sterile saline dressing
  • place infant prone
  • assess infant for motor,bladder,and bowel deficits
  • monitor VS
  • observe for signs of infection
  • comfort infant
  • create a latex safe environment
45
Q

LATEX ALLERGY

A
  • SB patients at high risk for latex allergy due to repeated exposure to latex products from multiple surgeries and repeated urinary cath.
  • 73% of pt have allergy
  • anaphylactic reactions possible
  • recommended that SB patients avoid latex from birth
46
Q

DISCHARGE TEACHING

A

-symptoms of increased ICP,hydrocephalus, shunt malformation , UTI

  • splints, wedges
  • ROM exercises
  • clean intermittent cath every 3-4 hrs
  • community based care-PT, OT,PCP,school nurse
  • braces , walkers,whelchairs
  • monitor adolescents for mental health issues
  • teach to self -cath when old enough
47
Q

CEREBRAL PALSY (CP)

A

-most common chronic disorder in childhood
disorder of impaired movement and posture
incidence 2 to 3 per 1000 live births

  • non-progressive may have perpetual problem ,language deficits, and intellectual impairment
  • most cases have abnormal muscle tone and lack of coordination with spasticity
48
Q

ETIOLOGY/PATHO

A
  • congenital- damage to the brain before or during birth
  • hypoxia,infection,abnormal brain structure
  • birth asphyxia,accounts for only 6-7% of cases
  • preterm, twin, and LBW increase risk
  • very low apgar score increase risk (0-3 at 5min)
  • multifactorial , unknown

-infant /child develops CP from asphyxia- near drowning, choking poisoning ,head trauma

49
Q

CLINICAL MANIFESTATIONS

A

Spastic

  • most common clinical type -75% of cases
  • persistent hypertonia and rigidity
  • impairment of fine and gross motor skills
  • contractures and abnormal curvature of the spine
  • exaggerated DTRs ,positive Babinski
  • classic gait- intoeing
50
Q

POSSIBLE MOTOR SIGNS OF CP

A
  • poor head control after age 3 months
  • persistent premature reflexes
  • stiff or rigid limbs
  • arching back/pushing away
  • floppy tone
  • unable to sit without support at age 8 months
  • clenched fists after age 3 months
51
Q

POSSIBLE BEHAVIOR SIGNS OF CP

A

-excessive irritability
-no smiling by age 3 months
feeding difficulties
-persistent tongue thrusting
-frequent gagging or choking with feeds

52
Q

DIAGNOSIS

A

-diagnosis is based o clinical findings
-failure to achieve milestone may be the first sign
-suspect CP if:
small for age
H/O prematurity
low apgar score
traumatic,inflammatory or anoxic event

53
Q

CLINICAL THERAPY

A
  • treatment focuses on helping the child to develop to his/her maximum potential
  • referrals for PT,OT,speech therapy
  • special education to improve motor function and ability
  • braces,splints, serial casting- prevent contractures, increase ROM
  • mobilizing devices- wheelchairs, scooters
54
Q

CLINICAL THERAPY

A
  • surgical intervention - lengthening of the Achilles tendon,dosal rhizotomy to decrease spasticity
  • medications anti seizure,muscle relaxants
  • prognosis depends on the severity amd presence of deficits
55
Q

SEIZURE DISORDERS

A
  • abnormal electrical discharges in brain
  • one in 20 children will have seizures
  • most children who have one wont experience a second

epilepsy -chronic disorder characterzed by recurrent unprovoked seizures, secondary to an underlying brain abnormality

56
Q

ETIOLOGY /PATHO

A

-result from abnormal excessive electrical discharges from the brain

- may occur due to:
infection
brain trauma
hypoxia
brain tumor
structural defect/electrolyte disturbance

-most common in children

57
Q

TYPES OF SEIZURES

A 
SIMPLE PARTIAL (FOCAL)
-no aura, less than 30sec, no postictal confusion

COMPLEX PARTIAL
- aura,LOC, automatisms(smack lips), may progress to generalized, postical confusion

58
Q

TYPES OF SEIZURES

A

ABSENCE
- no aura, lasts 5-10 sec ,hyperventilation ,staring, brief LOC, postical amnesia

TONIC CLONIC (GRAND MAL)
-LOC,aura?, stiffness F/B rhythmic jerking, eyes roll back, postical confusion,
59
Q

STATUS EPILEPTICUS

A
  • continuous or recurrent seizure, 20min or longer
  • may become hypoxic or hypoglycemic
  • emergency :airway,suction,oxygen,monitoring,neuro assessments
  • IV line for fluids and meds
  • blood glucose administer glucose as indicated
  • protect child from injury
  • administer benzodiazepines ,diazepam ,lorazepam, or midazolam. phenytoin or phenobarbital if seizures continue
60
Q

CLINICAL THERAPY

A
  • through history and physical
  • EEG
  • antiepileptic drugs -monotherapy preferred
  • serum drug level
  • surgery if indicated
  • trial of med withdrawl attempted for children who are seizure free for at least 2-5years
61
Q

NURSING ASSSESSMENT

A
  • monitoring of:
  • seizure activity
  • LOC
  • vital signs/neuro checks
  • signs of hypoxia
  • safe environment
  • family adaption and coping with uncertainty of when next seizure will occur
62
Q

ANTIEPILEPSY DRUGS

A
  • phenobarbital
  • phenytoin(Dilantin)
  • carbamazepine(tegretol)
  • valproic acid (depacon,depakote)
  • levetiracetam (keppra)
  • gabapentin(neurotin)
  • topiramate(topramax)
  • benzodiazepines- diazepam , lorazepam
63
Q

PLANNING FOR SAFETY

A
  • do not leave alone in pool ,use shower instead of bathtub
  • life vest when boating
  • helmet if child has frequent seizures to protect the head
  • wear a form of medical identification , such as medical alert bracelet
64
Q

FEBRILE SEIZURES

A
  • sensitivity of brain to fever
  • run in families , benign
  • 30-40% chance of having future febrile seizures
  • peak incidence between 18-24 months
  • generalized tonic-clonic movements with eyes rolling back, last 1-2min followed by brief postictal period
  • acetaminophen or ibuprofen

Pediatrics (7 decks)

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