Care Of The Child With Neurological Disorders Flashcards
Expected closure of the
Anterior Fontanel….
Posterior Fontanel….
Anterior (Front) Fontanel: 7 -18 months
Posterior (Rear) Fontanel: 2 - 3 months
A suture in the skull is a fibrous joint that connects the bones of the skull
The spaces where sutures meet are called _____ (soft spots).
fontanelles
5 states of consciousness
Full consciousness
Confusion
Obtunded
Stupor
Coma
cannot be aroused even with painful stimulation
limited response and falls asleep unless stimulated
disoriented, responds inappropriately
only responds to vigorous stimulation
Full consciousness: A & O x4 / age appropriate behavior
Confusion: disoriented, responds inappropriately
Obtunded: limited response and falls asleep unless stimulated
Stupor: only responds to vigorous stimulation
Coma: cannot be aroused even with painful stimulation
Posturing Description:
Arms flexed tightly to the chest
Legs extended and internally rotated
Feet plantar flexed
Indicates:
Damage to the cerebral cortex or above the brainstem (e.g., internal capsule, thalamus)
Posturing Description:
Arms extended and rotated outward
Wrists flexed, fingers curled
Legs extended with plantar flexion
Indicates:
Damage to the brainstem (below the red nucleus,
Decorticate / Decerebrate
Decorticate
Arms flexed tightly to the chest
Legs extended and internally rotated
Feet plantar flexed
Indicates:
Damage to the cerebral cortex or above the brainstem (e.g., internal capsule, thalamus)
Decerebrate Posturing
Description:
Arms extended and rotated outward
Wrists flexed, fingers curled
Legs extended with plantar flexion
Indicates:
Damage to the brainstem (below the red nucleus,
Categories for Glasgow coma scale…
Eye opening
Motor response/ movement
Verbal Response
Age < 3 years: 4
3–7 years: 3
7–13 years: 2
>13 years: 1
Gender
Male: 2
Female: 1
Diagnosis
Neurological / Metabolic / Seizures 4
Respiratory / Cardiac / Other 3
Other diagnoses 2
Cognitive
Not aware of limitations 3
Forgets limitations 2
Oriented to own ability 1
Environmental Factors
History of falls, sedated, traction: 4
Crutches / IV / Drainage tubes :3
None 2
Response to Surgery / Sedation
Anesthesia Within 24 hours: 3
Within 48 hours, 2
> 48 hours / None 1
Medication Usage:
On sedatives, anticonvulsants, etc. 3
On 1 high-risk med 2
None 1
Risk Levels….
Risk levels:
< 12 = Low risk
≥ 12 = High risk
Procedure to diagnose hemorrhage or infection in the cranium……
CSF analysis
Contraindicated with increased ICP
Lumbar puncture
X ray with an injection of contrast media.
Used to observe blood flow
Procedure….
Cerebral angiogram
Diagnose seizures or brain death, evaluates tumors / hemorrhages
Measures electrical activity in the brain
Electroencefalogram
Intercrainal pressure monitoring.
Device placed in head
Can drain CFS to reduce ICP
______ is the gold standard for ICP measurement.
Direct ventricular pressure measurement
Detects
Brain death
Localized seizures
Tumors
Encephalitis
Hydrocephalus
Uses radiopharmaceuticals.
Single- Photon Emission Computed Tomography (SPECT)
Increased ICP is often caused by Neurological Disorders
Normal ICP
Adult…
Children…
Infants…
Adult <15
Children 3 - 7
Infants 1.5 - 6 mm Hg
Early or Late signs of increased ICP
Headache
Vomiting Projectile
Visual changes
Dizziness
Decreased HR & RR
Early
Early or Late signs of increased ICP
Changes in pupils reactions
Sunset eyes
Changes in LOC
Seizures
Bulging fontanel
Increased circumference of head (Infants)
Early
Early or Late signs of increased ICP
Decreased LOC
Depressed motor / sensory response
Bradycardia
Irregular respiration
Cheyne-strokes
Decerebrate / decorticate posture
Fixed & Dilated Pupils
Late signs
Most seizures are causes by disorders outside the brain
Fever, metabolic compromise, toxins/drugs, HTN
Stroke, neoplasm, congenital brain abnormalities, trauma
Diffuse brain dysfunction
Fever, metabolic compromise, toxins/drugs, HTN, infection
Focal brain dysfunction
Stroke, neoplasm(tumor), congenital brain abnormalities, trauma
A seizure that does not respond to standard treatments, including antiepileptic medications. These are also called drug-resistant seizures and often require alternative therapies like surgery, vagus nerve stimulation, or ketogenic diet.
Refractory/Intractable Seizure
A medical emergency defined as a seizure lasting longer than 5 minutes or repeated seizures without regaining consciousness between them. It can lead to brain damage or death if not treated promptly.
Status Epilepticus:
A subjective sensation or experience that precedes a seizure, often acting as a warning sign. Auras can include visual changes, strange smells, deja vu, or emotional shifts and are technically considered focal aware seizures.
Aura
Involuntary, repetitive movements or behaviors that occur during certain types of seizures (often complex partial seizures). Examples include lip smacking, chewing, fidgeting, or wandering without awareness.
Automatism:
Recurring and unprovoked seizures is called…
Epilepsy
Valproic Acid (Depakote)
Levetiracetam (Keppra)
Carbamazepine (Tegretol)
Oxcarbazepine (Trileptal)
Laser Interstitial thermal therapy
Resection: hemispherectomy, focal Resection, Corpuscular Callosotomy
Ketogenic diet
Vagal nerve stimulator Placement
Treatment for..
Childhood epilepsy
Tonic clonic is a type of generalized seizure
What do the words mean…
Tonic: stiffen
Clonic: rhythmic Jerking
Generalized seizures affect both sides of the brain
Give 3 examples…
Tonic clonic
Absence seizure
Atonic seizure
Generalized (both sides of brain) seizures
Tonic-clonic
Absence
Atonic
Muscles suddenly become limp
Short period of “Blanking Out
Stiffening & rhythmic Jerking
Tonic-clonic
Stiffening & rhythmic Jerking
Absence
Short period of “Blanking Out”
Atonic
Muscles suddenly become limp
Focal (1 side of the brain) seizures
Focal Aware Seizure (Simple Partial)
Person is awake and aware but may have unusual sensations, emotions, or movements (like an aura).
Focal Impaired Awareness Seizure (Complex Partial)
Person is confused or unaware; may have automatisms (lip-smacking, picking at clothes).
True or False
True
Ataxia….
Ataxia refers to lack of coordination or control over voluntary muscle movements, unsteady movements, difficulty with balance, and fine motor problems: writing or speaking
Antiepileptic drugs SE…
Allergic reactions
Sleepiness
Changes in mood/behavior
Vision changes
Ataxia
Febrie seizures happen in children 6 months - 5 years with a temp higher than ____ without another possible cause of seizure.
38°c
Febril seizures peak between 12 - 18 months and are more common in males than females.
Use antipyretic to reduce fever
T or F
T
Neonatal seizures are treated aggressively to prevent brain damage.
Causes:
Hypoxic ischemic encephalopathy
Metabolic disorders
Neonatal infection
Infraction/ hemorrhage
When is the Neonatal period…
First 4 weeks of life
Safety precautions for seizures…
Oxygen & bag/mask
Suction & yanker
Padded rails
Continuous monitoring
PRN meds
Management of Status Epilepticus
Support vital functions how…
Check blood glucose… (T or F)
Administration Oxygen
IV Medication….
If not IV…
Vital functions CAB - Circulation, Airway, breathing
True check BS
IV lorazepam (Ativan) fast onset 2 - 5 min & long half life 12 - 24 hrs
Rectal diazepam 15 min onset
Or
IM, intranasal, buccal Midazolam 8min onset
Status Epilepticus
If IV / rectal lorazepam or
IM, intranasal, buccal Midazolam are ineffective
Give….
IV Phenytoin, fosphenytoin, phenobarbital
Difference in mode of meningitis contagion.
Direct vs secondary…
Direct: LP, Injury, surgery, implants
Secondary: ear, sinus, upper respiratory infection
Viral
antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs)
Autoimmune
May cause inflammation that can cause meningitis.
It is typically considered more serious than bacterial meningitis.
T or F
F
It usually resolves on its own but still very serious
Assessment Findings of Bacterial meningitis
HA
Photophobia
Nuchal rigidity
Rash
Irritation
Lethargy
Stiff muscles
Seizures
Name posistion infant might be displayed in….
Name 2 signs that are associated with bacterial meningitis…
Opisthotonic: back arched, head back, side laying
Brudzinski: Laying, pull neck towards chest and legs go up
Kernig: supine, flex leg 90°, attempt to straighten if pain is worse in head / neck positive sign
Ages most at risk for bacterial meningitis…
1 month - 1 year
&
15 - 24 yrs
Bacterial meningitis has this type of precaution…
Droplet precaution for atleast 24 hours after the start of antibiotics
Gloves, masks, possibly gown
Treatment for bacterial meningitis
(5)
- LP & Culture
- Antibiotics
- Corticosteroids
- Supportive measure
- Education
In addition to being less serious than bacterial meningitis, Aseptic meningitis is also the most common.
Treatment is usually supportive
T or F
T
Fungal, bacterial, viral, protozoan invasion can cause cerebral edema and neurological dysfunction.
Risk factors: travle, animals, outdoor activities
Problem….
Encephalitis
Can antiepileptics be given for encephalitis…
Yes
Rare causes swelling of the brain, liver failure, and death within hours…
Associated with acetylsalicylic acid
Reye syndrome
Don’t use aspirin containing products (Alka-selter / Pepto-bismol) in <15 when they have a fever/ viral infection.
Why….
Reye syndrome
Encephalitis, liver failure, death in hours
Which part of the brain has excess fluid in hydrocephalus…
Ventricles & subarachnoid
Results from an underlying brain disorder
This condition is an imbalance of CSF production & absorption
Results in enlarged ventricles and increased ICP.
Hydrocephalus
Most common type of hydrocephalus
CSF is blocked within the ventricles
Aqueductal stenosis, neural tube defects, trauma, tumors, Chiara malformation
Type of hydrocephalus…
Noncommunocating Obstructive hydrocephalus
CSF is blocked after it exits the ventricles
Usually defective absorption issue with in the subarachoid space
Subarachnoid hemorrhage, meningitis, leukemia infiltration
Tyoe of hydrocephalus…
Communicating nonobstructive hydrocephalus
Hydrocephalus Extracranial Shunt
Ventriculoperitoneal shunt VP - Most common
Atrioventricular Shunt AV
requires revision with growth
Monitor for….
Endoscopic third ventriculostomy ETV - Trials underway
Medications….
Infection
Acetazolamide/ Diamox
Furosemdie / Lasix
Hydrocephalus
Signs of infection:
Poor feeding
Vomiting
Seizures
Lethargy
Increased BP/HR/fever
When infection is present Antibiotics are started and Shunt is externalized with EVD until…
CSF is clear from infection
Hydrocephalus Shunt
Signs of malfunction….(3)
Increased Abdominal Circumference
Vomiting, dizziness
HA
Reasons for shunt malfunction in hydrocephalus….
Kinked or separated catheter
Blockage
Skull fractures:
Linear fractures
Depressed fractures
Diastatic fractures
Basilar Fractures
Most dangerous battle signs & raccoon eyes
Simple break follows straight line
Broken & pushed inwards increased pressure on the brain
Break through the sutures
Linear fractures:
Simple break follows straight line
Depressed fractures:
Broken & pushed inwards increased pressure on the brain
Diastatic fractures:
Break through the sutures
Basilar Fractures:
Break in bottom of the skull. Most dangerous battle signs & raccoon eyes
Compound skull fractures
Lacteration of skin & Splinter.
Exposes the cranial contents to the external environment.
Risks….
Infection Risk: Meningitis, brain abscess, or osteomyelitis due to open wound.
Neurological Damage: From bone fragments or direct trauma to the brain.
CSF Leak: Possible if dura mater is torn.
Hemorrhage: External or internal bleeding may occur.
Blood collection between the dura and the cerebrum…
Subdural hematoma
Subdural hematoma
Treatment….
Monitoring….(2)
Supportive care…(4)
Acute cases: Surgical evacuation via burr hole or craniotomy
Chronic cases: May be managed conservatively or with burr hole drainage
Monitoring: Neuro checks, ICP monitoring if indicated
Supportive care: Oxygen, IV fluids, seizure prophylaxis, manage BP
Injury caused by impact & results in disruption of electrical brain activity….
Concussion
Bruising of the cerebral tissue…
Contusion
Collection of blood outside of the dura but with in the skull…
Epidural hematoma
Priority interventions for severe closed head injury…
CAB
Circulation airway breathing
Severe closed head injury
Why cautious giving narcotics for pain relief…
May mask neurological decline
Retinal hemorrhages are common with this injury…
Shaken baby syndrome
Purple phase (Colic) is a normal phase of infants.
Happens during this time span of growth…
2 weeks & peaks at 2 months.
PURPLE phase of infants happens between 2 weeks & peaks at 2 months.
It is a normal part of development and doesn’t indicate a problem with thr infant.
What does PURPLE stand for…
Peak of crying
Unexpected
Resist soothing
Pain-like face
Long lasting
Evening
The premature brain is at greater risk for these types of problems…
Hemorrhage
Due to increased vascular
The nervous system Mylenation develops in this way….
Cephalocaudal.
Head - Toe
Inwards - Outwards
A head circumference is a normal part of peds measurement until this age….
2 yrs
Bulging fontanels is associated with increased ICP, Hemorrhage, Hydrocephalus, head trauma, meningitis.
When may it be a normal sign…
When crying- but will go way quick
Irritability or inconsolable crying
Lethargy or poor feeding
Vomiting
Seizures
High-pitched cry
Changes in level of consciousness
Downward deviation of the eyes (“sunsetting eyes”)
With a BULGING FONTANEL
can mean these issues…
Head trauma
Hemorrhage
Hydrocephalus
Meningitis
Increased ICP
Glasgow coma scale
What do the following values mean..
3
6
8
- Minimal
- Increased ICP
- Possibly Intubation
When do you close a External Ventricular Drain - used to drain CSF and decreased ICP…
When the pt. Is getting up / moving
When to diagnose epilepsy…
2 unprovoked seizures
1 unprovoked seizures with high risk of more
Surgery to treat childhood epilepsy includes LITT
Lazer interstitial thermal therapy
Describe…
Ablation - of abnormal areas of the brain
Why does a ketogenic diet help with seizures…
Reduces excitablity of the brain
Imbalances that may lead to seizures…
Hypoglycemia- High risk
Hyponatremia- High risk
Hypoglycemia-High
Hypomagnesemia- High
Febrile seizures are most likely in this age range…
<5yrs
Peaks 12 - 18 months
Why is a lumbar puncture contraindicated with Increased ICP…
Risk of brain herniation
Brain will move from area of more pressure to less.
Fatal
Where is CSF found in the brain…
Ventricles
Between the arachnoid mater and pia mater
Describe the 3 layers of the meninges…
Dura = hard outer case
Arachnoid = soft inner bubble wrap with fluid
Pia = cling wrap touching the object directly
With bacterial meningitis how quickly to give antibiotics…
Within 1st hrs.
Ensure Blood Cultures taken first
Vaccines that protects from meningitis….(3)
Meningococcal
Pneumnococcol
HiB
Diagnose meningitis with this procedure…
Lumbar puncture.
Contraindicated in increased ICP
CSF with meningitis
Describe:
WBC…
Protein…
Glucose….
WBC Increased
Protein Increased
Glucose Decreased
________ = “Stiff and Sick” → Stiff neck, headache, photophobia.
______ = “Mind is Messed” → Confusion, personality changes, seizures.
Meningitis = Stiff & Sick
Encephalitis = Mind is Messed
What is the first sign in hydrocephalus Infants ….
First sign of hydrocephalus in children….
Rapid increase in head circumference.
> 95%
Children: personality change
McEwen’s Sign (in Hydrocephalus)…..
Cracked pot sound heard when percussing the skull of an infant with hydrocephalus or raised intracranial pressure.
Setting Sun Sign (common in infants with hydrocephalus)
What it is….
Why…
A downward deviation of the eyes, where the sclera is visible above the iris.
Why it happens: Due to pressure on the brainstem or cranial nerves affecting eye movement.
Mcewins (Cracked Pot) signs is used to assess for…
Transillumination is used to assess for…
McEwins (cracked pot) for Non-Communicating Obstructive hydrocephalus- CSF Within Ventricles
Transillumination: Communicating nonobstructive hydrocephalus- CSF is blocked After leaving Ventricles
Hydrocephalus treatment.
Describe.
Ventriculoperitoneal shunt…
Atrioventricular Shunt….
Ventriculoperitoneal shunt:
Drains ventricular to perineum
Atrioventricular Shunt;
Drains ventricular to atrium of the heart
This type of skull fracture is most serious and may contain Battle signs (bruising behind ears) & raccoon eyes (black eyes) ….
CSF leakage is common and can be detected via glucose reading (presence of glucose in clear fluid = CSF) & Halo Sign (Allow fluid to drip onto gauze - CSF will form a Halo shape around the blood)
Battle sign
Cause:
Rupture of bridging veins between the brain and dura mater.
Often due to head trauma, especially in falls, child abuse (shaken baby syndrome), or elderly with brain atrophy.
Signs and Symptoms:
Gradual onset (hours to days or even weeks)
Headache
Decreased level of consciousness
Confusion or personality changes
Unequal pupils or motor deficits
Vomiting
Subdural Hematoma (SDH)
Cause:
Arterial bleed between skull and dura mater, often from middle meningeal artery rupture.
Usually caused by blunt trauma to the temporal area (e.g., hitting head on corner).
Signs and Symptoms:
Lucid interval: Brief unconsciousness → then awake → then rapid deterioration
Severe headache
Vomiting
Seizures
Hemiparesis
Fixed, dilated pupil (typically on side of bleed)
Rapid progression to coma
Nursing Considerations:
Medical emergency — neurosurgical intervention required
Epidural Hematoma (EDH)
Cause:
Mild traumatic brain injury (TBI) from a blow to the head, fall, or jolt.
No structural damage seen on CT/MRI.
Signs and Symptoms:
Temporary loss of consciousness (not always)
Headache
Dizziness, confusion
Nausea, vomiting
Memory problems (amnesia before/after event)
Sleep disturbances
Sensitivity to light/noise
Nursing Considerations:
Monitor for worsening symptoms (signs of ICP)
Educate about post-concussion syndrome: headaches, mood changes, fatigue lasting weeks
Encourage rest and gradual return to normal activity
Concussion
Cause:
Bruising of brain tissue, often from coup-contrecoup injury (brain hits skull, rebounds).
More severe than a concussion.
Signs and Symptoms:
Similar to concussion but more pronounced and longer-lasting
Loss of consciousness
Neurological deficits depending on location (speech, motor, vision)
Seizures
Personality changes
May show bleeding or edema on imaging
Nursing Considerations:
Monitor for progression of symptoms
Frequent neuro checks
Prevent seizures (possible anticonvulsant)
Reduce ICP triggers (coughing, pain, positioning)
Contusion
In Severe Closed Head Injury
Pt HT increased & becomes agitation
What could this suggest…
Storming.
Could be a good thing if pt is in a coma. Shows Brain is still working or something
A rash forms from taking an antiepileptic med.
After stopping the medication do what next…
HCP within 24 hrs
After a child has a febrile seizure they are at greater risk for developing them again….
False
But increased risk if family members have had them before.
Do you give febrile seizure pts antiepileptics…
No
Elevated liver enzymes
Elevated serum ammonia
Vomiting
Lethargy
Decline mental status
Hyperreflexia
This problem…
Reyes syndrome
Fever
Flu-like symptoms
Lowered LOC
HA
Seizures
Lethargy
This problem…
Encephalitis
HA
Photophobia
Nauchal rigidity
Rash
Drowsiness
Irritated
Muscle rigidity
Seizures
This problem…
Meningitis
4 reasons for aspirin administration in peds…
Kawasaki Disease
Aspirin is used to reduce inflammation and prevent blood clots.
High-dose aspirin during acute phase, followed by low-dose aspirin long-term.
- Rheumatic Fever
Aspirin is used to reduce joint inflammation and fever. - Juvenile Idiopathic Arthritis (less common now)
Used in some cases for pain and inflammation, though other NSAIDs are preferred today. - Pediatric Cardiac Conditions (e.g., post-cardiac surgery or congenital heart defects)
Low-dose aspirin may be prescribed to prevent thrombosis (blood clots), especially after procedures like Fontan surgery.
Chiari malformations can be seen with…
Hydrocephalus : Noncommunocating / obstructive
Chiari malformations = brain pushing into spinal cord
Subarchnoid hemorrhage
Meningitis
Leukemia infiltrate
Lead to this type of hydrocephalus….
Communicating
Nonobstructive
Aqueductal stenosis
Neural tube defects
Trauma
Tumors
Chiari malformations
Lead to this type of hydrocephalus…
Obstructive
Noncommunicating
Main difference between Subdural hematoma & Epidural hematoma….
Sub = Venous rupture, slow bleeding, abuse / falls
Epi = Arterial rupture, EMERGENCY SURGERY
