Cerebral and Endocrine Dysfunction Flashcards
Main functions/symptoms of endocrine dysfunction (4)
1) energy production
-fatigue, weakness
2) sexual reproduction
-delayed puberty, precocious puberty,
3) growth –> delayed
4) fluid and electrolyte balance
What does thyroid hormone regulate?
basal metabolic rate
2 hormones that the thyroid secretes
1) thyroid hormone
2) calcitonin
2 hormones that thyroid hormone is made up of
1) thyroxin (T4)
2) triiodothyronine (T3)
thyroid hormone function
metabolism
growth and development of body tissues
Juvenile hypothyroidism types (2)
1) congenital
2) acquired
Risk factor for congenital juvenile hypothyroidism
mom taking antithyroid drugs during pregnancy
Causes of acquired juvenile hypothyroidism
thyroidectomy
radiation (Hodgkin or other malignancy)
infection
When should hypothyroidism ideally be identified and treated by?
3 months
What happens if the child is not treated by then
intellectual delay
Clinical manifestations of junevile hypothyroidism (many)
cognitive decline
constipation
growth decline
Therapeutic management of juvenile hypothyroidism
LIFELONG oral TH replacement
increase amount over 4 to 8 weeks
What happens if TH replacement therapy is increased too quickly?
hyperthyroidism
What is important in the treatment of juvenile hypothyroidism?
prompt treatment
compliance
lifelong treatment
Goiter
hypertrophy of thyroid gland
Types of goiter (2)
1) congenital
2) acquired
Main cause of congenital goiter
maternal use of antithyroid drugs during pregnancy
If you know that child is at risk of being born with goiter, what should you be prepared to do?
be ready to intubate
increased risk of breathing difficulties
Causes of acquired goiter (many)
neoplasm
inflammatory disease
increased secretion of pituitary thyrotropic hormone
dietary deficiency - rare in kids
Most common cause of hyperthyroidism in childhood
Graves disease
Symptoms of hyperthyroidism (many)
enlarged thyroid gland
exophthalmos - bulging of the eyes
weight loss
diarrhea
hyperactivity
T or F: Treatment for hyperthyroidism is firmly established.
FALSE
Treatment for hyperthyroidism (3)
1) Antithyroid drugs (PTU and methimazole)
2) thyroidectomy
-if drugs don’t work
3) ablation with radioiodine
Which diabetes type is most common in children?
a) Type 1
b) Type 2
a) Type 1
Type 1 DM
destruction of beta cells, usually leading to absolute insulin deficiency
onset usually in childhood and adolescence
Type 2 DM
insulin resistance
usually later in life
Conditions that can lead to diabetes (2)
1) cystic fibrosis
-pancreas messed up
2) acute lymphocytic leukemia (ALL)
-steroid treatment
Main diabetes symptoms (4)
polyuria
polydypsia
fatigue
weight loss
Diabetes diagnosis (2)
1) glucose levels
2) A1C
Why may children be diagnosed with diabetes on vacation?
parents are with them for an extended period of time for the first time in a while
Diabetes management
insulin pens
insulin pumps
Diabetes is easier to control with:
a) pens
b) pumps
b) pumps
moving towards this
Challenge with insulin administration in childhood
timing of insulin with meals
child may not want to eat
may have to administer halfway through meal
Challenge with diabetes management in adolescence
puberty, growth
body image
drugs and alcohol
Symptoms of cerebral dysfunction in infants
tone
bulging fontanelles
high-pitched cry*
irritability
sleepy
feeding issues, uncoordinated suck
difficult to consol
Big thing in assessment of cerebral function in infants and young children
observe spontaneous and elicited reflex responses
what’s present and what’s not
Assessment of cerebral function
family history
medical history
head-to-toe
neuro
growth and development***
Pediatric Glasgow Coma Scale components (3)
eye opening
motor response
verbal response
Neuro exam components (many)
BP
HR - tachy initially
resp
skin
eyes - pupils, response to light
motor function
posture
reflexes
response to pain
What is a late sign of neuro issues?
hypertension***
bradycardia
T or F: Early signs and symptoms of increased ICP are obvious.
FALSE
may be subtle
What is a major, late sign of increased ICP?
altered LOC
LATE signs of increased ICP
decreased LOC
bradycardia
decreased motor response to command
decreased sensory response to painful stimuli
alterations in pupil size and reactivity
papilledema
decerebrate or decorticate posturing
Cheyne-Stokes respirations (periodic breathing)
Children with increased ICP will have vomiting
a) WITH nausea
b) WITHOUT nausea
b) WITHOUT nausea
Personality and Behavioral Signs of Increasing ICP
irritability, restlessness
lethargy
drowsiness, indifference
decrease in physical activity and motor skills
inability to follow commands
memory loss
lethargy
VERY sleepy and drowsy
but awaken to verbal or physical stimuli
obtunded
arouse with stimulation
confused
stupor
only respond to vigorous and painful stimulation
coma
no motor or verbal response, even to painful stimulation
T or F: Most brain injuries are mild.
TRUE
most are concussions, sustained during sports
Mild TBI - Pediatric Glasgow Coma Scale score
13 to 15
e.g. concussion
Moderate TBI - Pediatric Glasgow Coma Scale score
9 to 12
Severe TBI - Pediatric Glasgow Coma Scale score
< 8
Causes of TBI
falls
MVA
bicycle injuries
shaken baby syndrome
sports
Unique sign of shaken baby syndrome
retinal hemorrhages
Head traumas (3)
1) concussion
2) contusion and laceration
-tearing of tissue
3) skull fractures
-abnormal to see
Current protocol for concussions
do what you can tolerate
Complications of head trauma (many)
epidural hemorrhage
subdural hemorrhage
cerebral edema
herniation
Epidural hemorrhage
between dura and skull
can be LETHAL*
Subdural hemorrhage
in outermost meningeal layer
Cerebral edema
inadequate drainage
accumulation
Herniation
very very high ICP
shifts brain across structures
FATAL*
If child is suspected to have spine issue, what precautions are they put on?
spine precaution
C-spine collar on until excluded
needs to be maintained until excluded by assessment and imaging
Diagnostic eval of TBI
detailed history
ABCs
evaluation for shock
vital signs
neuro exam
LOC
special tests:
-CT scan
-MRI
-behavioral assessment
Care of the comatose child
neuro assessments - ICP*
vital sign monitoring
pain assessments/control
calm, quiet environment
family support
How to know if pain has decreased in comatose child
look at temp, HR, BP
treat pain and see if they go down
Nervous system tumours
difficult to treat
poor survival
signs and symptoms vary
BIG sign of nervous system tumour
chronic headache!
also ICP
Diagnostic eval of nervous system tumours
clinical signs
lumbar puncture*
MRI
-most common but need to be sedated
CT
-quick but radiation
EEG
Treatment of nervous system tumours
surgery
chemo
radiation (less so in children)
Cushing’s Triad
signs of ICP
1) hypertension
2) bradycardia
3) irregular respirations
Intracranial infections
limited response to injury
can affect meninges, brain, or spinal cord
difficult to distinguish
lab studies required*
Bacterial meningitis
acute inflammation of the meninges and CSF
Which vaccine targets bacterial meningitis?
Hib vaccine
Most common causative bacterial agents for meningitis (3)
1) Streptococcus pneumoniae
2) Group β streptococci
3) E. coli
Lab test signs of bacterial meningitis
white cells in CSF
LOW blood sugar (bacteria eat sugar)
HIGH protein
Definitive diagnostic test
lumbar puncture
Signs and symptoms of bacterial meningitis
increased ICP: bulging fontanelles
nuchal rigidity
fever
N/V
irritability
photophobia
no appetite
headache
Transmission of bacterial meningitis
nasopharyngeal secretions
If a child under 1 month has a fever, what do you do?
assume they have bacterial meningitis until proven otherwise!!
don’t have BBB until 1 month
Therapeutic management of bacterial meningitis
isolation precautions
antibiotics
RESTRICT fluids*
ventilation & perfusion
hemodynamics
systemic shock
control of seizures and temp
treat complications
Complications of bacterial meningitis
intellectual disability
seizures
hearing loss (antibiotics or disease itself)
How soon after the initiative of antibiotic therapy for meningitis should you see a response?
24 to 48 hours
Non-bacterial/aseptic meningitis
mainly caused by viruses
Symptoms of non-bacterial/aseptic meningitis (4)
meningeal irritation
headache
fever
malaise
What other diseases is non-bacterial/aseptic meningitis associated with?
measles
mumps
herpes
leukemia
Treatment for non-bacterial/aseptic meningitis
symptomatic
pain, hydration, fever
calm, quiet environment
Encephalitis
inflammatory process of CNS with altered function of brain and spinal cord
Causes of encephalitis (2)
1) direct invasion of CNS by a virus
2) post-infectious involves of the CNS after a viral infeciton
T or F: We usually know the cause of encephalitis.
FALSE
most frequently viral though
Clinical manifestations of encephalitis
malaise
fever
headache/dizziness
stiff neck
nausea/vomiting
ataxia
speech difficulties
poor feeding
Clinical manifestations of SEVERE encephalitis
high fever
stupor/seizures
disorientation/spasticity
coma
ocular palsies
paralysis
Therapeutic management of encephalitis
hospitalization
antimicrobial therapy: IV acyclovir & vancomycin
nutrition*
physio
manage complications like seizures
Reye’s syndrome
toxic encephalopathy associated with other characteristic organ involvement
What is Reye’s syndrome usually caused by?
aspirin
hepatic
Symptoms of Reye’s syndrome
fever
profoundly impaired consciousness
disordered hepatic function
Etiology of seizures (4)
1) acute symptomatic
-associated with head trauma or meningitis
2) remote symptomatic
-prior brain injury such as encephalitis or stroke
3) cryptogenic
-no clear cause
4) idiopathic
-genetic in origin
Seizures linked with a fever are associated with:
a) the temperature itself
b) how fast the temperature rises
b) how fast the temperature rises
Seizure classification (3)
1) focal
2) generalized
3) epileptic spasms
Focal seizure
local onset and involves a relatively small location of the brain
classified based on awareness during seizure
Generalized seizure
BOTH hemispheres, without local onset
awareness impaired
motor involved often bilateral
seizures can be convulsive or nonconvulsive
Epileptic spasm seizure
spasms of muscles of neck, trunk & extremities
mode of onset (focal vs. generalized not well understood)
Epilepsy criteria
at least 2 unprovoked seizures
occurring MORE than 24h apart
Generalized absence seizures
formerly petit mal or absence seizures
very brief
can keep talking, walking
minimal change in tone
can be mistaken for daydreaming
parent may not notice
Focal, Generalized, Unknown Onset Epileptic Spasms
onset in first 6 to 8 months of life
associated with cognitive impairment
spasm but then continue what they’re doing, don’t fall asleep
Febrile seizures
transient disorder - most will outgrow
associated with a febrile illness that is not a CNS infection
should return to alert mental status
Treatment of seizures
pharmacological
keto diet
vagus nerve stimulation device
surgery
avoid triggers
Considerations for seizures drugs
monitor therapeutic levels**
increase dosage as child grows (weight-based)
monitor for side effects
DO NOT STOP ABRUPTLY
Nursing interventions during a seizure
cushions for bed rails
oxygen and suction at bedside
suction if they vomit
time the seizure
positioning maybe
observe symptoms
Hydrocephalus
caused by an imbalance in the production and absorption of cerebrospinal fluid (CSF)
What type of seizure do people with hydrocephalus demonstrate?
pseudo-seizure
somatic presentation
very real to the patient
Etiology of Hydrocephalus
developmental abnormalities
usually apparent in early infancy
other causes include neoplasms, infection, and trauma
often associated with myelomeningocele
Treatment of of hydrocephalus
surgical
ventriculoperitoneal shunt
complications
Signs and symptoms of shunt infection
risk greatest: 1 to 2 months after placement
increased head circumference
symptoms of ICP
massive dose of antibiotics or shunt removal
