Ch. 30 Flashcards
brain ____ in childhood
continues to develop
the brain increasingly takes over ___ function
reflexive function
- purposeful movements
neuromotor function is (direction of development)
cephalocaudal (head to toe: child has to develop head control before total body movements like walking)
proximodistal (proximal before distal: hold a bottle before learning to walk)
50% of postnatal brain growth is achieved by
age 1 year
75% of postnatal brain growth is achieved by
age 3
90% of postnatal brain growth is achieved by
age 6
primitive reflexes are
involuntary in nature but signify that the child is developing their central nervous system properly
primitive reflexes are predominant in the first
4-6 months of life
if primitive reflexes persist past 6 months, suggests that the child will
struggle with motor and cognitive functioning as they get older
myelination of nerve tracks in the CNS allows for
progressive neuro motor function
follows a cephalocaudal pattern
children with open fontanels compensate for increased volume by
skull expansion
posterior fontanel closes within the first
2 months of life
anterior fontanel closes between the first
12-18 months of life
premature closure of the fontanels can result in
craniosynostosis
level of consciousness: assessment
- length of LOC (loss of consciousness)
- head injury? –> amnesia
LOC is a way to assess
improvement or deterioration in condition
retrograde amnesia
- inability to recall past memories
- unable to access memories of events that happened before the injury/disease that caused altered LOC
- generally able to remember meaning and information but not specific events or situations
anterograde amnesia
- inability to make new memories
- can be permanent
- often caused from trauma (head trauma)
- cannot transform short-term to long-term memory
the patient with a loss of consciousness may develop sx of:
seizure
vomiting
progressive headaches
nursing care for patient with LOC
- need thorough history
- monitor closely
LOC (loss of consciousness) is typically indicative of
increased intracranial pressure
earliest indicator of deterioration or improvement
level of consciousness
full consciousness
awake
A&O x4 with behavior appropriate for age
unconsciousness
the inability to respond to sensory stimuli and have subjective experiences
confusion
impaired decision making
disorientation
confusion regarding time, place; decreased LOC
lethargy
limited spontaneous movement, sluggish speech, drowsy
obtunded
arousable with stimulation
stupor
remaining in deep sleep, responsive only to vigorous and repeated stimulation
coma
no motor or verbal response to noxious (painful) stimuli
persistant vegetative state
- permanently lost function of the cerebral cortex
- eyes follow objects only by reflex or when attracted to the direction of loud sounds; all four limbs are spastic but can withdraw from painful stimuli; hands show reflexive grasping and groping; the face can grimace, some food may be swallowed, and the child may groan or cry but utter no words
a mini-neurologic exam includes
degree of responsiveness
vital signs: increase or decrease (ie hypothermia in infants with infection)
pupillary findings: pinpoint (accidental ingestion), dilated (post seizure) nonreactive (poisoning)
glasgow coma scale
assessing neuro in children under 2 years
subtle changes
- muscle tone: increase or decrease
- cry: high-pitched cry in infant
- respiratory changes
- presence or absence of primitive reflexes in babies under 6 months
- under 6 months: want moro, tonic neck, withdraw
- babinski reflex: present until 1 year after child is walking well, around 2 years old
tachycardia is a ___ sign of increased ICP
early
bradycardia is a ___ sign of increased ICP
late
glasgow coma scale meaures
eye opening
verbal response
motor
GCS: eye opening
- spontaneous: 4
- opens eyes to speech: 3
- opens eyes to pain: 2
- none: 1
GCS: verbal response
- oriented to person, place, and time: 5
- confused: 4
- inappropriate words: 3
- incomprehensible sounds: 2
- none: 1
GCS: motor
- obeys commands: 6
- moves and localizes to pain: 5
- withdraws from pain: 4
- abnormal flexion (decorticate): 3
- abnormal extension (decerebrate): 2
- none: 1
considerations for the unconscious child
ABCs
- airway: aspiration risk: cough or gag reflex
- breathing
- circulation
LOC: pupil response
- have to use a light
- only document what you test
pain
- scale for unconscious children
temperature
- changes indicate CNS dysfunction; q2-4hr
PEWS scale
- identifies pedi patients at risk for cardiac arrest
- higher score = more concern
ICP monitoring
position
- head is midline or turned to side if they have secretions
- elevate HOB
environment
- auditory is intact while comatose; decrease stimulus
- cluster care
- tactile stimulation may cause changes
FEN
- fluid electrolytes nutrition
- NG tube or G tube for nutrition
- less than prescribed maintenance fluid with increased ICP
elimination
- use urinary catheter
- measure output of infants and toddlers using collection bag and weighing diapers
skin
- eyes: assess for signs of dehydration
- artificial tears q1-2 hr
clinical manifestations of increased ICP in infants
- tense, bulging fontanel
- separated cranial sutures
- macewen sign (cracked-pot)
- irritability and restlessness
- drowsiness
- increased sleeping
- high-pitched cry
- increased frontooccipital circumference
- distended scalp veins
- poor feeding
- crying when disturbed
- setting-sun sign
clinical manifestations of increased ICP in children
- headache
- nausea
- forceful vomiting
- diplopia, blurred vision
- seizures
- indifference, drowsiness
- decline in school performance
- diminished physical activity and motor performance
- increased sleeping
- inability to follow simple commands
- lethargy
late signs of increased ICP
- bradycardia
- decreased motor response to command
- decreased sensory response to painful stimuli
- alterations in pupil size and reactivity
- extension or flexion posturing
- cheyne-stokes respirations
- papilledema
- decreased consciousness
- coma
submersion injury
- major cause of unintentional injury/death in children
- sites of submersion may vary by age
- infant: bathtub
- child: river, lake, ocean
submersion injury prevention
anticipatory guidance to parents
submersion injury: pathophysiology
- multiple body systems: resp, CV, neuro
- injury related to length of submersion
- physiologic factors- hypothermia, aspiration, hypoxia
submersion injury: management
- hospitalized: all children to treat/observe
- restore O2
- warm
- observe for seizures
- respiratory impairment
in cold water, metabolic demand ___
decreases
what reflex kicks in when the child is under water?
diving reflex
- forces the body to preserve the organs by shunting blood to the core and not periphery
what do we need to restore before temperature after submersion?
oxygen
aspiration during submersion is caused by
sucking in a lot of water
- water goes to pulmonary circulation: pulmonary edema, atelectasis, airway spasm
after ___ (time) submerged, the changes are irreversible
4-6 minutes
1st priority when treating a submersion patient
prevent further hypoxic damage
- draw blood gases and pH
- provide O2 as needed
- IVF, electrolyte replacements
nurse’s role during submersion injury
intensive nursing management; similar to the care of an unconscious child
- endotracheal tube, mechanical vent
- monitor blood gases
- assess respiratory, CV, neuro systems
- assess for signs of resp/metabolic acidosis
support family/child/siblings
- permanent damage: guilt/inhibits grieving
- spiritual care: H (hope) O (organized religion) P (personal beliefs) E (effect on child wanted)
prevention
- educate parents
- swimming lessons (preschool age and up)
- CPR education, water safety
hydrocephalus
excess cerebral spinal fluid
- non-obstructive or communicating-impaired absorption
- obstructive or non-communicating obstruction to flow
communicating hydrocephalus
when CSF is able to flow from one ventricle to another
- not able to be reabsorbed
non-communicating hydrocephalus
some kind of obstruction within the ventricle system; CSF cannot flow from one ventricle to another
sunset eyes may indicate __ when seen with hydrocephalus
increased ICP
sunset eyes
- eyes looking downward in corner
- sclera above the iris
- sluggish response to light
hydrocephalus early sx
- enlargement of the head
- lethargy
- poor feeding
- recurrent vomiting
- pushing away (isolation)
care of child with hydrocephalus
- age variations cause different presentations
- head circumference: compare with previous measurements (change by 1+ percentile lines very quickly)
- VP shunt: treatment
- nutrition: FTT, balanced diet is allowed
- developmental: delayed/attn deficit, need team approach to meet milestones
- prevent infection: educate parents; hygiene; no contact sports; helmets
- family support: focus on diagnosis, pre + post op teaching, discharge teaching
hydrocephalus late sx
- frontal bossing (enlarged/bulging ant fontanel)
- distended scalp veins
- high-pitched cry
- decreased muscle tone
- sunset eyes
secondary hydrocephalus sx
headache
decreased appetite
lethargy
N/V
double vision
irritable, restless
personality changes
incontinent
difficulty walking
seizures
VP shunt
mechanical device to treat hydrocephalus
- transports the excess CSF from point of obstruction to a reabsorption site
- planted under the skin
3 parts:
- proximal catheter: sm narrow tube implanted into ventricle in the brain above obstruction
- valve: controls how much fluid is withdrawn from the brain and stores it in the reservoir
- distal end: sm narrow tube that leads to where excess CSF will drain and be absorbed by the body (in the abdomen)
VP shunts are impacted by
magnets
- MRIs
VP shunt: nursing care
- positioning: on unaffected side or back, head elevated 15-30*
- pain mngment
- confirming shunt is working
- care of surgical site
- head circumference
- seizure
- infection signs
- parent education
2 functions of the VP shunt
shunt: allows fluid to go in one direction
valve: allows fluid to flow only when the pressure in the head has exceeded the opening pressure
this system regulated the amount of CSF in the body so it does not take too much or leave too much
life of a shunt
up to 10 years but can last minutes as well
s/sx of shunt infection
- elevated vital signs
- poor feedings
- vomiting
- decreased responsiveness
- seizure activity
- signs of local inflammation along the shunt tract
febrile seizures
- 6 months and <5 years
- generally last less than 5 minutes (1 in 24 hour period of time)
- family tendency
- prolonged >5 min call EMS to go to hospital
- no tepid bath (don’t induce shivering)
- no antiepileptic prophylaxis (not a seizure d/o)
- treatment: antipyretic therapy
febrile seizures (definition)
convulsions (whole body or part of body) in children
- cause by sudden rise in body temperature
- children have normal development, no preexisting conditions
- not a seizure disorder
- recover quickly
reye’s syndrome
child’s disease
toxic encephalopathy
- unknown cause
- effects all body systems but most harmful to the brain liver
- causes an acute instance of increased ICP and accumulation of fat in the liver and other organs (liver related complications)
- 2 phase: occurs with something else
- inborn metabolic error must be ruled out prior to dx with reye’s (liver biopsy and blood work)
s/sx of reye’s syndrome
- persistent, recurrent vomiting
- listlessness
- personality changes: irritable, combative
- disoriented, confused, delirium
- LOC
- fever
- convulsions
- seek immediate medical attn if following a viral illness
major preventable risk factor for reye’s syndrome
aspirin
- HCP should be consulted before giving ASA to a child
risk factors of reye’s syndrome
- a proximal viral illness, such as chickenpox, croup, flu, or an upper respiratory infection
- ingestion of salicylate-containing products (ie ASA) within 3 weeks of the start of the viral illness
how can reye’s syndrome by prevented?
avoid aspirin to treat fevers associated with viruses (inc. peptobismol)
- teach patients to read labels of all medications to determine if ASA is in it
- check with provider before giving OTC medications
cure/treatment of reye’s syndrome
NO CURE
early dx important
aggressive therapy aimed at protecting brain from irreversible damage
- reducing brain swelling
- preventing lung complications
- anticipating cardiac arrest
early stage of reye’s syndrome
lethargic
vomiting
signs of hepatic disfunction in bloodwork
hyperventilation
hyperactive reflexes
delirium
liver
late/severe stage of reye’s syndrome
posturing
coma
large fixed pupils
seizures
flaccid
no DTR
resp arrest
*likely won’t survive
nursing care for reye’s syndrome
monitor vitals
- oxygenation status
- pulse ox
- temperature (q15-30 min w hypothermia blanket)
monitor ICP
- if ICP is increasing, may need to do craniotomy– post op care
blood glucose levels to
assess I&O to prevent fluid overload
assess overall status: cardiac, resp, neuro
prep for seizures
assess cardiopulmonary
position patient: HOB 30*
est oxygen therapy
- ventilation
provide ordered meds; transfuse blood
neuro checks: reflexes, flaccidness
skin and mouth care
move joints if in comatose state
support family and patient
