Chapter 27: Neurologic Dysfunction Flashcards
What are the main cerebral pediatric differences?
4 main differences
- large head in proportion to body (chest circumference) – heavy skull
- poorly developed neck muscles – greater risk for cervical spine injury
- thin cranial bones
- unfused sutures
What are the 3 things that we’re examining for with pediatric LOC?
- what stimuli is needed?
- what is the quality of the response?
- what is the length of the response?
What are the 4 types of concerning LOC?
- confusion: disorientation to time, place, or person
- delirium: characterized by confusion, fear, agitation, hyperactivity, or anxiety; like a behavioral component of confusion
- stupor: response to vigorous stimuli only (sternal rub)
- coma: severely diminished response
Describe the Glasgow coma scale?
- the lower the score, the poorer the outcomes
- 0 - 15 scale
- loss of 1 point is pretty bad
- loss of 2+ points, likely the pt will suffer from long-term neuro consequences
What are some s/s of increased ICP in infants?
10 s/s
- irritability
- poor feeding
- high-pitched cry (cat-like cry)
- inconsolable using conventional methods
- tense and bulging fontanels
- separated cranial sutures
- setting-sun sign – visible eye whites above iris
- scalp veins are distended
- Macewen sign
- increased occipitofrontal circumference
What are some s/s of increased ICP in children?
- h/a
- vomiting – w/ or w/o nausea
- motor weakness
- discoordination
- seizures
- diplopia
- blurred vision
- irritability, restlessness
- behavioral changes
- sleep alterations
- somnolence – flat affect, problems staying asleep/waking
- personality changes
What are some late s/s of increased ICP (for both infants and children)?
- bradycardia
- decreased LOC
- decreased motor response to commands
- decreased sensory response to painful stimuli
- alterations in pupil size and reactivity
- papilledema
- flexion or extension posturing
- Cheyne-Stokes respirations
What is the difference between decorticate and decerebrate posturing?
- decorticate = flexion
- decerebrate = extension
What are seizures?
- abrupt, abnormal, excessive, and uncontrolled electrical discharges of neurons within the brain
- seizures may be symptoms or a diagnosis
What is a tonic-clonic seizure?
seizures with visible movement
What is status epilepticus?
- prolonged continuous seizure of 5 minutes
- serial intermittent seizures lasting >15 minutes without return to baseline
- medical emergency
What are febrile seizures?
5 aspects
- these are specific to peds – occurs 6 months - 6 y.o.
- parent hx of febrile seizures is common
- fever is cause of seizure
- the younger the child, the more likely febrile seizure will reoccur
- sepsis evaluation/work-up determines if there is an infection causing the fever
What are important items to document for seizures?
5 items
- time seizures began
- order of events – aura, where it began, where it progressed to, length from beginning to post-ictal stage
- associated symptoms
- LOC
- s/s when seizure stops
What are some interventions for seizures?
7 interventions
- remain calm
- stay with pt
- protect pt from injury
- keep pt warm
- provide time for child to recover
- reassure and support child and others
- document
How are seizures diagnosed?
- febrile = lumbar puncture
– r/o meningitis which can cause seizures - seizures = EEG, electrolytes, MRI
– EEG diagnoses if someone is currently having a seizure
How are seizures treated?
- prevent with adequate fever control
- meds:
– phenobarbital or diazepam – only if second febrile seizure
– valproic acid
– phenytoin
What is a major education topic for parents with a child with seizures?
diastat – rectal med admin for seizures
There are 2 types of meningitis. Which is the worse one?
bacterial
What causes bacterial meningitis?
- caused by various bacteria
– Step. pneumoniae
– Neisseria meningitidis
– GBS – infants < 2 months
– Listeria monocytogenes – children 2 months - 17 y.o.
– E. coli – rare after infancy - Hib and pneumococcal vaccines decrease incidence
How is bacterial meningitis transmitted?
- droplet transmission
- risk increases with number of contacts
- predominantly occurs in school-age children and teens
- an extension of other bacterial infections through vascular dissemination –> organisms spread to CSF
What are s/s of meningitis?
– newborns:
* poor muscle tone
* weak cry
* poor feeding
* bulging fontanels – late sign
– 2 months - 2 y.o.:
* seizures – high pitched cry
* fever
* nuchal rigidity
– 2 y.o. - adolescent:
* seizures
* nuchal rigidity
* positive brudzinski – flex head to chest while supine, involuntary flexion of knees = positive
* positive kernig’s – knee to chest flexion, then leg extension at knee – resistance or pain = positive
* fever
* h/a
* vomiting
* photophobia
* petechia
* irritability – coma
How is bacterial meningitis diagnosed?
lumbar puncture
* bacterial:
– cloudy CSF
– increased WBCs
– increased protein count
– decreased glucose
* viral:
– clear CSF
can also diagnose with:
* CBC – elevated WBCs
* blood cultures
How is bacterial meningitis managed?
8 management
- seizure precautions
- droplet isolation for 24H
- vitals
- neuro checks
- dark, quiet environment – cluster care, no lights, no TV, no noise
- monitor fluids to prevent overload
- head circumference
- meds:
– IV antibiotics
– corticosteroids – decrease inflammation and ICP
– anticonvulsants
– analgesics
What is Reye syndrome?
- toxic encephalopathy associated with other characteristic organ involvements
- associated with aspirin use and influenza – or other viral infections where aspirin was given
What are s/s of Reye syndrome?
5 s/s
- fever
- profuse vomiting
- neurologic impairment
- seizure
- disordered hepatic function
What is encephalitis? What are s/s?
– encephalitis: acute inflammation of the brain caused by a virus
* mosquitoes
* West Nile virus
* western equine virus
– s/s:
* fever
* irritability
* severe h/a
* bulging fontanel
* alternal mental status
What is hydrocephalus?
- “water on the brain”
- increase in the amount of CSF in the ventricles and subarachnoid spaces of the brain
- caused by obstruction to flow of CSF or impaired absorption of CSF
- commonly associated with myelomeningocele (most severe form of spina bifida; both are neural tube defects)
What are some s/s of hydrocephalus?
6 s/s
- increased head circumference
- split cranial sutures
- high pitched cry
- bulging fontanels
- irritability
- seizures
What are some interventions for hydrocephalus?
VP or AV shunt (ventricle to peritoneum or ventricle to atrium)
* drains CSF from ventricles
* observe for vomiting, h/a, irritability, redness along shunt line or fluid leakage
What is myelomeningocele?
- neural tube defect present at birth that affects the CNS and osseous spine
- posterior portion of vertebral laminae fails to close somewhere along spinal cord –> sac protruding containing CSF, meninges, and portion of spinal cord
What are some s/s of myelomeningocele?
6 s/s
- impairments depends on level of spinal injury
- joint deformities
- bowel and bladder incontinence
- developmental delays – common s/s
- hydrocephalus
- latex allergy – unique to this
What are some interventions for myelomeningocele?
7 interventions
- protect sac from injury and infection – sterile, moist dressings; prevent pressure on back
- surgery
- straight cath
- prevent latex allergy development
- PT and other departments to address developmental delays
- prevent neurogenic bladder and bowel
- prevent skin, urine, and respiratory infections
What is the major difference between pediatrics and adult pts who experience head injuries?
damage to intracranial contents – force of impact is greater than amount of support provided by skull and musculoligamentous system
What kinds of head injuries are pediatric pts more susceptible to?
acceleration-deceleration (shearing) injuries
What is a concussion?
6 aspects
- transient state of neurologic dysfunction caused by a jarring of the brain
- reversible
- result of trauma to the head
- instantaneous loss of awareness and responsiveness
- can last minutes to hours
- followed by amnesia and confusion
How are head traumas treated?
5 interventions
- NPO initially
- possible surgery
- frequent VS
- frequent neuro checks
- meds: analgesics and sedatives
