Lecture 5.2 - Neurological Conditions Flashcards
What things are assessed in the pediatric neurological assessment?
LoC
Posture & Tone
Pupil Reaction
Systemic effects of neuro failure - resp + cardio
What percent of an infant’s and adult’s body weight does the brain take up?
12% - infant
2% - adult
What percent of brain growth occurs in the first 1 and 6 years of a child’s life?
50% growth by 1 year
90% by age 6
How much CSF does an infant vs an adult have?
50 mls - infant
150 mls - adult
How much of cardiac output and oxygen does the brain use?
Receives 17% of cardiac output and uses 20% of body oxygen
How is the cerebral perfusion pressure calculated?
CPP = MAP - ICP
How is orientation assessed on a modified GCS for children under 2?
Smiles, listens, follows
–> Followed by cries, persistent cry, agitated, or no response
Why is motor control limited in neonates?
Peripheral nerves are not completely myelinated at birth
How is cerebral perfusion pressure autoregulated?
Cerebral arteries change diameter in response to changes in CPP to allow for steady blood flow to the brain despite changes in MAP or perfusion
What are some metabolic regulatory mechanisms for cerebral blood flow?
Low O2 or high CO2 can cause vasodilation of cerebral arterioles to increase blood flow to the brain
Fever increases metabolic activity and production of waste products - vasodilation will promote flushing of metabolites
Why does fever result in vasodilation of the cerebral arterioles?
Vasodilation will promote flushing of metabolites
Fever —> Higher metabolic rate –> Faster production of metabolites
What is a primary concern for a child under 3mo with a fever?
Infection becoming systemic
–> Sepsis –> Meningitis
What things are tested for in a full sepsis workup?
Urine, blood, CSF
Why are infants under 3 months more susceptible to meningitis?
Immature BBB + immune system
How does the brain compensate for increase ICP?
By decreasing CSF and venous volume to make space for the mass
–> Once compensatory mechanisms are exhausted, ICP rises quickly
An infant presents with bulging fontanels, a separation of cranial sutures, increased head circumference, distended scalp veins, and a high-pitched cry, and sunset eyes.
What are these indicative of?
Increased ICP
–> Also see poor feeding & vomiting, altered LoC
A child presents with N&V, altered LoC, headache, diplopia/blurring of vision, behavioural changes and slurred speech.
What might be wrong?
Increased ICP
–> seizures can also be seen
What are some late signs of increased intracranial pressure?
Altered pupil size and reactivity
Decreased motor or sensory response
Coma
Posturing (decerebrate/decorticate)
Papilledema
Projective vomiting
Absent gag reflex
Absent gag reflex is a late sign of what?
Increased intracranial pressure
What changes in VS are a late signs of increased intracranial pressure?
Bradycardia
Irregular or decreased respirations
–> Cheyne Stokes
What are sunset eyes? What are they a sign of?
whites of eyes visible above iris/pupil
–> Sign of increased intracranial pressure in infant
How does decrease HR and RR with increased intracranial pressure exacerbate the problem and lead to decompensation?
Leads to decreased O2, increased CO2 –> cerebral vasodilation –> increased ICP –> Further decrease in RR
How does the increase in temperature (or temperature instability) or seizures lead to an increased intracranial pressure lead to neurological decompensation?
Increased metabolic needs of brain –> increased ICP –> seizures –> Increased metabolic rate
How would you assess limb weakness in a baby?
Loss of flexion tone
What signs would indicate cerebellar dysfunction?
Pronator drift
Ataxia - poor balance, coordination, dizziness
Speech issues
What are the three steps of a head injury (pathophys)?
- Coup (1°)
- Contrecoup (2°)
- Cerebral edema
Why are children at a higher risk of head injury?
Larger heads
–> Kind of top heavy, bobble head :)
What are some important questions to ask when a child has a head injury?
Mechanism of injury
Loss of consciousness
Seizure
Vomiting
What are some important assessments for a child with a head injury?
Hx
Pulse, BP, temp, Resp SpO2
GCS - age appropriate
Pain
Sedation score
Fluids - SIADH & dilutional hyponatremia –> increased edema
What medications are often administered to a child with a head injury?
Anticonvulsants
Osmotic fluids or 2/3 maintenance fluid requirements
Analgesia
What are the goals of care for a child with a head injury?
Oxygenation
Normothermia
Pain management
NPO
Glucose checks q4h
Fluid restriction + osmotic diuretic
Cluster care - decrease stressors
Family assessment + support
–> Family contact has been shown to decrease ICP
Why is SIADH and associated dilutional hyponatremia a concern for a child with a head injury?
Hyponatremia Increases cerebral edema
Why should you prioritize clustering care in children with increased ICP?
Avoiding/minimizing stressors that cause increased ICP
What are the three main types of meningitis?
- Bacterial/pyogenic
- Viral/aseptic
- Tuberculous
What are the most common causative factor of bacterial meningitis?
GBS, Hib, N. meningitidis
How does meningitis often occur? What does it result in for surrounding tissues?
Using caused by vascular dissemination from infection elsewhere that has crosses the BBB and multiplied in CSF
Causes accumulation of WBCs, exudation, adhesions, cerebral edema
–> Tissue damage and narrowing of passages that obstruct the flow of CSF
What does a purpuric or petechial rash in children indicate?
meningococcal infection
With what infection is chronic ear drainage seen?
Pneumococcal meningitis
What are the two main kinds of hydrocephalus
Communicating - CSF can still flow between ventricles
Non-Communicating - Flow of CSF is blocked along one or more passages connecting ventricles
(Non-communicating hydrocephalus is also called obstructive hydrocephalus)
What kind of monitoring is necessary for a person with a ventriculoperitoneal shunt?
Infection & blockage
What cardiovascular changes are red flags for neurological failure?
Hypertension and/or bradycardia
What respiratory systems findings are indicative of neurological failure?
Irregular breathing patter
Absent gag/cough reflex
What does AVPU stand for?
Alert/ (responds to)Voice/(responds to) Pain/Unresponsive
Assesses LoC/responsiveness
What is the purpose of GCS?
To determine severity of injury and identify trends over time
–> Subtle changes are the most important indicators, input from those who know the child is very important
What kinds of infections can cause increase in intracranial pressure?
Meningitis, encephalitis, brain/spinal abscess
–> Might be d/t post-procedural or related to sepsis
What are some congenital anomalies that can lead to increased ICP?
Arteriovenous malformation, aneurysm, hydrocephalus, spina bifida
What are some diseases that can result in increased intracranial pressure?
Tumors, epilepsy, DM, DI, SIADH, Guillain Barre syndrome
What cranial nerves are being tested when we check PERRLA?
Size, shape, reactivity - CN3 Oculomotor
Focus - CN2 Optic
What cranial nerves are being tested when we assess if a person can track the 9 visual fields?
CN4 trochlear
CN6 abducens
What cranial nerve is being assessed when we assess facial symmetry?
CN7 facial
What cranial nerves are being assessed when we assess clarity and coordination of speech?
CN5 trigeminal
CN9 glossopharygeal
What cranial nerve is being assessed when we assess the sound of voice?
CN10 vagus
What cranial nerve is being assessed when we assess hearing?
CN8 auditory/acoustic
What cranial nerve is being assessed when we assess tongue movements?
CN12 hypoglossal
Headache, light sensitivity, seizures, nuchal rigidity, and the Brudzinski and Kernig signs are symptoms of what?
Meningitis in children and adolescents
What is a positive Brudzinski sign?
Lie patient supine
–> Knees and hips flex when head does
Sign of meningeal irritation
What is a positive Kernig sign?
Lie patient supine with hip and knee flexed at right angle
–> Pain/resistance when extending knee beyond 135°
Sign of meningitis
Why is meningitis challenging to diagnose in infants and young children?
The classic picture is rarely seen in children from this age group
–> Seizures with high pitched cry
–> Poor feeding
–> Bulging fontanels
–> vomiting
–> Fever
Nuchal rigidity may or may not be present, and Brudzinski and Kernig’s signs are difficult to elicit and evaluate in this age group
Bacterial meningitis is a medical emergency requiring ICU care. How is it managed by nurses?
Isolation, antibiotics, reduce ICP, manage pain.
Maintain temperature, ventilation, hydration and manage systemic shock
What should you do when a person has a seizure?
- Prevent injury
- Maintain airway
- Call for help
- Observe: duration, behaviour, movements in hands and face, resp effort, incontinence
What diet can help control chronic epileptic seizures?
Ketogenic diet
–> Increased ketone bodies have anti-seizure effect
What is the earliest indicator of improvement or deterioration in neurological status?
Changes in LoC
Widely dilated and reactive pupils that may involve one side are seen when?
Often seen after seizure
What causes decorticate posturing?
Dysfunction of the cerebral cortex
What causes decerebrate posturing?
Dysfunction at the midbrain or brainstem
What position should a child with increased ICP be in?
With the head of the bed is elevated to 15 to 30 degrees and child is positioned so that head is at midline
–> Facilitate venous drainage and
avoids jugular compression.
What is an epidural hematoma? How does it affect the brain?
Bleeding between the dura and skull to form a hematoma
–> Forces underlying brain downwards as it expands
Often begins with momentary unconsciousness followed by a normal period, then lethargy and coma d/t pressure on the brain
What is a subdural hemorrhage? How does it affect the brain?
Bleeding between the dura and arachnoid
–> Spreads thinly and widely until it is limited by dural barriers (results in increased ICP)
What are common complications following submersion injuries?
Reflex laryngospasm + pulmonary edema (exacerbates issue)
Aspiration pneumonia
How is meningitis diagnosed?
Lumbar Puncture
What is aseptic meningitis?
Meningeal symptoms without bacterial growth from CSF cultures
–> Viral in origin
Diagnosis is based on
How can we manage edema and prevent increased ICP in patients with head injury?
Osmotic fluids or 2/3 maintenance requirements
–> Mannitol, 3%NaCl, Lasix
What is a simple partial seizure?
Focal Aware
–> Characterized by localized bilateral motor symptoms
What is a complex partial seizure?
Focal Impaired Awareness
–> Complex aura with period of amnesia, impaired consciousness. Drowsiness afterwards
What are infantile spasms?
Seizures seen in infants 6-8 months
–> Numerous seizures daily without postictal drowsiness
May or may not include loss of consciousness. Often includes flexed head, arms extended, and legs drawn up.
How long should a child continue antiepileptic medication following a diagnosis?
Up to two years without a seizure
–> Taper slowly to avoid inducing seizure
Why should children with a history of unexplained seizures be closely monitored when sick?
Fever reduces seizure threshold
What is a febrile seizure?
A seizure associated with fever that occurs in a child who does not have a CNS infection
What are adaptive skills?
Skills that are required for people to function in everyday life
–> Include conceptual, social, practical
What factor has the most significant impact on education for individuals with intellectual impairment?
Motivation
What are the roles of nurses in caring for families of children with intellectual disability?
Education to both child and family
Teaching the child self-care skills
Promoting child’s optimal development
Encourage play and exercise.
Providing means of communication
Establishing discipline/limit setting
Encouraging socialization
Providing information of sexuality - esp in adolescence
Helping Family adjust to future care
