Module 1 - PEDS Neuro Flashcards
What are the pediatric differences of the head compared to an adult?
- Head is large, neck muscles underdeveloped
- Unfused suture
- highly vascular brain; less CSF cushion
- Cervical spine immature: Increased mobility
- Myelination incomplete at birth
What are children prone to with a large head and underdeveloped neck muscles?
head injury with falls
When are sutures unfused in peds patients?
< 18 months
this leads to being prone to fracture or brain injury - it requires time to solidify and become stronger
What does a highly vascular brain and less CSF lead Peds to be prone to?
hemorrhaging and trauma
When is myelination usually completed for children?
It matures by 4-5 years old but continues through and to late adolescence
Are pediatric seizures more common in children or infants?
Infants
How common are pediatric seizures in children
common
2-4 % of the peds population
How common are pediatric seizures in infants?
very common
1 in 1000 infants
What is the most common type of seizure in peds patients?
Febrile Seizure
Febrile Seizure
most common PEDS seizure
it is due to a sudden, rapid rise in temperature
could be hereditary with no other cause
Its incidence decreases with age
What causes the febrile seizure?
the rapid rise and fall, not the fever itself
What could help decrease a temperature gradually to prevent febrile seizure?
A tepid bath
Epilepsy
chronic Seizure disorder (sometimes in peds patients)
it occurs when you continue to have seizures with age
How does incidence of epilepsy and febrile seizure change with age?
Febrile seizure incidence decreases with age but epilepsy will continue with age
Medications that can treat pediatric seizures?
Dilantin
Phenobarbital
When is medication given for pediatric seizures?
with chronic disorders like epilepsy, but not for a single case febrile seizure
Why do you have to be careful when administering dilantin?
You have to give it with a straw to prevent gum dysplasia in epileptic children
Important types of seizure clinical manifestations?
Generalized
Partial
Absence
Generalized seizure clinical manifestations
Tonic Clonic
Loss of consciousness (grand mal/convulsive - widespread activity)
Partial seizure clinical manifestations
Simple, affect one hemisphere of the brain
Absence seizure clinical manifestations
may have non or minor motor movement
common
just a little out of it
Important infectious diseases that can cause neurological issues in children?
Bacterial Meningitis
Viral (Aseptic) meningitis
Reye’s Syndrome
Guillain-Barre Syndrome
Bacterial Meningitis
Bacterial etiology
Meninges infection / infection of the brain
somehow an infection crosses the blood brain barrier into CSF fluid
Who is at greatest risk for bacterial meningitis?
Infants (70% of cases) <5 years old
What may cause bacterial meningitis
May occur secondary to otitis media, sinusitis, pneumonia, brain trauma, neurosurgery, or many other things really
Meningococcal Meningitis has increased incidence in what population
College Age
so the vaccine is highly recommended for those living in dorms or highly populated living spaces
Rates of meningitis have declined with increased use of what?
HIB and pneumococcal vaccines
Clinical Manifestations of Meningitis in Infants
fever, change in feeding, vomiting, anterior fontanel BULGING, restless, lethargic, irritability
hard to consul even by the parent
piercing cry or lethargy/listless
What does a flat anterior fontanel indicate in infants?
dehydration
What does a bulging flat anterior fontanel indicate in infants?
Meningitis / brain infection with CSF buildup
Clinical manifestations of Meningitis in older children
Fever, irritability, lethargic, confused, combative, answering strangely, headache, back/neck pain, photophobia, nuchal rigidity
potential rash, petechiae, purpura (associated with meningococcal meningitis)
Nuchal Rigidity
back and neck pain by putting chin to chest
if there is pain in the neck or you cannot do it its a positive sign of meningitis
Opisthotonos Posturing
Awkward positioning more comfortable for infants and children with increased cranial pressure related to meningitis
condition in which a person holds their body in an abnormal position. The person is usually rigid and arches their back, with their head thrown backward. If a person with opisthotonos lies on their back, only the back of their head and heels touch the surface they are on.
Lumbar Tap/Puncture
Test checking for meningitis
you stick a needle in the spinal area and draw out CSF for testing
What lab results may occur in CSF for a positive lumbar tap for meningitis?
Increased WBC
low glucose
increased protein
gram stain - positive (60-90%)
culture - positive
contagious !!!
What are the initial steps of clinical therapy for meningitis?
Check and find history, physical exams, and labs
Do a lumbar puncture to evaluate CSF
Administer antibiotics as soon as all culture specimens are obtained
Why do we administer antibiotics as soon as all culture specimens are obtained from a lumbar tap?
We assume the meningitis is bacterial since it can make a kid sicker than viral, so we do not want to wait to start antibiotics
We want to be proactive
Sequelae of Meningitis
neurologic damage
seizure
hearing loss
developmental delays
multisystem organ failure or death
If the meningitis is bacterial what will occur in culture?
it will grow, be contagious, and come out positive
Viral (Aseptic) Meningitis
Less intense than bacterial meningitis
an inflammatory process of the CSF still
Patient will not appear as ill, but treatment is still aggressive until the 48 hour cultures are negative for bacterial - so we still administer antibacterial to be proactive
What will occur for a culture of viral (aseptic) meningitis?
Culture will NOT GROW any bacteria
What levels are normal in CSF from a viral (aseptic) meningitis patient?
Glucose and protein levels in the CSF are normal
Reye’s Syndrome
Unclear etiology
Acute swelling of the brain caused by a toxin or injury - causing inflammation
What is associated with the cause of Reye’s Syndrome
Viral Illness
Use of Aspirin (before the advent of Tylenol) (mimics meningitis when due to aspirin)
Why is Reye’s Syndrome rare?
Nowadays acetaminophen and NSAIDS are used rather than Aspirin (ASA) and we educate parents now
Important Nursing Care steps for Meningitis Patients
ABCs
Cerebral Edema control
Seizure control
Antibiotics (if bacterial)
Steroid use
Put into semi fowler’s position to alleviate some pressure
Guillain Barre Syndrome
A post infectious polyneuritis (inflammation of nerves)
It is an autoimmune response to some infectious process that existed before (in the last few weeks)
It causes deteriorating motor function and paralysis in ascending pattern
Almost like progressive paralysis
What leads to the autoimmune response of Guillain-Barre Syndrome?
GI or Resp infection 2-3 weeks prior
How does deteriorating motor function occur in Guillain-Barre syndrome?
Ascending pattern
so bad motor function and paralysis begins at the lower extremities and works its way up
Treatment for Guillain Barre Syndrome?
Immunoglobulins
How fatal is Guillain Barre syndrome?
rarely fatal
BUT, respiratory difficulty may require ventilation and physical therapy assistance to overcome some paralysis and motor weakness
Special needs for children with disabilities you should consider when nursing?
Growth and development
body image and self esteem
autonomy
socialization and schooling
communication
family interactions and sibling needs
financial needs of the family
family interactions as well
What is important in assisting a chronically ill child’s transition to adult life?
An individualized transition plan including:
Adult oriented healthcare
alternate living arrangements
work skill assistance
Cerebral palsy
A non progressive brain injury or malformation that effects movement, muscle tone, or posture
What does non-progressive mean?
the disease does not necessarily get worse as long as we care and help (especially in moving the child in cerebral palsy)
What may cerebral palsy be secondary to?
secondary to brain damage: congenital, hypoxic, or traumatic origin (like something in utero, during the birthing process, or something after)
The most common chronic disorder in childhood is?
Cerebral Palsy
Classifications of Cerebral Palsy
Spastic
Dyskinetic
Ataxic
Mixed
Spastic Cerebral Palsy
most common type of CP
can involve one or both sides of the body
involves persistent hypertonia - which is rigidity (including scissoring while walking), and exaggerated deep tendon reflexes; persistent primitive reflexes (like moro, and rooting) that do not go away
Issues lead to contractures and abnormal spinal curvatures
Dyskinetic Cerebral Palsy
involves abnormal involuntary movements that disappear during sleep and increases with strength
they keep moving tongue, hands, etc non stop
they have bizarre twisting movements, tremors, exaggerated posturing, and inconsistent muscle tone
Ataxic Cerebral Palsy
Lack of balance and position sense
muscular instability
gait disturbances
Mixed type Cerebral palsy
combination of dyskinetic, ataxic, or spastic cerebral palsy
The most common manifestation in all types of CP is …
delayed gross motor development
What may be the first sign of cerebral palsy?
Failure to achieve milestones - know them as CP leads to delays (ex: reaching with only one arm, poor sucking/uncoordinated, etc)
Manifestations of Cerebral Palsy
Delayed gross motor development
failure to achieve milestones
abnormal motor performance (early hand preference, poor sucking, etc)
alterations of muscle tone (ex: difficulty in diapering)
abnormal postures (ex: scissoring legs or persistence infantile posturing)
reflex abnormalities (persistent primitive reflexes or hyper reflexia)
mental impairment, seizures, ADHD, and sensory impairment sometimes
When first coming into contact with a cerebral palsy patient…
NEVER assume they are disabled initially
DO NOT ASSUME they are mentally impaired as their brain may still be working and are completely “normal”
The focus of clinical therapy for children is…
Helping them reach their maximum potential
Refer for evaluation if they have dev delays or bad reflexes
Refer to PT, OT, speech, special ed, ortho, hearing and vision assistance if they need it !
Ways to help a cerebral palsy child reach maximum potential?
Prevent physical injury and deformity
Promote mobility
Ensure adequate nutrition
Foster relaxation and general health through rest periods
Administer Medications
Encourage self care and independence when possible (they may have normal intellect)
A diet for cerebral palsy should involve…
high protein and high calorie since they have involuntary movements constantly occurring
also help get feeding devices as needs like G tubes
Duchenne Muscular Dystrophy (DMD)
Most common and most severe form of muscular dystrophy
Progressive and leads to death!
Muscular Dystrophy (MD)
disorder that causes progressive degeneration and weakness of skeletal muscles
Why does Duchenne Muscular Dystrophy lead to death in adolescence?
It is progressive and often leads to infection or cardiopulmonary failure
Half of DMD cases are …
X linked
Pathophysiology of Duchenne Muscular Dystrophy
- Dystrophin (protein product in skeletal muscle) is absent in muscles
- there is gradual degeneration of muscle fibers
When do MD symptoms begin?
between 2 and 6 years old (this is when they are noticeable but it begins at birth)
around 9-12 the calf muscles become fibrous and cardiac issues begin
Initial signs and symptoms of MD
delays in further motor development
frequent falls, trouble getting up from sitting/lying position (may not want to run or ride bikes)
difficulties in running, riding a bike, and crawling up stairs/trouble climbing stairs
Progressive Signs and symptoms of MD
abnormal gait becoming apparent
walking ability ceases between 9-12 years old due to calf muscle becoming fibrous
pseudohypertrophy of calf muscles (fatty/fibrous tissue)
cardiac problems (weakened heart muscles)
may start to be unable to eat or walk
Nursing Management for PEDS patients with MD
Assess for signs of disorder progression and complications
maintain optimal physical mobility possible (don’t allow misuse)
compensate for disuse syndrome with positioning, skin care, fluids, chest PT, and a bowel routine
Support the child and family in coping with this progressive disorder
Refer family members to support agencies like the MDA
teach the family and child about diagnosis, treatment, devices, complications, and prognosis
Neurological issues in PEDS patients because of Structural Defects
Hydrocephalus
Spina Bifida
Craniosynostosis
Hydrocephalus
condition caused by an imbalance in the production and absorption of CSF in the ventricular system
Production exceeds absorption, so CSF accumulates, usually under pressure, producing dilation of the ventricles
What can cause Hydrocephalus
congenital
(commonly) associated with spina bifida
could be from tumor, accident, or some issue leading to improper drainage and absorbing
Congenital Hydrocephalus
born with absorption and drainage issues leading to deficits and hydrocephalus
What is hydrocephalus most commonly associated with?
Spina Bifida
Acquired hydrocephalus
usually results from space occupying lesions, hemorrhage, intracranial infections, or dormant developmental deficits
Communicating Hydrocephalus
CSF flows freely but has IMPAIRED ABSORPTION within the arachnoid space
Non Communicating Hydrocephalus
OBSTRUCTION TO THE FLOW of CSF through the ventricular system
More common kind of hydrocephalus
Clinical Manifestations of Hydrocephalus in infants
First sign is BULGING FONTANELS, irritability, then head enlargement, sutures become palpably separated
frontal protrusion or bossing
Setting Sun Sign
pupils may be sluggish with unequal response to light
What is the first sign of hydrocephalus in infants?
Bulging Fontanels
Bossing
Frontal protrusion
front of the forehead comes out and moves forward
Setting Sun Sign / Sunset Eyes
sclera visible greatly/ more so than normal above the pupil with the eyes moved downward and pupils are sluggish to light
Clinical Manifestations of Hydrocephalus in Older Children
Different from infants since the closure of cranial sutures already occurred
There is NO bossing
morning vomiting, headache, confusion, apathy, ataxia, visual deficits/defects
Overall, signs of increased intercranial pressure
The key symptom of hydrocephalus in a brain scan is…
ventricular enlagement
What is absent in hydrocephalus in older children compared to infants?
No bossing / frontal protrusion since the sutures are closed in the skull
Treatment for Hydrocephalus
Ventriculoperitoneal (VP) Shunt
Infection prevention
VP Shunt (Ventriculoperitoneal)
A path for excess CSF from the ventricles to the peritoneum through a hose/tube for reabsorption
Must be replaced as the child grows
it can be blocked, kinked, or cause infection
comes back behind the ear and you may feel it back there when palpating
What does Malfunction of the VP shunt cause?
recurrent signs of increased ICP
Infection (a more serious complication)
Neural Tube Defects
the neural tube is a structure that develops into the brain and spinal cord as well as tissue that surround it for a baby
If it does not develop or close properly in the 3rd or 4th week of gestation then there will be defects in the spinal cord or nerves
The main neural tube defect is …
Spina Bifida
Encephalocele
Opening along the spine or in the facial area where the brain is
they are protrusions/sacs that stick out in these areas
Facial reconstruction can occur for the children
3 Types of Spina Bifida
SB Occulta
Meningocele
Myelomeningocele
Spina Bifida Occulta
SB that does not usually affect the spinal cord
External signs include a dimple or hair patch in the area of the spin
small gap or indent occurs but no opening is present for the spinal cord
Meningocele
Spina Bifida type
a fluid filled sac that protrudes outside the vertebrae
The spinal cord and root are OK where and where they should be
Myelomeningocele
Spina Bifida Type (worst kind)
fluid filled sac also containing the spinal cord and nerve routes protruding from the back
possible muscle weakness, paralysis, urinary bowel problems, joint and bone deformities (nerve issues mean they have trouble moving too)
As you get higher up the spinal column with spina bifida…
the worse the signs and symptoms will be
How does Spina Bifida related back to Hydrocephalus
Outpouching causes CSF flow issues so it may block movement and lead to hydrocephalus
Spina Bifida and ____ often go together
Hydrocephalus
Treatment for SB Occulta
no treatment unless neurologic damage or it opens (sinus needs to be closed)
keep the area clean
Treatment for Meningocele
requires closure as soon after birth as possible
the child should be monitored for hydrocephalus, meningitis, and spinal cord dysfunction
location is very important in determining treatment
Treatment for Myelomeningocele
requires a multidisciplinary approach (ex: neurology, neurosurgery, pediatrics, urology, orthopedics, rehabilitation, nursing, etc)
Closure needs to be done 2-3 days after birth to minimize infection and prevent further damage to the spinal cord and roots
Shunting is performed for hydrocephalus and antibiotics are initiated to prevent infection
the child will need correction of musculoskeletal deformities and management of urologic and bowel control problems
How to prevent infection and injury for the surgical closure of a meningocele or myelomeningocele within 24-48 hours of birth?
- Preoperative apply a MOIST sterile dressing to the lesion constantly having it moist
- Maintain a sterile damp dressing before and after, examine for leakage, avoid placing a diaper or other covering directly over the lesion (as it could cause fecal contamination), monitor for signs of local infection and meningitis (fever, irritability, poor feeding)
- Position in a prone or side lying position to prevent contamination by stool or urine
Position for a SB Patient to prevent stool/urine contamination
Prone or Side Lying Position
How can we prevent the development of neural tube defects?
Encourage women of childbearing age to get 0.4 mg of folic acid daily during preconceptual period
The women should consult their primary care provider or pharmacist to ensure that their multivitamin contain this amount of folic acid
Craniosynostosis
premature closure of the cranial sutures that can lead to skull deformities
can palpate over riding of the suture
brain will continue to grow but the skull is sealed now
When should reconstructive surgery be done for craniosynostosis for best outcome?
before age 1
When does the anterior fontanelle usually close when not diagnosed with craniosynostosis?
closes at 18 months old
Lead Poisoning
one of the most common pediatric problems in the US leading to neurological problems
When is the highest incidence for Lead Poisoning?
late infancy and toddlerhood
Etiology of Lead Poisonin
- Child exposed by eating contaminated food or nonfood, breathing contaminated air, or drinking contaminated water
- Lead dust from pain chips, paint powder, gasoline, unglazed ceramic containers, lead crystal, water from lead pipes, batteries, folk remedies, fishing weights, furniture refinishing supplies, art supplies, cosmetics, pool cue chalk, and even certain industrial pollutants
Why are children at greater risk for lead poisoning?
they absorb and retain more lead in proportion to their weight
What kind of problems with normal cell function does lead poisoning cause?
Nervous System - irreversible damage to developing brain
Blood - displace iron, which decreases heme production - causes Anemia
Kidneys - excreted through kidneys
Adverse affect on vitamin D and calcium metabolism - statute issues causing bone growth issue and decreased height
3 routes of Absorption for Lead
GI
Inhalation
Transplacental (in utero)
Clinical manifestations of Lead Poisoning
Decreased IQ Scores
cognitive deficits (affects ability to learn leading to learning disabilities and cognitive deficits)
Loss of hearing
growth delays
Anemia (offer multi vitamins)
Urine Abnormalities
acute crampy abdominal pain, vomiting, constipation, anorexia
short statue and lead lines in bones on x ray
How does low dose lead exposure cause neurologic manifestations?
behavioral changes like distractibility
hyperactivity
impulsivity
learning problems
hearing impairment
mild intellectual deficits
How does high dose lead exposure cause neurologic manifestations?
lead encephalopathy manifested by seizures, mental deficits, paralysis, blindness, coma, and even death
Important assessment findings for Lead Poisoning?
History of Pica?
Inquire as to housing conditions
How to diagnose/test Lead Poisoning?
Lead lab test revealing serum lead levels exceeding 10 mcg/dL is considered positive for lead poisoning
___ mcg/dL is an amount positive for lead poisoning?
10 mcg/dL
Treatment for Lead Poisoning?
Chelation therapy treatment is the blood lead levels is greater than 4 ug/dL through used of EDTA
EDTA
medicine that binds with lead to be excreted in urine as part of chelation therapy
What to teach the child and family to prevent lead poisoning?
assure they don’t have access to peeling paint or chewable surfaces coated in lead based paint
wash and dry Childs hands frequently
if the soil is likely contaminated plant grass or other ground coverings
if remodeling an old home, follow proper procedures
use only cold water from tap for consumption especially when preparing formula
have water and soil tested
do not store food in open cans
do no use inadequately fired ceramic ware or pottery for food or drink
do not store food or drink in lead crystal
avoid folk remedies or cosmetics that may contain lead
avoid home exposure to lead from occupations or hobbies
make sure that the child eats regular meals and consume adequate amounts of iron and calcium
