Neural Tube Defects & Neuro Concerns Flashcards
How much urine output is anticipated in an infant (0-12 months)
2mL/kg/hr
How much urine output is expected in a toddler?
1mL/kg/hr
How much urine output is expected in an adolescent?
0.5mL/kg/hr
what is the most common type of injury-related mortality for infants?
-suffocation
what is the most common type of injury-related mortality for those ages 1-24?
motor vehicle collisions
what is the most common type of injury-related mortality for those ages 25-69
suicide
what are unintentional causes of injury-related mortality?
motor vehicle accidents poisoning drowning suffocation falls fire
what are intentional causes of injury-related mortality?
suicide and homicide
what are some factors that make infants prone to head and neck injuries?
- have a heavy head in proportion to body
- neck muscles poorly developed
- thin cranial bones, not well developed
- unfused sutures in skull
- excessive spinal mobility
- immature musculature
- joint capsule and ligaments of cervical spine are immature
- incomplete ossification of vertebral bones
what type of spinal injury are infants at high risk of?
C1-C2 high cervical spin injuries
when are brain and spinal cord differentiated in fetal development?
at 3-4 weeks gestation
what can impact or alter brain and spinal cord development of a fetus?
- infection
- trauma
- malnutrition
- teratogen exposure
what are pediatric anatomical and physiological nervous system differences?
- nervous system complete, but immature
- maturation of nerve cells completes around age 4
- glial cells and dendrites increase
- mylenation process happens in cephalocaudal direction and is incomplete until 2 years of age
- head is fastest growing body part until age 5
- vertebrae are incompletely ossified until about age 9
- dislocation at c1-c3 more common in children under 9
- injury at c4-c6 more common in children over 9
what does confusion mean when assessing LOC?
-may be alert, but responses are inappropriate
what does obtundent mean when assessing LOC?
-patient has limited response, falls asleep unless stimulated
what does stuporous mean when assessing LOC?
-patient responds only to vigorous stimuli
what are some possible causes of altered level of conciousness in pediatric patients?
- infection of the brain and/or meninges
- increased intracranial pressure
- trauma
- hypoxia
- poisoning
- seizures
- substance use/abuse
- endocrine or metabolic disturbances
- electrolyte imbalances
- acid-base imbalances
- stroke
- brain tumor
- congenital structural defect
what are the three elements that contribute to ICP
brain tissue
cerebrospinal fluid
blood
what causes spina bifida?
it is a neural tube defect
what is hydrocephalus
- a build up of fluid in brain
- causes pressure, which can lead to problems
- causes abnormal enlargement of ventricles in brain
- may be congenital or happen because of infection, trauma, stroke, tumor, brain bleed
what are the three most common types of spina bifida?
myelomeningocele
meningocele
occulta
what is myelomeningocele?
a form of spina bifida where the spinal cord ends at the site of defect
- motor and sensory function absent below defect
- accounts for about 75% of cases of SB
- has an increased risk associated with it of meningitis, hypoxia, hydrocephalus, and hemorrhage
what are symptoms of myelomeningocele?
- depend on location of defect
- may have partial or complete paralysis of lower parts of body with partial or complete lack of sensation
- may have loss of bladder and/or bowel control
- hydrocephalus (about 90% of the time)
- visible sac-like protrusion on the mid to lower back of a newborn
- most serious form
what is meningocele?
a form of spina bifida
- spinal cord is usually normal, but meninges herniate through a defect in the vertebrae
- typically there are no associated neurologic deficits
- can be surgically corrected
what is spina bifida occulta
a defect in lumbrosacral area
-generally no immediate intervention is require
how can spina bifida be diagnosed before birth?
- 85% of women carrying fetus with spina bifida show elevated serum alpha fetoprotein
- ultrasound
- amniocentesis
what are some complications that can occur with surgical repair of spina bifida abnormalities?
- increased ICP
- shunt complications if shunt is inserted
- infection
what are signs and symptoms of hydrocephalus?
early signs:
- unusually large head
- rapid increase in head size
- vomiting
- distended scalp veins
late signs:
- decreased LOC
- bradycardia
- sunsetting eyes
- apnea
- shrill cry
what can cause hydrocephalus?
- obstuctive causes (obstruction in ventricular system preventing CSF from flowing or communicating with the brain)
- nonobstructive (problems with production or absorption of CSF)
- GR2 malformation (structural defect)
how is hydrocephalus treated?
- re-establishment of balance between CSF production and reabsorption
- shunt insertion
what are some complications that can occur with shunts?
- mechanical failure
- infection
- blockage
what kinds of mechanical failure can occur with a shunt?
- under or over drainage
- blockage
- failure of the valve system
highest incidence of failure is within first few months of surgery
what kinds of infections commonly infect shunts?
40% are staphylococcus epidermus
20% staphylococcus aureus
streptococci and gram negative organisms also common
what is normal intracranial pressure
1-10 mmHg
how can intracranial pressure be measured?
- by lumbar puncture
- by intraventricular catheter inserted into anterior fontanelle
how should the glasco coma scale be modified for infants?
- eye opening to loud noise instead of verbal stimuli
- verbal response - not r/t orientation, instead r/t normal response to stimuli like cooing or smiling.
- motor response - spontaneous instead of obeys commands
what are the normal characteristics of cerebrospinal fluid ?
- clear
- odorless
- WBCs 0-5
- Protein 15-45
- Glucose 50-80
- Pressure 50-180
what are characteristics of abnormal cerebrospinal fluid?
- turbid, cloudy
- elevated WBCs, protein
- Glucose level lower than blood sugar
- pressure greater than 180
what are some nursing diagnoses related to increased ICP?
- pain r/t increased pressure
- altered LOC
- risk for imbalanced nutrition
- risk for altered sleep
- risk for seizures
- impaired mobility
- risk for ineffective cerebral tissue perfusion
- potential for fluid volume deficit
what are some nursing interventions for elevated ICP?
- monitor ins and outs
- monitoring LOC
- monitor for signs of increased ICP
- monitor for signs of infection
- manage pain
- measure head circumference and monitor fontanelles
when an external shunt is installed, what are some care precautions?
- need to clamp shunt everytime child is picked up
- head must remain at same level as body
- sterile technique used when assessing shunt for specimens
- measure CSF output Q1H
what are early signs of dehydration?
- up to 5% weight loss
- increased thirst
- reduced urine output
what are moderate signs of dehydration?
- 6-9% weight loss
- lethargy
- irritability
- moderate thirst
- dry appearance
- sunken fontanelle(s)
- decreased capillary refill
- decreased urine output (less than 1ml/kg/hr for an infant)
- lightheadedness relieved by laying down
what are signs of severe dehydration?
- 10% or more weight loss
- altered behavior (confusion, anxiety, unable to stay awake)
- rapid pulse
- weak pulse
- faintness
- cold, clammy skin or hot, dry skin
- little or no urine
- loss of consciousness
- poor skin turgor
- low/decreased BP
how do isotonic fluids work in the body
- have a concentration of dissolved particles equal to intracellular pressure (osmotic pressure is the same)
- they do not promote a shift in fluids into or out of cells, but will help to rehydrate and bring up BP
- ringers lactate and normal saline (0.9% saline) are both isotonic solutions
how to hypertonic solutions work in the body?
- hypertonic means they have more dissolved particles than the bodies cells, so they draw fluid out
- shrink cells, expand extracellular space. bring fluid into vascular space
- 3% saline, 5% saline, D5W, D5NS, D10W, TPN, albumin are hypertonic solutions
how do hypotonic solutions work in the body?
- have less dissolved particles than cells, so they cause fluid to go into cells and swell them
- should be given with caution
- examples are 0.33% NS and D2.5W
what is one way spina bifida can be prevented?
-women of childbearing age taking folic acid at a dose of 400mcg/day
what are some risk factors for a fetus developing spina bifida?
- woman with no folic acid supplementation and inadequate dietary intake
- woman who takes anti-seizure medication
- family or personal history of neural tube disorders
- previous pregnancy affected by ntd
- clinically diagnosed obesity
why are latex precautions used with patients with spina bifida?
- because they often have many procedures
- especially if needing constant catheterization, are always exposed and have increased risk of developing sensitivity
what are some points to be discussed before discharge?
Discharge information is important part of RN role with these patients
Signs of infection
Signs of increased ICP
Need to know how to self-catheterize/catheterize child
Education r/t how shunt may need to be replaced or lengthened
May need to have guidance about what kind of sports or activities they can participate in
Medic-alert bracelet
Children with spina bifida are at higher risk of obesity/becoming overweight for a number of reasons
Genetic counselling
Diet: high fiber
o May need to be disimpacted, may need stool softeners depending on damage to spinal cord that they have
antibiotics
