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Peds Exam 1 > Neuro > Flashcards

Neuro Flashcards

1
Q

Basic Structures of the Neurologic System

A
  • Brain
  • Spinal Cord
  • Nerves
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2
Q

Nervous System at birth…

A

complete but immature at birth

-infant is born with all nerves they will have

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3
Q

Myelination of nerves

A
  • incomplete until age 4 years
  • progresses in a cephalocaudal direction
  • responsible for progressive development of fine and gross motor skills
  • need fat in diet for myelin
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4
Q

Pediatric Differences and Risks for Neuro

A
  • head is top heavy
  • neck muscles weak
  • thin cranial bones

-excessive spinal mobility, immature muscles and ligaments or cervical spine

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5
Q

LOC

A
  • most important indicator of neuro dysfunction

- conscious (awareness of stimuli)

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6
Q

Altered Levels of Consciousness

A
  • confusion
  • delirium
  • lethargy
  • stupor
  • coma

-in this order

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7
Q

Confusion

A

slight disorientation to time, place, or person

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8
Q

Delirium

A

restless, fussy, irritable

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9
Q

Lethargy

A

-profound slumber, responds to loud commands, painful stimuli

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10
Q

Stupor

A

-non-purposeful response to moderate stimulation, decorticate or decerebrate posturing

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11
Q

coma

A

no response

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12
Q

Causes of altered LOC

A
  • infection of brain and meninges
  • trauma
  • hypoxia
  • poisoning
  • seizures
  • DKA
  • electrolyte or acid-base imbalance
  • congenital structural defect
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13
Q

Any of causes of altered LOC can result in..

A
  • increased ICP

- decreased cerebral perfusion pressure

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14
Q

increased ICP

A

force exerted by brain tissue, CSF, blood

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15
Q

decreased CPP

A

amount of pressure needed to perfuse brain

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16
Q

increased ICP can lead to…

A

decreased cerebral perfusion pressure

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17
Q

Pediatric Glasglow coma scale

A
  • 3 part assessment
  • eyes
  • verbal response
  • motor response
  • score 15: unaltered LOC
  • score of 3: extremely decreased LOC; worst possible score on the scale
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18
Q

Pediatric Neuro Assessment Guidelines

A
  • LOC
  • VS
  • pain
  • cognition
  • head
  • eyes
  • neck
  • posture/movement
  • reflexes
  • cranial nerves
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19
Q

Bacterial Meningitis

A
  • inflammation of the meninges
  • newborns and infants at greatest risk
  • higher morbidity and mortality than viral meningitis
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20
Q

Newborns to 1 month

A
  • group b strep
  • e. coli
  • listeria monocytogenes
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21
Q

Over 1 month of age

A
  • streptococcus pneumoniae most common
  • neisseria meningitidis
  • haemophilus influenzae type B
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22
Q

Pathophysiology of Bacteria Meningitis

A
  • often secondary to OM, sinusitis, pharyngitis, cellulitis, pneumonia, or brain trauma
  • bacteria enter bloodstream “bacteremia”
  • bacteria cross BBB and enter CNS
  • inflammation occurs: WBCs accumulate and cover brain with purulent exudate
  • brain swells can lead to increased ICP and hydrocephalus
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23
Q

Clinical Manifestations

A

Classic Triad:

  • fever
  • nuchal rigidity
  • HA or change in mental status
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24
Q

Clinical Manifestations of Neonates

A
  • nonspecific
  • fever or hypothermia
  • poor feeding or suck
  • V/D
  • fontanel bulging
  • irritable or lethargic, weak cry
  • poor tone
  • seizures
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25
Q

Clinical Manifestations of Infants and Young Children

A
  • fever
  • vomiting
  • nuchal rigidity
  • opisthotonos
  • bulging fontanel
  • irritable or lethargic
  • difficult to console
  • high pitched cry
  • seizures
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26
Q

Clinical Manifestations of Older Children and adolescents

A
  • classic signs: fever, HA, nuchal rigidity
  • photophobia, opisthonotonos
  • positive Kernig and Brudzinski signs
  • confusion, delirium, irritable, lethargic
  • vomiting
  • petechial rash
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27
Q

Diagnosis of BM

A
  • based on hx, clinical presentation and labs
  • lumbar puncture (LP)
  • CBC, blood cultures, serum electrolytes and clotting factors, UA with C&S
  • CT scan for increased ICP or suspected brain abscess
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28
Q

Antibiotic Tx of BM

A
  • antibiotics administered as soon as blood, LP, urine obtained
  • IV antibiotics for 7 to 21 days
  • may be changed when culture results available
  • contacts may need prophylactic antibiotics (Cipro or Rifampin)
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29
Q

General Tx of BM

A
  • NPO, IVF (2/3 maintenance initially)
  • Tx of increased ICP with mannitol and furosemide
  • Tx seizures
  • Tx shock to maintain CPP
  • Tx fever/isolation
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30
Q

Nursing Management of BM

A
  • Monitor VS, LOC, pupils, neuro status, I and Os, labs, ICP, CPP
  • Assist with LP: position after LP, supine to prevent HA
  • Seizure precautions
  • Antibiotics, antipyretics
  • measure head circumference
  • promote comfort and quiet environment with minimal stimulation: reduce noise, light
  • isolate first 24-48 hours
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31
Q

Sequelae

A
  • most common: 8th cranial nerve, hearing loss
  • seizures
  • hydrocephalus
  • developmental delay
  • learning problems
  • severe: septic shock, stroke, death
  • EBP: study indicates that heparin and ASA may discourage stroke in pediatric bacterial meningitis
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32
Q

Preventative Measures for BM

A
  • HIB vaccine
  • Pneumococcal vaccine
  • Meningococcal vaccine
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33
Q

Microcephaly

A
  • small brain
  • head below 3rd percentile
  • due to:
  • fetal insult such as maternal rubella, Zika
  • genetic disorder
  • chromosomal
  • insult during infancy

-associated with DD

34
Q

Hydrocephalus

A
  • water on the brain
  • imbalance b/w production and absorption of CSF
  • body produces 500 mLs CSF/day
  • CSF cushions brain from injury, delivers nutrients, remove wasate and maintains normal ICP
  • circulates throughout ventricular system
  • absorbed within the subarachnoid spaces
35
Q

Etiology/Pathophysiology with hydrocephalus

A
  • congenital or acquired
  • congenital: present at birth, may not be apparent, may be assoc. with other CNS abnormalities (spina bifida)
  • acquired: may be result of illness (tumor) or trauma
36
Q

Most common type of hydrocephalus

A

non-communicating

caused by: obstruction to flow of CSF through ventricular system, ventricles enlarge

  • infection
  • hemorrhage
  • tumor
  • congenital defect
37
Q

Clinical Manifestations of Hydrocephalus in infant

A
  • vary with age of the child
  • rapidly increasing head circumference, decreased LOC, vomiting, irritability, sunset eyes, bulging fontanel, distended scalp veins, bossing of frontal skull
38
Q

Clinical Manifestations of Hydrocephalus in older child

A

signs of increased ICP

  • HA in AM with vomiting
  • ataxia (loss of body control)
  • strabismus (abnormal alignment of eyes)
39
Q

Diagnosis of Hydrocephalus

A
  • prenatally ultrasound
  • clinical manifestations after birth
  • head circumference
  • CT scan
  • MRI
  • U/S of infant head, open fontanel
40
Q

Clinical Therapy of Hydrocephalus

A
  • removal of obstruction
  • creating a new CSF pathway to divert excess CSF (VP shunt)
  • tx of complications
  • manage problems related to psychomotor development
41
Q

VP Shunt Complications

A
  • infection
  • malfunction (blocking or kinking of tube)
  • increased ICP
  • worsening neurological status/altered LOC
42
Q

Nursing care for hydrocephalus

A
  • measure head circumference (infants)
  • observe for signs of increased ICP, may indicate shunt malfunction
  • positioning: usually supine, HOB is raised gradually (post op)
  • provide emotional support to child, parents
  • teaching about medications, signs of shunt malfunction
43
Q

Neural Tube Defects

A

NTDs

  • neural tube is structure in embryo that becomes CNS - brain and spinal cord
  • neural tube fused by 28th day of gestation
  • if neural tube does not fuse properly, a NTD forms at open location
44
Q

Spina bifida occulta

A

spinal cord not completely fused, but does not protrude: tuft of hair or sacral dimple seen

  • mildest form of spina bifida
  • usually no problems with nervous system
-skin indicators:
sacral dimple
port-wine nevus
sacral tufts of dark hair
sacral lipoma
45
Q

spina bifida cystica

A

definition: visible defect with external saclike protrusion

two types:

  • meningocele: fluid filled sac protrudes from back, but spinal cord in normal position
  • meningomyelocele: fluid filled sac with spinal cord
46
Q

Causes of NTDs

A
  • 50% or more: folic acid deficiency

- other cases: multifactorial - environment, chemical, medications, genetic, maternal obesity

47
Q

Prenatal diagnosis of NTDs

A
  • amniocentesis: elevated alpha-fetoprotein in amniotic fluid (16-18 wks)
  • uterine ultrasound
48
Q

Prevention of NTDs

A
  • folic acid supplementation (0.4mg/day)
  • if history of NTD: 4 mg/day
  • 1998 FDA fortifies cereal grains with folic acid
  • begin at preconception
49
Q

Meningocele

A

sac contains meninges and spinal fluid but no neural elements

  • spinal cord in normal position
  • no neurologic deficits
50
Q

Myelomeningocele

A

sac contains meninges, spinal fluid, and nerves

51
Q

With Myelomeningocele: if defect below 2nd lumbar vertebra:

A
  • flaccid paralysis of lower extremities
  • sensory deficit
  • orthopedic braces, walkers, crutches, and wheelchairs
  • bladder and bowel sphincters may be affected
52
Q

Clinical Therapy for spina bifida cystica

A
  • prevent infection of sac
  • assessment of neurologic and associated anomalies
  • early closure in 24-48 hours after birth
  • prevent stretching of other nerve roots and further damage
  • Hydrocephalus - VP shunt placement
  • braces to support joint mobility
  • neurogenic bladder - clean intermittent catheterization q 3-4 hrs
53
Q

Nursing management of spina bifida cystica

A

cover sac with sterile saline dressing

  • place infant prone
  • assess infant for motor, bladder, and bowel deficits
  • monitor VS
  • observe for signs of infection
  • comfort infant
  • create a latex-safe environment
54
Q

Latex Allergy

A
  • SB patients at high risk for latex allergy due to repeated exposure to latex products from multiple surgeries and repeated urinary cath
  • 73 percent of SB patients have latex allergy
  • anaphylactic rxns possible
  • recommend that SB patients avoid latex from birth
55
Q

Discharge teaching for SB patients

A
  • symptoms of increased ICP, hydrocephalus, shunt malformation, UTIs
  • splints, wedges
  • ROM exercises
  • clean intermittent cath q 3-4 hrs
  • community based care
  • braces, walkers, wheelchairs
  • monitor adolescents for mental health issues
  • teach to self-cath when old enough
56
Q

Cerebral Palsy

A
  • most common chronic disorder in childhood
  • disorder of impaired movement and posture
  • 2-3 per 1,000 live births
  • non-progressive, may have perceptual problems, language deficits, and intellectual impairment
  • most cases have abnormal muscle tone and lack of coordination with spasticity
57
Q

Etiology/Patho for CP

A
  • congenital
  • damage to the brain before or during birth
  • hypoxia, infection, abnormal brain structure
  • birth asphyxia accounts for only 6-7 percent of cases
  • preterm, twin, and LBW increase risk
  • very low Apgar score increases risk
  • multifactoral, unknown
  • infant/child develops CP from asphyxia, near drowning, choking, poisoning, head trauma
58
Q

Clinical Manifestations of CP

A
  • spastic most common clinical type (75percent of cases)
  • persistent hypertonia and rigidity
  • impairment of fine and gross motor skills
  • contractures and abnormal curvature of the spine
  • exaggerated DTRs, positive babinski
  • classic gait: intoeing
59
Q

Possible Motor Signs of CP

A
  • poor head control after age 3
  • persistent premature reflexes
  • stiff or rigid limbs
  • arching back/pushing away
  • floppy tone
  • unable to sit without support at age 8 months
  • clenched fists after age 3 months
  • excessive irritability
  • no smiling by age 3 months
  • feeding difficulties (persistent tongue thrusting, freq gagging or choking with feeds)
60
Q

Diagnosis of CP

A
  • based on clinical findings
  • failure to achieve milestone may be the first sign

-suspect CP if:
small for age, H/O prematurity, low apgar score, traumatic, inflammatory or anoxic event

61
Q

Clinical Therapy for CP

A
  • tx focuses on helping the child to develop to his/her maximum potential
  • referrals for PT, OT, speech therapy
  • special education to improve motor function and ability
  • braces, splints, serial casting to prevent contractures, increase ROM
  • mobilizing devices: wheelchairs, scooters
62
Q

Surgical intervention for CP

A
  • lengthening of the achilles tendon

- dorsal rhizotomy to decrease spasticity

63
Q

Medications for CP

A
  • anti-seizure

- muscle relaxants

64
Q

Prognosis for CP

A

-depends on the severity and presence of deficits

65
Q

Seizure Disorders

A
  • abnormal electrical discharges in brain
  • one in 20 children will have a seizure
  • most children who have one seizure will never experience a second
  • epilepsy
66
Q

epilepsy

A

chronic disorder characterized by recurrent, unprovoked seizures, secondary to an underlying brain abnormality

67
Q

Etiology/Patho for Epilepsy

A

-result from abnormal excessive electrical discharges from the brain

may occur due to:

  • infection
  • brain trauma
  • hypoxia
  • brain tumor
  • structural defect/electrolyte disturbance
  • most common in children
68
Q

Types of Seziures

A
  1. simple partial
  2. complex partial
  3. absence
  4. tonic-clonic
69
Q

simple partial

A

-focal

  • no aura
  • less than 30 seconds
  • no postictal confusion
70
Q

complex partial

A
  • aura
  • LOC
  • automatisms (smack lips)
  • may progress to generalized, postical confusion
71
Q

absence

A
  • petit mal
  • no aura
  • lasts 5-10 seconds
  • hyperventilation
  • staring
  • brief LOC
  • postictal amnesia
72
Q

tonic-clonic

A
  • grand mal
  • LOC
  • aura
  • stiffness F/B rhythmic jerking
  • eyes roll back
  • postictal confusion
73
Q

Status Epilepticus

A
  • continuous or recurrent seizure, 20 min or longer
  • may become hypoxic or hypoglycemic
  • emergency: airway, suction, oxygen, monitoring, neuro assessment
  • IV line for fluids and meds
  • blood glucose: admin glucose as indicated
  • protect child from injury
  • administer benzodiazepines
74
Q

Benzodiazepines

A
  • diazepam
  • lorazepam
  • midazolam
  • phenytoin
  • phenobarbital
75
Q

Clinical Therapy for seizures

A
  • thorough hx and physical
  • EEG
  • antiepileptic drugs (AEDs)
  • monotherapy preferred
  • serum drug level
  • sx if indicated
  • trial of med withdrawal attempted for children who are seizure-free for at least 2-5 years
76
Q

Nursing Assessment for Seizures

A
  • monitoring of:
  • seizure activity
  • LOC
  • VS/neuro checks
  • signs of hypoxia
  • safe environment
  • family adaptation and coping with uncertainty of when next seizure will occur
77
Q

Antiepilepsy Drugs

A
  • Phenobarbital
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)
  • Valproic acid (Depacon, Depakote)
  • Levetiracetam (Keppra)
  • Gabapentin (Neurontin)
  • Topiramate (Topramax)
  • Benzodiazepines-Diazepam, Lorazepam
78
Q

Planning for Safety

A
  • do not leave alone in pool
  • use shower instead of bathtub
  • life vest when boating
  • helmet if freq. to protect the head
  • wear a form of medical identification, such as medical alert bracelet
79
Q

Febrile Seizures

A
  • sensitivity of brain to fever
  • run in families, benign
  • 30-40 percent change of having future febrile seizures
  • peak incidence between 18-24 months
  • generalized tonic-clonic movements with eyes rolling back
  • last 1-2 minutes followed by postictal period
  • acetaminophen or ibuprofen
80
Q

Pulsing fontanel

A

normal finding

81
Q

Checking LOC while chemically paralyzed

A

-check pupils is the only way to check LOC

Peds Exam 1 (6 decks)

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