Neuro Flashcards
Categories of Neurologic Disorders
- Structural
- Seizure
- Infectious
- Trauma
- Blood Flow
- Chronic
When does the brain and spinal cord develop from the neural tube?
3-4 weeks gestation
What is myelinization?
The formation of myelin, which covers and protects the nerves. In pediatrics, this formation is incomplete. The speed and accuracy of nerve impulses increases as myelinization increases. The process accounts for the acquisition of fine and gross motor movements and coordination.
In which direction does myelinization occur?
Myelinization proceeds in the cephalocaudal direction. For example, infants are able to control the head and neck before the trunk and extremities.
Deep tendon reflexes in the newborn
Are present at birth and are initially brisk and progress to average over the first few months. Sluggish deep tendon reflexes indicate an abnormality.
What is included in the neurological physical exam?
- LOC
- Vital signs
- Head, face, neck
- Cranial nerves
- Motor function
- Reflexes
- Sensory function
Level of Consciousness
- Full consciousness
- Confusion
- Obtunded (dulled to sensitivity)
- Stupor (state of near unconsciousness or insensibility)
- Coma
What can VS tell you during the neuro assesment?
- Can explain causes for altered LOC
- Tells you if oxygenation and circulation are adequate
* * If there is a decrease in BP and O2 sat and an increased RR = problem
What is included in the neuro assessment of the head, face, and neck?
- Palpation of fontanels
- Inspect size/shape of head and facial symmetry
- Assess ROM of neck
- Measure head circumference
- Alternations in eye movements
- Sunsetting sign of increased ICP
Horizontal nystagmus
May indicate lesion in brainstem (or certain meds)
Vertical nystagmus
Indicates brainstem dysfunction
Pinpoint pupil size
Commonly observed in poisonings, brain stem dysfunction, and opiate use
Dilated but reactive pupils
Seen after seizures
Fixed and dilated pupils
Associated with brainstem herniation secondary to increased ICP
One dilated but reactive pupil
Associated with intracranial mass
What is included in the neuro assessment of motor response?
- Assess bilaterally
- Observe spontaneous activity and resting posture
- Examine for decorticate or decerebrate posturing
Decorticate posturing
Posturing in which there is rigid flexion of arms and extension of legs
- Indicates cerebral cortex damage
Decerebrate posturing
Posturing in which there is rigid extension and pronation of arms and legs
- Indicates brainstem damage
What is the Moro reflex?
To elicit this reflex, place the newborn on his or her back. Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the newborn off the surface. Then release the arms suddenly. The newborn willthrow the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C. The newborn initially appears startled and then relaxes to a normal resting position
When does the Moro reflex disappear?
Around 4 months
Tonic neck reflex
Test this reflex by having the newborn lie on the back. Turn the baby’s head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly.
When does the tonic neck reflex disappear?
Around 4 months
Withdrawal/Babinski reflex
TheBabinski reflexshould be present at birth and disappears at approximately 1 year of age. It is elicited by stroking the lateral sole of the newborn’s foot from the heel toward and across the ball of the foot. The toes should fan out.
When does the withdrawal/babinski reflex disappear?
Disappears around 12 months
Laboratory and Diagnostic Testing in the Neuro Assessment
- Lumbar puncture
- Xrays of head/neck
- Cerebral angiography
- Ultrasound
- CT
- MRI
- EEG
- PET
- ICP monitoring
Lumbar Puncture
- Nurse assist with positioning (fetal or sitting for infant)
- Sedation as needed
- Topical anesthetic 1 hour before
- Space L3-L4 subarachnoid space
- Post-procedure care:
- Lie flat for 30 minutes to an hour post procedure
- Increase fluid intake for 24 hours after the procedure to decrease incidence of headache
Causes of ICP
- Traumatic head injury
- Hypoxemia (near drowning)
- Bleeding in brain
- Congenital or acquired defect (hydrocephaly)
- Infection (meningitis)
- Tumors or cysts
S/Sx of increased ICP in infants
- Poor feeding or vomiting (sucking increases ICP)
- Irritability or restlessness
- Lethargy
- High-pitched cry
- Tense bulging fontanels
- Increasing head circumference
- Separation of cranial sutures - may separate up to five years of age
- Seizures
S/Sx of increased ICP in children
- Severe headache
- Vomiting
- Change in LOC
- Confusion
- Sluggish pupils (or unequal or blown)
- Diplopia (double vision)
- Papilledema
- Changes in VS
Treatment for ICP
- Elevate HOB!!!
- Steroids
- Osmotic diuretics
- Keep oxygenated
- Keep head in midline
- Prevent straining
- Fluid restriction
- Skin care
- No sedatives or opioids
What is the purpose of giving steroids to a patient with increased ICP?
It decreases inflammation
What osmotic diuretic is given to patients with increased ICP?
Mannitol
How do you prevent a patient with increased ICP from straining?
Give stool softeners
What is a MAJOR complication of increased ICP?
Cushing’s Triad
What is Cushing’s triad?
- Widening pulse pressure (increasing systolic pressure)
- Bradycardia
- Respiratory changes
Diagnostic testing for epilepsy
- Blood work
- LP
- CT/MRI
- EEG
Why would blood work be done if epilepsy is suspected?
Blood work is done to rule out metabolic causes such as hypoglycemia and hypocalcemia
Why would a LP be done if epilepsy is suspected?
To analyze CSF to rule out meningitis or encephalitis
Why would a CT/MRI be done if epilepsy is suspected?
To identify abnormalities and intracranial bleeds and rule out tumors
Why would an EEG be done if epilepsy is suspected?
EEG findings may be noted with certain seizure types, but a normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. EEGs are useful in evaluating seizure type and assisting in medication selection. They can be useful in differentiating seizures from nonepileptic activity
If you observe seizure activity directly, a thorough description of the event is needed. What should be included in this description?
- Time of onset and length of seizure activity
- Changes in crying, facial expression, motor abilities, or sensory alterations before the seizure that may indicate an aura
- Precipitating factors such as fever, anxiety, just walking, or eating
- Description of movements and any progression
- Description of respiratory effort/apnea
- Changes in color
- Position of mouth, any injury to mouth or tongue, inability to swallow, or excessive salivation
- Loss of bladder or bowel control
- State of consciousness during and after seizure
- Duration of postictal state
General Epilepsy Treatment
- Aimed at controlling and reducing frequency
- Anticonvulsants
- Surgical intervention
- Family support and education
- Teach on care for seizing child
Surgical Intervention for Epilepsy
Depending on the area of the brain that is affected, it may be possible to remove the area that is responsible for the seizure activity or to interrupt the impulses from spreading, and therefore stop or reduce the seizures.
Educate parent of seizure patient to call EMS if:
- The child stops breathing
- Any injury has occurred
- Seizure lasts for more than 5 minutes
- This is the child’s first seizure
- Child is unresponsive to painful stimuli after seizure
Status Epilepticus
Medical EMERGENCY
- Treat with diazepam or lorazepam
- Dilute only with normal saline
- Give in port closest to vein
- Follow up with continuous IV infusion of phenytoin or fosphenytoin
Febrile Seizures
- Most common type in childhood
- Associated with fever usually related to a viral illness
- Need to make sure not due to infectious disease
- Usually seen in kids 6 months - 5 years old
Neonatal Seizures
- Within first 4 weeks of life
- High age range for seizures due to immaturity of brain
- Can be due to metabolic causes (hypoglycemia or hypocalcemia), hemorrhage, hypoxic encephalopathy
* * Phenobarbitol usually prescribed (dosage will look high)
* * Increased risk of damage to the brain tissue
Specific Nursing Care During a Seizure
- Maintain airway
- Place on side
- Protect from injury but don’t restrain
- Do NOT use tongue blade
- Suction set up and pulse ox
Occulta
** Neural tube defect
Defect of the vertebral bodies without protrusion of spinal cord or meninges
Meningocele
** Neural tube defect
Meninges herniate through a defect in the vertebra (less serious); spinal cord usually normal
Myelomeningocele
** Neural tube defect
Spinal cord ends at defect - results in absent sensory and motor function
Anencephaly
** Neural tube defect
Missing brain hemispheres, skull, and scalp
- Obvious and distinctive appearance
Encephalocele
** Neural tube defect
Protrusion of brain and meninges through a skull defect
Nursing Management of Anencephaly
- Supportive for family
2. Comfort measures
Encephalocele Prognosis
Prognosis depends on size, location, and extent of cognitive defects
Nursing Management of Encephalocele
- Supportive and symptomatic
- Pre and Post Op care (preventing rupture of sac, preventing infection, and providing adequate nutrition and hydration)
* * Monitor for s/sx of increased ICP and head circumference
Arnold Chiari Malformation
Usually associated with hydrocephalus and myelomeningocele. The deformity results from the cerebellum, the medulla oblongata, and the fourth ventricle displacing into the cervical canal, resulting in an obstruction of the CSF can causing hydrocephalus.
Arnold Chiari Prognosis
Depends on the extent of the defect
Arnold Chiari Treatment
Surgical decompression
Hydrocephalus
- Imbalance in production and absorption of CSF
- Accumulates in ventricles
- Congenital or acquired
- Obstructive or non-obstructive
Hydrocephalus Prognosis
Prognosis depends on the cause and if brain damage has occurred
Obstructive Hydrocephalus
Occurs when the flow of CSF is blocked within the ventricular system
- More common than non-obstructive
- Also called noncommunicating hydrocephalus
- Causes: Chiari, encephalocele, trauma, tumor, infection
Non-obstructive Hydrocephalus
Occurs when the flow of CSF is blocked after it exits from the ventricles
** Causes: subarachnoid hemorrage
Nursing Management for Hydrocephalus
- Monitor vital signs
- Monitor neurological status
- Check perfusion (capillary refill, pulse ox)
- Intake and output
- Head circumference and fontanels in infants
Treatment for Hydrocephalus
Ventriculoperitoneal shunt
Post-Operative Care for Hydrocephalus
- Position off shunt
- Frequent vital signs
- Daily head circumference
- Monitor fontanels
- Watch for signs of ICP
- Watch for infection
- Antibiotics as ordered
- Educate parents
S/Sx of shunt infection
- Elevated VS
- Poor feeding
- Vomiting
- Decreased responsiveness
- Seizure activity
- Signs of local inflammation along the shunt tract
S/Sx of shunt malfunction
- Vomiting
- Drowsiness
- Headache
* * S/sx of increased ICP can also be indicative of shunt complications
Craniosynostosis
Craniosynostosis is a birth defect in which one or more of the fibrous joints between the bones of your baby’s skull (cranial sutures) close prematurely (fuse), before your baby’s brain is fully formed. Brain growth continues, giving the head a misshapen appearance.
Streptococcus pneumoniae
- Causes 95% of meningitis cases
- Commonly follows otitis media
- Can be prevented with vaccines
- Pneumovax protects against 23 strains
- Prevnar used in ages under 5 years
Neisseria meningitidis
- May kill within 12 hours
- Petechial rash is identifying finding
- Can cause loss of limbs
Neisseria meningitis vaccine
- Menomune
2. Menatra
S/Sx of Meningitis
- Fever/chills
- Changing LOC
- Seizures
- Irritability
- Lethargy
- Emesis
- Severe headache
- Photophobia
- Opisthotonic position
- Poor feeding
- N/V
- Nuchal rigidity in older children
Kernig Sign
Is tested by flexing legs at the hip and knee, then extending the knee. A positive report of pain along the vertebral column and/or inability to extend knee is a positive sign and indicates irritation of the meninges
Brudzinski Sign
Is tested by the child lying supine with the neck flexed. A positive sign occurs if resistance or pain is met. The child may also passively flex hip and knees in reaction, indicating meningeal irritation.
Meningitis CSF Results
- Increased WBCs from infection
- Decreased glucose
- Increased protein
- Bacteria grows from culture
- Fluid is cloudy
- Pressure is elevated
Nursing Management for Meningitis
- Antibiotics ASAP (after culture obtained)
- Droplet precautions for 24 hours on abx
- Corticosteroids
- Osmotherapy
- Fluid restriction PRN
- Anticonvulsants PRN
- Non-opioid analgesics
- Antipyretics
- Dark room PRN
- Quiet non-stimulating environment
Osmotherapy for Meningitis
- Hypertonic IV fluids
2. Diuretics
Complications of Meningitis
- SIADH (low sodium, high urine specific gravity)
- Brain damage (mental retardation or cerebral palsy)
- Blindness
- Deafness
- Hydrocephalus
- Waterhouse-Friderichsen Syndrome
- Sepsis/Death
Waterhouse-Friderichsen Syndrome
Bleeding into the adrenal glands, caused by severe bacterial infection
- DIC
Encephalitis
Inflammation of the brain
- Can be bacterial, viral, fungal
The S/Sx of Encephalitis are similar to what other disease?
Symptoms are similar to meningitis but may be milder
Encephalitis Diagnostics
- CSF may show increased protein and WBC with normal glucose
- MRI may be done
What is Coup-Countrecoup?
When a child’s head hits an object so hard that the front of their skull fractures (coup)
- Countrecoup (back of the skull fracture)
- Coup-Countrecoup (both front and back)
- Seen in babies that have been shaken and MVAs
Raccoon Eyes
Indicative of a basal skull fracture
Battle’s Sign
Is an indication of fracture of posterior cranial fossa of the skull
Subdural Hematoma
Bleeding between the dura and the brain
- Most common in children under 2
- Symptoms may take 3-20 days to manifest
Epidural Hematoma
Bleeding between the dura and the skull
- Rare in children
Spina Bifida Occulta Nursing Management
- Usually causes no defects so no immediate intervention is required
- Management is usually aimed at education
Meningocele Nursing Management
- Keep the sac intact
- Pre and post op care
- Monitor neuro function and for complications if lesion increasing
Myelomeningocele Nursing Management
- Prevent infection/KEEP CLEAN
- Protect sac until surgical intervention
- Prone positioning
- Attention to urinary/bowel elimination
- Promote adequate nutrition
- Avoid exposure to latex product to reduce risk of developing allergy
- Education
Complications of Myelomeningocele
- Neurogenic bladder
2. Largely associated with hydrocephalus and type 2 Chiari defect in 80% of cases
Muscular Dystrophy
Refers to a group of inherited conditions that result in progressive muscle weakness and wasting
- Duchenne is most common type
- Can see contractures, lordosis, and kyphosis
The Gower Sign
Muscular Dystrophy
First the child must roll onto his hands and knees. Then he must bear weight my using his hands to support some of his weight, while raising his posterior. The boy then uses his hands to “walk” up his legs to assume an upright position.
Muscular Dystrophy Nursing Management
Aimed at promoting mobility, maintaining cardiopulmonary function, preventing complications, and maximizing quality of life.
Cerebral Palsy (CP)
- Nonprogressive motor disorder of the CNS resulting in alteration in movement and posture
- Alteration in voluntary muscular control is related to cerebral insult
How is Cerebral Palsy (CP) Classified?
Classified by type of movement disturbance
- Spastic
- Athetoid
- Ataxic
- Rigid
- Mixed
Spastic CP
Most common type
- Scissor gait
- Toe walking
- Jerky
- Tense muscles
Dyskinetic (athetoid) CP
- Slow writhing uncontrolled movements
- Spasms
Ataxic CP
- Loss of coordination
- Trouble with balance
- “Clumsy”
Nursing Management of Cerebral Palsy
Takes a “village” to take care of these patients
- PT, OT, speech therapy, dietician, orthopedic, neuro
- Medications: Baclofen
- Surgery
- Promote: mobility, nutrition, support, education
Baclofen
Administered for cerebral palsy to manage spaticity
When does the anterior fontanel close?
12-18 months
When does the posterior fontanel close?
By 2 months
Monroe-Kellie Hypothesis
The pressure-volume relationship between ICP, volume of CSF, blood, and brain tissue. When one of these increases in volume, the others must compensate by decreasing in volume (except brain tissue) up to 100 mL
Ketogenic Diet
Believed to help with seizure control by inducing ketosis
- High protein, low carbohydrate
