Neuro Flashcards
(82 cards)
1
Q
neuro assessment of pediatric pt
A
- complete a comprehensive hx of the child’s developmental and neurological status prior to investigation
- basic components:
- LOC
- pupillary responce
- motor function
- V/S
- head circumference: tape around widest part at or above eyebrow and pinna
- fontanels
- sutures
- inc flexor tone
- response to simulation
- ability to suck: if not coordinated, may aspirate or stop feeding
- assess cry
- assess head control
2
Q
LOC
A
- assess amount of stimulation required to awaken child
- assess if stimulation is required to keep awake
- Glasgow Coma Scale (GCS):
- 3 parts: eye opening response, verbal response, motor response
- document best of each
- used in ED, ICU, neuro floors
- higher the number, the more stable the patient
- minimal–3
- maximal–15
- score of 8 or less: coma
- changes should be documented and reported to the physician immediately
3
Q
define full consciousness
A
- awake and alert
- oriented to time, place, person
- behavior appropriate for age
4
Q
define confusion
A
- impaired decision making
5
Q
define disorientation
A
- confusion regarding time and placed
- dec LOC
6
Q
define lethargy
A
- limited spontaneous movement
- sluggish speech
7
Q
define obtundation
A
- arousable with stimulation
8
Q
define stupor
A
- remains in deep sleep
- responsive only to vigorous and repeated stimulation
9
Q
define coma
A
- no motor or verbal response to noxious (painful) stimuli
10
Q
persistent vegetative state (PVS)
A
- permanently lost function of the cerebral cortex
- eyes follow objects only when by reflex or when attracted to te direction by loud sounds
- all 4 extremities are spastic but can w/ draw from painful stimuli
- hands show reflexive grasping and groping
- face can grimace, some food may be swallowed and the child may groan or cry but utter no words
11
Q
pupillary response
A
- use small penlight
- normal: 2-6 mm
- examine eyes in darkened room
- direct response: if light in R eye, R pupil constrict
- consensual response: if light in R eye, L pupil constrict
- conjugate gaze: both pupils are moving in same direction
- PERRLA: CANNOT test accommodation on the littlest ones b/c they can’t cooperate to do this
12
Q
motor function
A
- posture and muscle tone
- grip strength: fingers in their palm to squeeze
- symmetry of movements made to commands
13
Q
vital signs
A
- heart rate should be WNL–>increases with pain and fear
- normal RR: normal for neonates to have episodes of periodic breathing
- problem if persistent apnea
- BP should be WNL
- temp should be WNL
14
Q
signs of decreasing LOC
A
- gradual loss of eye contact (infant); confusion (child)
- weak irritable cry (infant); less responsive (child)
- less responsive (infant); lethargy (child)
- lethargy (infant); coma (child)
- coma (infant)
15
Q
signs of deterioration in pupillary response
A
- could become–larger, smaller, unequal, sluggish
- disconjugate gaze: eyes moving in different directions
- dilation and unresponsiveness to light: blown pupil–>emergency
- inc in ICP and can lead to herniation
16
Q
signs of deterioration with V/S
A
- change as neuro changes occur-changes in pulse and BP are more important than the direction of change
- tachycardia then bradycardia
- could be inc or dec
- wideneing PP: indicative of IICP
- can be hyper or hypothermic
- esp in neonates–can be hypothermic and this can be infection
17
Q
Cushing’s reflex (triad)
A
- caused by IICP
- triad: bradycardia, inc in BP, irregular breathing
- very late and ominous sign
- means the brain is about to herniate
- resp changes:
- best to describe what is happening than put a label on it
- periodic breathing: ominous sign which indicates brainstem (esp medullary) dysfunction–usually precedes complete apnea
- assess fontanels and head circumference
18
Q
DTRs and other reflexes
A
- DTRs: diminished or absent
- only tested by trained person, not nurse
- oculocephalic reflex (doll’s eyes): move head from side to side
- but don’t do if client has a SCI
- when normal: when head turned to R, eyes go to L
- oculovestibular reflex (ice water calorics):
- don’t do if pt is alert
- put ice water into ear and should see nystagmus toward ear
- so if put in R ear, eyes move to R if normal
19
Q
when should child have good head control?
A
- 4 mos
- unless not sufficient tummy time, which strengthens neck and shoulder Ms
20
Q
Babinski reflex
A
- normal until about 2 yo
21
Q
Moro reflex
A
- strongest during first 2 mos
- if present after 4 mos, it is indicative of brain damage
- could indicate infantile spasms
- absence could indicate hearing impairment
22
Q
Palmar reflex
A
- should disappear by 3-4 mos
23
Q
Rooting reflex
A
- disappears by 3-4 mos
- may persist up to 12 mos when the child is sleeping
- absence is indicative of severe neurological disorder
24
Q
Sucking reflex
A
- reflex persists throughout infancy
- weak or absent reflex indicates developmental delay or neurological abnormality
25
grading of reflexes
* 4+ is hyperactive
* 3+ is brisker than normal
* 2+ is normal
* 1+ is diminished
* 0 is absent
26
neuro assessment in older child
* assess response to command
* assess speech
* orientation: person, place, time, and event
* note mood
* pupillary response
* ability to read, write, copy, draw shapes
27
nursing implications of developmental differences
* nurses must be aware that the assessment of infants and children is limited by the child's developmental level
* can't always tell use how they are feeling or what hurts
* child's neuro status can appear to change rapidly b/c of limitations of assessment
* b/c of open cranial sutures and fontanels--help to compensate for inc in ICP
* neuro signs may be evident or may manifest in more subtle ways, such as lack of interest in eating, irritability
28
factors influencing neuro function assessment
* rate of change
* severity of problem: static or progressive
* nature and location of problem:
* focal: 1 site
* multi focal: multi site
* diffuse: all over
29
non invasive diagnostic neuro testing
* CT scan: allergies, fluids, urine output
* MRI
* EEG
* evoked potentials
* echoencephalogram
* teach pts what is required for tests
* use developmentally appropriate language w/ child and parents
30
invasive diagnostic neuro testing
* LP
* collecting CSF to dx meningitis
* don't do if IICP --get ICP down before can do this test
* use EMLA cream 45 min before with a transparent dressing over it as a topical anesthetic
* cisternal puncture
* subdural tap
* do with substernal hematoma and successively testing to remove pressure
* myelogram
* cerebral angiography
* pneumoencephalogram
31
LP and CSF exam
* normal:
* pressure \<200 cm H2O
* color: clear and colorless
* blood: none
* assess serum glucose before LP and compare to glucose in CSF
32
age related differences in brain growth and cerebral blood flow and O2 consumption
* 50% of brain's growth completed by 1 year
* 75% by 3 yo
* 90% by 6 yo
* CBF and O2 consumption are faster in children b/c of inc in metabolism
* it is important to note the brain is inactive organ that uses 10 times the O2 used by the rest of the body
33
microcephaly vs macrocephaly
* microcephaly: can be genetic or non genetic
* may be caused by a variety of insults that occurs during the 3rd trimester of pregnancy, perinatal period, or early infancy
* macrocephaly: differentiate b/w macrocephaly assocated with hydrocephalus and familial macrocephaly
* large head
* if familial, family all has larger heads
34
craniosynostosis (craniostenosis)
* premature closure at birth of one or more cranial sutures
* more common: premature closure of the sagittal suture with resulting elongation of the skull in the AP direction (similar shape seen in premature infants due to postnatal positioning)
* problematic b/c brain is growing but no where to grow, so growing against closed vault
35
craniosynostosis (craniostenosis) clinical manfestations
* inc ICP: which may or may not cause mental retarfation
* can result in progressive papilledema, optic atrophy, and blindness
36
craniosynostosis (craniostenosis) therapeutic mgmt
* surgical excision of long bars of bone along or parallel to fixed suture
* surgery should be done before 6 mos of age for best cosmetic and neurodevelopmental results
37
craniosynostosis (craniostenosis)
* assessment of premature closure and neuro status
* observe post op for hemorrhage and infection
* don't allow child to lay on the side where skull was removed
38
dynamics of ICP
* definition: pressure exerted by CSF w/in ventricles of brain
* continually fluctuates--responds to arterial pulsation and respiratory cycle
* valsalva maneuver (cough, sneeze, straining): inc ICP, standing up or shifting erect dec ICP
39
volume in the brain and ICP
* skull is rigid compartment, filled to capacity with essentially noncompressible contents:
* brain matter = 80%
* intravascular blood = 10%
* CSF = 10%
* volume of these has to be constant
* if any one inc, another must dec, otherwise ICP inc
40
inc ICP
* diminishes cerebral perfusion
* leads to brain ischemia, infarction = poor prognosis
* sustained inc ICP results in brainstem compression and hernation of the brain from one compartment to another
* becomes irreversible and fatal
* herniations force the cerebellum and brainstem downward thru foramen magnum, compresses brainstem, leads to resp arrest
41
complications of IICP
* inadequate cerebral perfusion
* cerebral herniation
42
clinical manifestations of IICP
* anterior fontanel: bulging, tense, absence of normal pulsations
* head circumference: inc OFC \>2 cms/month in first 3 mos
* HAs: generalized or localized; pain inc with valsalva maneuver
* altered mental status: irritable, fatigued
* vomiting: may or may not be nauseous, may occur after resing in morning
* altered V/S: bradycardia--late sign
* altered vision: diplopia, setting sun sign (eyes moving down and see sclera on top); restricted fields; papilledema
* pupillary changes: normal--\>sluggish--\>fixed and dilated
* altered LOC
* high pitched cry
43
strategies for nursing care of child with IICP
* early recognition and tx:
* establish baseline
* monitor V/S frequently
* recognition of hypercapnia and hypoxia:
* maintain patent aiirway
* may need to suction and hyperventilate but inc ICP, so give extra O2 to help keep ICP normal
* maintenance of normothermia and temp regulation: maintain temp b/w 36.5 and 38 dedg C
* inc temp causes inc O2 needs
* fever causes vasodilation which inc CBF
* don't use cooling mattress/blankets b/c could drop temp too quickly and cause shivering
* maintain optimal head and neck position:
* prevent neck flexion or extension
* elevate HOB 30 deg to promote venous drainage and prevents inc CBF
44
brain tumors
* most common solid tumor of childhood
* clinical manifestations:
* directly related to where tumor is
* in infants whose sutures are still open, no symptoms may be detected early - when obstruction in CSF occurs, then OFC will inc
* most common:
* HA: brain insensitive to pain; compression of arteries/veins produce HAs
* most often continous, but worse in morning
* straining or movement may inc pain
* vomiting: usually not preceded by nausea
* inc ICP compresses brainstem which directly stimulate vomiting center in medulla
45
diagnostics with brain tumor
* MRI
* CT
* cerebral angiography
* electroencephalogram
* LP
* biopsy
46
therapeutic mgmt of brain tumor
* surgery: sterotatic--\>involves use of MRI and CT
* reconstructs the tumor in 3 dimensions
* lasers used
* brain scanning clearly delineates area of brain to be avoided
* radiotherapy: used to shrink tumor
* chemo: controversial; used in combo with surgery and radiation
* does not cross BBB, so may have to give directly in SC which is intrathecal administration
* consequances:
* may harm areas of normal brain and cause deficits
47
radiation somnolence syndrome
* may develop 5-8 weeks after CNS irradiation
* lasts 4-15 days
* may indicate long term CNS sequelae
* child is somnolent and lethargic and may have long term problems
* always potential for recurrence
48
nursing considerations with brain tumor
* assess for S/S--establish baseline
* child and fmaily prep
* post op complications:
* assessment
* positioning
* fluid regulation
* pain control
* may have to give narcotics, but have naloxone ready
* SIADH: dec in urine output, hyponatremia
* watch I/O; limit fluids; have to dilute abx in minimal amt of fluids but still be effective
* DI: inc in urine output; hypernatremia
* need to monitor I/O; check for dehydration
* support family
* promote return to optimum functioning
49
Myelodysplasia
* AKA spina bifida or NTD
50
anencephaly
* absence of brain tissue above rudimentary brainstem
* incompatible with life
51
encephalocele
* external mass or sac that may occur at any place above the skull
* may be covered with scalp or transparent membrane
52
types of spina bifida
* cystica:
* myelomeningocele: contains meninges, spinal fluid, and neural tissue
* spinal nerve roots end in the sac, so sensory and motor function will end at this point
* meningocele: contains meninges and CSF
* occulta: cleft in back, tuft of hair
53
nursing implications with NTDs
* usually cover sacs with damp, sterile 4x4
* put baby prone position b/c have to protect the sac
* parents can hold baby in prone on a pillow
* motor and neural fcn ends in sac so nothing below this
* may not have bowel and bladder elimination function, so straight cath and bowel regimen
54
problems with NTDs
* orthopedic problems:
* clup feet: talipes equinovirus
* contractures
* dislocated hips
* scoliosis
* bowel and bladder dysfunction: almost always apparent
* nerves that supply these organs are in sacral region
* obstruction of CSF--\>hydrocephalus
55
Mitrofanoff Procedure
* appendix is used to provide an alternative route for intermittent catheterization
* appendix is removed from the colon and used to create a conduit b/w abdominal wall and bladder
* if appendix won't work: a monti tube is placed--part of intestine, ileum, or colon is used to create conduit
56
4 prognostic factors of NTDs
* degree of neural involvement
* size and location of sac
* presence of other anomalies
* complications that occur
57
hydrocephalus
* obstruction to flow of CSF, so it builds up in ventricles
* can be temporary d/t injury or chronic w/ NTD
* also assoc with NTD, TBI, brain tumor, prematurity from intraventricular hemorrhage
* communicating vs non communicating
* communicating: impaired absorption of CSF in subarachnoid space
* non-communicating: obstruction to flow of CSF thru ventricular system
* usually from developmental malformation
58
S/S of hydrocephalus
* head grows at abnormal rate
* bulging anterior fontanel
* setting sun sign: eyes rotated down with sclera visible above
* poor feeding irritable with increasing lethargy
* changes in LOC
* opisthotonos: extreme arching-only back of head and heels on bed
* lower extremity spasticity
59
tx of hydrocephalus
* VP shunt
* rarely a VA shunt b/c problems with infection going straight to heart
* complications: infection, malfunction
* S/S of malfunction: vomiting, pupillary changes, change in LOC--same as things you see with IICP
* typically give a little extra length to let child grow
* most ppl will need a new shunt for complication
* fluid put into peritoneal space, absorbed with peritoneal fluid, and eliminated normally
60
ommaya reservoid
* put into top of skull
* can inject into it to pull excess CSF off
61
meningitis
* can be seasonal
* most often in kids under 5, but peak b/w 6-12 mos
* dec incidence due to Hib vaccine
* if baby less than 28 days with high fever: septic workup done
62
clinical manifestations of meningitis
* depends on age of child
* neonates:
* stop eating and refuse feedings
* bulging fontanel usually not present
* won't have nuchal rigidity b/c really supple necks
* can progress to cardiovascular collapse, sz, apnea
* infants/children:
* fever, poor feeding, comiting, marked instability, restless, sz
* _bulging fontanel is most significant_
* nuchal rigidity
* Brudzinski and Kernig signs positive
63
Brudzinski vs. Kernig
* Brudzinski: flex head
* pain or involuntary flexing of knees is abnormal
* Kernig: child lies supine, leg flexed at hips
* resistance or pain upon extension is abnormal
64
older child and adolescent with meningitis
* fever, chills, HA, vomiting assoc with changes in sensorium
* may:
* have sz
* be irritable/agitated
* have photophobia
* nuchal rigidity
* opisthotonis
* + Brudzinski and Kernig
* hyperactive reflexes
* signs of cardiovascular collapse
* petechiae/purpura
* can't just pump fluids freely b/c SIADH can develop
* use 20-30 mL/kg for fluid bolus
65
complications of meningitis
* obstructive hydrocephalus
* subdural effusions
* thrombosis in meningeal veins or venous sinuses
* brain abcesses
* deafness, blindness, and paralysis
* Waterhouse Friderichesen Syndrome:
* overwhelming septic shock
* DIC
* massive b/l adrenal hemorrhage
* purpura
* SIADH: occurs in most with meningitis
* also have dec Na, Cl, and osmolality levels
* may need fluid restrictions--1/2 maintenance
* sz: caused by irritation and destructive changes in cerebral cortex and hyponatremia as a result of SIADH
* w/in first 3 days does not interfere with prognosis, but after 3 days, poor prognosis
66
diagnostics for meningitis
* LP is definitive:
* samples are obtained for:
* culture and gram stain
* bloof cell count
* protein
* glucose: compare serum glucose and CSF glucose levels
* pressure is measured
* if ICP is elevated, start abx first, then if not sensitive to broad spectrum, then may have to switch
* hold off on LP until ICP dec b/c LP and positioning can inc ICP
* blood, nasal, throat cultures
67
therapeutic mgmt of meningitis
* isolation precautions: respiratory/droplet for first 24 hours--\>wear a mask!
* initiation of abx therapy
* maintenance of hydration (may do fluid restriction of 1/2 or 3/4 maintenance if SIADH occurs) and ventilation
* reduction of IICP
* mgmt of shock
* control of sz--anticonvulsants
* control of extremes of temperature
* correction of anemia
* tx of complications
68
preventative and prophylactic measures for meningitis
* preventive measures: prompt tx for URIs, otitis media, etc.
* immunization with Hib vaccine
* prophylactic tx: tx for family and vulnerable populations
* anyone exposed to an individual with Neisseria Meningitis should be given prophylactically
* anyone \<48 mos of age who has not been fully immunized against Hib or is immunocompromised or lives with these children should be treated prophylactically
* prophylaxis: Rifampin
69
seizures and epilepsy
* partial (focal/local) sz:
* simple and complex
* generalized sz
* absence: brief change in LOC, staring off, looks like staring for 3-5 sec
* myoclonic
* tonic
* tonic clonic: note where sz starts at
* protect airway and put child on side
* don't put anything in mouth unless can see something, then use Yankar
* atonic: absence of tone, fall to ground, where helmet
70
define seizure
* sudden, involuntary, time limited alteration in function
* abnormal discharge of cortical neurons
71
define epilepsy
* chronic condition
* lasts \>6 mos
72
define ictal state
* during sz
* may experience incontinence
73
define post ictal state
* after sz
* often fall asleep
74
define status epilepticus
* sz that lasts \>30 min or series of sz that do not allow child to regain consciousness in b/w each sz
75
infantile spasm
* most commonly b/w 6-8 mos of age
* more common in boys
* numerous sz during day w/o postictal drowsiness
* poor outlook for normal intelligence
* suspect these if child has a startle reflex after 4 mos of age
76
clinical manifestations of infantile spasms
* possible series of sudden, brief, symmetric, muscular contractions
* head flexed, arms extended, legs drawn up
* eyes sometimes rolling upward or inward
* may be preceded or followed by cry/giggling
* may or may not include loss of consciousness
* flushing, pallor, cyanosis
77
febrile sz
* more common in boys
* in ages 6 mos-3 yo
* inc incidence if child attends day care
* occurs during temperature spike
* tx:
* tylenol/ibuprofen
* protect airway
* protect form injury
* prophylactic: antiepileptics
* children with focal or prolonged dz
* child with primary relative who had febrile sz
* child \<1 yo
* child with multiple incidents
78
anticonvulsants
* won't use phenobarb b/c ineffective and can lower IQ
* often seed drug cocktail b/c may work at different parts of sz cycles or may work on different types of sz
* SEs: gingival hyperplasia, teratogenic, hepatotoxicity
* therapeutic level:
* if low, don't assume child not getting meds
* make sure parents know to continue meds even if haven't had sz in a while
* phenytoin
* carbamazepine
* lorazepam: used for status epilepticus
* used to use diazepam but more respiratory effects
79
alternative measures to tx sz
* ketogenic diet: high fat, low carbs and proteins
* forces body to shift from using glucose to fat as energy source
* patient develops state of ketosis
* diet is deficient in vitamins/minrals so have to give supplements
* vagus nerve stimulator: implanted and used for kids who have not achieved control with meds
* used for kids 12 and older
* sends stimulus to left vagal nerve--cranial N X, parent activates with magnet at onset of sz
80
surgery for epilepsy
* when sz caused by hematoma, tumor, or other lesion, removal is tx
* if a child's szs are non responsive to drug therapy, surgery may be done to remove focal area of sz activity
* hemispherectomy is used to tx pt who had severe epilepsy and hemiparesis or nonfunctional hand use
81
HAs
* migraines: common
* autosomal dominant
* often proceeded by aura and accompanied by n/v
* w/ aura: take meds asap
* tension HAs: strain and stress
82
current tx for HAs
* if trigger identified, avoid trigger
* biofeedback and relaxation techniques
* tylenol and NSAIDs--first line of tx and then progress as needed for stronger meds
* cyprheptadine: perlactin (antihistamine)
* propanolol
* amitriptyline/nortriptyline
