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Pediatrics Test III > Neuro > Flashcards

Neuro Flashcards

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
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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
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3
Q

define full consciousness

A
  • awake and alert
  • oriented to time, place, person
  • behavior appropriate for age
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4
Q

define confusion

A
  • impaired decision making
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5
Q

define disorientation

A
  • confusion regarding time and placed
  • dec LOC
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6
Q

define lethargy

A
  • limited spontaneous movement
  • sluggish speech
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7
Q

define obtundation

A
  • arousable with stimulation
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8
Q

define stupor

A
  • remains in deep sleep
  • responsive only to vigorous and repeated stimulation
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9
Q

define coma

A
  • no motor or verbal response to noxious (painful) stimuli
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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
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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
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12
Q

motor function

A
  • posture and muscle tone
  • grip strength: fingers in their palm to squeeze
  • symmetry of movements made to commands
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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
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14
Q

signs of decreasing LOC

A
  1. gradual loss of eye contact (infant); confusion (child)
  2. weak irritable cry (infant); less responsive (child)
  3. less responsive (infant); lethargy (child)
  4. lethargy (infant); coma (child)
  5. coma (infant)
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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
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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
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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
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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
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19
Q

when should child have good head control?

A
  • 4 mos
    • unless not sufficient tummy time, which strengthens neck and shoulder Ms
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20
Q

Babinski reflex

A
  • normal until about 2 yo
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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
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22
Q

Palmar reflex

A
  • should disappear by 3-4 mos
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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
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24
Q

Sucking reflex

A
  • reflex persists throughout infancy
  • weak or absent reflex indicates developmental delay or neurological abnormality
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25
Q

grading of reflexes

A
  • 4+ is hyperactive
  • 3+ is brisker than normal
  • 2+ is normal
  • 1+ is diminished
  • 0 is absent
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26
Q

neuro assessment in older child

A
  • assess response to command
  • assess speech
  • orientation: person, place, time, and event
  • note mood
  • pupillary response
  • ability to read, write, copy, draw shapes
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27
Q

nursing implications of developmental differences

A
  • 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
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28
Q

factors influencing neuro function assessment

A
  • rate of change
  • severity of problem: static or progressive
  • nature and location of problem:
    • focal: 1 site
    • multi focal: multi site
    • diffuse: all over
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29
Q

non invasive diagnostic neuro testing

A
  • 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
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30
Q

invasive diagnostic neuro testing

A
  • 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
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31
Q

LP and CSF exam

A
  • normal:
    • pressure <200 cm H2O
    • color: clear and colorless
    • blood: none
    • assess serum glucose before LP and compare to glucose in CSF
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32
Q

age related differences in brain growth and cerebral blood flow and O2 consumption

A
  • 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
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33
Q

microcephaly vs macrocephaly

A
  • 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
Q

craniosynostosis (craniostenosis)

A
  • 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
Q

craniosynostosis (craniostenosis) clinical manfestations

A
  • inc ICP: which may or may not cause mental retarfation
  • can result in progressive papilledema, optic atrophy, and blindness
36
Q

craniosynostosis (craniostenosis) therapeutic mgmt

A
  • 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
Q

craniosynostosis (craniostenosis)

A
  • 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
Q

dynamics of ICP

A
  • 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
Q

volume in the brain and ICP

A
  • 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
Q

inc ICP

A
  • 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
Q

complications of IICP

A
  • inadequate cerebral perfusion
  • cerebral herniation
42
Q

clinical manifestations of IICP

A
  • 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
Q

strategies for nursing care of child with IICP

A
  • 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
Q

brain tumors

A
  • 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
Q

diagnostics with brain tumor

A
  • MRI
  • CT
  • cerebral angiography
  • electroencephalogram
  • LP
  • biopsy
46
Q

therapeutic mgmt of brain tumor

A
  • 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
Q

radiation somnolence syndrome

A
  • 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
Q

nursing considerations with brain tumor

A
  • 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
Q

Myelodysplasia

A
  • AKA spina bifida or NTD
50
Q

anencephaly

A
  • absence of brain tissue above rudimentary brainstem
  • incompatible with life
51
Q

encephalocele

A
  • external mass or sac that may occur at any place above the skull
  • may be covered with scalp or transparent membrane
52
Q

types of spina bifida

A
  • 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
Q

nursing implications with NTDs

A
  • 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
Q

problems with NTDs

A
  • 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
Q

Mitrofanoff Procedure

A
  • 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
Q

4 prognostic factors of NTDs

A
  • degree of neural involvement
  • size and location of sac
  • presence of other anomalies
  • complications that occur
57
Q

hydrocephalus

A
  • 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
Q

S/S of hydrocephalus

A
  • 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
Q

tx of hydrocephalus

A
  • 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
Q

ommaya reservoid

A
  • put into top of skull
  • can inject into it to pull excess CSF off
61
Q

meningitis

A
  • 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
Q

clinical manifestations of meningitis

A
  • 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
Q

Brudzinski vs. Kernig

A
  • 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
Q

older child and adolescent with meningitis

A
  • 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
Q

complications of meningitis

A
  • 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
Q

diagnostics for meningitis

A
  • 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
Q

therapeutic mgmt of meningitis

A
  • 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
Q

preventative and prophylactic measures for meningitis

A
  • 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
Q

seizures and epilepsy

A
  • 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
Q

define seizure

A
  • sudden, involuntary, time limited alteration in function
  • abnormal discharge of cortical neurons
71
Q

define epilepsy

A
  • chronic condition
  • lasts >6 mos
72
Q

define ictal state

A
  • during sz
  • may experience incontinence
73
Q

define post ictal state

A
  • after sz
  • often fall asleep
74
Q

define status epilepticus

A
  • sz that lasts >30 min or series of sz that do not allow child to regain consciousness in b/w each sz
75
Q

infantile spasm

A
  • 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
Q

clinical manifestations of infantile spasms

A
  • 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
Q

febrile sz

A
  • 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
Q

anticonvulsants

A
  • 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
Q

alternative measures to tx sz

A
  • 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
Q

surgery for epilepsy

A
  • 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
Q

HAs

A
  • migraines: common
    • autosomal dominant
    • often proceeded by aura and accompanied by n/v
      • w/ aura: take meds asap
  • tension HAs: strain and stress
82
Q

current tx for HAs

A
  • 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

Pediatrics Test III (6 decks)

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