Neuro/Autism Flashcards
How much does the brain grow in the first year of life?
2.5 times original weight
What does babies brain need to grow?
Glucose
What percent does a babies head weight vs adult head weigh?
10% of newborns weight
2% of adult weight
Which electrolyte has an inverse relationship with water? What does this mean?
Salt
80% of newborns brain is water –> shifts in salt/water can provoke seizures
When does the fontanel close? What does this matter?
Anterior: 18 months
Posterior: 2 months
Can accommodate for increased ICP and hydrocephalus better than adults d/t expanding fontanels
What is papilledema? Is this common?
Swelling of the optic nerve form increase intracranial pressure
Rare
How much cerebrospinal fluid does an infant have vs. and adult?
50ml for infant
150ml for adult
Much lower baseline ICP
What are some tips and tricks to complete a pediatric neuro exam? (9)
Observation of play/activity
Doorway assessment
“Not acting right”
Hand sized toys to assess motor coordination,neuro-muscular strength
Extra ocular movements
Cognitive skills/speech
Finger to nose
Silly games
Sensory function such as soft/hard, cold/hot
What are some red flags on a neuro assessment? (5)
Delay in expected milestone
Regression or loss of milestone
Persistence or reappearance of primitive reflexes that should be gone by 5-9 months
Rapid change in head circumference - bulging fontanels
High pitched cry (underlying neuro/IICP)
What is full LOC?
awake, oriented, interacts with objects
What is confused LOC?
Lacks ability to think clearly
What is disoriented LOC?
Lacks ability to recognize place or person
What is lethargic LOC?
awakens easily but exhibits limited responsiveness
What is obtunded LOC?
sleep unless aroused, once aroused they have limited interaction with the environment
What is stupor LOC?
requires considerable stimulation to arouse
What is coma LOC?
vigorous stimulation and still produces no verbal or motor response
If a parent tell you their child is lethargic, obtunded, ect.. what should you ask them?
Also ask them what they mean. They may have different meanings than healthcare.
What causes ICP? If increase ICP is not relieved what can occur?
Brain mass
CSF
Blood
Unrelieved –> herniation and death
What does herniation present as?
EOL posturing
Cushing triad
Cheyne-strokes respirations
What is the nursing diagnosis for increased ICP?
Ineffective tissue perfusion r/t increased ICP d/t too much pressure on brain tissue
What is the cause of IICP r/t congenital hydrocephalus? TBI?
Congenital hydrocephalus: imbalance of CSF
TBI: tissue edema, bleeding
What should the head be the same size of?
Chest
What is a neural tube defect? What if it is a high defect? What is the most common cause?
Defect in vertebrae that can occur at any level in spinal column
The higher the defect, the greater neurological dysfunction
Lack of folic acid in mom
What is the cause of neural tube defect? When do neural tubes form? How is it diagnosed?
Multifactorial etiology
4th week of gestation
Parental or postnatal diagnosis
What is a protective factor against neural tube defect?
Folic acid
What type of defect is Spina Bifida?
Neural tube defect
What are the classifications of Spina Bifida? (3)
Occulta (most minor)
Meningocele
Myelomeningocele (most severe)
What are the CM of Spina Bifida occulta? (8)
Cutaneous lesions - dimple in the skill
Vertebral malformation ONLY
Tethered cord
Presentation/diagnosis delayed
Bowel and bladder deficits
Persistent toe walking
Back pain
Not much neuro impairment
What does a tethered cord present as?
Pain
Toe walking
Bowel and bladder issues
Where does Spina Bifida myelomeningocele affect?
Spinal cord
Meninges
CSF
What are the nursing diagnoses r/t Spina Bifida myelomeningocele
Risk for poor cerebral perfusion
Risk for infection
What is the nursing management for Spina Bifida myelomeningocele?
Prepare for surgery (either 24-48 hours after life or intrauterine)
Support ABCDs (depend on level of lesion)
Monitor ICP/neuro
Monitor s/s of infection (no diaper)
Prone to sideline position
What does monitor ICP/neuro look like for a patient with Myelomeningocele?
HC once/shift if pt is stable
Frequent pupil reaction, sternal rub/heel flick, moro/sucking reflex
What can Myelomeningocele lead to? What are s/s?
Meningitis
Congenital hydrocephaly
Meningitis: Nuchal rigidity, fever, decrease BP, not feeding well, irritability, crying, inconsolability, increase desating
If a child has Myelomeningocele how will the birthing plan differ?
Planner c-section d/t hydrocephaly and rupture of the sac
May have to help parents engage with baby other than holing
What is the most common cause of increased ICP?
congenital hydrocephalus
What are risk factors for congenital hydrocephalus? (confirm this)
Neural tube defect
Prematurity
What is congenital hydrocephalus?
Imbalance between CSF production and absorption –> enlarged ventricles –> affect cerebral perfusion
What are nursing interventions for risk for poor cerebral perfusion r/t Myelomeningocele?
Hourly VS
Daily head circumference
Neuro assessments every 1-2 hours
Support family bonding by encouraging breast feeding and education
What does the neuro assessments include r/t Myelomeningocele?
Fontanels
Assess motor sensation above and below lesion
Assess bowel and bladder function
What should be done immediately in the post natal period r/t risk for infection?
Maintain skin integrity of sac by keeping it sterile and moist with sterile saline dressing
Assess for CSF leaks
Positioning to keep pressure of the area,
Avoiding contamination form urine/stool
Assess for infection and administer per-op antibiotics
Head circumference is steadily increasing, baby more irritable, frequently desatting, and not meeting feeding goals. What does this infant have?
What are early s/s of increased ICP in an infant? (7)
Rapid head growth
Bulging fontanels
Irritability
Poor feeding
Prominent scalp veins
Shrill, high pitched crying
desat –> bradycardia
What are early s/s of increased ICP in an child? (6)
HA that is worse in morning or when supine
HA relieved by emesis or sitting up
N/V (projectile possibly)
Diplopia
Irritable
Fatigue
What are late s/s of increased ICP? (3)
Pronounced frontal bone enlargement (bossing - bulging frontal lobe that is popping out to sides/outside facial feature)
Seizures
Visual changes such as abnormal pupil response, strabismus fixed, setting sun sign
What are the goal around ICP management? (2) Acute? (4)
Treat underlying cause
Preserve cerebral function (decrease demands and nourish tissue)
Maintain airway
Assess neuro status
Assess for ICP decompensation
ICP management
How does care differ d/t seizure risk with IICP?
Rescue meds
Padded rails
No loose clothing or objects
Safety and timing
What is possible underlying causes for increase ICP that need to be treated and what is the treatment?
Remove mass or lesion such as tumor/hemorrhage
Reduce brain tissue edema with diuretics. mannitol, steroids, hypertonic IVF
Decrease vascular volume
Congenital defect place VP shunt
What is the acute management for IICP?
Maintain airway
Assess neuro status
Assess for ICP decompensation
ICP management
What should you do for increase ICP? (9)
VS hourly
Oxygen
Control temp and BP
HOB 30-45 degrees to avoid flexion at hips/neck
Decrease stimulation
Cluster care
Neuro/LOC assessments
I&Os
Monitor electrolytes
What should be avoided what patient has increase ICP? (5)
Hyperventilation
Fever
Hypotension
Hip or neck flexion
Prone or supine
What is ICP decompensation r/t? What does it present as?
R/t pressure on brainstem/lower cranial nerves aka brainstem herniation
Cushings triad and Cheyne-stokes respiratory pattern
What is cushings triad?
Bradycardia
Systolic HTN with widening pulse pressure (higher systolic, lower diastolic)
Irregular respirations
What is Cheyne stokes respiratory pattern?
AKA agnol breathing
Long periods of apnea –> hyperventilation –> hypoventilation –> apnea
What can be done to meet the goal of reducing ICP in hydrocephalus?
Ventricle-peritoneal shunt (VP shunt)
Shunts CSF from the ventricles
What are nursing considerations r/t a VP shunt?
Infection
Obstruction
Pain (post-op)
Parental education regarding ICP home monitoring
Seizure
What does care for Spina Bifida depend on?
How many issues the patients will have and where the lesion is
Upper lesion: resp and arms
Lower lesion: Legs, need help walking, bowel and bladder incontinence
What are long term chronic complications of Spina Bifida?
Neurogenic bladder and CKD
Neurogenic bowel
Orthopedic/mobility issues
Skin ulceration
Latex allergy
How do you treat neurogenic bladder/CKD? Treat neurogenic bowel? Treat mobility issues?
CIC regimen - clean intermittent cath 4x/day and foley at night
High fiber and high fluid, rectal stims and laxatives
PT/OT
What should be taught about skin r/t Spina Bifida?
Child and family should inspect the skin areas with decreased sensation on a regular basis
What is the collaborative care for Spina Bifida?
Neurosurgery
Nursing
Urology/Nephrology
Ortho
Rehab
PT/OT
Social services
What are the 3 primary mechanisms of a head injury?
Closed
Open/penetrating/impalement (MVA)
Asphyxia (decreased perfusion to brain)
What are the 2 types of close head injuries?
Concussion
Diffuse axonal injury - shaking
What are the 2 examples of asphyxia head injuries?
Near drowning
Loss of oxygen
What are worsening outcomes that can occur with a head injury?
Contusion
Concussion
Skull fracture
Intracranial hemorrhage
Brainstem herniation
What are the 4 types of intracranial hemorrhages?
Subdural hematoma
Epidural hematoma
Intra-parenchymal hematoma
IVH (stroke in preemies)
What is the management for a concussion?
Cease play
Evaluation HCP
Restricted by until asymptomatic with rest/exertion
Psych testing - should have routine one before concussion to determine changes in score when injured
How long does it take for a concussion to heal?
7 days to months
What is the best way to prevent a head injury?
Wear helmet
What type of injury is shaken baby syndrome?
Coup-coutrecoup
Coup is the acceleration injury form initial impact
Coutrecoup is the counter or deceleration injury
Trauma occurs as brain moves over the skill and subdural vessels are torn
Sheering force of all blood vessels and direct injury to brain itself
What are complications of a head injury?
Increase ICP from secondary injury like brainstem herniation
DIC
Death
CSF leak
Meningitis
Focal neurological deficit (motor, seizures, ect)
Global neurological deficit (severe impairment, asphyxia)
What s/s would make you suspect a skull fracture?
Battle signs like raccoon eyes and mastoid petechiae/eccymosis
What is the max score for GCS for Peds? Minor injury? Moderate injury? Severe injury?
Max: 15
Minor: 13-15
Moderate: 9-12
Severe: less that 8
What are red flags for ASD?
Impaired social interactions, communication (decreased ability to interpret social cues) and emotional regulation
Repetitive behavior/hyperfixation
Restricted interests
What are early warning signs of ASD?
Poor eye contact
Poor or unusual use of toys
Preoccupation with creating order
Poor attachment to family/poor socialization skills
Repetitive body movement like hand flapping, rocking, head banging
Problems with using/understanding language
Difficulty with transitions such as changes in enviornment d/t sensory
Walking on toes
Sensory fussiness - if they don’t stop even when they get what they want. Fussy as in pain
Playing alone and being socially withdrawn
Aggressive
Lack of responsiveness to verbal stimulation
Issues with food textures and clothing textures d/t sensory issues
When are early warning signs of ASD present by?
4 months of age
What is a 2 month old missing with ASD?
Social smile
What is brain imaging done in ASD? What is it looking for?
2 months and 4 months
Looking to see deficit
