Neurological Alterations - Cerebral Neuromuscular Flashcards
Traumatic Brain Injury and major causes:
blunt force to the head or penetrating injury that disrupts normal brain functioning, such as loss of LOC
Major causes:
- Falls
- MVA
- Bicycle
proportionately large & heavy head
incomplete motor development -> falls
natural curiosity & exuberance
Primary Head injuries
occur at time of trauma (skull factures, contusions, intracranial hematomas)
Subsequent complications
hypoxic brain injury, increased ICP & cerebral edema
Pathophysiology of Head Trama
Directly related to force of impact
Intracranial contents (brain, blood, CSF) damaged b/c force is too great to be absorbed by skull & muscles and ligaments
Young child particularly vulnerable to acceleration-deceleration injuries
Predominant feature is diffuse swelling of brain
Concussion or mild brain injury
Low-grade headache that will not go away
Slowness in thinking, acting, speaking, reading
Memory problems
Loss of balance, unsteady walking
Poor concentration, change in performance at school, lack of motivation, or lack of interest in favorite toys
Feeling tired all the time, change in sleeping pattern
Change in eating patterns
Increased sensitivity to lights, sounds, distractions
Easily irritated.
NO LOSS OF CONSCIOUSNESS
Glasgow coma scale 13-15
Moderate brain injury
Glasgow coma scale score of 9-12
posttraumatic amnesia for 1-24 hours
LOSS OF CONSCIOUSNESS
Severe Brain Injury
glasgow coma scale score of 8 or less
posttraumatic amnesia lasting longer than 24 hours
coma or unconsciousness
increased ICP
posttraumatic seizures
Concussion
alteration in mental status with or without loss of consciousness, which occurs immediately after a head injury
Hallmark signs: confusion & amnesia
Usually resolve within 7-10 days without complications
Rest until symptoms resolve, then resume activities gradually
May be result of shearing forces -> stretching, compression, & tearing of nerve fibers
Concussion
alteration in mental status with or without loss of consciousness, which occurs immediately after a head injury
Hallmark signs: confusion & amnesia
Usually resolve within 7-10 days without complications
Rest until symptoms resolve, then resume activities gradually
May be result of shearing forces -> stretching, compression, & tearing of nerve fibers
Incidence
Males accounted for 70% of all concussion hospitalizations
Falls and sports
Concussion Complications: Epidural hematoma
Hemorrhage into space b/n dura & skull
dura stripped rom skull as hematoma enlarges
low-velocity falls; child abuse; MVA
classic clinical picture: momentary unconsciousness followed by normal period for several hours, then lethargy or coma (because of swelling and bleeding in the brain)
cushing triad: systemic hypertension, bradycardia & respiratory depression
LATE SIGN OF IMPENDING BRAINSTEM HERNIATION
Complications: Subdural Hemorrhage
- bleeding b/n dura & arachnoid membrane
- develops slowly and spreads thinly & widely
- infants: birth trauma, falls, violent shaking
- signs: irritability, vomiting, increased HC, bulging anterior fontanel, lethargy, coma, seizures
Post-concussion syndrome: Sequela to brain injury with or without loss of consciousness
- typically occurs after mild head injury
- at least 3 of the following
Headache
Dizziness
Light sensitivity
Fatigue
Nausea
Irritability
Restlessness
Difficulty concentrating
Memory impairment
Clinical Manifestations of Head Injury: Minor injury
May or may not lose consciousness
Transient period of confusion
Somnolence
Listlessness
Irritability
Pallor
Vomiting (one or more episodes)
Clinical Manifestations of Head Injury: Signs of Progression
Altered mental status (e.g. difficulty rousing child)
Mounting agitation
Marked change in VS
Clinical Manifestations of Head Injury: Severe Injury
Signs of increased ICP
Bulging fontanel
Retinal hemorrhages
Hemiparesis
Quadriplegia
Elevated temperature
Unsteady gait (older child)
Papilledema (older child)
Retinal hemorrhages
Meningitis
acute inflammation of meninges & CSF
organisms
- bacterial or pyogenic (meningococci, pbeumococci, haemophilus)
- viral or aseptic
- tuberculosis
bacterial or viral; bacterial more virulent & sometimes fatal
majority of reported cases between 1 month and 5 years
increased mortality risk in adolescent & young adult
Etiology and Patho of Meningitis
May occur secondary to other infections
Bacteremia spreads infectious agent to CNS; inflammatory response follows; WBC accumulate & cover brain in thick, white, purulent discharge; brain becomes hyperemic & edematous
If infection spreads to ventricles, obstruction may occur = hydrocephalus
clinical manifestations: infant - meningitis
fever; poor feeding; vomiting; bulging fontanel; marked irritability; rocking or cuddling irritates infant (paradoxical irritability)
clinical manifestations: older children - meningitis
abrupt onset; fever, chills; seizures; irritability, agitation; c/o muscle or joint pain; headache, photophobia & nuchal rigidity;
Hemorrhagic rash (starts as petechiae and the becomes purpura)
may progress to: seizures, apnea, cerebral edema, subdural effusion, hydrocephalus, DIC, shock & increased ICP
Diagnosis of meningitis
Blood - CBC, blood C&S, electrolytes, clotting factors
LP - WBC, protein, glucose; gram-stain & culture
Medications:
IV antibiotic therapy ASAP (7-21 days)
corticosteroids, antipyretics, anticonvulsants
Prophylaxis for contacts
Lumbar puncture: looking for presence of bacteria or virus
CSF if there is an active infection: cloudy (WBC), test for glucose and then they culture it, also looking at the pressure at which it comes out when they puncture
Takes 24-48 hours to get culture back
Start on broad spectrum
Swelling in the brain and inflammation and fevers can cause seizures
Therapeutic Mangement of Meningitis
Isolation precautions
Antimicrobial therapy
Maintenance of hydration
Maintenance of ventilation
Reduction of increased ICP
Management of systemic shock
Control of seizures
Control of temperature
Treatment of complications
Measure head circumference
Minimize stimulation
Dark quiet rooms
Treat with antibiotics
Status Epilepticus
Continuous seizure that lasts more than 30 minutes
OR
Series of seizures from which the child does not regain a premorbid LOC
NOTE: treatment for seizures from which the child does not regain a premorbid LOC
Febrile Seizures
Criteria
Simple Febrile Seizures
Complex Febrile Seizures
Criteria:
- convulsion associated with temperature > 38
- child > 6 months & < 5 years of age
- absence of CNS infection or inflammation
- absence of systemic metabolic abnormality that may produce convulsions
- no history of previous afebrile seizures
Simple Febrile Seizures
- most common type
- generalized seizures, lasting < 15 min (most last < 5 min) & do not recur in a 24-hour period
- recur in approx 1/3 of children in early childhood but risk of future epilepsy is only slightly higher than general population
Complex febrile seizures
- focal onset
- last > 15 minutes or occur more than once in 24 hours
- higher risk of recurrent febrile seizures and slightly higher risk of future nonfebrile seizures than with simple febrile seizures
Febrile Seizures: Epidemiology and Risk Factors
most common neurologic disorder of infants and young children
Risk Factors
- age
- high fever
- infection (particularly viral)
- immunization (DTwP & MMR)
- Genetic Susceptibility
Seizure Management
Remain calm
Observe Seizure (time, triggers, behaviour at onset, type, behaviour after)
Ease child to floor and protect head with blanket or pillow
Loosen clothes
If vomits, turn head to side
Do not restrain
Do not put anything in the child’s mouth
Seizure Management - Hopsital
0-5 minutes
- manage ABCs
- cardiac monitor & oximeter; place in recovery position
- check blood glucose with glucometer
- establish IV access
- blood work - electrolytes, toxicology, anti-seizure medication levels
Seizure Management - Hopsital
5-15 minutes
- IV access (lorazepam OR diazepam)
- No IV access (buccal or intranasal midazolam OR IM midazolam OR rectal diazepam)
- repeat same medications once if seizures persist 5 minutes after 1st dose
Seizure Management - Hopsital
15-40 minutes
Phebytoin IM/IV/IO OR Levetiracetam IV/IO OR Phenobarbital IV OR Valproic acid IV/IO
Seizure Management - Hopsital
40-60 minutes
- consider intubation
- consult ICU & neurology
- may give a different 2nd line medication
Nursing Priorities for Seizures
Safety during seizures
Normal developmental needs (support at school)
Family support
Home medication
Seizure precautions in home & hospital setting
Family education
Etiology & pathophysiology of Cerebral Palsy
Prenatal
Perinatal
Childhood
Prenatal: insufficient nutrients & oxygen; teratogens
Perinatal: trauma to brain, asphyxia, prematurity, sepsis
Childhood: head trauma, submersion injury, meningitis, shaken-baby syndrome
Cerebral Palsy Signs in Infants
Poor head control after 3 months
Stiff or rigid arms or legs
Arching back, pushing away
Floppy or limp body posture
Cannot sit up without support by 8 months
uses only one side of body, or only arms to crawl
Clenched hands after 3 months
Cerebral Palsy Signs in older children
Hand preference before 18 months
Feeding/swallowing difficulties - drooling, aspiration, persistent tongue thrusting
seizures
leg scissoring
sensory impairment (vision, hearing)
Extreme irritability or crying
little interest in surroundings
Excessive sleeping
Cerebral Palsy: nursing priority concerns (6)
Impaired physical mobility
Potential for muscular deformity (contractures)
Communication impairment
Potential for impaired feeding and nutrition
Disturbed body image
Family Stress
Cerebral Palsy: goals of therapy
the ability to move, navigating the school system.
gain optimum appearance and motor function. provide education opportunities to needs and capabilities and socialization opportunities
Manage at home and optimize what they can do and life for their family
Cerebral Palsy: nursing responses
- Family support
- Normalization - especially at school
- OT, PT and appropriate equipment to prevent further problems, maximize function and prevent contractures
- well child care - immunizations, and care for episodic illness
- feeding therapy
Difference between CP degenerative conditions
CP ins permanent and non progressive and starts from time of birth or injury. children don’t gain and lose developmental milestones, they just were never there. limitations of movement and perception. whereas degenerative: develop normally and then regress. start to lose milestones
hypotonia is one of the first signs. dont usually live past 2 years
Normal milestones progress forward –> never backward
Rolling
Sitting
Pull to stand
Walk
Rolling: 3-5 months
Sitting: 6-7 months
Pull to stand: 8-12 months
Walk: 10-16 months
Diagnosis of Degenerative Neuromuscular disease
child’s history and clinical presentation of developmental regression
genetic testing
EEC showing denervation
Nursing Priorities for Degenerative Neuromuscular Disease
- family support
- physical support
- symptom care
- making each moment count
- genetic counseling
