Neurological disorders - exam 3 Flashcards
How does the scoring of the Glasgow Coma Scale work?
Scores range from 3-15; 15 is best and 3 is worst
Babinski reflex
should be positive in infants, but negative in kids 2 and older (some kids loose it after 12 months)
what is Cushing’s triad
-bradycardia
-bradynpea
-wide pulse pressure
(signs of increasing cranial pressure)
What are the 3 areas of evaluation in the glasgow coma scale?
- eye opening (1-4
- verbal response (1-5)
- motor response (1-6)
What is spina bifida?
- a protruding sac anywhere along the spine
- a birth defect where the neural tube fails to close as a fetus (this is why it’s super important for women to take folic acid prenatally AND during pregnancy)
Types of spina bifida (3)
- spina bifida occulta (least severe, often no observable manifestations)
- Meningocele (CSF protrudes from spine)
- Myelomeningocele (spinal cord and CSF protrude from spine. Most severe and most common. Hernial protrusion from spine)
What is the cause of spina bifida?
- unknown causes
- lack of folic acid
Signs and Sx of spina bifida?
- neural tube abnormalities
- **dimpling near buttocks
- hydrocephalus
How do you check for spina bifida in a newborn baby?
-Flip baby on stomach and check for dimple above the anus (indicative of spina bifida)
Signs and Sx of spina bifida occulta
- dark tufts of hair
- dimple (above anus)
- port wine angiomatous nevi (spider angioma)
- soft, subcutaneous lipomas
How and when do you Dx spina bifida?
- prenatal (usu it is Dx in utero btwn 16-18 weeks by measuring fetoprotein in amniotic fluid)
- ultrasound (if it’s not Dx prenatally)
Nursing interventions for spina bifida?
- PREVENTION!!! (recommend folic acid for all women of child bearing age)
- infection control for SB pts (they are more prone to infection)
- surgical prep (lay child on side or prone; keep site moist until surgery)
What is hydrocephalus?
- enlargement of the ventricles due to increase in CSF
- happens due to too much production, or too little absorption of CSF
- this is why it’s important to track head circumference!
What are the signs and Sx of hydrocephalus?
- headache
- bulging eye (“sun-setting”)
- bulging fontanels
- increased head circumference (head feels soft to touch)
- signs of cushing’s triad
What are the nursing interventions for hydrocephalus?
- surgical prep for ventriculoperitoneal shunt (“VP shunt”)
- monitor head circumference
- monitor for seizure activity
- careful position changes (avoid anything that changes pressure or can cause kinks in VP shunt)
What is a “VP shunt”?
- device used to drain fluid from cranial ventricles in children with hydrocephalus
- permanent device! (sometimes is has to be extended or revised as kid grows bigger)
- tube drops down from head to abdomen
- caution for KINKS!!!
What is cerebral palsy?
- group of PERMANENT disorders of development of movement and posture, causing activity limitation, attributed to NONPROGRESSIVE disturbances that occurred in developing fetal or infant brain
- affects movement and speech
- affects voluntary and involuntary muscles
- also involves disturbances of sensation, perception, communication, cognition, and behavior; secondary musculoskeletal problems; and epilepsy
What are the causes of cerebral palsy?
- 70-80% caused by unknonwn prenatal factors
- Often diagnosed in first year of life d/t birth hypoxia or hypoxia in utero
- can occur later in life d/t a hypoxic event (e.g. drowning, collapsing from asthma attack)
- other possible prenatal causes: genetics, congenital infections, prematurity, neonatal encephalopathy
Signs and Sx of Type 1 cerebral palsy?
Type 1 = Spastic aka STIFF type (MOST COMMON/70-80%)
- hyper-reflexia and hypertonia (abnormal increase in muscle tension and a reduced ability of a muscle to stretch)
- muscle spasticity
- toe walking (d/t achilles tendon, muscles are shrunken bc they’re so tight/contractures)
- scissoring (d/t tightness)
- continues to have neonatal reflexes
- scoliosis
Signs and Sx of Type 2 cerebral palsy?
Type 2 = Dyskinetic CP aka INVOLUNTARY MOVEMENTS
- writhing movement (twisting, clenching, random involuntary movement)
- Chorea
- –these Sx usu worsen when person is under stress and get better while sleeping
- trouble speaking (Involvement of the pharyngeal, laryngeal, and oral muscles causing drooling and dysarthria (imperfect speech articulation)
Signs and Sx of Type 3 cerebral palsy?
Type 3 = Ataxic aka SHAKY
- uncoordinated movements (difficults with walking, but muscles aren’t as “tight” as spastic type)
- trouble speaking bc face muscles shake
Nursing interventions for cerebral palsy
- Teaching: no cure but there are multidisciplinary opportunities
- surgery can improve function
- early intervention (PT, OT, SE, early intervention team)
- –promote optimum development
- encourage opportunities for socialization
- teach meticulous dental hygiene
Head injury is defined as:
mild to total brain injury
-mild head injury is falling from standing or anything less than one’s height
pathophysiology of head injuries:
- car accidents
- abusive head trauma (previously called “shaken baby syndome”) - injury occurs on both sides of head
- biking, skiing, hockey, football, etc
What are some signs and Sx of abusive head trauma?
bruising behind eyes, highly irritable
Signs and Sx of head trauma
- *vomiting (big red flag bc this only happens when there’s a concussion (bruise on brain), a bleed, or a seizure
- bruises
- *headache
- dizziness
- lacerations
What is the time frame that a kid should be monitored post head injury?
4-6 hours after time of trauma
Nursing interventions for head injury
- concussion scale
- prep for CT vs MRI
- emergency mngment (might need to make burr hole in head to release pressure if there’s a bleed)
- concussion teaching and f/u
- in order for brain to heal, needs to REST and have MINIMAL STIMULI!
- educate about head safety
What is a seizure?
- times of abnormal electrical discharge in brain
- causes involuntary movements
What is epilepsy?
-chronic illness w recurrent, unprovoked seizures d/t an abnormality in brain
Pathophysiology of seizures?
- genetic link
- injuries
- infection
- idiopathic (MOST COMMON)
- fever (febrile seizures)
Types of seizures (3)
1) FOCAL seizures (aka partial seizures), have a local onset and involve a relatively small location in the brain;
2) GENERALIZED seizures, involve both hemispheres of brain and are w/o local onset; and
3) unclassified epileptic seizures
Focal seizures
- aka partial seizures
- originate in neuronal networks of 1 cerebral hemisphere w/ localized activity
- on one side of brain (affects opposite side of body)
Generalized seizures
- originate in and spread across neuronal networks of both cerebral hemispheres (e.g. tonic-clonic seizures)
- generalized misfiring of electrical activity
- causes bilateral and symmetric abnormalities
- loss of consciousness
What is status epilepticus?
-Series of seizures at intervals too brief to allow the child to regain consciousness btwn time one event ends and next begins
• Requires emergency intervention
• Can lead to exhaustion, respiratory failure, and death
(Hockenberry 1465)
Hockenberry, Marilyn, David Wilson. Wong’s Nursing Care of Infants and Children, 10th Edition. Mosby, 2015. VitalBook file.
The citation provided is a guideline. Please check each citation for accuracy before use.
What is the postictical state of a seizure?
Child appears to relax
• May remain semiconscious and difficult to arouse
• May awaken in a few minutes
• Remains confused for several hours
• Poor coordination
• Mild impairment of fine motor movements
• May have visual and speech difficulties
• May vomit or complain of severe headache
• When left alone, usu sleeps for several hours
• On awakening is fully conscious
• Usu feels tired and complains of sore muscles
• No recollection of entire event
What is a febrile seizure?
must meet the following 3 criteria: 1. 6 months to 6 years of age 2. lasts no more than 15 minutes 3. only 1 per 24 hr period (these usu depend on how fast fever spike, rather than the duration of fever)
What are “tonic” seizure movements
- unconsciousness
- muscle contraction
- stiffnes
What are “clonic” seizure movements
- alternating contraction and relaxation
- rhythmic, repeated jerking (very strong)
Nursing interventions for seizures
- seizures are usu self-limiting
- safety intervention KEY!
- –Put rails up, stay with pt, document what’s happening, protect the head, nothing in mouth
- O2 (in case they become hypoxic
- monitoring Sx and V/S
- bloods
- IV placed
- meds as ordered (diazepam can be used to help stop brain activity from seizures. and RECTAL DIAZEPAM–parents can even give this med at home)
Nursing interventions for simple febrile seizures
- self-limiting
- safety intervention
- monitor frequency
- antipyretics (for febrile seizures)
What is Reye’s Syndrome?
-metabolic encephalopathy associated w other characteristic organ involvement (e.g. liver, kidneys).
What causes Reye Syndrome?
-Viral illness plus aspirin leads to fat metabolism in liver, kidneys, and brain are affected (can lead to brain swelling and death
Signs and Sx of Reye Syndrome?
- Characterized by fever, profoundly impaired consciousness (confusion), and disordered hepatic function.
- hypoglycemia
- increased ammonia levels
- vomiting
- **may suffer from permanent brain damage
Stages of Reye syndrome?
- Stage 1: Sleeping/vomiting/tachypnea
- Stage 2: combative/positive babinski/no response to pain
- Stages 3-5: decorticate to decerebrate posturing; then seizures and death
- Stage 6: Unable to classify due to meds
Decerebrate posturing
abnormal body posture that involves the arms and legs held straight out, toes pointed downward, and head and neck being arched backward. The muscles are tightened and held rigidly.
Decorticate posturing
abnormal posturing that involves rigidity, flexion of the arms, clenched fists, and extended legs (held out straight). Arms are bent inward toward body with the wrists and fingers bent and held on the chest.
-this is LESS serious compared to decerebrate posturing
What is some important information to teach parents of a child suffering from Reye’s syndrome?
child may suffer from permanent brain damage
what is the most common CNS infection?
meningitis
What is meningitis? What are the types?
inflammation of the meninges/pathogens invade the meninges 3 types: 1. bacterial meningitis (most deadly) 2. viral meningitis 3. TB meningitis
Signs and Sx of meningitis
-Sx vary in infants/young children vs older kids/adults
-increased ICP
-hyper OR hypo-thermia
-poor feeding
-seizures (late sign)
-vomiting (sign of ICP)
fever
-confusion
-light sensitivity and stiff neck (in older children)
Nursing interventions for meningitis
-ISOLATION!! (DROPLET PRECAUTIONS until on antibiotic for 24 hrs)
-blood work
-prep for lumbar puncture
-throat culture
-antibiotics
If NOT bacterial: bed rest and antipyretics
what type of isolation precautions are needed for bacterial meningitis?
droplet precautions
Pathophysiology of a brain tumor?
- hereditary
- unknown/idiopathic
Signs and Sx of brain tumors
- **vomiting (esp MORNING vomiting)
- **headaches (usu you can pinpoint where pain is)
- **ataxia (loss of full control of body movements
- seizures
- increased head circumference
- abnormal speech and eye movements
- surgical prep (mass removal)
- VP shunt may be needed (if mass can’t be removed)
- chemo/radiation
What is neuroblastoma?
- cancers that begin in early nerve cells (tissues that form the sympathetic nervous system)
- turn into tumors as kids grow up
In what demographic do we typically see neuroblastoma?
-in early childhood and infants
Pathophysiology of neuroblastoma
-unknown!
Signs and Sx of neuroblastoma?
- can occur anywhere in the body (often it’s first in abdomen)
- can be a painless mass
How do you Dx neuroblastoma?
- CT scan or MRI (if it’s more invasive)
- genetic testing
- extra testing for other problems (find the underlying cause)
Nursing interventions for neuroblastoma?
- surgical prep
- family support
- chemo/radiation
- follow-up care
Increased ICP definition?
-pressure d/t a growth, inflammation, or increased CSF in the central nervous system
Pathophysiology of ICP
- head injury
- CNS infection
- tumor
- excess CSF
Signs and Sx of ICP
- cushing’s triad (bradycardia, bradypnea, widening pulse pressure)
- incr head circumference
- separated sutures
- bulging fontanels
- enlarged fontanels
- frontal bossing (forehead protrudes out)
- shrill cry (aka “neuro cry”)
- seizures (later sign)
- headache
- visual changes
- papilledema
- vomiting
Nursing interventions for ICP
- elevate HOB to 15-30 degrees
- keep child’s head straight (esp if there’s a VP shunt) (to not increase jugular pressure)
- minimize environmental stimuli
- medicate as odered
- prep for VP shunt
