Neurological Dysfunction Flashcards
1
Q
What family Hx do you need to know about during a neuro assessment?
A
Intellectual & Developmental Disabilities
Deaf/blind
Epilepsy
Stroke
2
Q
What HEALTH Hx do you need to know about during a neuro assessment?
A
Injury with loss of consciousness
Febrile illness
Encounter with animal/insect - RABIES/WEST NILE
Ingestion of neurotoxic substance - FUEL/ANTIFREEZE
Past illness (recent – Meningitis or Green)
3
Q
What are the neuro assessment PHYSICAL EXAM findings?
A
Size/shape of head – esp. infants
LOC Awake & alert/drowsy or lethargic
Activity – spontaneous or pain stimuli
Tone – tense, flaccid
Symmetry - equal
Facial features - Syndromes
High-pitched cry esp. in infants
Respiratory pattern – apnea, hyper vent
Muscular activity/coordination - ticks/twitch
Reflexes/strength
4
Q
What neuro-assessment characteristic is the earliest sign of improvement or deterioration?
A
Level of Consciousness
- fully, lethargic, coma
5
Q
The Glasgow Coma Scale is used to assess
A
- LOC
- impairments in infants to very young (<2 y/o) can be problematic
6
Q
What is the standard system of evaluating and assessing LOC?
A
Glasgow Coma Scale
7
Q
A Glasgow Coma scale in pediatrics is used for ages
A
< 2 y/o
8
Q
During a Glasgow coma scale in pediatrics, what is a helpful strategy to fully evaluate the child
A
family member interactions with the child
9
Q
What are the 3 parts of assessments for the Glasgow Coma scale?
A
eye-opening
verbal response
motor response - Best
10
Q
What is the score range on a Galsgow Scale from lowest to highest?
A
3-15
- lowest = deep coma/death
- highest = awake and aware
11
Q
What Glasgow score is generally accepted as coma?
A
less than or equal to 8
12
Q
What Glasgow score does the patient need to be intubated?
A
less than 8; intubate
13
Q
Glasgow scores for eye-opening responses (all ages)
A
4-spontaneous
3-to speech
2-to pain/pressure
1-none
14
Q
Glasgow’s scores for verbal responses
>2 y/o
A
5: oriented
4: confused
3: inappropriate words
2: incomprehensible/sounds
1: no response
T: Endotracheal tube or Trach
15
Q
Glasgow’s scores for verbal responses
<2 y/o
A
5: coos, babbles, smiles
4: irritable cry, consolable
3: inappropriate crying/screaming
2: moans/grunts
1:none
16
Q
Glasgow’s scores for motor responses
< 2 y/o
A
6: spontaneous/purposeful
5: withdraws to touch
4: withdraws to pain
3: flexion abnormal
2: extension abnormal
1: none
17
Q
Glasgow’s scores for motor responses
> 2 y/o
A
6: obeys commands
5: localizes pain
4: flexion withdrawal
3: flexion abnormal
2: extension abnormal
1: none
18
Q
Neuro Assessment of Pupils uses what to measure them
A
Pupillometer (1-8mm)
19
Q
What are the different reactions in a pupil assessment?
A
Brisk
Sluggish
No reaction
Eyes closed by swelling
Pinpoint, Dilated/fixed, Unequal
20
Q
If the pupils are fixed or dilated for more than 5 minutes, what does this mean?
A
brain stem damage
21
Q
Atropine
A
eye dilated
22
Q
Pinpoint pupils reasons
A
medications
barbiturate poisoning
23
Q
What is considered a neurologic emergency regarding pupils?
A
sudden appearance of a fixed/dilated pupil
24
Q
When a child has a sudden appearance of dilated pupils, the nurse’s priority action is?
A
remain with the child
25
With atropine pupils, the child is at high risk for
respiratory arrest
26
Decorticate (flexion) position means what neurological problem?
dysfunction of the cerebral cortex/above brainstem
27
The decorticate (flexion) position looks like
flexion of the elbows onto the chest with adduction of the arms
extension of the legs
feet together
28
Decerebrate (extension) position means what neurological problem?
dysfunction at the midbrain/brainstem
29
The Decerebrate (extension) position looks like
Extremities rotate abduction of the arms and legs with inversion of the feet
Hands out and back
30
Will you see posturing if they are not stimulated?
no
31
How would you document posturing?
describe the appearance do not label it
32
Herniating
Posturing only on one side
33
Total Cranium vol for Intracranial Pressure percentages
Brain = 80%
CSF = 10%
Blood = 10%
34
If there is a chnage in 1 area of ICP, then the others will
compensate
- maintain constant vol and pressure
35
In cerebral swelling, what happens to the ICP?
absorb more CSF causing a low blood flow
36
Bulging fontanels if open means
more compensation
37
Increased ICP early S/S onset
subtle when more noticeable when pressure increases
38
What are the early s/s of increased ICP? SATA.
HA
Vomiting
Fatigue
Irritability
Dizziness
Personality changes
HA
Vomiting
Fatigue
Irritability
Personality changes
39
Increased ICP S/S in Infants
**tense, bulging fontanels**
**separate cranial sutures**
irritable/restless
drowsy
Increased sleep (no eating)
**High-pitched cry**
**Increased head circumference**
- distended scalp veins
**Setting Sun Sign**
40
What is the Setting Sun Sign?
eyes rotating downward with the white above the eyes exposed
41
What are some s/s of increased ICP in a 1-month-old infant? SATA.
Bulging fontanels with separate sutures
Seizures
Sleeping and not waking up to eat
Diplopia
Decreased head circumference
Setting Sun Syndrome
Bulging fontanels with separate sutures
Sleeping and not waking up to eat
Rationale: Seizures and Diplopia is seen in toddlers; not infants. They would have Increased FOC- head circumference and Setting Sun "Sign"; setting sun syndrome is in elderly patients becoming hyperactive at night.
42
Children s/s of increased ICP
HA (coughing, bending, sitting up)
Nausea
**Forceful vomiting**
**Diplopia, blurred vision
Seizures**
Indifference, drowsiness
Increased sleeping
Not following simple commands
Lethargy
43
What is the difference between infant and children s/s of increased ICP?
infants have more objective s/s
children are subjective s/s
44
What are **late s/s** of Increased ICP in infants and children?
**Bradycardia**
decreased motor response to a command
decreased sensory to painful stimuli
**sluggish/fixed/dilated pupils**
**flexion/extension posturing**
altered respiratory patterns
decreased LOC
coma
45
Why does the pediatric patient have bradycardia?
compensation has stopped in the circulatory system
46
Brain herniation is what type of bleed
epidural bleed = extra volume
47
Subalpine means what has occurred in the brain
midline shift
48
Trantenurial UNCAL
Downward brain mvmt
49
What are the indications for invasive ICP monitoring?
Glasgow less than = 8
Glasgow greater than 8 with respiratory assistance
Traumatic brain injury with abnormal CT
Deterioration of condition
Subjective neurosurgeon judgement
50
What are the different invasive ICP monitoring/drainage routes?
Subdural
Epidural
Subarachnoid
Intraparenchymal
**Ventricular**
51
What is the gold standard used for increased ICP with drainage systems?
Ventricular
52
What order will the nurse predict the neurosurgeon make regarding draining of fluid from the Intracranial space?
Sustained ICP > 20 then you can drain some of the fluid
53
What are some nursing interventions for a patient with an increase in ICP?
Familiar with the drainage/monitoring system and insertion procedure
- Readings and s/s
- all equipment and in working order
Mannitol, Sedation/Paraltics, Artificial Tears, Hypertonic Saline
Positioning, Pain control, Cool/Ice packs
**Minimal Stimulation**
- stool softeners, suction PRN,
54
Mannitol does what to the ICP
osmotic diuretic to lower ICP (1-5 min quickly carries lots Na and water)
- can cause hypovolemia
55
Hypertonic Saline
increased Na to pull fluid
- great use with hypovolemia or hypotonic
HTN
56
How should a patient with increased ICP be positioned for venous drainage?
Head elevated and midline
- venous drainage
57
What is a minimal stimulation environment?
dim lights
Pain mgmt
crowd control
quiet
calming effect with family
**Only lay a hand on them do not rub**
58
With a patient with increased ICP, other than a quiet zone what other way do you calm down the patient?
Sedate and Paralyze
59
In sedating and paralyzing a patient to prevent them from raising their ICP, what drugs would you use?
Midazolam - sedative
Fentanyl – sedative analgesic
Vecuronium - paralytic
ALSO, Artificial tears ointment for eye lubrication
60
Never use a paralytic without a
sedative
61
Midazolam
- sedative
62
Fentanyl
– sedative analgesic
63
Vecuronium
- paralytic
64
When do you suction a patient with High ICP?
only as needed
- due tot he stimulation of the activity
65
How do you thermoregulate an increased ICP patient?
Cooling or ice packs
- do not use antipyretics
66
With a patient with increased ICP you want to avoid constipation, so what will be used in conjunction with the other medications?
stool softeners to avoid constipation
67
Head injury is defined as
damage to the brain or surrounding structures due to mechanical force
68
What are the 1st to 3rd most common types of head injuries?
1st = falls
2nd = MV injuries
3rd = bicycle injuries
69
Infants and young children are prone to head injuries due to their
large head
immature neck muscles
thin skull bones
open fontanels
70
What are the secondary diagnoses due to a primary head injury?
hypoxic
increased ICP
infection
cerebral edema
71
Minor head injury s/s
*Possible LOC*
temporary confusion
lethargy
drowsy
irritable
pallor
vomiting
72
S/S of progression to severe head injury
altered mental status
increased agitation
Tachycardia to Bradycardia
73
Severe head injury s/s
increased ICP s/s
**bulging fontanels**
**retinal hemorrhage
pupil pinpoint
hyperthermia
unsteady gait**
seizures
posturing (flexion and extension)
respiratory depression
74
Head Injury Dx
H&P (preexisting blood disorders, Hx matches injury, ABCD assessment, neuro, baseline VS)
X-Ray
CT
MRI (for structures)
75
What does ABCD mean in neuro?
Airway
Breathing
Circulation
Disability
76
When the brain strikes the skull, what are the medical terms for the impacts?
Coup and countercoup
77
Coup
point of impact
78
Countercoup
injury opposite from impact
79
Acceleration
the stationary head receives a blow
80
Deceleration
head in motion comes to an abrupt stop
- car crash, fall
81
With the skull receiving a blow, what increases from the head injury hit?
deformation of the skull increases ICP
82
Skull fractures occurs as a
direct blow/injury to skull associated with intracranial injury
- depressed, open
83
Which age range has the most flexible skull?
infants
84
Basilar Skull Fx
bones at the base of the skull fracture
85
What are the basilar bones?
Ethmoid
Sphenoid
Temporal
Occipital
86
Basilar Skull Fractures usually result in
dural tears
87
Why is the basilar skull fx a serious injury?
proximity to the brainstem
88
Basilar Skull Fx CONTRAINDICATED to have
NG Tube as it could go into the brain
- request OG Tube
89
With a basilar fx, the patient has a high risk of infection, so they need to have what vaccine hx or have it now?
Pneumovax
90
S/S of a Basilar Fx
SubQ bleeding on the mastoid behind the ear
Raccoon eyes
Red tympanic membrane
CSF leak from ears or nose
91
How do you detect CSF leakage?
HALO effect with a glucose dipstick test
92
Complications of Head Injuries
Hemorrhage
Infection
Edema
Herniation
93
How long should the head injury patient be monitored for swelling?
24-72 hours after injury
94
Epidural Hemorrhage Patho
Blood accumulates rapidly between the dura and skull
Hematoma
Forces brain tissue down and in
95
Classic S/S of Hemorrhage
momentary unconsciousness
normal period
altered lethargy or coma for hours
96
What is usually not evident in children with epidural hemorrhages?
classic s/s
- no unconscious period
normal period has (irritability, HA, vomiting, pale, and bulging fontanels)
97
Epidural Hemorrhage means
Brain bleed on top of the head
- in relation pushes the brain down and inward
98
How is the epidural hemorrhage diagnosed?
CT
99
Epidural hemorrhage causes tearing of what artery?
lower meningeal artery
- brain compresses rapidly on the artery causing the tear
100
Epidural hemorrhage with the lower meningeal tear is more common in what ages?
2+ y/o
because the artery has fully formed after 2 y/o
101
The lower meningeal artery is fully formed at what age?
2 y/o
102
Subdural Hemorrhage Patho
vascular injury
**between the dura and cerebellum**
spreads **slowly** through the dural space (around the side)
103
What type of bleed is a subdural hemorrhage?
venous
104
Venous bleeds are
slow
105
What is the difference between Basialr Fx, Epidural Hemorrhage, and Subdural Hemorrhage?
Basilar Fx = dural tear, Sub Q bleeding
Epidural = lower meningeal artery tear, bleeding btw dura and skull
Subdural = if also retinal bleed = child abuse, venous bleed, btw dura and cerebellum
106
Subdural Hemorrhage S/S
irritability
vomiting
Increased head circumference
lethary
coma
seizure
107
With an infant what is a sign of a subdural hemorrhage?
bulging anterior fontanel
- fontanels have not closed yet and will develop hemorrhagic shock before noticing
108
A child with a subdural hematoma and retinal hemorrhages needs to be evaluated for?
child abuse = Abusive Head Trauma or Shaken Baby Syndrome
109
What is the treatment for a Subdural Hematoma?
If small = observation
Butterfly subdural taps in infants
Subdural Drains with cath staying inside
Burr Hole
Surgical Evacuation of Hematoma
110
Tx for Mild Head Injuries
care and observe at home
family education
111
Tx for Severe Head Injuries
admit for possible surgery and observation
- Rehab
112
What do you give a head injury patient for a HA?
Acetaminophen
113
Comfort care and consults for head injuries are brought in for
palliative/spiritual with child life for siblings
when the damage is too severe and no possibility of survival
114
What painkiller do you not give to a head injury patient?
Morphine (alter mental status)
115
Submersion Injuries can occur where?
Bathtubs (infants)
Bucket (toddlers)
Swimming Pools (adolescents)
Lake, ponds, river, ocean
**Anywhere with water**
116
Bathtub submersions occur in what age?
Why?
infants; left unobserved in the bathtub
117
Bucket submersions occur in what age?
Why?
Toddlers; top heavy
118
What measurement can cause submersion?
1 inch of water
119
Submersion Injuries are usually unintentional from what ages?
0-19 y/o
birth to 4 y/o having the highest rate
120
What are the items related to a Submersion Injury?
Hypoxia
Hypothermia
Aspiration
121
Hypoxia by Submersion happens within
minutes
Lack of O2 -> loss of consciousness -> progressive decrease of cardiac output ->apnea and cardiac arrest
122
Hypoxia by Submersion
Irreversible damage after
4-6 minutes
123
The heart and lungs can survive up to how long without O2
30 minutes
124
What is the primary cause of death with submersion?
hypoxia
125
What is the key to stopping hypoxia with a submersion injury?
early resuscitation
126
Aspirated fluid is quickly absorbed in pulmonary circulation resulting in the following:
Pulmonary edema
Atelectasis
Airway Spasms
127
Pulmonary edema, Atelectasis, and Airway Spasms aggravate what other factor of submersion?
Hypoxia
128
What percentage of drowning victims die without aspirating fluid?
approximate 10%
129
What children are at an increased risk of hypothermia?
large surface area
low sub Q fat
Limited Thermoregulation
130
Diving Reflex activates when
cold water decreases metabolic demands
131
Diving Reflex
blood shunts away from the periphery to vital organs
= cardiac arrest
132
Hypothermia and aspiration occur from
submerged for lengthy period of time
133
Priority Tx for submersion injury
Restore O2 delivery/prevent further damage
1st Airway
- spontaneous respiratory effort then O2
- no spontaneous effort then intubate with mechanical ventilation
134
Treatment for Submersion Injury
**Airway
ABGs
Rewarm** (hypothermic)
Monitor for **seizures**
Blood **glucose**
IVF for electrolyte imbalances
Admit to **PICU**
135
Submersion Injury Complications
**respiratory compromise
cerebral edema
Aspiration pneumonia**
- bronchospasm, gas exchange damage, atelectasis, abscess formation, acute RDS
136
Respiratory compromise and cerebral edema occur when
4-8 hours
up to 24 hours after the incident
137
Aspiration pneumonia can occur how many hours after the incident
48-72 hours
138
The best prognosis for submersion injury is
submersion less than 5 minutes with
- sinus rhythm
- reactive pupils
- neurologic responsiveness at the scene
139
The worst prognosis for submersion injury is
submersion greater than 10 minutes
- unresponsive to advanced life support within 25 minutes
140
Children without _____________, ______________, and _______ ________ function 24 hours after submersion injury suffered severe neurologic deficits or death.
spontaneous, purposeful mvmt, and normal brainstem function
141
Prevention of submersion injuries
Parental teachings
Adequate supervision
Pool covers, fencing, lifeguard
Basic CPR skills, water safety/survival training
142
Intracranial Infections
Bacterial Meningitis
Aseptic (Viral) Meningitis
Reye Syndrome
143
Bacterial Meningitis is the
inflammation of the membranes covering the brain and spinal cord
144
Bacterial Meningitis is a medical
emergency
145
Bacterial Meningitis PATHO
bacteria invades from a focus of infection (respiratory illness)
bacteria crosses the Blood Brain Barrier (BBB)
spreads into the CSF and subarachnoid space
Brain swells
Brain surface is covered with purulent exudate
infections spreads to ventricles
pus obstruct narrow passages
Obstruction of CSF flow
Cerebral edema an increased ICP
146
Infants and young children s/s of bacterial meningitis
Fever/Hypothermia
**Poor feeding**
Vomiting
Marked irritability
Restlessness
Seizures
Bulging/tense fontanel
High-pitched cry
147
older children/adolescents s/s of bacterial meningitis
Fever/Chills
Headache
Vomiting
Altered mental status
Lethargy
Irritability/agitation
**Nuchal rigidity**
Poor perfusion
148
older children/adolescents may develop what from bacterial meningitis
seizures, photophobia, confusion, hallucinations, aggressive behavior, drowsiness, stupor, coma
149
What type of temperature would Bacterial Meningitis present?
high or low (not normal)
150
Bacterial Meningitis patients will have a history of this illness
URI
151
Kernig Sign is tested by
supine
flex the knee
extend the leg at the knee
resistance or pain in the hamstring?
152
Brudzinski Sign
flex head while in the supine position
knee or hip flex involuntary
153
Bacterial Meningitis Dx
LP - spinal needle between L3-L4 or L4-L5 vertebral spaces into subarachnoid space
154
Lumbar Puncture measures and collects
measures CSF pressure with stop cock and marks the point of ICP
- collect CSF sample
155
What sedation medications might be done for LP?
possibly versed or fentanyl
156
What are the contraindications for LP?
increased ICF cause herniation from decreased pressure
CT with midline shift
seizures
bad respirations
157
LP Pre-Op
Obtain consent(s)
Educate patient & family
EMLA?
Lidocaine
158
What are the anatomical markers for LP
top of iliac crest and straight across
L3-L5 spaces
- below the spinal nerve for low risk of paralysis
159
Positioning for an LP
Close to edge of exam table
Side-lying (infants & small children)
Bedside table (children & adolescents)
Head flexed
Knees drawn up toward chest
Immobilize child’s spine in flexed position
160
CSF Analysis for a Bacterial infection
WBC elevated (increased neutrophils)
Elevated protein
**low glucose**
Positive gram stain
cloudy color
elevated pressure
161
The lab has sent back the CSF Analysis. Which of these readings indicates a bacterial infection? SATA.
Elevated WBCs (esp. in neutrophils)
Negative Gram stain
Low Protein
High glucose
Elevated WBCs (esp. in neutrophils)
Rationale: The following are the correct results for a Bacterial infection.
WBC elevated (increased neutrophils)
Elevated protein
**low glucose**
Positive gram stain
cloudy color
elevated pressure
162
What are the ACUTE complications of Bacterial Meningitis?
SIADH
Cerebral edema/herniation
Subdural effusion
Seizures
Septic Shock
Disseminated Intravascular Coagulation
**Hydrocephalus**
163
What are the LONG-TERM complications of Bacterial Meningitis?
**Deafness** – most common
**Hydrocephalus**
**Cerebral Palsy**
Cognitive impairments
Learning disorders
ADHD
Seizures
164
Half of the Bacterial Meningitis patients will have
long term complications
165
Meningococcal Meningitis
peripheral rash
isolation grab
166
Bacterial Meningitis Tx
Isolation
Broad Antibiotics
Hydration (little less than maintenance)
Airway and shock
Reduce ICP (midline and elevated HOB)
Seizure control
Thermal Regulation
167
What isolation precaution is taken with a Bacterial Meningitis patient?
Droplet
168
Tx of Bacterial Meningitis is needed quickly to avoid
long-term complications
169
Nuchal Rigidity
arch their back with head back
170
What nursing interventions would you perform in a Bacterial Meningitis patient?
Minimal stimulation
Comfort position
Pain mgmt
Safety Precautions
Family support due to sudden and severe outcomes
171
Prognosis of Bacterial Meningitis depends on
time from onset to antibiotic therapy
type of organism
prolonged/complicated seizures
Low CSF glucose
172
What is the highest mortality rate for meningitis and age?
Pneumococcal meningitis
infants less than 6 months
173
What vaccination is used for the prevention of bacterial meningitis?
Haemophilus influenzae type b (Hib)
pneumococcal
meningococcal
174
For Bacterial Meningitis, what are the patient outcome goals?
Early recognition
Antibiotics
Prevent cerebral edema
Isolation to prevent spreading
Manage symptoms
Prevent neurologic complications
175
CSF Analysis of Viral (Aseptic) Meningitis
slight elevation of WBC (esp. lymphocytes)
normal (slight elevate) of protein
normal glucose
Negative gram stain
clear color
normal opening pressure
176
Nonbacterial Meningitis aka
Aseptic, **Viral**
177
What type of virus is aseptic meningitis?
entero viruses
- common in young
178
S/S of Viral Meningitis
HA
Fever
Photophobia
Nuchal Rigidity
179
What is used to dx and differentiate Meningitis
S/S
CSF Analysis
180
Tx for Viral Meningitis
Primarily tx symptoms with
**Acetaminophen**
Hydration
Positioning for comfort
-*Possible antibiotics/isolation until definitive dx*
181
Reye Syndrome is
acute illness causing **encephalopathy and liver dysfunction**
- cerebral edema
- fatty liver
182
Reye Syndrome is characterized by
Fever
impaired consciousness
liver dysfunction
183
Encephalopathy
cerebral edema
184
What is used to dx reye syndrome?
liver Bx
185
Reye Syndrome is caused by
viral (flu or varicella) aftermath
- salicylate = Pepto Bismol and aspirin in meds
186
What are the nursing interventions for Reye Syndrome?
Manage ICP
Strict I&Os (no overload)
Labs (HIgh ammonia and coagulation)
Support/Teachings
- liver function works after
187
Acute seizures aka
Nonrecurrent
188
Chronic seizures
Recurrent
189
What history do you need to know for seizures?
Anoxic (prenatal, perinatal, or postnatal)
Family Hx
190
Triggers of seizures
191
Postictal feelings and behaviors after seizures
192
Dx of Seizures
LP r/o infection
CT/MRI r/o cerebral hemorrhages/structures in the brain
**EEG - measures the electrical activity of cortex**
Split-Screen EEG (24 hours)
- video with EEG
193
EEG
Electroencephalography
194
Neonatal Seizures are a clinical manifestation of
serious underlying disease
195
Neonatal Seizures are usually due to what underlying disease?
Hypoxic Ischemia Encephalopathy
196
What are the s/s of neonatal seizures?
subtle
tongue sucking or eyes to the side
- frequent blinking
- smacking of tingue
- excessive sucking
- chewing mvmt
- *Rare spasms/jerky tonic-clonic*
197
Tx of neonatal seizures
underlying cause
Respiratory support (apneic or hypoxic)
Medication-
198
Infantile Spasms - Seizures
Sudden, brief, symmetric muscular contractions that occur in clusters – exaggerated startle
- possible altered consciousness
199
Infantile spasms over time increase in
severity
200
How does infantile spasms affect Growth and development?
regression of milestones
201
Infantile Spasms are most common in
4-8 months of life
NOT after 2 y/o
202
Febrile Seizures associated with
febrile illness without CNS infection
203
Do infants with febrile seizures have a history of them?
No
204
Febrile Seizures usually have a temperature of
38 C
100.4 F
205
Febrile Seizures occur between these ages
6-60 months
206
Febrile Seizures usually resolve
by themselves
207
Parental Education for Febrile Seizures
208
Febrile Seizures Tx
Ativan for mvmt
Alternate with Acetaminophen and Tylenol for fever
209
Seizure Safety
If standing or sitting _ ease to the floor
Side-lying
Protect from injury (DO NOT RESTRAIN)
NPO
Do no try to forcibly stop seizures
210
Seizure Precautions in the hospital
Side rails
Pads
Always someone in the room (family)
O2 Setup (flow meter, extension tubing, and mask)
Suction (suction unit, extension tubing, cath)
211
Seizure Precautions in the home
Waterproof mattress or pad (incontience)
No hard objects and pad next to bed
Showers (bath if observed)
- submersion therapy
Swim with a friend
Protective Gear
Med ID
212
Hydrocephalus
Imbalance in production & absorption of CSF in the ventricular system
213
Hydrocephalus CAUSE
Congenital
associated with myelomeningocele
214
Complications of illness Hydrocephalus
meningitis
brain tumor
215
Complications of injury Hydrocephalus
intraventricular hemorrhage
brain injury
216
Communicating/nonobstructive hydrocephalus
impaired absorption of CSF **within subarachnoid space**
- ventricles communicate
217
Non-Communicating/obstructive hydrocephalus
**obstruction** to the flow of CSF **within the ventricles**
- no talking
development of malformation
218
Hydrocephalus Dx Infants
head circumference **increases one percentile line within 2-4 weeks at least**
- progressive associated neurologic signs
219
How do you dx hydrocephalus on older infants and children?
CT/MRI
220
Hydrocephalus S/S WITH **OPEN FONTANELS AND SUTURE LINES**
**Rapidly increasing head circumference**
**Tense, full, bulging fontanel**
**Bulging scalp veins**
Shrill, high-pitched cry
**Setting sun sign**
Irritability or lethargy
Poor feeding
Vomiting
Change in level of consciousness
221
Hydrocephalus S/S WITH **CLOSED FONTANELS AND SUTURE LINES**
**Headache upon awakening**
Irritability or lethargy
Poor appetite
**Strabismus**
Personality change, apathy
Alterations in motor skills
Confusion
Vomiting
222
Tx of Hydrocephalus
remove obstruction
Ventriculoperitoneal (VP) shunt
Placement of reservoir
223
Ventriculoperitoneal (VP) shunt consists of
ventricular catheter
flush pump
unidirectional flow valve (only 1 direction no backflow)
distal catheter – allows coiling as the child grows uncoils
224
Placement of reservoir in a VP shunt
requires taping of the reservoir
not permanent
225
Where is the reservoir of VP shunt in a premature infant?
bottom with no tubing
butterfly needle to pull off
Evaluation of long-term shunt placement
226
Post-Op VP Shunt
Position on **non-operative side**
keep **flat initially**
Raise HOB when told by HCP
Assess for signs of increasing ICP
neuro checks
Monitor for infection
surgical sites & shunt tract
Pain management
FOC /head circumference
Abdominal assessment
Hypoactive or distension
Family support
227
VP Shunt Malfunction Complication
Symptoms of increased ICP** - not draining
Kinking, plugging, separation, or migration of tubing
mechanical obstruction
particulate matter (tissue/exudate)
thrombosis
displacement because of growth
Requires shunt revision
228
VP Shunt Infection Complication
**Most serious** complication
Generally the result of an infection before placement
Treatment - **massive doses of IV antibiotics**
229
VP Shunt persistent infection
Shunt removal
Placement of External Ventricular Drain (EVD)
Continue IV antibiotics
Daily CSF cultures until infection clears
Replace VP shunt
230
Shunt Alternatives for Hydrocephalus
External Ventricular Drain (EVD)
Endoscopic 3rd Ventriculostomy
231
Out of the VP Shunt Complications, which is the most serious?
Malformation
Infection
Corrosion
Swelling
Infection
Rationale: Malformation and Infection are VP shunt complications; however infection is the most serious. Corrosion and swelling are not complications.
232
Hydrocephalus Discharge Teachings
Notify HCP immediately with
- signs of shunt malfunction
- signs of infection
- seizures
233
In car seat safety, the children should be placed where, regardless of age?
In the middle of the back seat facing the rear
esp. infants with large head and poor head control
234
What referrals should be placed on a patient with and/or recovering from hydrocephalus?
helmet
- no contact sports
235
What are the 2 congenital neuromuscular disorders included on the test?
Cerebral Palsy
Neural Tube Defects
236
Cerebral Palsy is
non progressive impairment of motor function
237
Cerebral Palsy affects what 3 motor function
categories?
muscle control (abnormal vision, speech, hearing)
coordination (seizure and cog impairment)
posture
238
Leading cause of Cerebral Palsy
asphyxia at birth and prenatal abnormalities (maternal infection or substance abuse)
239
Prenatal Causes of Cerebral Palsy
maternal infection or substance abuse
240
Perinatal Causes of Cerebral Palsy
nuchal cord
ischemic stroke (hypoxia)
241
Postnatal Causes of Cerebral Palsy
meningitis/encephalitis
motor vehicle crash
child abuse
242
Highest risk for Cerebral Palsy occurs in what age
preterm with LBW
243
An injury during this time can result in CP
Prenatal to 2 years
244
What are the different types of CP?
Spastic (70-80%)
Dyskinetic
Ataxia
245
Spastic Cerebral Palsy
HYPERTONICITY
muscle stiffness and permanent contractions
246
Dyskinetic Cerebral Palsy
abnormal mvmt
uncontrolled, slow writhing
247
Ataxic Cerebral Palsy
poor coordination, balance, posture
248
Cerebral Palsy S/S
**delayed gross motor**
- Preschoolers, universal, symmetry/asymmetrical
-**more noticeable as they grow**
**abnormal motor**
- very **early** unilateral **hand preference** (6 months)
- stand/walk on toes
- uncoordinated/invol. mvmt
- poor suck and feeding
- persistent tongue thrust
**altered muscle tone**
- **stiff/flaccid**
- Opisthotonos posturing (arch)
- stiff when dressing
- hard diapering
- unbending hip/knee joints when sitting
**Persistent primitive reflexes**
**scissoring and extension of legs when flexed in supine**
- arms abducted at sides
- flexed elbows and fists
**fail to meet milestones**
249
Hypertonicity
stiff
250
Hypotonicity
flaccid
251
Opisthotonos posturing
arching of the back
252
What is a early sign of spasticity CP?
rigid and unbending hip/knee joints when pulled to sitting
253
CP patients have a head lag and clenched fists after
3 mns of age
254
CP Associated Disabilities
Seizures
Cog deficits
Behavior problems
Speech and sensory impairment (vision and hearing)
255
Cerebral Palsy associated issues from s/s
feeding/Gastroesophageal reflux
orthopedic contractures
constipation
poor bladder and retention of urine
cavities, gingivitis
skin breakdown
chronic URI
256
PO Medications for CP
HELP DECREASE SPASMS
dantrolene sodium
Baclofen (reduce spasticity)
Diazepam (spasms)
Gabapentin (neurologic neuropathy
257
Injection Medications for CP
Botulism toxin A (reduce spasms)
- target upper and lower extremities
258
What can be implanted into the CP patient and initially give a test dose?
Baclofen pump
- LP test for adverse effects
then Hockey puck with cath into intervertebral space
259
dantrolene sodium
hepatotoxic
260
Baclofen
-constipation and HTN
261
Diazepam
reduces spasms
262
Gabapentin
neuropathic neuropathy
263
What other drug classes could be used for Cerebral Palsy?
antiepileptic drugs - Dilantin
drugs for dystonia
drugs for hyperkinetic mvmt disorders
264
Treatment and Mobilization for Cerebral Palsy
Ankle-foot braces/orthotics
Wheelchairs
Surgery
Physical therapy
265
Cerebral Palsy Nursing Interventions
Airway
Monitor for seizures
- Administer antiepileptic drugs (Dilantin)
Dental care (feeding tube)
Bowel and bladder care
Support Family
266
With Dilantin, what is an adverse effect to watch for?
gum enlargement
267
What is a great therapy for CP?
Hippotherapy (horses)
- increases core and cognitive
268
Spina Bifida (Occulta and Cystica)
failure of neural tube to close during early development of embryo
269
What multiple factors contribute to Spina Bifida?
genetic
environment (maternal drug use, radiation exposure, hot tub/sauna in pregnancy, antiepileptic drugs)
Syndromes
270
Spina Bifida is associated with what deficiency
folic acid
271
What is the recommended daily dose for the prevention of spinal bifida?
0.4 mg
272
Spina Bifida Occulta
not visible externally - closed skin
- spinal vertebrae does not completely encase cord
273
Spina Bifida Cystica
visible externally
- meningocele
- myelomeningocele/meningomyelocele
274
The skin is closed in which type of spina bifida?
Occulta
275
Spina Bifida Occulta develops in what spinal areas?
Lumber
Sacral
276
Spina Bifida Occulta looks like
**dimple**
tuft of hair
Port wine nevi (red rash)
depression of skin
277
Meningocele
herniation of delicate sacs containing spinal fluid
protrudes outside the fluid
**NOT associated with neurological deficits**
278
Myelomeningocele
herniation of delicate sac containing spinal fluid **and spinal cord**
- outside of the skin
**Neruo deficits occur in varying degrees
- 80% develop Type 2 Chiari malformation
279
Type 2 Chiari malformation
Cerebellum and medulla oblongata
280
Myelomeningocele Dx when
Ultrasound
Alpha-fetoprotein at 16-18 weeks gestation
Post: CT/MRI/Ultrasound S/S
281
Myelomeningocele associated problems
**Hydrocephalus**
Pneumonia
Paralysis and/or orthopedic deformities
Neurogenic bladder
Bowel incontinence
282
Myelomeningocele Pre-Op
Sterile, moist, nonadherent dressing
**Soaked in normal saline**
change every **2 – 4 hrs**
**Do not let to dry out**
**Incubator** / warmer – balance with moist
Antibiotics - prophylactic
**Early detection of hydrocephalus - FOC and CSF leakage**
Prone with tactile stimulation
-No fecal contamination or rectal temps
283
The myelomeningocele is treated when
12-24 hours of birth
284
You should assess the myelomeningocele for what
Assess sac
**leaks
abrasions
irritation
signs of infection**
285
Myelomeningocele Pre-Op positioning
Prone
hips slightly flexed
abduction with pad between knees
small roll under the ankles
286
No rectal temperatures on a Myelomeningocele baby because
cause rectal prolapse
287
Myelomeningocele - Postop
Routine postop care
**Prone position initially**
Monitor FOC for hydrocephalus
**Encourage breastfeeding – positioning challenge**
No rectal temps
**High risk for latex allergies**
Urinary/bowel independence
Clean INT cath at home
288
What allergy is a Myelomeningocele baby/CP patient at high risk for
latex
289
What does a spina bifida baby need for the remainder of life?
Multiple health care observations
- mobility, self-sufficience
Developmental focus
Optimal quality of life
290
Anencephaly
absence of both cerebral hemispheres
291
What is the most serious neural tube defect?
Anencephaly
292
What is the Tx of Anencephaly for the survivors?
no specific tx (a portion of the brainstem) as most are stillborn
- able to **maintain vital functions for few hours to several weeks**
- temperature
- cardiac function
- **respiratory function**
293
Guillain-Barré Syndrome is a
autoimmune disorder affecting the peripheral nervous system
- results in progressive and usually ascending flaccid paralysis (toes to nose)
294
What is the hallmark symptom of Guillain-Barré Syndrome?
acute peripheral motor weakness
295
Paralysis occurs when in Guillain-Barré Syndrome
10 days after a nonspecific viral infection
296
Guillain-Barré Syndrome usually occurs in what age group?
4-7 y/o
297
Guillain-Barré Syndrome is often associated with
rabies
polio
Menincoccl and Influenza vaccines
298
Guillain-Barré Syndrome PATHO
- viral/bacterial infection
- inflammation and edema of the spinal cord and cranial nerves
- rapid segmented demyelination and compression of nerve roots
- impaired nerve conduction
- ascending partial/complete muscle paralysis
299
3 Phases of Guillain-Barré Syndrome
1) Acute (4 weeks)
- symptoms starts
- cont till **new symptoms stop appearing**
2) Plateau (few days to weeks)
- s/s constant
3) Recovery
- improvement begins
- progression to optimal recovery
300
Guillain-Barré Syndrome Dx
**ascending paralysis with symmetrical acute peripheral motor weakness**
CSF Analysis
TENS
EMG findings
301
Guillain-Barré Syndrome Tx
Airway support to **temp. tracheostomy**
**IVIG** – first 2 weeks
**Plasmapheresis** – replaces plasma, causes hypotension
**Stool softeners** - constipation
**Gabapentin** - neuropathic pain
**Rehab** – regain muscle strength and occupational strength
302
Plasmapheresis causes
hypotension
303
Does GBS affect with the brain or cognition?
no
304
What is the best prognosis of GBS?
YOUNG
no mech vent
**Tx with IVIG or plasmapheresis**
305
The recovery of GBS is
reverse order of onset
r/t degree of involvement
306
CP referrals also infer with what other healthcare teams
SLP
Dentist
- brushing, fluoride, and flossing are vital at early age
307
FOC means
Frontal occipital circumference
