Neurological Dysfunction Flashcards
What family Hx do you need to know about during a neuro assessment?
Intellectual & Developmental Disabilities
Deaf/blind
Epilepsy
Stroke
What HEALTH Hx do you need to know about during a neuro assessment?
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)
What are the neuro assessment PHYSICAL EXAM findings?
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
What neuro-assessment characteristic is the earliest sign of improvement or deterioration?
Level of Consciousness
- fully, lethargic, coma
The Glasgow Coma Scale is used to assess
- LOC
- impairments in infants to very young (<2 y/o) can be problematic
What is the standard system of evaluating and assessing LOC?
Glasgow Coma Scale
A Glasgow Coma scale in pediatrics is used for ages
< 2 y/o
During a Glasgow coma scale in pediatrics, what is a helpful strategy to fully evaluate the child
family member interactions with the child
What are the 3 parts of assessments for the Glasgow Coma scale?
eye-opening
verbal response
motor response - Best
What is the score range on a Galsgow Scale from lowest to highest?
3-15
- lowest = deep coma/death
- highest = awake and aware
What Glasgow score is generally accepted as coma?
less than or equal to 8
What Glasgow score does the patient need to be intubated?
less than 8; intubate
Glasgow scores for eye-opening responses (all ages)
4-spontaneous
3-to speech
2-to pain/pressure
1-none
Glasgow’s scores for verbal responses
>2 y/o
5: oriented
4: confused
3: inappropriate words
2: incomprehensible/sounds
1: no response
T: Endotracheal tube or Trach
Glasgow’s scores for verbal responses
<2 y/o
5: coos, babbles, smiles
4: irritable cry, consolable
3: inappropriate crying/screaming
2: moans/grunts
1:none
Glasgow’s scores for motor responses
< 2 y/o
6: spontaneous/purposeful
5: withdraws to touch
4: withdraws to pain
3: flexion abnormal
2: extension abnormal
1: none
Glasgow’s scores for motor responses
> 2 y/o
6: obeys commands
5: localizes pain
4: flexion withdrawal
3: flexion abnormal
2: extension abnormal
1: none
Neuro Assessment of Pupils uses what to measure them
Pupillometer (1-8mm)
What are the different reactions in a pupil assessment?
Brisk
Sluggish
No reaction
Eyes closed by swelling
Pinpoint, Dilated/fixed, Unequal
If the pupils are fixed or dilated for more than 5 minutes, what does this mean?
brain stem damage
Atropine
eye dilated
Pinpoint pupils reasons
medications
barbiturate poisoning
What is considered a neurologic emergency regarding pupils?
sudden appearance of a fixed/dilated pupil
When a child has a sudden appearance of dilated pupils, the nurse’s priority action is?
remain with the child
With atropine pupils, the child is at high risk for
respiratory arrest
Decorticate (flexion) position means what neurological problem?
dysfunction of the cerebral cortex/above brainstem
The decorticate (flexion) position looks like
flexion of the elbows onto the chest with adduction of the arms
extension of the legs
feet together
Decerebrate (extension) position means what neurological problem?
dysfunction at the midbrain/brainstem
The Decerebrate (extension) position looks like
Extremities rotate abduction of the arms and legs with inversion of the feet
Hands out and back
Will you see posturing if they are not stimulated?
no
How would you document posturing?
describe the appearance do not label it
Herniating
Posturing only on one side
Total Cranium vol for Intracranial Pressure percentages
Brain = 80%
CSF = 10%
Blood = 10%
If there is a chnage in 1 area of ICP, then the others will
compensate
- maintain constant vol and pressure
In cerebral swelling, what happens to the ICP?
absorb more CSF causing a low blood flow
Bulging fontanels if open means
more compensation
Increased ICP early S/S onset
subtle when more noticeable when pressure increases
What are the early s/s of increased ICP? SATA.
HA
Vomiting
Fatigue
Irritability
Dizziness
Personality changes
HA
Vomiting
Fatigue
Irritability
Personality changes
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
What is the Setting Sun Sign?
eyes rotating downward with the white above the eyes exposed
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.
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
What is the difference between infant and children s/s of increased ICP?
infants have more objective s/s
children are subjective s/s
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
Why does the pediatric patient have bradycardia?
compensation has stopped in the circulatory system
Brain herniation is what type of bleed
epidural bleed = extra volume
Subalpine means what has occurred in the brain
midline shift
Trantenurial UNCAL
Downward brain mvmt
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
What are the different invasive ICP monitoring/drainage routes?
Subdural
Epidural
Subarachnoid
Intraparenchymal
Ventricular
What is the gold standard used for increased ICP with drainage systems?
Ventricular
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
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,
Mannitol does what to the ICP
osmotic diuretic to lower ICP (1-5 min quickly carries lots Na and water)
- can cause hypovolemia
Hypertonic Saline
increased Na to pull fluid
- great use with hypovolemia or hypotonic
HTN
How should a patient with increased ICP be positioned for venous drainage?
Head elevated and midline
- venous drainage
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
With a patient with increased ICP, other than a quiet zone what other way do you calm down the patient?
Sedate and Paralyze
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
Never use a paralytic without a
sedative
Midazolam
- sedative
Fentanyl
– sedative analgesic
Vecuronium
- paralytic
When do you suction a patient with High ICP?
only as needed
- due tot he stimulation of the activity
How do you thermoregulate an increased ICP patient?
Cooling or ice packs
- do not use antipyretics
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
Head injury is defined as
damage to the brain or surrounding structures due to mechanical force
What are the 1st to 3rd most common types of head injuries?
1st = falls
2nd = MV injuries
3rd = bicycle injuries
Infants and young children are prone to head injuries due to their
large head
immature neck muscles
thin skull bones
open fontanels
What are the secondary diagnoses due to a primary head injury?
hypoxic
increased ICP
infection
cerebral edema
Minor head injury s/s
Possible LOC
temporary confusion
lethargy
drowsy
irritable
pallor
vomiting
S/S of progression to severe head injury
altered mental status
increased agitation
Tachycardia to Bradycardia
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
Head Injury Dx
H&P (preexisting blood disorders, Hx matches injury, ABCD assessment, neuro, baseline VS)
X-Ray
CT
MRI (for structures)
What does ABCD mean in neuro?
Airway
Breathing
Circulation
Disability
When the brain strikes the skull, what are the medical terms for the impacts?
Coup and countercoup
Coup
point of impact
Countercoup
injury opposite from impact
Acceleration
the stationary head receives a blow
Deceleration
head in motion comes to an abrupt stop
- car crash, fall
With the skull receiving a blow, what increases from the head injury hit?
deformation of the skull increases ICP
Skull fractures occurs as a
direct blow/injury to skull associated with intracranial injury
- depressed, open
Which age range has the most flexible skull?
infants
Basilar Skull Fx
bones at the base of the skull fracture
What are the basilar bones?
Ethmoid
Sphenoid
Temporal
Occipital
Basilar Skull Fractures usually result in
dural tears
Why is the basilar skull fx a serious injury?
proximity to the brainstem
Basilar Skull Fx CONTRAINDICATED to have
NG Tube as it could go into the brain
- request OG Tube
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
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
How do you detect CSF leakage?
HALO effect with a glucose dipstick test
Complications of Head Injuries
Hemorrhage
Infection
Edema
Herniation
How long should the head injury patient be monitored for swelling?
24-72 hours after injury
Epidural Hemorrhage Patho
Blood accumulates rapidly between the dura and skull
Hematoma
Forces brain tissue down and in
Classic S/S of Hemorrhage
momentary unconsciousness
normal period
altered lethargy or coma for hours
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)
Epidural Hemorrhage means
Brain bleed on top of the head
- in relation pushes the brain down and inward
How is the epidural hemorrhage diagnosed?
CT
Epidural hemorrhage causes tearing of what artery?
lower meningeal artery
- brain compresses rapidly on the artery causing the tear
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
The lower meningeal artery is fully formed at what age?
2 y/o
Subdural Hemorrhage Patho
vascular injury
between the dura and cerebellum
spreads slowly through the dural space (around the side)
What type of bleed is a subdural hemorrhage?
venous
Venous bleeds are
slow
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
Subdural Hemorrhage S/S
irritability
vomiting
Increased head circumference
lethary
coma
seizure
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
A child with a subdural hematoma and retinal hemorrhages needs to be evaluated for?
child abuse = Abusive Head Trauma or Shaken Baby Syndrome
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
Tx for Mild Head Injuries
care and observe at home
family education
Tx for Severe Head Injuries
admit for possible surgery and observation
- Rehab
What do you give a head injury patient for a HA?
Acetaminophen
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
What painkiller do you not give to a head injury patient?
Morphine (alter mental status)
Submersion Injuries can occur where?
Bathtubs (infants)
Bucket (toddlers)
Swimming Pools (adolescents)
Lake, ponds, river, ocean
Anywhere with water
Bathtub submersions occur in what age?
Why?
infants; left unobserved in the bathtub
Bucket submersions occur in what age?
Why?
Toddlers; top heavy
What measurement can cause submersion?
1 inch of water
Submersion Injuries are usually unintentional from what ages?
0-19 y/o
birth to 4 y/o having the highest rate
What are the items related to a Submersion Injury?
Hypoxia
Hypothermia
Aspiration
Hypoxia by Submersion happens within
minutes
Lack of O2 -> loss of consciousness -> progressive decrease of cardiac output ->apnea and cardiac arrest
Hypoxia by Submersion
Irreversible damage after
4-6 minutes
The heart and lungs can survive up to how long without O2
30 minutes
What is the primary cause of death with submersion?
hypoxia
What is the key to stopping hypoxia with a submersion injury?
early resuscitation
Aspirated fluid is quickly absorbed in pulmonary circulation resulting in the following:
Pulmonary edema
Atelectasis
Airway Spasms
Pulmonary edema, Atelectasis, and Airway Spasms aggravate what other factor of submersion?
Hypoxia
What percentage of drowning victims die without aspirating fluid?
approximate 10%
What children are at an increased risk of hypothermia?
large surface area
low sub Q fat
Limited Thermoregulation
Diving Reflex activates when
cold water decreases metabolic demands
Diving Reflex
blood shunts away from the periphery to vital organs
= cardiac arrest
Hypothermia and aspiration occur from
submerged for lengthy period of time
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
Treatment for Submersion Injury
Airway
ABGs
Rewarm (hypothermic)
Monitor for seizures
Blood glucose
IVF for electrolyte imbalances
Admit to PICU
Submersion Injury Complications
respiratory compromise
cerebral edema
Aspiration pneumonia
- bronchospasm, gas exchange damage, atelectasis, abscess formation, acute RDS
Respiratory compromise and cerebral edema occur when
4-8 hours
up to 24 hours after the incident
Aspiration pneumonia can occur how many hours after the incident
48-72 hours
The best prognosis for submersion injury is
submersion less than 5 minutes with
- sinus rhythm
- reactive pupils
- neurologic responsiveness at the scene
The worst prognosis for submersion injury is
submersion greater than 10 minutes
- unresponsive to advanced life support within 25 minutes
Children without _____________, ______________, and _______ ________ function 24 hours after submersion injury suffered severe neurologic deficits or death.
spontaneous, purposeful mvmt, and normal brainstem function
Prevention of submersion injuries
Parental teachings
Adequate supervision
Pool covers, fencing, lifeguard
Basic CPR skills, water safety/survival training
Intracranial Infections
Bacterial Meningitis
Aseptic (Viral) Meningitis
Reye Syndrome
Bacterial Meningitis is the
inflammation of the membranes covering the brain and spinal cord
Bacterial Meningitis is a medical
emergency
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
Infants and young children s/s of bacterial meningitis
Fever/Hypothermia
Poor feeding
Vomiting
Marked irritability
Restlessness
Seizures
Bulging/tense fontanel
High-pitched cry
older children/adolescents s/s of bacterial meningitis
Fever/Chills
Headache
Vomiting
Altered mental status
Lethargy
Irritability/agitation
Nuchal rigidity
Poor perfusion
older children/adolescents may develop what from bacterial meningitis
seizures, photophobia, confusion, hallucinations, aggressive behavior, drowsiness, stupor, coma
What type of temperature would Bacterial Meningitis present?
high or low (not normal)
Bacterial Meningitis patients will have a history of this illness
URI
Kernig Sign is tested by
supine
flex the knee
extend the leg at the knee
resistance or pain in the hamstring?
Brudzinski Sign
flex head while in the supine position
knee or hip flex involuntary
Bacterial Meningitis Dx
LP - spinal needle between L3-L4 or L4-L5 vertebral spaces into subarachnoid space
Lumbar Puncture measures and collects
measures CSF pressure with stop cock and marks the point of ICP
- collect CSF sample
What sedation medications might be done for LP?
possibly versed or fentanyl
What are the contraindications for LP?
increased ICF cause herniation from decreased pressure
CT with midline shift
seizures
bad respirations
LP Pre-Op
Obtain consent(s)
Educate patient & family
EMLA?
Lidocaine
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
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
CSF Analysis for a Bacterial infection
WBC elevated (increased neutrophils)
Elevated protein
low glucose
Positive gram stain
cloudy color
elevated pressure
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
What are the ACUTE complications of Bacterial Meningitis?
SIADH
Cerebral edema/herniation
Subdural effusion
Seizures
Septic Shock
Disseminated Intravascular Coagulation
Hydrocephalus
What are the LONG-TERM complications of Bacterial Meningitis?
Deafness – most common
Hydrocephalus
Cerebral Palsy
Cognitive impairments
Learning disorders
ADHD
Seizures
Half of the Bacterial Meningitis patients will have
long term complications
Meningococcal Meningitis
peripheral rash
isolation grab
Bacterial Meningitis Tx
Isolation
Broad Antibiotics
Hydration (little less than maintenance)
Airway and shock
Reduce ICP (midline and elevated HOB)
Seizure control
Thermal Regulation
What isolation precaution is taken with a Bacterial Meningitis patient?
Droplet
Tx of Bacterial Meningitis is needed quickly to avoid
long-term complications
Nuchal Rigidity
arch their back with head back
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
Prognosis of Bacterial Meningitis depends on
time from onset to antibiotic therapy
type of organism
prolonged/complicated seizures
Low CSF glucose
What is the highest mortality rate for meningitis and age?
Pneumococcal meningitis
infants less than 6 months
What vaccination is used for the prevention of bacterial meningitis?
Haemophilus influenzae type b (Hib)
pneumococcal
meningococcal
For Bacterial Meningitis, what are the patient outcome goals?
Early recognition
Antibiotics
Prevent cerebral edema
Isolation to prevent spreading
Manage symptoms
Prevent neurologic complications
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
Nonbacterial Meningitis aka
Aseptic, Viral
What type of virus is aseptic meningitis?
entero viruses
- common in young
S/S of Viral Meningitis
HA
Fever
Photophobia
Nuchal Rigidity
What is used to dx and differentiate Meningitis
S/S
CSF Analysis
Tx for Viral Meningitis
Primarily tx symptoms with
Acetaminophen
Hydration
Positioning for comfort
-Possible antibiotics/isolation until definitive dx
Reye Syndrome is
acute illness causing encephalopathy and liver dysfunction
- cerebral edema
- fatty liver
Reye Syndrome is characterized by
Fever
impaired consciousness
liver dysfunction
Encephalopathy
cerebral edema
What is used to dx reye syndrome?
liver Bx
Reye Syndrome is caused by
viral (flu or varicella) aftermath
- salicylate = Pepto Bismol and aspirin in meds
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
Acute seizures aka
Nonrecurrent
Chronic seizures
Recurrent
What history do you need to know for seizures?
Anoxic (prenatal, perinatal, or postnatal)
Family Hx
Triggers of seizures
Postictal feelings and behaviors after seizures
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
EEG
Electroencephalography
Neonatal Seizures are a clinical manifestation of
serious underlying disease
Neonatal Seizures are usually due to what underlying disease?
Hypoxic Ischemia Encephalopathy
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
Tx of neonatal seizures
underlying cause
Respiratory support (apneic or hypoxic)
Medication-
Infantile Spasms - Seizures
Sudden, brief, symmetric muscular contractions that occur in clusters – exaggerated startle
- possible altered consciousness
Infantile spasms over time increase in
severity
How does infantile spasms affect Growth and development?
regression of milestones
Infantile Spasms are most common in
4-8 months of life
NOT after 2 y/o
Febrile Seizures associated with
febrile illness without CNS infection
Do infants with febrile seizures have a history of them?
No
Febrile Seizures usually have a temperature of
38 C
100.4 F
Febrile Seizures occur between these ages
6-60 months
Febrile Seizures usually resolve
by themselves
Parental Education for Febrile Seizures
Febrile Seizures Tx
Ativan for mvmt
Alternate with Acetaminophen and Tylenol for fever
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
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)
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
Hydrocephalus
Imbalance in production & absorption of CSF in the ventricular system
Hydrocephalus CAUSE
Congenital
associated with myelomeningocele
Complications of illness Hydrocephalus
meningitis
brain tumor
Complications of injury Hydrocephalus
intraventricular hemorrhage
brain injury
Communicating/nonobstructive hydrocephalus
impaired absorption of CSF within subarachnoid space
- ventricles communicate
Non-Communicating/obstructive hydrocephalus
obstruction to the flow of CSF within the ventricles
- no talking
development of malformation
Hydrocephalus Dx Infants
head circumference increases one percentile line within 2-4 weeks at least
- progressive associated neurologic signs
How do you dx hydrocephalus on older infants and children?
CT/MRI
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
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
Tx of Hydrocephalus
remove obstruction
Ventriculoperitoneal (VP) shunt
Placement of reservoir
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
Placement of reservoir in a VP shunt
requires taping of the reservoir
not permanent
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
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
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
VP Shunt Infection Complication
Most serious complication
Generally the result of an infection before placement
Treatment - massive doses of IV antibiotics
VP Shunt persistent infection
Shunt removal
Placement of External Ventricular Drain (EVD)
Continue IV antibiotics
Daily CSF cultures until infection clears
Replace VP shunt
Shunt Alternatives for Hydrocephalus
External Ventricular Drain (EVD)
Endoscopic 3rd Ventriculostomy
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.
Hydrocephalus Discharge Teachings
Notify HCP immediately with
- signs of shunt malfunction
- signs of infection
- seizures
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
What referrals should be placed on a patient with and/or recovering from hydrocephalus?
helmet
- no contact sports
What are the 2 congenital neuromuscular disorders included on the test?
Cerebral Palsy
Neural Tube Defects
Cerebral Palsy is
non progressive impairment of motor function
Cerebral Palsy affects what 3 motor function
categories?
muscle control (abnormal vision, speech, hearing)
coordination (seizure and cog impairment)
posture
Leading cause of Cerebral Palsy
asphyxia at birth and prenatal abnormalities (maternal infection or substance abuse)
Prenatal Causes of Cerebral Palsy
maternal infection or substance abuse
Perinatal Causes of Cerebral Palsy
nuchal cord
ischemic stroke (hypoxia)
Postnatal Causes of Cerebral Palsy
meningitis/encephalitis
motor vehicle crash
child abuse
Highest risk for Cerebral Palsy occurs in what age
preterm with LBW
An injury during this time can result in CP
Prenatal to 2 years
What are the different types of CP?
Spastic (70-80%)
Dyskinetic
Ataxia
Spastic Cerebral Palsy
HYPERTONICITY
muscle stiffness and permanent contractions
Dyskinetic Cerebral Palsy
abnormal mvmt
uncontrolled, slow writhing
Ataxic Cerebral Palsy
poor coordination, balance, posture
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
Hypertonicity
stiff
Hypotonicity
flaccid
Opisthotonos posturing
arching of the back
What is a early sign of spasticity CP?
rigid and unbending hip/knee joints when pulled to sitting
CP patients have a head lag and clenched fists after
3 mns of age
CP Associated Disabilities
Seizures
Cog deficits
Behavior problems
Speech and sensory impairment (vision and hearing)
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
PO Medications for CP
HELP DECREASE SPASMS
dantrolene sodium
Baclofen (reduce spasticity)
Diazepam (spasms)
Gabapentin (neurologic neuropathy
Injection Medications for CP
Botulism toxin A (reduce spasms)
- target upper and lower extremities
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
dantrolene sodium
hepatotoxic
Baclofen
-constipation and HTN
Diazepam
reduces spasms
Gabapentin
neuropathic neuropathy
What other drug classes could be used for Cerebral Palsy?
antiepileptic drugs - Dilantin
drugs for dystonia
drugs for hyperkinetic mvmt disorders
Treatment and Mobilization for Cerebral Palsy
Ankle-foot braces/orthotics
Wheelchairs
Surgery
Physical therapy
Cerebral Palsy Nursing Interventions
Airway
Monitor for seizures
- Administer antiepileptic drugs (Dilantin)
Dental care (feeding tube)
Bowel and bladder care
Support Family
With Dilantin, what is an adverse effect to watch for?
gum enlargement
What is a great therapy for CP?
Hippotherapy (horses)
- increases core and cognitive
Spina Bifida (Occulta and Cystica)
failure of neural tube to close during early development of embryo
What multiple factors contribute to Spina Bifida?
genetic
environment (maternal drug use, radiation exposure, hot tub/sauna in pregnancy, antiepileptic drugs)
Syndromes
Spina Bifida is associated with what deficiency
folic acid
What is the recommended daily dose for the prevention of spinal bifida?
0.4 mg
Spina Bifida Occulta
not visible externally - closed skin
- spinal vertebrae does not completely encase cord
Spina Bifida Cystica
visible externally
- meningocele
- myelomeningocele/meningomyelocele
The skin is closed in which type of spina bifida?
Occulta
Spina Bifida Occulta develops in what spinal areas?
Lumber
Sacral
Spina Bifida Occulta looks like
dimple
tuft of hair
Port wine nevi (red rash)
depression of skin
Meningocele
herniation of delicate sacs containing spinal fluid
protrudes outside the fluid
NOT associated with neurological deficits
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
Type 2 Chiari malformation
Cerebellum and medulla oblongata
Myelomeningocele Dx when
Ultrasound
Alpha-fetoprotein at 16-18 weeks gestation
Post: CT/MRI/Ultrasound S/S
Myelomeningocele associated problems
Hydrocephalus
Pneumonia
Paralysis and/or orthopedic deformities
Neurogenic bladder
Bowel incontinence
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
The myelomeningocele is treated when
12-24 hours of birth
You should assess the myelomeningocele for what
Assess sac
leaks
abrasions
irritation
signs of infection
Myelomeningocele Pre-Op positioning
Prone
hips slightly flexed
abduction with pad between knees
small roll under the ankles
No rectal temperatures on a Myelomeningocele baby because
cause rectal prolapse
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
What allergy is a Myelomeningocele baby/CP patient at high risk for
latex
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
Anencephaly
absence of both cerebral hemispheres
What is the most serious neural tube defect?
Anencephaly
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
Guillain-Barré Syndrome is a
autoimmune disorder affecting the peripheral nervous system
- results in progressive and usually ascending flaccid paralysis (toes to nose)
What is the hallmark symptom of Guillain-Barré Syndrome?
acute peripheral motor weakness
Paralysis occurs when in Guillain-Barré Syndrome
10 days after a nonspecific viral infection
Guillain-Barré Syndrome usually occurs in what age group?
4-7 y/o
Guillain-Barré Syndrome is often associated with
rabies
polio
Menincoccl and Influenza vaccines
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
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
Guillain-Barré Syndrome Dx
ascending paralysis with symmetrical acute peripheral motor weakness
CSF Analysis
TENS
EMG findings
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
Plasmapheresis causes
hypotension
Does GBS affect with the brain or cognition?
no
What is the best prognosis of GBS?
YOUNG
no mech vent
Tx with IVIG or plasmapheresis
The recovery of GBS is
reverse order of onset
r/t degree of involvement
CP referrals also infer with what other healthcare teams
SLP
Dentist
- brushing, fluoride, and flossing are vital at early age
FOC means
Frontal occipital circumference
