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N342 > Neuromuscular > Flashcards

Neuromuscular Flashcards

1
Q

What is part of the nervous system?

A

brain, spinalcord

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2
Q

Peripheral nervous system

A

pain, muscle control

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3
Q

Autonomic nervous system

A

involuntary function (heart, breathing)

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4
Q

What are the two rapid growth periods?

A

15-20 weeks of gestation - dramatic increase in # of neurons; sensitive times for infection or injury that can lead to brain damage. Viruses are especially dangerous as they easily cross the placenta and can not be easily treated
30 weeks of gestation to 1 year of age - another period of increased growth; sensitive time for infection, hypoxia, malnutrition

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5
Q

Why is there increased blood flow and O2 consumption in young kids?

A

increased metabolic requirements with growth and development

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6
Q

What is the first major organ system to be recognized in the embryo?

A

Brain and spinal cord. It also takes the longest to develop fully

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7
Q

Other pediatric differences

A

Cephalocaudal development
Head and brain are greater proportion of body at birth
Sensory pathways develop first, then motor pathways q

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8
Q

What is the % of head and brain of an infant compared to an adult?

A

12% - adult
2% - child

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9
Q

What is the brain growth percentage that is achieved at 1 year?

A

50%

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10
Q

What is the brain growth percentage that is achieved at 3 years?

A

75%

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11
Q

What is the brain growth percentage that is achieved at 6 years?

A

90%

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12
Q

What are the meninges?

A

Dura mater
Arachnoid membrane
Pia mater

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13
Q

Dura mater

A

double layer, tough, outer meningeal membrane and inner periosteum of cranial bones

Epidural space (between 2 dura mater layers)
Subdural space (between dura mater and arachnoid)

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14
Q

Arachnoid membrane

A

middle meningeal layer, delicate, avascular, weblike structure that surrounds brain

Filled with CSF

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15
Q

Pia mater

A

innermost covering; delicate, transparent membrane that adheres closely to outer surface of brain (includes arteries and veins of brain)

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16
Q

What are the cerebral hemispheres?

A

cerebellum (motor movement and area of concern for neurological disorders)
brain stem (cranial nerves, motor and sensory neurons, coordinates motor control signals from brain to body; autonomic functions of the PNS)

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17
Q

Cerebral blood flow

A

Autoregulation
Oxygen
Blood brain barrier

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18
Q

Autoregulation in the brain

A

the brains protection of itself to keep the pressure constant
- intracranial pressure
- cerebral arteries change their diameter in response to fluctuating cerebral perfusion (blood still gets to brain in crisis)
- CPP = MAP - ICP

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19
Q

CPP

A

cerebral perfusion pressure

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20
Q

MAP

A

mean arterial pressure

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21
Q

Oxygen of the brain

A

needs altered with temp
- fever increases oxygen needs
- cold decreases oxygen needs
- sensitive to PaO2 and PaCO2 (ICP increases with high levels)

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22
Q

Blood Brain Barrier

A

allows passage of protein, oxygen and glucose

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23
Q

Neurological assessment in children

A

Behavior
Cognitive status
Coordination and gait
Cranial nerves
Spinal nerves – sensation and feeling in dermatomes
Strength and power
Pupils – late sign

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24
Q

2 components of LOC

A

Alertness (ability to react to stimuli)
Cognitive power (ability to process data and respon verbally or physically)

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25
Q

Unconsciousness

A

depressed cerebral function, or inability of brain to respond to stimuli

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26
Q

Levels of deterioration (best to worst)

A

Confusion
Disorientation (unable to say date and time)
Lethargy (sluggish)
Obtundation (limited response to environment)
Stupor (remaining in deep sleep, moaning)
Coma (no response to painful stimuli)
Persistent Vegetative state ((permanently lost function of the cerebral cortex)

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27
Q

Causes of decreased LOC

A

Hypoxia
Trauma
Infection
Poisoning
Seizures
Endocrine or metabolic disturbances
Electrolyte or biochemical imbalance
Acid-base imbalance
Cerebrovascular pathology
Congenital structural defect

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28
Q

What can be included in a history?

A

head trauma, infection, ingestion of toxins; shunt, tumor

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29
Q

What are lab tests that can be done?

A

CBC, blood chemistry, clotting factors, blood culture; toxicology of blood & urine; urinalysis with culture; LP; EEG; CT scan or MRI; X-ray

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30
Q

Signs of increased ICP in infants

A

Tense, bulging fontanel
Separated cranial sutures
Irritability & restlessness
Drowsiness
High-pitched cry
Increased fronto-occiptal circumference
Distended scalp veins
Poor feeding
Crying when disturbed
Setting-sun sign - eyes open with iris downward
- common in hydrocephalus

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31
Q

Signs of increased ICP in children

A

Headache
Nausea
Forceful vomiting
Diplopia, blurred vision
Seizures
Indifference, drowsiness
Decline in school performance
Diminished physical activity & motor performance
Increased sleeping
Inability to follow simple commands
lethargy

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32
Q

Late signs of increased ICP

A

Bradycardia
Decreased motor response to command
Decreased sensory response to painful stimuli
Alterations in pupil size & reactivity
Extension or flexion posturing (decorticate and decerebrate)

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33
Q

Decorticate

A

Flexion
towards the core
severe dysfunction of cerebral cortex or lesions to the corticospinal tracts above brainstem
Cheyne-Stokes respirations
Papilledema
Decreased consciousness
Coma

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34
Q

Decerebrate

A

out towards the air

dysfunction at level of midbrain or lesions to brainstem

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35
Q

Cheyne-strokes respirations

A

period of apnea followed by gradually increasing depth & rate of respiration (hyperventilation)

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36
Q

Papilledema

A

edema & inflammation of optic nerve at its point of entrance into retina; caused by increased ICP often due to tumour pressing on optic nerve

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37
Q

Glasgow coma results

A

15 is highest
less or equal to 8 is coma
3 is lowest score (death or deep coma)

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38
Q

Nursing management of unconscious child

A

Maintain patent airway
Respiratory management
Monitor neurological status
Pain management
ICP monitoring
Fluid management
Nutrition
Bowel elimination
Thermoregulation
Medications
Routine care – skin care, turning & positioning, artificial tears, mouth care, ROM
Sensory stimulation
Family support & Discharge Planning

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39
Q

Traumatic brain injury

A

blunt force to the head or penetrating injury that disrupts normal brain functioning, such as loss of level of consciousness

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40
Q

major causes of TBI

A

falls
MVA
bicycle

41
Q

Most common characteristics that cause children to experience a TBI

A

Proportionately large & heavy head
Incomplete motor development  falls
Natural curiosity & exuberance

42
Q

patho of TBI

A

Intracranial contents (brain, blood, CSF) damaged b/c force is too great to be absorbed by skull & muscles and ligaments

predominate feature is swelling of the brain

43
Q

Primary head injuries

A

occur at time of trauma (skull fractures)

44
Q

Subsequent complications

A

hypoxic brain injury, increased ICP, and cerebral edema

45
Q

Coup injury

A

results from initial impact

46
Q

Contrecoup injury

A

results from secondary impact as the brain moves forward and then backward within the skull

47
Q

Manifestations of mild brain injury or concussions

A

Low grade headache that wont go away
memory problems
loss of balance
poor concentration
feeling tired
irritability
vomiting

48
Q

Manifestations of moderate brain injury

A

GCS 9-12
Post traumatic amnesia for up to 24 hours
Loss of conciousness
altered mental status
marked changed VS

49
Q

Manifestations of severe brain injury

A

GCS 8 or less
Posttraumatic amnesia lasting longer than 24 hours
coma
increased intracranial pressure
seizures
signs of increased ICP
elevated temp
unsteady gait and papilledema

50
Q

Concussion

A

alteration in mental status with or without loss of consciousness, which occurs immediately after a head injury

usually resolve within 7-10 days

may be result of shearing in the brain

51
Q

What are the hallmark signs of concussion?

A

confusion and amnesia

52
Q

Complications of concussions

A

Epidural hematoma
- Hemorrhage into space b/n dura & skull
- Dural stripped from skull as hematoma enlarges
Subdural hematoma
- Bleeding b/n dura & arachnoid membrane
- Develops slowly and spreads thinly & widely
Post concussion syndrome
- Sequela to brain injury with or without loss of consciousness

53
Q

What is the classic clinical signs of epidural hematoma?

A

momentary unconsciousness followed by normal period for several hours, then lethargy or coma

54
Q

What is a late sign of impending brainstem herniation?

A

Cushing triad – systemic hypertension, bradycardia, & respiratory depression

55
Q

What are the signs of subdural hematoma?

A

irritability, vomiting, increased HC, bulging anterior fontanel, lethargy, coma, seizures

56
Q

Diagnosis of post concussion syndrome

A

At least 3… in the first 3 days that resolve in 3 mos
Headaches (most common)
Dizziness
Light sensitivity
Fatigue
Nausea
Irritability
Restlessness
Difficulty concentrating
Memory impairment

57
Q

what is meningitis

A

acute inflammation of meninges & CSF

can be bacterial or pyogenic/viral or aseptic

can be caused by TB

58
Q

Patho of meningitis

A

secondary to other infections

Bacteremia spreads infectious agent to CNS; inflammatory response follows; WBC accumulate & cover brain with thick, white, purulent discharge; brain becomes hyperemic & edematous

59
Q

What is hydrocephalus in meningitis?

A

obstruction that occurs when infection spreads to ventricles

60
Q

What are infant manifestations of meningitis?

A

fever; poor feeding; vomiting; bulging fontanel; marked irritability; rocking or cuddling irritates infant (paradoxic irritability)

61
Q

What are manifestations of meningitis with older children?

A

abrupt onset; fever, chills; seizures; irritability, agitation; c/o muscle or joint pain; headache, photophobia & nuchal rigidity; positive Kernig & Brudzinski signs

Hemorrhagic rash (get to the hospital right away)

May progress to: seizures, apnea, cerebral edema, subdural effusion, hydrocephalus, DIC, shock & increased ICP

62
Q

Kernig sign with meningitis

A

can not extend leg up when lying on back

63
Q

Brudzinski sign with meningitis

A

lift head up on back and knees and hips draw up

64
Q

How to diagnose meningitis

A

Blood - CBC, blood C&S, electrolytes, clotting factors
LP - WBC, protein (elevated), glucose (decreased depending on severity); gram-stain & culture
Medications (Iv antibiotic therapy ASAP, corticosteroids, antipyretics and anticonvulsants)

65
Q

Meningitis interventions

A

Hydration, ventilation, reduction of ICP, systemic shock, control of seizures, control of temp

66
Q

Complications of meningitis

A

Hearing loss
SIADH (retain too much fluid)
Subdural effusion
Septicemia
Seizures
Hydrocephalus

67
Q

Treatment with SIADH

A

ampicillin
gentamicin
2/3 fluid restriction

68
Q

What are seizures?

A

Spontaneous hyper-excitation of neurological cells

69
Q

What are partial (focal) seizures?

A

limited to a local area of brain

70
Q

Generalized seizures

A

involves both hemispheres of the brain
tonic clonic
absense

71
Q

What are juvenile myoclonic seizures?

A

Epilepsy
Infantile spasms
May be idiopathic

72
Q

Tonic phase of seizures

A

arms up, back arched, extended

73
Q

Clonic phase of seizures

A

arms down, legs drawn up

74
Q

Status epilepticus

A

Continuous seizure that lasts more that 30 minutes
OR
Series of seizures from which the child does not regain a premorbid LOC

IF LONGER THAN 5 MIN, START TREATMENT

75
Q

What is the criteria for febrile seizures?

A

Convulsion associated with temperature > 38 C
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

76
Q

What are simple febrile seizures?

A

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 only slightly higher than general population

77
Q

What are complex febrile seizures

A

Focal onset
Last > 15 min., or occur more than once in 24 hours

Higher risk of recurrent febrile seizures & slightly higher risk of future nonfebrile seizures than with simple febrile seizures

78
Q

Treatment for seizure

A

0-5 min
- ABCs, place in recovery position, glucose, IV access, bloodwork
5-15 min
- IV access (lorazepam)
- No IV access (midazolam)
- repeat same med once if seizure longer than 5 min after 1st dose
15-40
- phenytoin or levetiracetam or phenobarbital or valproic acid
40-60 min
- consider intubation, ICU

79
Q

Rescue midazolam for seizures

A

teach how to give buccally or intranasally for seizures > 5 minutes or 3 seizures in 30 minutes (if doesn’t work, send to ER)

80
Q

What is cerebral palsy?

A

“a group of permanent disorders of movement and posture development causing activity limitation, which is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain”

81
Q

Spastic Cerebral Palsy

A

tense, contracted muscles (most common)

82
Q

Athetoid CP

A

constant, uncontrolled motion of limbs, head and eyes

83
Q

Ataxic CP

A

poor sense of balance, often falls and stumbles

84
Q

Rigidity CP

A

tight muscles that resist effort to make them move

85
Q

Tremor CP

A

uncontrollable shaking, interfering with coordination

86
Q

Hemiplegia for CP

A

one side of body is affected
arm is usually more involved than leg

87
Q

Diplegia for CP

A

all four limbs are affected
legs are more affected than arms

88
Q

Quadriplegia for CP

A

all four limbs are involved

89
Q

Monoplegia with CP

A

only one limb affected

90
Q

Triplegia with CP

A

3 limbs are involved (both arms and a leg)

91
Q

Patho for prenatal (CP)

A

Insufficient nutrients & oxygen; teratogens

92
Q

Patho for perinatal (CP)

A

Trauma to brain, asphyxia, prematurity, sepsis

93
Q

Patho for childhood (CP)

A

Head trauma, submersion injury, meningitis, shaken-baby syndrome

94
Q

Manifestations for CP **

A

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
Hand preference before 18 months
Feeding/swallowing difficulties – drooling, aspiration, persistent tongue thrusting
Seizures
Leg scissoring
Sensory impairment (vision, hearing)
Extreme irritability of crying
Little interest in surroundings
Excessive sleeping

95
Q

Nursing priorities with CP

A

Impaired physical mobility
Potential for muscular deformity (contractures)
Communication impairment
Potential for impaired feeding and nutrition
Disturbed body image
Family stress

96
Q

Interventions with CP

A

Family Support
Normalization – especially at school
OT, PT and appropriate equipment to prevent further problems, maximize function, and prevent contractures (muscle wasting)
Well child care – Immunizations, and care for episodic illness
Feeding therapy (dysphagia)

97
Q

Normal progression of infant development milestones

A

Sitting – 6-7 months
Pull to stand 8-12 months
Walk – 10-16 months

98
Q

Degenerative Muscular Disease

A

when the milestones of infant development start to undo

99
Q

DMD diagnosis

A

Child’s history and clinical presentation of developmental regression
Genetic testing
EEG showing denervation

N342 (7 decks)

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