Neuromuscular Flashcards
What is part of the nervous system?
brain, spinalcord
Peripheral nervous system
pain, muscle control
Autonomic nervous system
involuntary function (heart, breathing)
What are the two rapid growth periods?
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
Why is there increased blood flow and O2 consumption in young kids?
increased metabolic requirements with growth and development
What is the first major organ system to be recognized in the embryo?
Brain and spinal cord. It also takes the longest to develop fully
Other pediatric differences
Cephalocaudal development
Head and brain are greater proportion of body at birth
Sensory pathways develop first, then motor pathways q
What is the % of head and brain of an infant compared to an adult?
12% - adult
2% - child
What is the brain growth percentage that is achieved at 1 year?
50%
What is the brain growth percentage that is achieved at 3 years?
75%
What is the brain growth percentage that is achieved at 6 years?
90%
What are the meninges?
Dura mater
Arachnoid membrane
Pia mater
Dura mater
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)
Arachnoid membrane
middle meningeal layer, delicate, avascular, weblike structure that surrounds brain
Filled with CSF
Pia mater
innermost covering; delicate, transparent membrane that adheres closely to outer surface of brain (includes arteries and veins of brain)
What are the cerebral hemispheres?
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)
Cerebral blood flow
Autoregulation
Oxygen
Blood brain barrier
Autoregulation in the brain
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
CPP
cerebral perfusion pressure
MAP
mean arterial pressure
Oxygen of the brain
needs altered with temp
- fever increases oxygen needs
- cold decreases oxygen needs
- sensitive to PaO2 and PaCO2 (ICP increases with high levels)
Blood Brain Barrier
allows passage of protein, oxygen and glucose
Neurological assessment in children
Behavior
Cognitive status
Coordination and gait
Cranial nerves
Spinal nerves – sensation and feeling in dermatomes
Strength and power
Pupils – late sign
2 components of LOC
Alertness (ability to react to stimuli)
Cognitive power (ability to process data and respon verbally or physically)
Unconsciousness
depressed cerebral function, or inability of brain to respond to stimuli
Levels of deterioration (best to worst)
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)
Causes of decreased LOC
Hypoxia
Trauma
Infection
Poisoning
Seizures
Endocrine or metabolic disturbances
Electrolyte or biochemical imbalance
Acid-base imbalance
Cerebrovascular pathology
Congenital structural defect
What can be included in a history?
head trauma, infection, ingestion of toxins; shunt, tumor
What are lab tests that can be done?
CBC, blood chemistry, clotting factors, blood culture; toxicology of blood & urine; urinalysis with culture; LP; EEG; CT scan or MRI; X-ray
Signs of increased ICP in infants
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
Signs of increased ICP in children
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
Late signs of increased ICP
Bradycardia
Decreased motor response to command
Decreased sensory response to painful stimuli
Alterations in pupil size & reactivity
Extension or flexion posturing (decorticate and decerebrate)
Decorticate
Flexion
towards the core
severe dysfunction of cerebral cortex or lesions to the corticospinal tracts above brainstem
Cheyne-Stokes respirations
Papilledema
Decreased consciousness
Coma
Decerebrate
out towards the air
dysfunction at level of midbrain or lesions to brainstem
Cheyne-strokes respirations
period of apnea followed by gradually increasing depth & rate of respiration (hyperventilation)
Papilledema
edema & inflammation of optic nerve at its point of entrance into retina; caused by increased ICP often due to tumour pressing on optic nerve
Glasgow coma results
15 is highest
less or equal to 8 is coma
3 is lowest score (death or deep coma)
Nursing management of unconscious child
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
Traumatic brain injury
blunt force to the head or penetrating injury that disrupts normal brain functioning, such as loss of level of consciousness
major causes of TBI
falls
MVA
bicycle
Most common characteristics that cause children to experience a TBI
Proportionately large & heavy head
Incomplete motor development falls
Natural curiosity & exuberance
patho of TBI
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
Primary head injuries
occur at time of trauma (skull fractures)
Subsequent complications
hypoxic brain injury, increased ICP, and cerebral edema
Coup injury
results from initial impact
Contrecoup injury
results from secondary impact as the brain moves forward and then backward within the skull
Manifestations of mild brain injury or concussions
Low grade headache that wont go away
memory problems
loss of balance
poor concentration
feeling tired
irritability
vomiting
Manifestations of moderate brain injury
GCS 9-12
Post traumatic amnesia for up to 24 hours
Loss of conciousness
altered mental status
marked changed VS
Manifestations of severe brain injury
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
Concussion
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
What are the hallmark signs of concussion?
confusion and amnesia
Complications of concussions
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
What is the classic clinical signs of epidural hematoma?
momentary unconsciousness followed by normal period for several hours, then lethargy or coma
What is a late sign of impending brainstem herniation?
Cushing triad – systemic hypertension, bradycardia, & respiratory depression
What are the signs of subdural hematoma?
irritability, vomiting, increased HC, bulging anterior fontanel, lethargy, coma, seizures
Diagnosis of post concussion syndrome
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
what is meningitis
acute inflammation of meninges & CSF
can be bacterial or pyogenic/viral or aseptic
can be caused by TB
Patho of meningitis
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
What is hydrocephalus in meningitis?
obstruction that occurs when infection spreads to ventricles
What are infant manifestations of meningitis?
fever; poor feeding; vomiting; bulging fontanel; marked irritability; rocking or cuddling irritates infant (paradoxic irritability)
What are manifestations of meningitis with older children?
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
Kernig sign with meningitis
can not extend leg up when lying on back
Brudzinski sign with meningitis
lift head up on back and knees and hips draw up
How to diagnose meningitis
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)
Meningitis interventions
Hydration, ventilation, reduction of ICP, systemic shock, control of seizures, control of temp
Complications of meningitis
Hearing loss
SIADH (retain too much fluid)
Subdural effusion
Septicemia
Seizures
Hydrocephalus
Treatment with SIADH
ampicillin
gentamicin
2/3 fluid restriction
What are seizures?
Spontaneous hyper-excitation of neurological cells
What are partial (focal) seizures?
limited to a local area of brain
Generalized seizures
involves both hemispheres of the brain
tonic clonic
absense
What are juvenile myoclonic seizures?
Epilepsy
Infantile spasms
May be idiopathic
Tonic phase of seizures
arms up, back arched, extended
Clonic phase of seizures
arms down, legs drawn up
Status epilepticus
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
What is the criteria for febrile seizures?
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
What are simple febrile seizures?
Most common type
Generalized seizures, lasting < 15 min. (most last < 5 min.) & do not recur in a 24-hour period
Recur in approx. 1/3 of children in early childhood but risk of future epilepsy only slightly higher than general population
What are complex febrile seizures
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
Treatment for seizure
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
Rescue midazolam for seizures
teach how to give buccally or intranasally for seizures > 5 minutes or 3 seizures in 30 minutes (if doesn’t work, send to ER)
What is cerebral palsy?
“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”
Spastic Cerebral Palsy
tense, contracted muscles (most common)
Athetoid CP
constant, uncontrolled motion of limbs, head and eyes
Ataxic CP
poor sense of balance, often falls and stumbles
Rigidity CP
tight muscles that resist effort to make them move
Tremor CP
uncontrollable shaking, interfering with coordination
Hemiplegia for CP
one side of body is affected
arm is usually more involved than leg
Diplegia for CP
all four limbs are affected
legs are more affected than arms
Quadriplegia for CP
all four limbs are involved
Monoplegia with CP
only one limb affected
Triplegia with CP
3 limbs are involved (both arms and a leg)
Patho for prenatal (CP)
Insufficient nutrients & oxygen; teratogens
Patho for perinatal (CP)
Trauma to brain, asphyxia, prematurity, sepsis
Patho for childhood (CP)
Head trauma, submersion injury, meningitis, shaken-baby syndrome
Manifestations for CP **
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
Nursing priorities with CP
Impaired physical mobility
Potential for muscular deformity (contractures)
Communication impairment
Potential for impaired feeding and nutrition
Disturbed body image
Family stress
Interventions with CP
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)
Normal progression of infant development milestones
Sitting – 6-7 months
Pull to stand 8-12 months
Walk – 10-16 months
Degenerative Muscular Disease
when the milestones of infant development start to undo
DMD diagnosis
Child’s history and clinical presentation of developmental regression
Genetic testing
EEG showing denervation
