Nursing care of the child with an alteration in intracranial regulation / neurologic disorder Flashcards
Exam 3
Neurologic disorders:
What is intracranial regulation?
Intracranial regulation is the process that affects equilibrium within the brain, and therefore neurologic function.
Categories of neurologic disorders:
Structural
Seizure
Infectious:
Trauma
Blood flow disruption:
Chronic:
Categories of neurologic disorders:
Infectious:
Bacterial meningitis,
aseptic meningitis (viral),
encephalitis,
Reye Syndome
Categories of neurologic disorders:
Blood flow disruption:
stroke,
Periventricular and Intraventricular hemorrhage
Categories of neurologic disorders:
Chronic:
headaches,
breath holding
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development: What is the central nervous system made up of?
Central Nervous system (CNS) is made up of brain and spinal cord
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development: When does development occur?
Development occurs within 3-4 weeks of gestation from the neural tube
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development:
What can occur?
Infection, trauma, teratogens (environmental substance that can cause physical defects in the developing embryo), and malnutrition
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development: What are premature infants at greater risk for? Why?
Premature infants are a greater risk for bleeds due to the presence of more capillaries
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development: How is the brain? What can that lead to?
Brain is highly vascular: increased risk for hemorrhage
Variations in pediatric anatomy and physiology:
Brain and Spinal Cord development: How is the brain flexible? Why is it flexible?
The sutures and the fontanels make the skull more flexible to accommodate for brain growth
Variations in pediatric anatomy and physiology:
Nervous System: How is the development of the nervous system at birth?
The development of the nervous system is complete but immature at birth
Variations in pediatric anatomy and physiology:
Nervous System: How are nerve cells at birth?
Born with all nerve cells
Variations in pediatric anatomy and physiology:
Nervous System: How is myelinization at birth?
Myelinization, formation of myelin, which covers and protects the nerves, is incomplete
Variations in pediatric anatomy and physiology:
Nervous System: As myelinization increases what happens?
Speed and accuracy of nerve impulses increases as myelinization increases
Variations in pediatric anatomy and physiology:
Nervous System: Speed and accuracy of nerve impulses leads to what?
Process accounts for acquisition of fine and gross motor movements and coordination
Variations in pediatric anatomy and physiology:
Nervous System: How does myelinization occur? (What direction)
Myelinization proceeds in the cephalocaudal direction (ex: infants able to control head and neck before the trunk and extremities)
Variations in pediatric anatomy and physiology:
Head size: How is the head size of infants and young children?
Head size in an infant and young child is large in proportion to the body.
Variations in pediatric anatomy and physiology:
Head size: The head grows until what age?
The head continues to grow until 5 years of age.
When does the brain have the most rapid growth? When is the second rapid growth?
Brain has most rapid growth at first year of life and second rapid growth at adolescent.
When can you start potty training a child?
When myelinization is complete, that is when we can start potty training.
Nursing process for the child with a neurologic disorder:
Health History: PMH
Prematurity, difficult birth, infection during pregnancy
Nursing process for the child with a neurologic disorder:
Health History: Family history
genetic disorders, seizure disorders, headaches
Nursing process for the child with a neurologic disorder
Health History: HPI
inquire about : nausea, vomiting, changes in gait, visual disturbances, headaches, recent trauma, changes in cognition, change or loss of consciousness, poor feeding, lethargy, increased irritability, fever, pain, altered muscle tonicity, delays in growth and development, ingestion or inhalation of neurotoxic substances or chemicals.
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: 5 states:
Vital signs
Head, face, neck:
Cranial nerve function:
Motor function:
Reflexes
Sensory function:
Increased ICP
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness
alertness and ability to respond to stimuli and show verbal or motor response.
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: What are the five states
Full consciousness
Confusion:
Obtunded:
Stupor:
Coma:
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: Confusion
Confusion: disoriented, responds inappropriately to questions
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: Obtunded
limited responses and falls asleep if not stimulated
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: Stupor
responds to vigorous stimulation only
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION:
Level of consciousness: Coma:
not arousable
Nursing process for the child with a neurologic disorder:
INSPECTION AND OBSERVATION: Head, face, neck:
size and shape of head, asymmetry, head circumference
Nursing process for the child with a neurologic disorder
Cranial nerve function:
doll’s eyes maneuver
nystagmus:
sunset eyes may be ICP as with hydrocephalus;
pupillary response is abnormal
Nursing process for the child with a neurologic disorder
Cranial nerve function: doll’s eyes maneuver
doll’s eyes maneuver for III, IV, VI;
Nursing process for the child with a neurologic disorder
Cranial nerve function:nystagmus:
vertical – brain stem dysfunction, horizontal – lesions or med (phenytoin);
Nursing process for the child with a neurologic disorder
Cranial nerve function: sunset eyes
sunset eyes may be ICP as with hydrocephalus; pupillary response is abnormal
Nursing process for the child with a neurologic disorder
Motor function:
observe spontaneous activity, posture, and balance; asymmetric movements; decorticate (flexed), decerebrate (flexed and pronated)
Nursing process for the child with a neurologic disorder
Sensory function:
Explain what you are doing! Distinguish between light touch, pain, vibration, heat and cold
Pediatric Glasgow Coma Scale:
Pediatric version
Pediatric version –> verbal & motor response related to the child’s age
Pediatric Glasgow Coma Scale:
Pediatric version: Higher the score indicates?
What is highest? What is 8 and below? What is 3?
Higher the score –> normal neurological function
15 highest score
8 or below –> definition of coma
3 (lowest score) indicates deep coma or death
Nursing process for the child with a neurologic disorder:
PALPATION AND AUSCULTATION
Palpation of newborn or infant skull and fontanels
Auscultation of intracranial bruits
What is the number one health risk for children and leading cause of death in children greater than 1 year?
Unintentional injury is the number one health risk for children & leading cause of death in children greater than 1 year
Head Injury:
Etiology?
Unintentional Falls
MVA
Common Causes of Head Trauma in Children
Falls
Motor vehicle accidents
Sports injuries
Pedestrian and bicycle accidents
Child abuse
Types of Closed Head Injuries (CHI) include:
Concussion
Contusion & laceration
Fractures
Other hemorrhagic lesions
Types of Closed Head Injuries (CHI):
What are complications?
Epidural hematoma
Subdural hematoma
Types of Closed Head Injuries (CHI): What are Other hemorrhagic lesions?
Cerebral edema
Sequelae of traumatic brain injury
Types of Closed Head Injuries (CHI):
Sequelae of traumatic brain injury:
Post concussion syndrome
Posttraumatic headaches
Posttraumatic seizures
Hydrocephalus
Causes of Non-accidental Head Trauma
Violent shaking: shaken baby syndrome (SBS)
Blows to the head
Intentional cranial impacts against the wall, furniture, or the floor
Increased icp
CNS has a dynamic balance of fluid (called CSF) that bathes the brain and spinal cord at a specific pressure called intracranial pressure (ICP).
Increased ICP: What is it a sign of?
Elevated ICP is a sign of a neurologic disorder.
Early signs of ICP include?
Headache
Vomiting (projectile)
Visual changes
Dizziness
Decreasing HR and respirations
Changes in pupil reactions
sunset eyes
Changes in LOC
Seizures
Bulging fontanel and increasing head circumference
Late signs of ICP include?
Decreased LOC
Depressed motor sensory responses
Bradycardia
Irregular respirations
Cheyne- Strokes respirations
Decerebrate/decorticare postures
Fixed and dilated pupils
Common Types of Structural Defects include
Neural tube defects:
Microcephaly
Arnold–Chiari malformation:
Hydrocephalus:
Intracranial Arteriovenous malformation:
Craniosynostosis
Positional Plagiocephaly:
Increased ICP: What are possible causes?
head trauma,
birth trauma,
hydrocephalus,
infection,
brain tumors.
Hydrocephalus- What is it caused by?
Caused by an imbalance in the production and absorption of CSF
Hydrocephalus: What kind of signs may be seen?
May see signs of ICP including increase in head size and loss of developmental milestones or changes in personality in older children.
Hydrocephalus: What may it require?
May require surgical intervention to relieve pressure with a ventricular shunt (temporary or permanent).
Hydrocephalus: What is the surgical intervention that may be needed?
Ventriculoperitoneal (VP) Shunt
Hydrocephalus:
What is included in Nursing Management?
Careful observation
Pre & postoperative care
Family Support
Long-term care
Hydrocephalus:
What is included Careful Observation in Nursing Management?
Measurement of head circumference
Fontanels & suture line assessment
Behavioral changes
H/A, N/V, irritability
Signs and Symptoms of Shunt Infection include:
Elevated vital signs
Poor feeding
Vomiting
Decreased responsiveness
Seizure activity
Signs of local inflammation along the shunt tract
Types of seizures
Infantile spasms :
Absence:
Tonic:
Tonic-Clonic:
Myoclonic:
Atonic:
Focal seizure without impairment of consciousness:
Focal seizure with impaired consciousness:
Status epilepticus:
Types of seizures:
Infantile spasms :
Spasm seen in infancy 3-12 months, occurs in series or clusters
Types of seizures: (4 things to know)
Absence:
Type of generalized seizures,
uncommon before 5 years old,
not associated with post ictal state, numerous seizures per day.
May be staring, twitching
Types of seizures:
Clonic:
Muscle will spam, jerk, and then relax
Types of seizures:
Tonic:
Stiffening of the muscles, arms legs, back; consciousness preserved
Types of seizures:
Tonic-Clonic:
combination of the above; a/w aura
Types of seizures:
Myoclonic:
Sudden brief muscle jerks that may involve the entire body or one part, may lose consciousness
Types of seizures:
Atonic:
Drop seizures, sudden loss of muscle tone, may lose consciousness
Types of seizures:
Focal seizure without impairment of consciousness:
tonic and clonic movements, sensory, autonomic, psychic symptoms
Types of seizures:
Focal seizure with impairment of consciousness:
Automatisms and complex purposeful movements
Types of seizures:
Status epilepticus: What is it? How long does it last? What is a distinguishing quality of it?
neurologic emergency; seizure lasting longer than 5 minutes/2 or more within a 5min.
Period without returning to normal in between
What is the most common type of seizure seen in children less than 5 years old?
Febrile seizures
Most common type of seizure seen in children less than 5 years old.
Febrile seizures: What does it occur with?
Fever usually related to viral illness.
Febrile seizures: What symptoms are associated with it?
Associated with rapid rise in core temperature to 102.2F or higher.
Febrile seizures: What is the prognosis?
Excellent prognosis
Febrile seizures: How long does it last? What accompanies it?
Generalized seizure lasting less than 15 minutes that occurs once in a 24 hour period and accompanied by a fever without any CNS infection present.
Bacterial meningitis
Infection of the meninges, the lining that surrounds the brain and spinal cord.
Bacterial meningitis: What can it lead to?
Serious illness that can lead to brain damage, nerve damage, deafness, stroke and even death.
Bacterial meningitis: What does it cause? (Symptom-wise)
Causes inflammation, swelling, purulent exudates, tissue damage to the brain. Can occur secondary to sinus or ear infections.
Bacterial meningitis: How are symptoms for most children?
Most children have sudden onset headache, fever, vomiting & severe headache with irritability
Bacterial meningitis:
How are symptoms of infants?
Infants may have fever or hypothermia, poor feeding & bulging fontanel
Bacterial meningitis:
Physical Assessment: How would babies rest? How are older children? What else?
May rest in opisthotonic position, older child may complain of neck pain, bulging fontanel in infant late sign.
Bacterial meningitis:
What can indicate irritation of the meninges?
Positive Kernig and Brudzinski signs can indicate irritation of the meninges.
Bacterial meningitis:
What should you inspect children for?
Inspect child for rash; a petechial, vesicular, or macular rash may be seen (abrupt eruption could be meningococcemia).
Common Laboratory and Diagnostic Tests
Lumbar puncture (LP), CSF analysis
Intracranial pressure (ICP) measurements
Electroencephalogram (EEG)
Head and neck radiograph
Ultrasound
Fluoroscopy:
MRI:
Computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography, uses radio isotopes (PET), and single photon emission computed tomography, used to detect brain death (SPECT)
Other Procedures and Treatments for Neurologic Disorders:
Ventricular shunt placement
Hyperventilation
Physical, Occupational, or Speech Therapies (PT/OT/ST)
External ventricular drainage (EVD)
Ventricular tap
Vagal nerve stimulator
Ketogenic diet
Medications Used to Treat Neurologic Disorders
Antibiotics
Anticonvulsants
Benzodiazepines
Analgesics
Osmotic diuretics
Corticosteroids
Acute Stroke in Children: What are the types?
Ischemic or hemorrhagic types.
Acute Stroke in Children:
How are the risk factors compared to adults? How are signs and symptoms compared to adults?
Risk factors in children are different than in adults.
Will see same signs and symptoms as in adults.
Acute Stroke in Children:
What are the signs and symptoms of stroke in children (which are the same in adults)?
Weakness on one side or hemiplegia
Facial droop
Slurred speech
Speech deficits
Managing Disturbed Sensory Perception:
What should be assessed?
Assess for changes in sensory perception.
Managing Disturbed Sensory Perception
When should you monitor providers?
Notify physician or nurse practitioner of changes in sensory perception.
Managing Disturbed Sensory Perception
What should be monitored?
Monitor child for risk of injury secondary to changes in sensory perception.
Managing Disturbed Sensory Perception:
What should you assist with?
Assist child to learn to use adaptive methods to live with permanent changes in sensory perception (i.e., use of eyeglasses) and maximize the use of intact senses.
Managing Disturbed Sensory Perception:
What should you provide?
Provide familiar sounds (voices, music).
Closed Head Injuries:
How are brain injuries graded?
Brain injury graded on severity (mild, moderate, severe) based on symptoms.
Closed Head Injuries:
How may it occur?
May occur with an accident or intentional injury.
Closed Head Injuries:
What is it?>
Non-penetrating injury to head.
Closed Head Injuries:
How is consciousness?
Normal behavior before the injury, may or may not lose consciousness.
Promoting Child and Family Teaching
Assess child’s and family’s willingness to learn.
Provide family with time to adjust to diagnosis.
Repeat information.
Teach in short sessions.
Gear teaching to a level of understanding of the child and family.
Provide reinforcement and rewards.
Use multiple modes of learning involving many senses.
