Pedi Neuro Flashcards
Premature closure of one or more cranial sutures. Common in certain syndromes. Simple (1 suture) vs complex (multiple sutures). Abnormal head shape. Can cause increased ICP and/or brain/facial/eye abnormalities.
Craniosynostosis
Treatment: Surgery. Endoscopic before 6 months. Helmet post op- 23 hours/day x 3-4 months (open surgery- no helmet)
Nursing: Neuro baseline, CBC, wound care, post-op pain, helmet adherence
Craniosynostosis Treament and Nursing Care
Asymmetry and flattening of the head due to external forces on skull. Supine for long periods ("Back to Sleep" campaign, prematurity...)
Skull deformity (R occiput greater than L). May cause uneven facial features. Determine cause
(? Decreased ROM, ? torticollis - SCM muscle)Deformational Plagiocephaly (DP)
Treatment: Positioning, orthotics (helmet less than 12 mo)
Nursing: Helmet 20-23 hours/day x 2-6 mo. Tummy time; limit car seats, swings
Deformational Plagiocephaly (DP) Treatment and Nursing Care
Abnormally small head. Head circumference 2 SDs below mean. Primary (genetic, chromosomal or hereditary cause). Secondary (exposure to irradiation, maternal infection or ETOH/tobacco). Varying degrees of cognitive impairment and motor delays.
Microcephaly
No cure: Supportive treatment.
Nursing care: Support for special needs child and family. Services, resources, equipment
Coping with appearance and raising a special needs child.
Microcephaly Treatment and Nursing Care
Build up of CSF in brain- imbalance between production and absorption. Increased production of CSF, decreased absorption of CSF, obstruction of flow (non communicating) (no LP) leads to increased ICP.
Hydrocephalus
Common cause: Arnold-Chiari malformation Types 1 & 2. Narrow foramen magnum and low cerebellar tonsils (blowing flow). Other causes: Abnormal CNS development, tumors, lesions, bleeding, head injury.
Hydrocephalus Causes
Treatment: Relieve ICP leads to VP shunt (lateral ventricle - peritoneum)
Complications: infected, clogged, kinked, clotted; need replacement with growth.
Monitor neuro status closely; head circ, temp, lethargy, feeding, N & V, seizure, skin. No contact sports
Hydrocephalus Treatment, Complications, and Nursing Care
Part of the cerebellum at the back of the skull bulges through the opening in the skull and extends into spinal canal.
Headache, neck ache, difficulty swallowing, balance, hearing issues; other neuro S/s
Arnold Chiari Malformation
Treatment only if symptomatic: Posterior fossa decompression. Applies to both types
Arnold Chiari Malformation Treament
Congenital vascular lesions- failure of vessels to differentiate. Bypass of capillaries; higher pressure causes dilation/weakening/susceptibility. Most common cause of spontaneous hemorrhage in children. Headache, weakness, seizure activity, cognitive impairment, sudden change in LOC.
Arteriovenous Malformation
Diagnosis: Neuroimaging; CT, MRI
Treatment: surgical resection; evacuation.
Outcomes depend on severity, time elapsed.
Post op: frequent neuro checks; ICU management. Serious complications common leading to disability and death. Rehab and family support
Ateriovenous Malformation Treatment, Complications, and Nursing Care
Infection of the meninges (membranes protecting brain). Spread through respiratory secretions. Bacterial/septic (or viral). S. pneumoniae, N meningitidis, E. coli or HiB. Pathogen disseminates; through CSF into brain.
Meningitis
S/s include inflammatory response: fever, headache, stiff neck, lethargy, photophobia, purpuric rash (treat immediately). Brudzinki’s and Kernig’s signs; Lumbar Puncture
S/s and Diagnosis of Meningitis
Isolation! Neuro checks; antibiotics; supportive care. Prophylaxis for those near
Nursing interventions for Meningitis
Very rare, potentially fatal toxic metabolic encephalopathic condition. Mitochondrial injury related to aspirin given during VIRAL illness. Influenza A or B, varicella; (paraflu, CMV, Coxsackie, EBV, HIV, Hep A and B, rota). Imcreased ammonia levels leading to acute encephalitis and liver failure.
Reyes Syndrome
Stages 0-6- vomiting, lethargy, disorientation - rapid progression (3-5 days): fulminant liver failure, encephalopathy, organ failure.
Diagnosis: liver biposy, LP, blood (ammonia) (specific CDC diagnostic criteria)
Reyes Syndrome S/s and Diagnosis
PICU care: specifically neuro and resp
Increased risk of bleeding due to liver involement.
Diuretics, corticosteroids, insulin, electrolytes
Teach prevention: no ASA in children over 19.
NO ASPIRIN
Reyes Syndrome Nursing Interventions
Infection surrounding meninges with CEREBRAL EDEMA. Usually viral; associated with mosquito bite-based and herpes type 1. Similar to meningitis
Encephalitis
Similar presentation to meningitis (stiff neck, lethargy, photophobia) but s/s can progress rapidly to decreased LOC, seizures.
Confirmed with MRI
Encephalitis S/s and Diagnosis
Interventions include close monitoring, IV antibiotics/antivirals, antipyretics, anti-inflammatories, anti epileptics. NOT a seizure disorder
Encephalitis Nursing Interventions
Electrical disturbance in the brain. Large # of brain cells abnormally activated at once. Causes motor, sensory/language/motor and cognitive changes.
Classified according to where they begin/area of brain affected, altered LOC and type of activity, frequency and duration.
Focal (1 hemisphere) vs generalized (both hemispheres)
Seizure Disorders
Causes include: Structural (tumor, cyst, brain defect), genetic, infectious, metabolic derangement, abnormal immune response, unknown
Causes of Seizure Disorders
Motor manifestations: Impaired awareness vs unconsciousness. Jerking in 1 extremity. Stiffness on 1 side. Lip smacking
Non-motor: Tingling, buzzing sounds, flashing lights. Feeling anxious, fearful, angry
Focal Manifestations of Seizure Disorders
Loss of consciousness
Motor manifestations: tonic (stiff, increased tone), clonic (rhythmic jerking x 4 extrem), tonic-clonic (loss of conscience), myoclonic (looks like tics, tremors), atonic (“drop attack” injury risk).
Non motor: challenging to diagnose (ADD), can look like daydreaming. Can look like daydreaming. Absence seizures: eyes flutter, lip smacking, rubbing fingers together
Generalized Manifestations of Seizure Disorders
0.5- 1% of pediatric population. Recurrent and unprovoked seizures. 2 seizures more than 24 hours apart. Probability of another (EEG activity)
Epilepsy
EMERGENCY. Prolonged seizures or series of seizures with no recovery in between. More than 5 minutes or multiple within 5 minutes. Convulsive or non convulsive. Medically induced coma.
Status Epilepticus
Seizures triggered by fever over 101.2 (Fever may follow seizure). Most common 6mos to 3 years.
Simple: less than 10 mins, happens once
Complex: More than 10 minutes, more than 1x
Febrile Seizures
Diagnose: CT/MRI (r/o lesion, mass, bleed), EEG; labs (lytes, infection, levels)
Assess/Document: Start time, length, preceding activity, clinical manifestations (deat?), post ictal (state/behavior after)
Treatment: Anti-epileptics, seizure precautions (O2, pads, meds at bedside), pt adherence to meds; “grids and strips” - locate focus area, safety (no swim alone), individualized plan at school
Epilepsy Diagnosis, Treatment, and Nursing Interventions
(TBI). Blow/jolt to head, disrupts normal brain function. Once of leading preventable causes of death in children. Infants and toddlers at greatest risk (large head); teenagers. Primary and secondary
Accidental head trauma
Injury cause directly from trauma at time of injury. Skull fracture, bleed (epidural, subdural, intracerebral), concussion, contusion (“brain bruise)
Primary head trauma
Indirectly from trauma, later.
Ischemia/hypoxia, cerebral edema, increased ICP
Secondary head trauma
Includes Shaken Baby Syndrome (SBS)/Abusive.
Infant or small child shaken or beaten by adult. #1 cause of brain damage in infants in US. 1300 cases reported yearly, 25% result in death. 80% of survivors have permanent, severe disability. Silent condition. S/s similar to other conditions. Vomiting, irritability, increased sleeping leading to apnea. Retinal hemorrhage, skeletal survery. RN is a mandated reporter
Non-Accidental Head trauma
S/s include: Photophobia, N/v, headache, vertigo, irritability, lethargy, poor feeding, amnesia/confusion, apnea, altered LOC, drainage from ears/nose (CSF)
Early signs of head trauma
Increased ICP, hydrocephalus, seizure activity, posturing, unequal or nonreactive pupils, ecchymosis around eyes, diminished reflexes, herniation, cushing’s triad, coma. RED FLAGS
Late signs of head trauma
Rapid recognition, diagnosis, treatment critical for good outcomes. Classification based on GCS score. Exam/LOC/Q1hr neuro checks. CT/MRI, ICP monitoring, Central Perfusion Pressure = MAP - ICP. Posturing? Decorticate or decebrate (brainstem)
Diagnosis of head trauma
Treatment: Supportive; neuroprotective - HOB, Na+, cool, quiet. Period of peak swelling- 72 hours.
Priorities: Maintain adequate Bp, O2 sat, ventilation. Antiseizures, prevent hypoglycemia, Mannitol and 3% saline, keep electrolytes WNL, Monitor urine output (DI, SIADH), nutrition
Discharge: rehab, trach, helmet?
Head Trauma treatment and Nursing Interventions
Common complaint, mild to severe. Acute. If its acute and recurrent its a migraine. Girls more often than boys. Paroxysmal.
Chronic - tension; psych.
Chronic non-progressive- abnormal, increased ICP tumor
Headaches
Assess location and accompanying symptoms.
Treat underlying cause: OTC meds, relaxation, triggers, keep journal.
If reported needs immediate follow up: Increase in frequency and severity, awaken a child from sleep, occur early in AM, become worse on arising, persistent in frontal or occipital areas, change in gait personality/behavior, made worse by Valsalva
Headaches Nursing interventions
Umbrella term- complex, multifactorial non progressive disorder of the brain.
Developing brain does not form properly or insult damages brain. Impaired control of muscles/movement. Impaired sensory functions, perception, cognitive ability, communication. Feeding difficulties.
Cerebral Palsy
Varying degrees of disability: spastic (80%), dyskinetic (increased/decreased tone), ataxic (coordination/gait), mixed.
Support- patient and family; in school/community: El, multiple therapies
Meds- prevent spasticity, seizures (gum hyperplasia).
Adaptive devices? WC, braces, assistive technology
Cerebral Palsy S/s and Nursing Interventions
Incomplete formation of spinal cord. Nervous tissue not encased/protected. Open vs closed. Associated with folate deficiency
Neural Tube Defects (NTDs)
1600 children/year (most common NTD) 80% also have hydrocephalus (serial measurements). 3 types. Neurological impairment and paralysis below level of defect
Spina Bifida
Interventions include: C section- minimize birth trauma; surgical repair 24-36 hours old (protect lesion before: sterile, moist drape)
Spina Bifida Nursing Interventions
No visual defect, vertebral arch abnormality. Type of spinal bifida
Spina bifida occulta
Protrusion of meninges. Type of spina bifida
Spina bifida with Meningocele
sac with meninges and spinal cord. Associated with chiari type 2. Type of spina bifida
Spina bifida with myelomeningocele
Skull fails to fuse in week 3-4 of gestation: brain and cranial membranes protrude anywhere along skull midline (nose-neck) 1 in 12000
Encephalocele
Failure of major parts of brain to develop; neural tube does not close at cranial end. More than 1.2 in 10,000. Fatal, no treatment (most stillborn or die within a few hours)
Ancephaly
Progressive muscle weakness due to muscle fiber degeneration, caused by genetic defect. Dystrophin (protein)- muscle fibers break down and lose function (Duschenne MD and Becker MD)
Muscular Dystrophy
Generalized weakness in proximal muscles of arms/legs. Not keeping up with peers, toe walk, difficulty getting up/with stairs. Gower sign.
Eventual impairment in ambulation then respiratory and cardiac function.
Treatment: Glucocorticoids can delay loss of function but affect bone health. Physical therapy. Monitor respiratory and heart function; nutrition
Muscular Dystrophy S/s and Treatment
Genetically inherited mutation in survival motor neuron 1 (SMN1) gene. Causes loss of motor function in all muscles. Degeneration of nerve cells/motor neurons in anterior horn of spinal cord. Muscles don’t receive signals from the nerve cells; atrophy. 4 types. Children present with varying degrees of motor delay, hypotonia,. and absent reflexes.
Spinal Muscular Atrophy (SMA)
Infantile onset less than 6 months; most severe; 50%; cant sit, swallow. Type of SMA
Type 1 Spinal Muscular Atrophy
6-12 mos: sit/stand, never walk. Type of SMA
Type 2 Spinal Muscular Atrophy
2-3 years; trouble with stairs, lose ability to walk. Type of SMA
Type 3 Spinal Muscular Atrophy
Diagnosis after 18 years. Type of SMA
Type 4 Spinal Muscular Atrophy
Interventions include: Pulmonary interventions, PT; assistive devices. Feeding/nutrition. Skin/positioning. Surgery for scoliosis
Nursing Interventions for Spinal muscular atrophy
Damage to spinal cord resulting is loss of physical and or sensory function. Over 50% due to MVA. Determined by mechanism of injury and direction of forces. Injury types: Hyperflexion, rotational, hyperextension, compression
Spinal Cord Injury
Absence of sensory, motor, and autonomic function below level of injury.
Complete spinal cord injury
Some motor/sensory/autonomic function below level of injury
Incomplete spinal cord injury
Xray, CT/MRI to determine level and extent of injury. Immobilization to prevent further injury; prevent sequelae.
Interventions: managing spasticity with splints, stretching PT. Baclofen, valium, clonidine. Dysautonomia (bladder and temp)- monitor; decrease triggers (catheterization. Neurogenic bladder/bowel- intermittent cath; bowel regimen. Skin integrity. Nutrition/feeding (swallowing). Family support; rehab, home modifications, home care needs, adaptive devices, services.
Spinal Cord Injury Diagnosis and Nursing Interventions
transient suppression of nerve function
Spinal shock
loss of vasomotor tone and sympathetic innervation of the heart
Neurogenic shock
Increased BP, decreased HR, sweating, full bladder/bowels
Autonomic dysreflexia
AKA acute inflammatory demyelinating polyradiculoneuropathy. Triggered by recent viral or bacterial infection. Autoimmune response: attack on PNS (CNS unaffected). Inflammation and demyelination of peripheral nerves. Causes progressive weakness, can lead to neuromuscular paralysis and resp failure. ASCENDING (feet up to check and neck) hypotonia, numbness, pain (over a few days- weeks).
Guillain-Barre Syndrome
Diagnosis: CSF = increased protein (more than 2x normal)
Treatment: IVIG x 5 days or phasmapheresis.
Nursing: Extended hospitalization. Monitor resp status (intubation?) Skin/immobility, nutrition
Guillian Barre Syndrome Diagnosis, Treatment and Nursing Interventions
Type of Arnold Chiari. Affects only cerebellum
Arnold Chiari 1
Type of Arnold Chiari. Affects cerebellum and brainstem.
Arnold Chiari 2
