Peds - Exam 3 - Neuro Flashcards
Levels of consciousness in descending order
Full consciousness
Confusion—impaired decision making
Disorientation—to time and place
Lethargy—sluggish speech
Obtundation—arouses with stimulation
Stupor—responds only to vigorous and repeated stimulation
Coma—no motor or verbal response to noxious stimuli
Persistent vegetative state—permanently lost function of cerebral cortex
Increased ICP - Clinical Manifestations in Children
Headache
Vomiting—with or without nausea (projectile)
Seizures
Diplopia, blurred vision
Increased ICP - Clinical manifestations in infants
Irritability, poor feeding High-pitched cry, difficult to soothe Fontanels—tense, bulging Cranial sutures—separated Eyes—setting-sun sign (eyes bilaterally deviate downward) Scalp veins—distended
Late signs of increasing ICP
Decreased LOC
Decreased motor response to command
Decreased sensory response to painful stimuli – really late sign
Alterations in pupil size and reactivity
Papilledema – swelling to optic disc
Decerebrate or decorticate posturing
Cheyne-Stokes respirations – periods of fast breaths and apnea – look at video posted with lecture
Seizure vs. Epilepsy
Seizure
A single seizure not generally classified as epileptic
Single seizure not generally treated with long-term Rx
Will resolve once medical condition is resolved
Epilepsy
Condition characterized by two or more unprovoked seizures
Multiple causes by a variety of pathologic problems in the brain
Behavioral signs of increasing ICP
Irritability, restlessness
Drowsiness***, indifference, decrease in physical activity and motor skills
Complaint of fatigue, somnolence
Inability to follow commands, memory loss
Weight loss
What to note when assessing pupil size
Medications can affect - important to know what medications that patient is on
Size of pupils, whether they are reactive - large pupils may be normal if they are reactive
Bilateral fixed pupils for longer than 5 mins usually indicates brainstem damage
One pupil dilated and fixed –
Bleed or lesion on same side of brain
Neurosurgical emergency - should be reported immediately!
Doll’s Head Maneuver
ONLY perform this after a spinal cord injury is ruled out!
- Rotate child’s head quickly from one side to the other
- Positive - brainstem intact, eyes move in opposite direction of head (normal reaction)
- Negative - eyes are remaining in fixed position no matter where head is being moved, brainstem dysfunction or damage to CN III (oculomotor)
Caloric test
Used to assess brain death in child
** Never going to be performed on an awake/conscious child
Very painful
Irrigate auditory canal over 20 seconds with ice cold water
HOB elevated 30 degrees
Normal response—eyes move toward the side of stimulation.
Abnormal response—no response
Very precise procedure, physician likely performing, nurse assisting
Decorticate/Decerebrate Positioning
Posturing may only be present with painful stimuli
Neither type of posturing is good
Ideal response – patient would withdraw
Decorticate – flexion – bringing it into the CORE
- Occurs with severe dysfunction of cerebral cortex or lesions above the brainstem
Decerebate – extension of extremities
- Occurs with dysfunction at level of midbrain or damage to brainstem
CT or MRI considerations
Most kids will need to be sedated for them - not because it’s painful
But just can be really hard for the child to lay still, especially for an MRI
Nurse or parent may be present in room (behind window) to comfort child, if facility permits
Signs of pain in comatose patient
- Tachycardia
- Increased respiration
- Increased BP
- Sats drop
(Pain can also increase ICP, so try not to do things to increase pain)
Drug therapies for pain in comatose child
Opioids – morphine or dilaudid
Fentanyl (opioid) + midazolam (versed – short-acting, causes amnesia) + vecuronium (paralytic, neuromuscular blocker, frequently used in pediatric pts who are intubated)
Acetaminophen and codeine – comfort measures
Comatose child - respiratory management
- Airway management is primary concern
- Cerebral hypoxia lasting more than 4 minutes will likely cause irreversible brain damage
- CO2 causes vasodilation, increased cerebral blood flow, and increased ICP
- May have minimal gag and cough reflexes
- Risk of aspiration of secretions
*** periodic or irregular breathing is an ominous sign – usually indicates brain stem is affected – often see prior to death with head injury
Indications for ICP monitoring
Glasgow Coma Scale score 8 with respiratory assistance
Deteriorating neurologic condition
Subjective judgment
Subarachnoid bolt
- Most frequently seen
- Scary looking for parents
- Place bolt directly to the ventricles – monitors ICP
- Held intact by dressings on the outside
- Need to be VERY careful around it – only neurosurgeon should touch it
- Nurses don’t even touch the dressing to assess the site
Nursing care for child with increased ICP
Patient positioning
- HOB 15-30 degrees
- Head should be maintained midline ideally
- Avoid frequently turning head
Avoid doing things that increase ICP
- Pain
- Too much stimuli
- Avoid doing things that will make a child cry
- ROM exercises still done but GENTLY
Suctioning issues
- Usually poorly tolerated
- May need to do because of loss of gag reflex –> will have to suction
- Really GENTLE suction & hyperoxygenate beforehand
Nutrition and Hydration
- Avoid overhydration – strict I&O – to avoid cerebral edema
- IV fluids and TPN and lipids or gastric feedings
Comatose patient - nursing care needs
- Elimination – will always have foley initially, need to record BMs (may require stool softeners as needed)
Hygienic care – skin integrity and good mouth care
- Emollients to lips – often very dry
- Eye drops/ointments
- Position and exercise
Stimulation
- Hearing is last sense to go – may be capable of hearing/sensing – still going to explain what you are doing
- Encourage family to talk with patient
- Soft music
Family support
Concussions
- transient and reversible
- Results from trauma to the head
- Instantaneous loss of awareness and responsiveness lasting for minutes to hours – DONT always have to lose consciousness for it to be concussion
- Can have nausea and vomiting afterwards
- Generally followed by amnesia and confusion
Post concussion syndrome
- Headache, dizziness, fatigue, irritability, issues with concentration or memory impairment
- Usually develop the day of injury and last up to 3 months (typically resolve by 3 months)
Behavioral changes, memory, concentration issues are normal/expected
What to report ASAP or bring in right away:
- Vomiting
- Suddenly report blurred vision, or any LOC
(Generally later signs of ICP)
Worry about repeated concussion, repeated injuries
A lot of sudden death in sports is related to multiple injuries
Rule of thumb
3 head injuries during contact sports and you’re done – no more contact sports
Contusion and laceration
Terms used to describe visible bruising and tearing of cerebral tissue
Coup—bruising at the point of impact
Contrecoup—bruising at a site far removed from the point of impact (brain hits the back of the skull)
KNOW with any head injury
Assess ABCs first
THEN stabilize head and neck
Reye Syndrome (RS)
- A disorder defined as metabolic encephalopathy associated with other characteristic organ involvement
- Characterized by fever, profoundly impaired consciousness, and disordered hepatic function
- Etiology is not well understood
- Most cases follow a common viral illness (usually influenza or varicella)
- Potential association between aspirin therapy for fever and development of RS
** If you think a child has varicella or influenza, educate parents do NOT give any aspirin or aspirin-containing products (a lot of cold preps can also contain aspirin)
Diagnostic evaluation
Definitive diagnosis by liver biopsy
Majority of children recover rapidly – if intervention is done early
1/3 of patients can die or have long-term neuro deficits
Reye Syndrome (RS) Patho
Cerebral edema
Fatty liver changes – changes of AST, ALT
Neurologic changes
Reye Syndrome Therapeutic Management
Therapy is supportive
Prevent dehydration
Monitor for increased ICP
Monitor liver function
Reye Syndrome - Onset
- Onset – pt with profuse vomiting
- Typically following varicella or influenza infection
- Neuro changes:
Personality changes or seizures
Bacterial Meningitis by age group
Occurs in epidemic form, predominantly in school-age children and college students because of close contact or living conditions
≥1 month and 3 months and <19 years
Meningitis - Signs and Symptoms
Brudzinski’s sign +
- Passively elevate the head, knees would also flex toward abdomen
Kernigs sign +
Passively elevate the leg and try to extend it at the knee, there would be resistance
Most definitive test - LP done to rule out meningitis
Onset can be abrupt or develop over 1-2 day
- High fever (103-104 typically)
- Headache
- Rash
- Neck pain, nuchal rigidity
- Vomiting
- Then deteriorating neuro changes
- Many times present with seizure or will have seizure within 48 hours
Infants
- Fever or hypothermia
- Poor feeding
- Irritability
- Restlessness
- Bulging tense fontanel
- High pitched cry
Meningitis - Treatment and nursing considerations
- IV antibiotics STAT
- Maintain strict iso precautions, maintain adequate hydration, manage sepsis and septic shock as needed
- Decrease stimuli – quiet dark room, to help keep them comfortable
- Manage pain
- Encourage vaccines (Hib, Menectra)
Nonbacterial Meningitis (Aseptic Meningitis)
Causative agents are principally viruses
Frequently associated with other diseases
- Measles, mumps, herpes, leukemia
Onset abrupt or gradual
- Manifestations—headache, fever, malaise
- Symptoms usually milder
Diagnosis and treatment
- Might start abx even before the results of LP
- Also manage symptoms – maintain hydration, manage pain
Prognosis
- Prognosis good, self-limiting
- Would work it up as we would bacterial meningitis
Seizures
- Seizure is a SYMPTOM, rather than a disease, caused by malfunctions of brain’s electrical system
- Determined by site of origin
- Most common neurologic dysfunction in children (mostly under 2 years of age)
Seizure vs. Epilepsy
Seizure
- A single seizure not generally classified as epileptic
- Single seizure not generally treated with long-term Rx
- Will resolve once medical condition is resolved (e.g., meningitis)
Epilepsy
- Condition characterized by two or more unprovoked seizures
- Multiple causes by a variety of pathologic problems in the brain
Seizures - S/S
Change in LOC
Involuntary movements
Posturing
Changes in perception, behaviors, or sensations
Seizures - Major causes
Birth injuries (anoxia) or congenital defects of CNS
Acute infections in late infancy and early childhood
In children older than 3 years, usually is idiopathic (no known cause)
What to know about seizure medications
- Monotherapy - gradually increase dose until seizure controlled or signs of toxicity
- Polypharmacy if uncontrolled with just one
- Monitor therapeutic levels, increase dose as child grows
- Monitor side effects
- Avoid abrupt discontinuation - needs to gradually dose reduce to take child off med
Are they going to have to be on medication life-long?
- Can come off when seizure-free for 2 years and normal EEG
- Not going to d/c during puberty or times when pt suffers frequent illnesses
- Recurrence can occur within first year and they may have to go back on meds
When seizure happens
- Side lying
- Maintain patent airway
- No suctioning during - ready for after (many secretions)
- No tongue blade
- Put pillow under their head
- Do not restrain
- Time seizure
Home mgmt:
- CPR training for fam members
- How to give rectal diazepam
More than 5 minute seizure at home/school: CALL 911!
First time having seizure, regardless of duration, CALL 911!
Absence Seizures
Formerly called petit mal or lapses
Sudden onset
Brief loss of consciousness, a blank stare, and automatisms (motor changes - lip smacking or eye twitching)
Most common between ages 5 and 12 years
Often stop spontaneously in the teenage years
Sudden onset of 20+ events per day
No warning/no aura
Duration 5 to 10 seconds
Motor—lip smacking, twitching of eyes, face, slight hand movements
May drop object; child rarely falls
No incontinence
Often misdiagnosed with inattention or ADHD –Inattention/daydreaming
ADD/ADHD
School issues– missing bits of information throughout day
Generalized Seizures
AKA tonicclonic seizure
Formerly known as grand mal
Usually occurs without warning
Consists of two distinct phases
Tonic
Eye rolling and loss of consciousness
Tonic muscle contractions
Clonic
Intense jerking movements
Average duration 30-50 seconds
May have incontinence, caution w/ airway concerns
Partial seizures
Further subdivided into three parts
Simple partial seizures
No alteration of consciousness
Clinical manifestations related to the area of cerebral involvement
May consist of motor, sensory, autonomic, or psychic symptoms.
Complex partial seizures
Complex symptoms and impairment of consciousness.
Simple or complex seizures secondarily generalize
Simple or complex partial seizures that evolve into generalized seizures, usually a tonic–clonic event
Atonic seizure
Sudden momentary loss of muscle tone
Onset usually ages 2 to 5 years
May or may not have loss of consciousness
Sudden fall to ground, often on face – no motor ability to catch themselves
Patient will wear helmet to protect themselves if it happens frequently
Less severe—head droops forward several times
Myoclonic seizure
Sudden brief contractions of muscle group
May be single or repetitive
No loss of consciousness
Often occur when falling asleep
May be nonspecific symptom in many CNS disorders
Nonspecific symptom of other disease
May be mistaken as exaggerated startle reflex in infant
If you can flex head forward, then NOT a seizure
Febrile seizure
Transient disorder of childhood
Affect approximately 3% of children
Usually occur between ages 6 months and 3 years
Rare after age 5
Twice as frequent in males
95% to 98% of children with febrile seizures do not have epilepsy or neurologic damage – usually happens with that rapid temp change
Management Avoid tepid baths—usually ineffective Vigorous use of antipyretics Protect child from injury during seizure Call 911 if seizure lasts more than 5 minutes
Cause?
Usually in temperatures higher than 101.8° F
Seizure occurs when temperature is rising, not after
Seizure usually over before the child arrives in the emergency department
Status Epilepticus
Definition—seizure lasting more than
30 minutes or series of seizures without regaining
premorbid LOC
Treatment
Maintain airway
Establish IV access ASAP – can be difficult w/patient actively seizing
Medications to stop it
Neural Tube Defect prevention
Treatment aimed at prevention
Supplementation—0.4 mg/day folic acid
If history of NTD—4 mg/day folic acid
1998 FDA fortifies cereal grains with folic acid
Begin at preconception
Ideally 3 months prior
Women of child bearing age should be supplementing with folic acid
NTD diagnosis
Elevated α-fetoprotein in amniotic fluid at 16 to 18 weeks
Chorionic villus sampling but not until 10 weeks of gestation
Uterine ultrasound
Why do we want to know?
Family to be prepared – especially if they are considering termination
If giving birth, will be delivered via c-section
Spina Bifida (SB) Types
Spina bifida occulta
Not visible externally
Spina bifida cystica
Visible defect
Saclike protrusion
Myomeningocele
Neural tube fails to close
May be anywhere along the spinal column
Lumbar and lumbosacral areas most common
May be diagnosed prenatally or at birth
Sac contains meninges, spinal fluid, and nerves
Varying and serious degrees of neurologic deficit
Clinically, the term “myelomeningocele” is interchangeable with “spina bifida”
The sac
May be fine membrane
Prone to leakage of CSF; easily ruptured
May be covered with dura, meninges, or skin
Degree
Location and magnitude of defect determine nature and extent of impairment
Not necessarily uniform on both sides of defect
Initial management
Prevent infection
Assessment of neurologic and associated anomalies (hydrocephalus)
Positioning – prone position / parents won’t be able to hold
Early closure within 12 to 72 hours after birth – surgery to repair
Hydrocephalus
Commonly associated with myelomeningocele
Hydrocephalus develops in 80% to 85% of children with SB
May not be apparent at birth
May appear after primary closure of defect
Results from disturbances in dynamics of CSF
Enlarged lateral and third ventricle
Management
Head Circumferences daily
Fontanel tension – increased ICP? (tense bulging fontanel?)
Serial ultrasounds—ventricle size
CT or MRI for initial diagnosis – enlarged ventricles?
EVD—External ventricular drainage
Drains CSF intermittently or continuously
Closed, sterile system with transparent pliable tubing, a collection bag, and possibly a drip chamber between the parts
Hung on IV pole at bed-side
Placed at the level of the child’s external ear HOB at 20- to 30-degree elevation
** If lower or raise HOB, close system (for short periods of time) / but generally maintain position
VP Shunt Complications
Infection
Signs/symptoms
Shunt malfunction (Fever and inflammation of tract
Abdominal pain
Malfunction- Emergency!
can happen from exudate, kinking, plugging, displaced by child’s growth spurt)
Chances greatest in 1-2 mos after placement
Signs/symptoms
Increased ICP
Worsening neurologic status/altered LOC
Types of CP
Spastic
Most common clinical type
Initially presents with hypotonia
Hypertonicity and poor control of posture, balance, and coordinated motion
Athetoid/dyskinetic
Slow, wormlike movements of extremities, trunk, face, tongue
Drooling, speech problems
Lead to jerky involuntary movements worsen w/ emotional stress
Ataxic
rapid repetitive movements; wide gait, unable to hold onto objects
Mixed/dystonic
combination or spastic and athetosis
Goals of therapy for CP
- *Goals of therapy for children with CP are early recognition and promotion of an optimum developmental course to allows these children to attain their potential within the limits of their dysfunction. There is no cure for CP and therapy is symptomatic and preventive.
- orthotics used on feet to prevent or reduce deformity and control alignment
- customized devices to help with mobility
- surgery reserved for kids who do not respond to conservative measures or if spasticity is causing progressive deformities (correct contractures, stabilize joint, bone alignment, tendon-lengthening)
- Meds: to control spasticity and pain
- technical aides: toys used to improve functioning. Computerized toys to enhance hand-eye coordination or to aide with speech difficulties
CP and IQ
**Children with CP have a wide range of intelligence, and 50-60% have normal IQ. A large percentage of children with CP do not have mental impairment.
Can be difficult to assess intelligence d/t motor and sensory deficits.
Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise.
Autism Diagnostic Criteria
- Children with ASD have core deficits in social interaction, communication and behavior. Impaired social interaction is one of the hallmarks- may include early abnormal eye contact, failure to mile, failure to orient to name, lack of imitation, lack of interactive play, and lack of gesture use, such as waving or pointing.
- communication impairment may be absent to delayed speech or abnormal speech like grunting or humming
- autism regression= when the ASD child develops normally and then regresses suddenly.
- any kid who doesn’t babble or gesture by 12 mo, a single word by 16 mo, and 2-word phrases by 2 years should have immediate hearing and language eval
- behavior impairments range from mild-severe
- repetitive impulsive spinning, twirling, rocking, flapping hands, head nodding are all common with ASD
Autism Nursing considerations
When inpatient should provide decreased stimulation and place child in private room when possible. Each child with ASD are unique and their care should be individualized. Communication should be at the child’s developmental level, brief, and concrete.
Wide variation in individual client response to treatment efforts
No cure for autism
Most promising results seem to be through highly structured routines and intensive behavior modification programs
