Quiz 2: Neurological Alterations Flashcards
Seizures
- Brief paroxysmal behavior caused by excessive abnormal discharge of neurons.
- The earlier and more frequent the seizure, the poorer the outcome.
Infant seizures
Are difficult to detect due to being so subtle
Seizures are classified into what two categories?
- Partial Seizures: local onset, involves a small location of the brain
- Generalized Seizures: involves both hemispheres of the brain
Seizure Assessment:
- Obtain info from the parents about: Time of onset, precipitating events, behavior before & after seizure
- Determine the child’s hx r/t seizures
- Ask child about presence of an aura (warning sign of impending seizure)
- Monitor for apnea & cyanosis
- Post-seizure: the child is disorientated & sleepy
- Video recording and EEG monitoring help ID seizure
- Identify metabolic causes
- CT and MRI: to ID trauma, tumor or congenital malformation.
- Neonate labs: TORCH (Toxoplasmosis, other agents, rubella, cytomegalovirus, HSV)
Seizure Managment
- Treat the whole child
- Maintain airway: turn on side and support head (avoid neck flexion)
- Maintain seizure precautions
- Monitor therapeutic drug levels
Seizure precautions
- Raise side rails when child is resting
- Pad side rails & hard objects
- Waterproof mattress or pad
- Carry medical identification
- Swim with a companion
What are goals for seizure management?
- Identify and correct the cause
- Eliminate the seizure with minimal side effects
- Normalize the lives of the child and family
Seizure treatment
- Vagus Nerve Stimulation (delivers electrical impulse to the brain to reduce number and severity of seizures)
- Ketogenic Diet (carb free, mostly fat: produces state of ketosis that is though to control seizures)
- Antiepileptic Medications
Febrile Seizures
- Generally seen in young children.
- Due to height and rapidity of temperature elevation
- Occurs during the temperature rise
Infantile spasms
- Infantile spasms are not clearly understood
- Cause: Perinatal aspyxia and Intracranial hemorrhage
Increased ICP
- Reflects the pressure exerted by the blood, brain, CSF and other space occupying fluids.
- Defined as pressure sustained at 20 mm Hg or higher for 5 minutes or longer.
What are complications of increased ICP?
- Will compromise cerebral perfusion and produce shifting of brain tissue -> herniations.
- Types of herniations include: transtentorial herniation, temporal lobe herniation, tonsillitis herniation, and brainstem herniation (results in death).
Signs and Symptoms of Increased ICP in Infants
- Poor feeding/vomiting
- Lethargy
- Bulging fontanel
- High-pitched cry
- Increased head circumference (at 2 y/o, stop measuring)
- “Sun setting” eyes
- Separation of cranial sutures
- Distending scalp veins
- Increased/decreased response to pain .
What are signs and symptoms of increased ICP in a child?
- Headache
- Diplopia
- Mood swings
- Slurred speech
- Papilledema
- Altered LOC
- N/V (especially in the morning)
How do vital signs change with increased ICP?
- Cushing’s response: increased systolic, widened pulse pressure, bradycardia, change in RR.
- As ICP rises: Cheyne-stokes repspiration -> neurogenic hyperventilation or apneustic breathing.
Hydrocephalus
-Results from imbalance between production and absorption of CSF; and/or obstruction to the flow of CSF.
What can cause hydrocephalus?
- Developmental malformations
- Neoplasms
- Trauma
- CNS infections
Hydrocephalus affect on the ventricles
- Causes an increased accumulation of CSF in ventricles
- Ventricles become dilated and compress the brain substance against the surrounding cranium.
- If it happens before the sutures fuse -> enlargement of the skull and dilation of the ventricles occur.
Since infants have open fontanels, how does it affect their ability to handle ICP?
Gives them more time until ICP becomes a real issue because the pressure has somewhere to go.
Glasgow Coma Scale
- Assesses LOC
- Consists of a 3 part assessment:
1. Eye opening
2. Verbal response
3. Motor response. - Total numerical scores range from:
1. 15 = no change in LOC
2. 3 = deep coma and poor prognosis
*NEED TO KNOW
Hydrocephalus: Dandy-walker malformation
- Involves cystic expansion of the 4th ventricle
- Obstruction of CSF flow
What are clinical manifestations of hydrocephalus in infants?
- Abnormal rate of head growth
- Frontal bossing
- Irritable & lethargic
- Lower extremity spasticity
- Cries when held and rock, calms when lying still
- Setting-sun sign
What are clinical manifestations of hydrocephalus in children?
- Symptoms caused by increased ICP
- Headache in morning
- Papilledema
- Strabismus
Fetal Evaluation of Hydrocephalus consists of
-Ultrasonography as early as 14-15 weeks gestation
Infant evaluation of hydrocephalus
Diagnosis based on head circumference
Primary diagnostic tools for hydrocephalus include
- CT
- MRI
Treatment for Hydrocephalus
Ventriculoperitoneal Shunt
Ventriculoperitoneal Shunt
- Provides primary drainage of CSF from ventricles to an extracranial compartment. (Usually peritoneum)
- Allows for excess tubing (minimizes the number of revisions that are needed.
What are major concerns associated with ventriculoperitoneal shunts?
- Infection: can occur anytime; at greatest risk during the first 6 months after placement; treated with IV ABT for 7-10 days.
- Malfunction: most often caused by mechanical obstruction.
Meningitis
- Infectious process infecting the CNS
- Droplet Transmission
How is meningitis diagnosed?
- Testing CSF via lumbar puncture
- Clinical Findings:
- Increased CSF pressure
- Cloudy SCF
- High protein concentration
- Low glucose level
What are clinical manifestations of meningitis?
No single hallmark sign. Vague and non-specific in children: -poor feeding -vomiting -bulging fontanel -irritability -headache -photophobia -altered level of consciousness -petechial or purpuric rash
What are signs of meningitis?
- Kernig’s sign: inability to extend the leg when flexed anteriorly at the hip
- Brudzinski’s sign: neck flexion -> adduction and flexion movements of lower extremities
Treatment for Viral Meningitis
- Supportive
- Usually complete recovery
Treatment for Bacterial Meningitis
- ABT: administered after lumbar puncture
- Steroid therapy
- Supportive: recovery good with early recognition and treatment.
- Pneumococcal conjugate vaccine: for all children beginning at age 2 months to protect against meningitis
What are complications associated with meningitis?
- Hydrocephalus
- Vision and hearing loss
- Delayed growth and development
- Seizures
- Cranial nerve palsy
Reye Sydnrome
- Metabolic encephalopathy with organ involvement that follows a viral illness or toxin (or giving aspirin with viral disease)
- Body’s response from exposure to virus or toxin: elevated temperature.
- Not well understood
Reye Syndrome can lead to
- Liver cell damage
- Toxic levels of serum ammonia
- Cerebral dysfunction, F&E imbalances and coagulopathies.
Reyes Syndrome is characterized pathologically by:
- Cerebral edema
- Fatty liver changes
What are clinical manifestations of Reyes Syndrome?
- Nausea & vomiting
- Progressive neurological deterioration
- Elevated serum ammonia levels
- Hypoglycemia
- Increased ICP
- Staged from I to V
How is Reyes’s Syndrome managed?
- Monitor in hospital setting
- Frequent neurological checks
- Hydration
- Correct acid-base imbalances
- Protect from coagulation injuries
What does the neural tube close?
1 month after conception.
Defects of Neural Tube Closure: Degree of Neurological Dysfunction
- Depends on where the sac protrudes through the vertebrae
- Anatomical level of the defect
- Amount of nerve tissue involvement
What can decrease the change for neural tube defects?
Folic acid intake of 0.4 mg daily.
Where do neural tube defects most often occur?
Neural tube defects can happen anywhere along the spinal column BUT the lower back is the most common
Myelodysplasia
Refers to any malformation of the spinal canal and cord
Spina Bifida
Midline defects involving the failure of the osseous spine to close.
What are the two types of spina bifida?
- Spina Bifida Occulta
2. Spina Bifida Cystica: meningocele and myelomeningocele
Spina Bifida Occulta
- Defect not visible externally but you can feel it
- Has superficial cutaneous indications
- Has neuromuscular disturbances
- Evaluated by MRI
Spina Bifida Occulta: Superficial cutaneous indications include
- Skin depression/dimple
- Port wine nevi
- Tufts of hair
- Soft cutaneous lipomas
Spina Bifida Occulta: Neuromuscular disturbances include
- Changes in gait with foot weakness: may walk pigeon toed
- Foot deformity
- Bowel and bladder sphincter disturbances
- May not be evident until child is walking or toilet trained
Spina Bifida Cystica
- Visible defect with external saclike protrusion.
- Two types:
1. Meningocele: contains meninges and spinal fluid; no neural elements
2. Myelomeningocele: contains meninges, spinal fluid and nerves.
Myelomeningocele
- Most frequently associated with hydrocephalus (neural tube fails to close)
- Sac contains meninges, CSF and nerves.
- Varying and serious degrees of neurologic deficit.
Where are myelomeningoceles most often found?
May be found anywhere along the spinal column but lumbar and lumbosacral areas are most common.
Myelomeningocele: Degree
- Location and magnitude of defect determine nature and extent of impairment.
- Not necessarily uniform on both sides of defects.
Myelomeningocele: If defect is below second lumbar vertebra, it can result in
flaccid paralysis of lower extremities and sensory deficit
When are myelomeningoceles monitored?
After repair
What are clinical manifestations of myelomeningoceles?
Prenatal: 16-18 weeks gestation Post natal: -Readily apparent on inspection -Incontinence -Poor anal and sphincter control -Sensory disturbances -Motor dysfunction
Myelomeningocele Management
- Prevent infection: keep site covered until closure, skin care
- Surgical closure (very gently, surgeon will “shove” contents back into the spinal column and close it up)
- Possible life long management of neurological, orthopedic and urinary problems
Myelomeningocele Post Procedure Management
- ATB
- Bladder elimination
- Administering antispasmodics (increase bladder capacity and improve incontinence)
- Bowel program: increase fiber, water and suppositories prn
- Risk for allergy to latex and rubber.
Cerebral Palsy
- A chronic non-progressive permanent disorder of posture and movement which causes activity limitation.
- Due to disturbances that occurred in the developing fetal or infant brain.
Cerebral Palsy: Involves disturbances in
- Sensation
- Perception
- Communication
- Cognition
- Behavior
Cerebral Palsy: Manifestations
- Delayed gross motor development
- Poor control of oral musculature
- Seizures: Most common generalized tonic clonic and minor motor
- Many associated disabilities
Possible Physical Signs of Cerebral Palsy
- Poor head control after 3 mo
- Stiff or rigid arms or legs
- Pushing away or arching back
- Floppy or limp body posture
-Cannot sit up without support by 8 mo - Uses only one side of the body
- Clenches hands after 3 mo
- Persistence of primitive reflexes past 6 mo
-Hand preference demonstrated before 18 mo - Leg scissoring
- Seizures
- Sensory impairment (hearing, vision)
-Persistant tongue thrusting (after 6mo old)
Possible Behavioral Signs of Cerebral Palsy
- Extreme irritability or crying
- Feeding difficulties
- Little interest in surroundings
- Excessive sleeping
Diagnostic Evaluation of Cerebral Palsy
- Neurologic examination and history: primary method for diagnosis
- Neuroimaging: MRI to identify lesions or abnormalities
- Metabolic and genetic testing: if not structural abnormalities identified with neuroimaging
Cerebral Palsy: Diagnosis cannot usually be confirmed until
After two years
- Motor tone abnormalities may be indicative of another neuromuscular illness
- Some children who demonstrate signs before 2 years do not demonstrate signs after 2 years
Cerebral Palsy Management
- Orthotics: to prevent or reduce deformity
- Surgery: to improve function
- Medications: pain, spasticity, seizure management
- Physical therapy: prevention of contracture deformity; directed toward good skeletal alignment
Cerebral Palsy Prognosis
- Depends on type and severity: activities and work depend on this as well.
- Achieve adulthood
- Survival influences by existing morbidities
- If child does not ambulate by 7 years of age: chances are poor for ambulation and independence.
Guillain-Barre Sydnrome
- AKA infectious polyneuritis
- Uncommon acute demyelinating polyneuropathy (progressing ascending flaccid paralysis)
- Immune mediated disease: associated with viral or bacterial infections or vaccine administration
Guillain-Barre Syndrome: Nerve Conduction
Nerve conduction is impaired due to inflammation and edema of spinal and cranial nerves.
How is Guillain-Barre Syndrome diagnosed?
- Based on paralytic manifestations: Symmetric nature of paralysis helps to differentiate
- EMG
Guillain-Barre Syndrome has 3 phases
- Acute or Progressive
- Plateau
- Recovery
Guillain-Barre Syndrome: Acute or Progressive Phase
- Onset of symptoms
- Continues until new symptoms stop appearing or deterioration ceases
- May last up to 4 weeks.
Guillain-Barre Syndrome: Plateau Phase
- Symptoms remain constant
- No further deterioration
- Lasts from days to weeks
Guillain-Barre Syndrome: Recovery Phase
- Begins to improve
- Progress to complete recovery
- Lasts weeks to months
What are clinical manifestations of Guillain-Barre Syndrome?
- Influenza-like symptoms precede GBS
- Rapid onset
- Ascending paralysis from lower extremities
- Tendon reflexes diminished or absent
- Inability or asymmetric: Smile, raise eyebrows, puff out cheeks, grasp bilaterally, raise legs
- Shallow, irregular respirations
- Lower limb or back pain
- Urinary incontinence/retention or constiparion
Guillain-Barre Syndrome Treatment
- Supportive
- Mechanical ventilation
- IVIG: primary treatment if started within two weeks of disease onset
- Steroids
Guillain-Barre Syndrome Prognosis
- Recovery begins 2-3 weeks after onset
- Most regain full muscle strength
- Progress in the reverse order of paralysis (Lower extremities the last to recover)
Nursing Care for Guillain-Barre Sydnrome
- Emphasis on close observation of paralysis
- Support all aspects related to paralysis
- Prevention of Complications
Guillain-Barre Syndrome Management: Prevention of Complications
- Susceptible to skin infections
- Passive range of motion exercises: Prevent muscle and joint contractures
- Prevention of DVT
Guillain-Barre Syndrome Management: Supporting all aspects related to paralysis
- Especially respiratory function
- May need to feed thru NG or GT
- Temporary catheter may be needed
- Pain management
