Test #5 - Neurological Flashcards
What is autoregulation? (in the brain)
Known as self-regulation
Process allows cerebral arteries to change diameter in response to changes in cerebral perfusion pressure
Auto regulation may be impaired by trauma, ischemia, increased intracranial pressure (ICP)
What are some newborn sensory items? (What affects their sensory experience)
Lights
Sounds
Effects of Gravity
Abundance of tactile stimuli @ birth
Orientation= Ability to be alert, follow and fixate on complex visual stimuli for short periods of time & able to attend to and interact with environment
Vision= Prefers face, eyes and bright shiny object
Auditory= Searches for appealing sounds
Habituation-Diminish response to specific repeated sounds
Selects people by smell
Responds differently to different tastes
Sensitive to being touched, cuddled & held
Self-quieting behavior
What are some signs of overstimulation in preterm infants?
Oxygenation Changes:
Blood pressure, pulse and resp instability
Cyanosis, pallor or mottling
Flaring nares
Decreased oxygen saturation levels
Sneezing, coughing
Behavior Changes:
Stiff, extended arms and legs
Fisting of the hands or playing (spreading wide apart) of the fingers
Arching
Alert, worried expression
Turning away from eye contact (gaze aversion)
Regurgitation, gagging, hiccupping
Yawning
Fatigue signs
What are some interventions to reduce stimuli?
Cluster Care
Reduce stimuli
Low noise
Face bed away from bright lights
Soft classical music
Promote rest - Have designated time for lights off/no sound
What are some asseessments of cerebral/cognitive function?
Appearance, behavior, orientation, speech patterns, memory, logic and affect
Level of consciousness-Alert, awakes easily
How do you assess the cerebellar function?
Balance
Coordination
Gait
How do you assess reflexes?
Superficial deep tendon reflexes
What do you assess for with the head of an infant?
Infant- Head circumference, fontanels, sutures (sizes, tenseness, pulsation)
Anterior fontanel- Closes ~12-18 months
Posterior fontanel – Closes ~2-4 months
Head & Facial symmetry, spacing, movement, control, shape, check tongue for deviation, dysmorphic features
What do you assess for in the eyes of infants?
Position, size, visual acuity, color vision, peripheral vision, strabismus, field of vision, muscle function, PERRLA, cornea and blink reflex
Note: True eye color does not occur before 6 month
What do you assess for in the ears of an infant?
Alignment- Low-set, external ear, hearing acuity
Infant assessment, audiometry, whisper test, conduction tests)
Otoscope examination, history for risk factors for hearing loss
3 and younger: Pull pinna down and back
3 and older: Pull pinna up and back
How do you assess the neuromuscular system?
Symmetry & strength of movements
Head lag of less than 45 degrees
Ability to hold head erect briefly
Tremors or seizures
Is infant able to move all extremities?
Is there a visible defect present on the spine
What are some abnormal neurological findings?
Failure to attain a skill by expected time
Persistent reflex behavior beyond normal time
High-pitched shrill cry
Behavior disturbances
Change in level of consciousness
Glasgow Coma Scale
Seizures
Change in pupil reactivity
Pain
What are some neurological diagnostics?
Head & Spine X-Rays
CT Scans
MRI
EEG
Lumbar Puncture
Lab
Angiography
Nuclear brain scan
Extensive history
What is Level of Consciousness and the different types?
Most important indicator of neurologic dysfunction
Describing LOC
Conscious vs. Unconscious
Alertness: Ability to react to stimuli
Cognitive Power: processing of data
Levels of Consciousness
What are some causes of loss of consciousness?
Trauma and/or injury
Space-occupying Lesion
Aneurysm
Hypoxia
Infection (MC cause of altered LOC in children)
Poisoning
Seizures
Fluid – Overproduction or malabsorption
Endocrine or metabolic disturbances
Electrolyte or acid-base imbalance
Congenital structural defect
What are some interventions for neurological disorders?
Evaluating neurological status
The pediatric Glasgow Coma Scale
Eye opening, verbal response & motor response
Monitor vital signs
Manage the airway
Manage bladder and bowel elimination
Maintain hydration and nutrition
Provide proper hygiene
Position & perform exercises
Ophthalmic ointment/patches
Provide for safety
Anticipate seizures
What is increased intracranial pressure?
Intracranial pressure (ICP) = The pressure exerted by the blood, brain, Cerebral spinal fluid (CSF) and any other space-occupying fluid or mass inside the skull
IICP = 20mmHg or > for 5 minutes or longer
What are some assessments of IICP?
What are some interventions for IICP?
Close monitoring (neurological status) + ICP
Maintain a patent airway-No hyperventilation
Monitor Vital signs closely (Cooling blankets)
IV fluids, I&O, Labs include glucose and weight
Elevate HOB 30 degrees, maintain alignment
Protect from injury
Appropriate stimuli
Administer anticonvulsant medications
Provide emotional support
Administer medications to DEC cerebral edema
Analgesia and sedation
BE CAREFUL with O2…. Can cause increase in swelling
What is a prevention for neural tube defects (Spina Bifida)?
Mother needs 4/10 mg of Folic Acid daily (10x that if trouble absorbing or hx or neural tube defects in family)
What are some risk factors for spina bifida?
Diabetes, Poor maternal nutrition, obesity, inability to absorb folic acid, seizure medications
What are some assessments of Spina Bifida?
There are three forms: Occulta, Cystica (Meningocele), Cystica (Myelomeningocele)
What are some diagnostics for Spina Bifida?
Prenatal Ultra sound
Maternal serum testing for alpha-fetoprotein (AFP)
Done @ 16-18 weeks gestation
If elevated, amniocentesis and fetal ultrasound are performed
After birth – CT scan or myelography
What are some interventions for SPina Bifida?
Surgery happens soon after birth (within 48 hours)
Place newborn in prone position with hips slightly flexed and legs abducted (To prevent injury to sac)
Cover sac with sterile, warm, saline dressing
Monitor for CSF leakage
V/S, I&O, head circumference & assess fontanel
Provide Latex free environment to prevent sensitization
Foods that have cross-reactions with latex: Banana, avocado, kiwi, chestnut
Provide postoperative care for laminectomy & closure of defect, prone or side-lying position
POST OP- Assess Neurological status
Assess bowel & bladder function – Clean cath
Prevent constipation (Inc fluids and fibers)
May use anticholinergics
@ risk for UTI
Regular diaper changes to prevent it from getting in hole
Evaluate orthopedic function – Braces & devices
Prevent joint contractures
Manage pain
Crying leads to IICP
Feed with head turned to side
Promote collaboration of specialists and therapies
Educate & support patient and family
Refer to organizations
NEVER do rectal temps
Monitor for signs of infection
Irritability, INC VS, Lethargy
What is hydrocephalus?
Develops as a result of an imbalance between production and absorption of CSF.
Excess CSF accumulates in the ventricular system, the ventricles become dilated and the brain is compressed against the skull
This results in enlargement of the skull if the sutures are open; If fused=S&S of IICP
What are some risk factors for hydrocephalus?
Congenital
Results from defects such as:
Arnold-Chiari malformations, arachnoid cysts, tumors, aqueductal stenosis
Trauma
Disease:
Often associated with Myelomeningocele
Older children it usually results from meningitis
Intrauterine infection and perinatal hemorrhage can cause in infants
What are some assessments for hydrocephalus?
Rapid INCREASED head circumference-newborns-fontanels
Increased ICP
What are some diagnostics for hydrocephalus?
Ultrasound during prenatal exam, CT, MRI, Lumbar puncture pressure-Monitor
Surgical shunt replacement is a treatment for hydrocephalus, what do you assess and do post op?
Surgical Shunt Replacement
Post-Op Interventions:
Lay flat, INC HOB slowly over days, prepare parents
Infection of shunt: IV antibiotics
Surgically remove shunt til gone
Post-Op Assessment for Infection:
IICP, seizures, poor feeding, N/V, Malaise, redness on skin along where shunt is placed, apnea, INC VS
What are some interventions for IICP?
Measure head daily
Give pre-op and post-op antibiotics
Assess neurological status
VS
Assess abdominal status (pain, bowel sounds and circumference)
Position flat then elevate gradually
Anticipatory guidelines-Regular visits with PCP
Refer to community support
www. hydroassoc.org
www. hydrosupport.org
Educate family and provide emotional support
Recognize complication & shunt malfunction
No contact sports
Safe transport (Need to be in rear facing, reclining seat)
Medications
What is Cerebal Palsy?
Chronic, nonprogressive disorder of posture & movement
Characterized by difficulty in controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system
What are some risk factors for cerebral palsy?
What are some assessments for cerebral palsy?
Vary Depending on the area of the brain involved and extent of damage
Persistence of infant reflexes
Delayed motor development by exam & history
Muscular hypotonia or hypertonia
Abnormal posture, gait or spasticity
Comorbidities include:
Cognitive impairment
Cognitive Impairment
Hearing and speech impairment
Visual impairment
Seizures
What are some diagnostics of cerebral palsy?
EEG, CT, MRI, metabolic workup
The Gross Motor Function Classification System (GMFCS)
Classify severity of CP and assess acquisition of future motor skills
What are the different types of cerebral palsy and what are the assessments?
**Spastic: MC type. **
Most effected brain is cortex
ASSESSMENTS:
Inc deep tendon reflexes
Hypertonia
Flexion
Contractures
Scissors gait
Hip flexion w/ adduction and internal rotation
Toe walking due to tight heel cords
Ataxic:
Effected area of the brain is the cerebellum
ASSESSMENT:
Loss of coordination, equilibrium, and kinesthetic sense
Child appears clumsy
Dyskinetic (Athetoid)
Disorder in the basal ganglia
ASSESSMENT:
Slow writhing
Uncontrolled, involuntary movements involving all extremities
Mixed
Combination of spastic and dyskineti
Rigid (Tremor Atonic)
Rare in children
Assessment:
Tremors are apparent both at rest and during movement
What are some interventions for cerebral palsy?
Use splints & braces
Promote Self-care
Surgery
Address feeding problems
Provide intellectual stimulation
Ensure safe environment
BENEFIT from massage therapy
Administer Medications
Muscle Relaxants
Dantrolene Sodium – Dantrium
Baclofen – Lioresal by infusion pump
Botox
Phenobarbital – Luminal
Phenytoin – Dilantin
Diazepam – Valium
What is a closed head injury?
Nonpenetrating injury to the head in which no break occurs in the integrity of the barrier between the outside environment and the intracranial cavity
What is an open head injury
Penetrating injury to the head in which there is a break in the integrity of the barrier (skull, meninges) between the outside environment and the intracranial cavity;
Infection is a MAJOR concern
What is a coup injury?
Cerebral injury sustained directly below the site of impact
What is a contrecoup injury?
Cerebral injury sustained in the region or pole opposite the site of impact
Caused by the rapid movements of the semisolid brain within the cranial vault
What is a missle injury?
Penetrating injury of the skull or brain
Most often caused by bullet
What is an impalement injury?
Penetrating injury caused by piercing of the scalp, skull or brain by a sharp object
What are 3 different types of skull fractures?
Linear: straight-line fracture; dura not involved
Depressed: Bone pressing downward, indented
Basilar: Fracture of the base of the skull
What are some assessments for a Basilar fracture at the base of the skull?
Battle sign (bruising over the mastoid process)
Raccoon Eyes
Rhinorrhea
Otorrhea
Hemotympanum (Blood behind eardrum)
What are some diagnostics for a head injury?
Spine X-Ray
CT
MRI
EEG
ICP Monitoring
Cerebral blood flow
Profusion pressure
What are some interventions for a head injury?
Provide immediate care to prevent life-threatening complications
Maintain airway patency & oxygen administration
Immobilize cervical spine
Insert IV
Monitor I&O hourly and serum electrolytes
Assess neurological status: LOC, VS
NO nasotrachiosuction or NGT
NO packing or blowing nose
Position HOB 30-45 degrees and maintain alignment
Assess & Manage pain
Document assessments, interventions, evaluations and changes
Check nasal drainage
Glucose stick – If + for glucose spinal fluid leak
Ph stick – If alkaline means spinal fluid leak
What is abusive head trauma?
Caused by vigorously shaking of the infant while the child is held by the extremities or shoulders
Leads to whiplash-induced intracranial and retinal bleeding
Usually no external signs of trauma
What are some assessments for Shaken baby?
Inconsistent caregiver report & other signs of abuse should raise suspicion
Retinal Hemorrhage
Seizure activity, apnea, budging fontanels, coma, bradycardia & cardiovascular collapse
Less severe-Vomiting, hypothermia, lethargy, irritability, difficulty arousing
Cerebral edema 24-72 hours after trauma
What are some diagnostics for shaken baby?
CT Scan or MRI
Skull radiography
Ocular funduscopic Exam
What are some interventions for Shaken baby?
Provide respiratory & cardiovascular support
Assess for ICP
Insert OG tube
Maintain seizure precautions
Maintain adequate fluid & nutritional intake
Assess & document visible injuries
Discuss short or long term care
Assess parental concerns
Legal & ethical responsibility
What is a submersion injury (Near Drowning)?
Known as “silent” event
Survives more than 24 hours after submersion
Poor prognosis if child was under longer than 10 min, received CPR for longer than 25 min, arrive at the ED in deep coma (Glasgow score of 5 or lower) and did not regain consciousness within 48-72 hours of hospitalization
What are some assessments for submersion injuries (near drowning)?
Airway, breathing rate, depth & effort, lung sounds, continuous pulse ox
LOC, Glasgow coma scale, reflexes
Cardiac – Cap refill and heart rate
Conscious - Hypothermia
Conscious – Minor blood gas alterations
Unconscious – Moderate hypothermia
Unconscious – Moderate respiratory distress
What are some interventions for submersion injury? (After assessment and emergency Mangement)
Assess and maintain airway/oxygenation
Initiate IV, I&O, Electrolytes
Prevent IICP
Maintain normal body temperature
Insert NG tube for nutrition
Control infection
Pain management
Provide Emotional support
What are seizure disorders?
Epilepsy
Seizure disorder lasts seconds to minutes
Status epilepticus
Seizure lasts >30 minutes
Or a series of small seizures in which consciousness is not regained
What are the different classifications of seizures?
What are the risk factors for seizure disorders?
Children who have febrile seizures
Perinatal Asphyxia leading to hypoxic-ischemic encephalopathy
Intracranial hemorrhage
Metabolic disturbances
Intrauterine and perinatal infectious disorder
Cerebral infarcts
Drug withdrawal
Hyperthermia
Hypoglycemia
Congenital anomalies of the CNS
Inherited Syndromes
What are some assessments for seizure disorders?
Neonates: eyelid fluttering, sucking, smacking, drooling, tongue thrusting, pedaling movements of the legs, swimming movements of the arms and apnea
History
What are some diagnostics for seizure disorders?
CT
MRI
Skull radiograph
angiography
EEF
Lab
Lumbar puncture
What are some interventions for seizure disorders?
Observation & Nursing care during seizure
Ensure airway management-position, suction, oxygen
Implement seizure precautions (Padded side rails, oxygen, suction equipment, IV access and anticonvulsant medications)
Provide continuous cardiac, respiratory & oxygen monitoring
Check blood sugar & give glucose if needed (During seizures glucose stores are depleted)
Complete a detailed history/documentation progression
Identify possible triggers
Educate & support client and family
Instruct caregivers in CPR
Keep school nurses, teachers and club leaders informed
Encourage medical alert identification bracelet
Long term management of seizures
Medications
Adjunct Therapy:
Ketogenic Diet
Vagus nerve stimulation
Family teaching
Management of seizure at home, school
Importance of giving meds as prescribed
Blood levels may be needed to monitor anticonvulsant dosing
What is some observations and nursing care during a seizure?
Common seizure medication chart
What are some assessments of brain tumors?
Depends on the tumor location, tumor type and the age of child
History: Developmental milestones achieved, headache, vomiting
Neurological deficits
Signs of IICP, GCS, VS, LOC
Nutritional status, weight
Pain
HALLMARK SIGN: Headache and morning vomiting related to getting out of bed
The shift in intracranial pressure with the change in position from lying flat to standing up causes the vomiting.
What are some treatments for brain tumors?
Surgical Resection
Radiation therapy
Chemotherapy
Combination
What are some interventions for brain tumors?
Educate and support through selected therapy
Post-Op care
IV steroids and anticonvulsants
Neurological assessment
Airway and fluid management
Prevent infection
Manage pain
Ensure adequate nutrition
Promote normal growth and development
Ensure good communication & collaboration
Provide Emotional Support
Potential Functional deficits related to a brain tumor chart
Pediatric differences in vision function chart
What are some assessments for alteration in vision?
Vision screening, signs of problem
Amblyopia
Color Blindness
Nystagmus
Blindness
Signs & Symptoms of potential vision problems
Types of refractive disorders chart
Types of Strabismus chart
What are some interventions for a child with visual impairmetn?
Educate
Promote Relationships
Promote optimum development
What is ROP (Retinopathy of prematurity)?
Immature blood vessels in retina constrict & necrose may lead to vision loss
What is a risk factor for ROP?
High Levels of OXygen
What are some treatments for ROP?
Laser therapy
Surgical procedure
What are some interventions for ROP?
Minimize exposure to light
Titrate oxygen closely
Educate parents regarding eye exams
What is Hyphema?
Hemorrhage into the anterior chamber of the eye
What are some interventions for hyphema?
Rest, sedation
Monitor for further hemorrhage
Monitor increased intraocular pressure – pain, N/V, inflamed
Promote decreased activity – music, books
HOB 30-40 degrees
Protective shielding
How do you treat a chemical splash eye injury?
Rapid eye flushing 30 minutes to 4 hours followed by pH analysis of the chemical agent at ED
What are some interventions for chemical splash injury?
Prescribed medical treatment
Comfort
Injury prevention
Education
Follow-up
What is hearing loss?
Adequate hearing depends on intact auditory structures and quality of sound.
Sound is defined in terms that combine volume and pitch or frequencies.
Types of hearing loss:
Slight: failure to hear at 16-25dB
Mild: failure to hear at 26-40dB
Moderate: failure to hear at 14-55dB
Moderately Severe: failure to hear at 56-70dB
Severe: failure to hear at 71-90dB
Profound: failure to hear more than 90dB
Types and Etiology of hearing loss chart
What are some interventions for hearing loss?
Newborn hearing screening
Risks that indicate more hearing screening is neededAssess hearing and language development at each visit
Early detection & treatment has best results
Treatment depends on cause – Amplification aid or cochlear implant
When caring for hearing impaired infant/child:
Encourage use of hearing aid before speaking
Look directly into child’s face, speak clearly
Eliminate background noise, use of visual aids
American sign language, Promote communication
Prevent hearing loss, genetic counseling
Risk Factors indicating the need for hearing screening chart
What is the criteria for developmental disabilities?
Criteria for Intellectual Impairment/Disability
- IQ below average
- Limitations in functions of daily life
- Onset before 18 years old
Expected Skills according to intelligence scores chart
Causes of Intellectual Disabilties Chart
What is down syndrome?
Occurs when three representatives of chromosome 21 are present instead of just the normal 2
A particular region of chromosome 21 is responsible for the facial features, heart defects, intellectual impairment and dermatologic changes.
What are some assessments for down syndrome?
Brachycephaly (Disproportionate shortness of the head)
Flat profile
Inner epicanthal folds
Wide Flat nasal bridge
Narrow, high arched palate
Protruding tongue
Small, short ears which may be low set
Short stature
Singular transverse creases across the palm and sole of the foot
Wide gap between first and second toes
Dry skin with tendency to crack and fissure
Hyper extensibility of joints with hypotonicity of muscles
Atlantoaxial instability (At the first and second vertebrae)
Hearing deficits
What are some interventions for down syndrome?
Be sensitive to needs of the parents
Promote early intervention
Ensure that care is geared toward physical, developmental and emotional needs
Coordinate programs
Help families cope emotionally
Provide resource information
What is Fragile X syndrome?
Caused by an underlying single gene defect on the X chromosome
Most common inherited cause of cognitive impairment
Most common cause of Autism (But can present with or without autism)
Males present with more severe form versus females
What are some assessments for Fragile X Syndrome?
Characteristics, family history
Parental concerns
Deoxyribonucleic acid test
Overall areas that are affected span 6 categories:
Intellectual functioning
Physical Characteristics
Social and emotional relatedness
Speech and language capability
Sensory impairment
Presence of co-morbid disorders that are commonly associated w/syndrome
What are some interventions for Fragile X syndrome?
Assist with identifying
Educate
Support
Refer to resources
What are autism spectrum disorders?
Pervasive developmental disorders
Symptoms noticeable by 3 years of age
What are some assessments for autism spectrum disorders?
Impairment in social reciprocity
Communication impairment
Restrictive and repetitive behaviors, interests, or activities
Screening of all children during well visits
What are some interventions for autism spectrum disorders?
Promote awareness of need for early intervention
Promote early language development
Encourage social competence
Stay aware of the child’s physical boundaries and reluctance to be touched
When hospitalized work with routine and communication
What is a concussion?
Concussion—most common head injury
Confusion, amnesia, transient, reversible,
Children will not always have a loss of consciousness
What will a child with concussion have?
loss of awareness and responsiveness lasting a few minutes to hours.
– followed by amnesia for the moment of injury and maybe for a period after the injury
What is Edema?
Hypoxia (↓0 ₂) and hypercapnia (↑ CO₂) threaten the energy requirements of the brain and ↑ cerebral blood flow (CBF).
The ↑ volume across the blood-brain barrier along with the loss of autoregulation, exacerbates cerebral edema.
Pressure inside the skull that is > arterial pressure results in inadequate perfusion.
compresses the brainstem and occludes the posterior cerebral arteries
