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Pediatrics > The child w/ cerebral dysfxn > Flashcards

The child w/ cerebral dysfxn Flashcards

1
Q

Development of the neuro system

A

-Grow proportionally vs rapid after birth
-Brain growth reflected in head circumference
-Cerebral blood flow and oxygen consumption twice that of adults

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2
Q

Cerebral structure and fxn

A

-CNS –> (2 cerebral hemispheres: brainstem, cerebellum, spinal cord)
-PNS –> cranial nerves and spinal nerves (efferent/afferent)
-ANS –> (sympathetic and parasympathetic)

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3
Q

CNS

A

-Brain coverings: meninges –> dura mater, arachnoid membrane and pia mater
-Brain: cerebral hemispheres, basal ganglia, brain stem
-Cerebral blood flow: autoregulation, O2, BBB

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4
Q

Stages of consciousness

A

-Full consciousness: the child is awake and alert; is oriented to time, place, and person; and exhibits age-appropriate behaviors
-Confusion: disorientation exits; the child may be alert but responds inappropriately to questions
-Obtunded: the child has limited responses to the environment and falls asleep unless stimulation is provided
-Stupor: the child only responds to vigorous stimulation
-Coma: the child cannot be aroused, even w/ painful stimuli

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5
Q

Glasgow coma scale

A

-Verbal and motor response r/t child’s age
-Score of 15: unaltered LOC (highest score)
-Score of 8 or below: definition of coma
-Score of 3: extremely decreased LOC (worst possible score on scale), deep coma or death

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6
Q

Neuro exam

A

-Trended info
-Descriptions –> objective, simple, easily interpreted
-VS
-Skin
-Eyes
-Motor fxning
-Posturing
-Reflexes

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7
Q

Special dx procedures

A

-Lab test: glucose, CBC, electrolyte, blood culture (if fever is present), toxins, liver fxn
-Imaging: CT, MRI, PET
-Lumbar puncture: apply EMLA 30-60 in before procedure and help to position pt
-EEG: if pt is being video monitored then maintain camera on pt at all times
-X ray to rule out skull frxs or dislocations and eval degenerative changes and suture lines

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8
Q

Nursing care of unconscious child

A

-Respiratory mgmt
-LOC
-Nutrition: altered pituitary secretion
-Elimination: hygiene
-Stabilization of spine
-Treating shock
-Reducing ICP
-Thermoregulation
-Pain mgmt
-Protection of skin

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9
Q

Assessment parameters

A

-LOC
-Pupillary rxn
-VS

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10
Q

Respiratory mgmt

A

-Airway mgmt
-Cerebral hypoxia lasting longer than 4 min may cause irreversible brain damage
-CO2 causes vasodilation in the brain –> increased cerebral blood flow and increased ICP
-May have minimal gag and cough reflexes
-Risk of aspiration of secretions

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11
Q

Increased ICP

A

-Total volume –> brain (80%), CSF (10%), and blood (10%)
-Etiology: tumors or other space-occupying lesions, accumulation of fluid within ventricular system, bleeding or edema of cerebral tissues
-s/s become more pronounced and LOC deteriorates

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12
Q

ICP monitoring

A

-Scale score of 8
-Scale of < 8 w/ respiratory assistance
-Deteriorating neurological condition

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13
Q

Clinical manifestations of increased ICP in infants

A

-Irritability; poor feeding
-High-pitched cry; infant is difficult to soothe
-Fontanels are tense and bulging
-Cranial sutures are separated
-Eyes have the setting-sun sign
-Scalp veins are distended
-Increased occipitofrontal circumference

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14
Q

Clinical manifestations of increased ICP in children

A

-Headache
-N/V
-Motor weakness, discoordination, seizures
-Diplopia and blurred vision
-Irritability, restlessness, behavioral changes
-Sleep alterations and somnolence
-Personality changes

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15
Q

Late signs of increasing ICP

A

-Bradycardia
-Decreased LOC
-Decreased motor response to commands
-Decreased sensory response to painful stimuli
-Alterations in pupil size and reactivity
-Papilledema
-Flexion or extension posturing
-Cheyne-stokes respirations (rapid breathing followed by apnea)

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16
Q

Nursing care for child w/ increased ICP

A

-Pt positioning
-Avoid certain activities
-Eliminate environment noise
-ICP monitoring: HOB > 15-30 degrees, monitor for infection, reduce stimulation and pain
-Suctioning: vibration

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17
Q

Nutrition and hydration

A

-IV administration of fluids and parenteral nutrition
-Caution w/ overhydration: fluid overload –> cerebral edema
-Later begin gastric feedings via nasogastric or gastrostomy tube
-Pt may continue to have risk of aspiration

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18
Q

Intracranial infections

A

-CNS has limited response to injury
-Difficult to distinguish the cause by looking at clinical s/s
-Lab studies to identify causative agent
-Inflammation can affect meninges, brain, or spinal cord

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19
Q

Bacterial meningitis

A

-Acute inflammation of the CNS
-Agents: streptococcus pneumoniae, neisseria meningitidis, GBS in infants < 2 m, listeria monocytogenes in children 2 m - 17 y, e-coli (rare after infancy)
-Lumbar puncture for dx
-Start ABX asap
-Isolate pt as soon as meningitis is suspected

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20
Q

Transmission of bacterial meningitis

A

-Droplet infection from nasopharyngeal secretions
-Risk increases w/ number of contacts; disease occurs predominantly in school-age children and teens
-Another common risk: crowded living conditions

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21
Q

Meningitis s/s and mgmt

A

-Common s/s: fever, photophobia, irritability, headache (most children have sudden onset headache, fever, vomiting, severe headache w/ irritability; infants may have fever or hypothermia, poor feeding and bulging fontanel
-Mgmt: isolation (droplet) precaution, give antimicrobial therapy and antipyretics, control temp and manage seizures, maintain hydration and ventilation

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22
Q

Nonbacterial/aseptic meningitis

A

-Causative agent is primarily viruses
-Frequently associated w/ measle, mumps, herpesvirus infection, leukemia
-s/s: headache, fever, malaise
-Dx based on CSF fluid and clinical features
-Tx: abx and isolation until bacterial meningitis is ruled out

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23
Q

Encephalitis

A

-Inflammatory process of CNS; w/ altered fxn of brain and spinal cord
-Viral is most frequent
-HSV encephalitis (most common cause of sporadic fatal encephalitis worldwide)
-Vector reservoir in US includes mosquitoes and ticks (west nile)

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24
Q

Clinical s/s of encephalitis: onset sudden or gradual

A

-Malaise and fever
-Headache and dizziness
-Stiff neck
-N/V
-Ataxia
-Speech difficulties

25
Q

Clinical s/s of severe encephalitis

A

-High fever
-Disorientation, stupor, coma
-Seizures and spasticity
-Ocular palsies
-Paralysis

26
Q

Encephalitis

A

-Dx: CT scan
-Mgmt: of ICP, contact precautions

27
Q

Reye syndrome (RS)

A

-Life threatening disorder that involves acute encephalopathy and fatty changes of the liver
-Usually after viral illness or secondary to taking aspirin for a viral illness
-s/s: fever, profuse vomiting, neurologic impairment (cerebral edema), disordered hepatic fxn (fatty liver)

28
Q

Seizure disorders

A

-Malfxns of brain’s electrical system
-Seizure: transient occurrence of s/s d/t abnormal excessive and synchronous neuronal activity in the brain (most common pediatric neurologic disorder)
-Epilepsy: disease of brain defined by at least 2 unprovoked seizures occurring > 24 hrs apar
-Occur w/ wide variety of CNS condition: neurologic, metabolic or indigestion, traumatic, infectious

29
Q

Seizures

A

-Classification: partial, generalized, unclassified
-s/s: change in LOC, involuntary mvmts, posturing, changes in perception

30
Q

Epilepsy

A

-2 or more unprovoked seizures > 24 hrs apart
-Single seizure is not epileptic
-Single seizure is not treated w/ long-term meds

31
Q

Dx of seizures

A

-Must differentiate epilepsy from other brief alterations in consciousness or behavior
-Witness of events: duration, progression, postictal behavior
-Lab values: poisoning, hypoglycemia, infection
-EEG: video monitoring

31
Q

Nursing care of child w/ seizures: during

A

-Protect from injury
-Airway maintenance
-Side lying position
-Note onset, time, and characteristics
-Stay w/ pt
-Remain calm
-Administer meds as appropriate

32
Q

Nursing care of child w/ seizures: post seizure/postictal

A

-Maintain side-lying position
-VS and neuro checks
-Reorient pt
-Note time of postictal period
-NPO until swallow reflex returns
-Ask pt about auras or triggers

33
Q

Absence seizures

A

-Formerly called petit mal seizures or lapses
-Brief LOC (5-10 sec)
-Minimal or no change in muscle tone (lip smacking, staring spell, twitching)
-Almost always appear in childhood (at age 4-12 y)
-Sudden onset; up to 20 events or more per day
-No warning or aura
-Often misdiagnosed as ADHD

34
Q

Atonic seizures

A

-AKA drop attacks
-Sudden momentary loss of muscle tone
-Onset is usually age 2-5 years
-May or may not have LOC
-Sudden fall to the ground, often on the face
-In less severe seizures, the head droops forward several times
-Helmet for frequent seizures

35
Q

Myoclonic seizures

A

-Sudden brief contractions of a muscle group (symmetric or asymmetric movement)
-May be single or repetitive
-No LOC
-Often occur w/ falling asleep
-May be a nonspecific s/s in many CNS disorders
-May be mistaken for an exaggerated startle reflex

36
Q

Tonic-clonic seizures

A

-Previously grand mal
-Onset is w/o warning
-Main cause of all seizure types
-Tonic phase (10-20 sec)
-Clonic phase (30-50 sec, can be longer)
-Postictal state (30 min)

37
Q

Tonic phase

A

-Piercing cry
-Pallor
-Generalize stiffening of body and limbs, back arched

38
Q

Clonic phase

A

-Salivary phase
-Eye blinking
-Pallor
-Incontinence
-Clonic jerks of limbs, body, head

39
Q

Postictal confusional fatigue

A

-Limbs and body limp

40
Q

Status epilepticus

A

-Seizures lasting > 30 min or a series of seizures in which the pt doesn’t regain premorbid LOC
-Medical emergency
-Mgmt: maintain airway and monitor for apnea, safety of pt, establish IV access, meds (IV diazepam or lorazepam, fosphenytoin followed by phenobarbital)

41
Q

Mgmt of seizures

A

-Ketogenic diet
-Vagal nerve stimulation
-Surgical therapy
-Monotherapy is tx of choice
-Gradual increase of dose until seizure is controlled or there are s/s of toxicity
-Polypharmacological if seizures cannot be controlled w/ one drug
-Wean child from dose
-Increase dose as child grows

42
Q

Antiepileptic drugs (AEDs)

A

-Diazepam
-Phenytoin
-Carbamazepine
-Valproic acid
-Topiramate
-Lamotrigine
-Clonazepam
-Levetiracetam

43
Q

When to discontinue seizure meds

A

-When child has been seizure free for 2 years
-When EEG is normal
-Avoid during puberty (abrupt growth) or when subject to frequent infections
-Dose is gradually decreased over week-months
-Recurrence of seizures is possible within 1st year following cessation of tx

44
Q

Home mgmt of seizures

A

-CPR training for family members
-Rectal diazepam for intractable seizures
-Activity restriction
-Child must wear helmet and not swim alone

45
Q

Febrile seizures

A

-Transient disorder
-Associated w/ febrile illness in absence of CNS infection
-Benign
-Btwn ages 6-60 m
-Rare after age 5 y
-More common in males
-Occurs w/ temp 100.5 and above
-Occurs when temp rapidly increases
-Usually over before ED arrival
-Most pts don’t have epilepsy of neurologic damage
-Mgmt: avoid tepid baths, long-term antipyretics are ineffective, protect child from injury, call 911 if seizure is > 5 min

46
Q

Hydrocephalus

A

-Imbalance in production and absorption of CSF
-Associated w/ myelomeningocele
-Not apparent at birth
-May appear after primary closure of defect

47
Q

Hydrocephalus monitoring

A

-Daily head circumference (occipitofrontal circumference)
-Fontanel tension
-Serial ultrasound examin of ventricle size

48
Q

Initial mgmt of hydrocephalus

A

-Treat excessive CSF (VP shunt)
-Prevent infections and malfxns

49
Q

Headache

A

-Assessment: primary –> migraine, tension-type headache, trigeminal autonomic cephalalgias, secondary –> caused from another condition and resolved once underlying cause is treated
-Determine pattern of headache: acute, acute recurrent chronic progressive, chronic nonprogressive
-Mgmt: headache hygiene, prevention, meds

50
Q

Migraine

A

-Top 5 common childhood disease (earlier in boys than girls until puberty)
-Migraine w/ aura or w/o
-Paroxysmal s/s
-Mgmt: migraine hygiene, triggers, sleep, nutrition, stress,

51
Q

Head injury

A

-Unintentional injury is number 1 health risk for children and leading cause of death in children greater than 1 yr
-Cause: unintentional falls or MVA

52
Q

Types of closed head injuries (CHI)

A

-Concussion
-Contusion and laceration
-Frxs
-Epidural and subdural hematoma
-Cerebral edema
-Sequelae of traumatic brain injury (post concussion syndrome, posttraumatic headaches, posttraumatic seizures, hydrocephalus)

53
Q

Dx eval

A

-Detailed health hx
-Initial assessment
-Emergency assessment
-Special test

54
Q

Therapeutic mgmt of traumatic brain injury (TBI)

A

-No loss of consciousness can be observed and cared for at home if no serious cranial injury
-Physical exam in 1-2 days after injury
-If child loses consciousness or develops a severe headache –> requires medical intervention
-IV fluids, sedating drugs withheld in acute phase, headache controlled w/ acetaminophen/opioids if needed
-Antiepileptics for seizure control
-Abx for lacerations or penetrating injuries
-Mgmt of cerebral edema
-Hypothermia –> tepid sponges or blanket

55
Q

TBI surgery

A

-Scalp lacerations are sutured –> topical anesthetic
-Depressed fxs require surgical reduction and removal of bone fragment

56
Q

TBI nursing mgmt

A

-Bed rest w/ HOB slightly elevated and head in midline position
-Seizure precautions
-Limit stimulation

57
Q

Submersion injury

A

-s/s: duration of loss of consciousness and neurologic status after rescue and resuscitation
-Highest mortality in children ages 1-4 yrs

58
Q

Clinical death

A

-Brain death: total cessation of brainstem and cortical brain fxn that causes irreversible widespread brain injury and coma
-Common causes: trauma, anoxic, encephalopathy, infections, cerebral neoplasms
-Requires 2 conditions: complete cessations, irreversibility of condition

Pediatrics (24 decks)

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