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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
Clinical s/s of severe encephalitis
-High fever -Disorientation, stupor, coma -Seizures and spasticity -Ocular palsies -Paralysis
26
Encephalitis
-Dx: CT scan -Mgmt: of ICP, contact precautions
27
Reye syndrome (RS)
-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
Seizure disorders
-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
Seizures
-Classification: partial, generalized, unclassified -s/s: change in LOC, involuntary mvmts, posturing, changes in perception
30
Epilepsy
-2 or more unprovoked seizures > 24 hrs apart -Single seizure is not epileptic -Single seizure is not treated w/ long-term meds
31
Dx of seizures
-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
Nursing care of child w/ seizures: during
-Protect from injury -Airway maintenance -Side lying position -Note onset, time, and characteristics -Stay w/ pt -Remain calm -Administer meds as appropriate
32
Nursing care of child w/ seizures: post seizure/postictal
-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
Absence seizures
-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
Atonic seizures
-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
Myoclonic seizures
-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
Tonic-clonic seizures
-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
Tonic phase
-Piercing cry -Pallor -Generalize stiffening of body and limbs, back arched
38
Clonic phase
-Salivary phase -Eye blinking -Pallor -Incontinence -Clonic jerks of limbs, body, head
39
Postictal confusional fatigue
-Limbs and body limp
40
Status epilepticus
-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
Mgmt of seizures
-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
Antiepileptic drugs (AEDs)
-Diazepam -Phenytoin -Carbamazepine -Valproic acid -Topiramate -Lamotrigine -Clonazepam -Levetiracetam
43
When to discontinue seizure meds
-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
Home mgmt of seizures
-CPR training for family members -Rectal diazepam for intractable seizures -Activity restriction -Child must wear helmet and not swim alone
45
Febrile seizures
-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
Hydrocephalus
-Imbalance in production and absorption of CSF -Associated w/ myelomeningocele -Not apparent at birth -May appear after primary closure of defect
47
Hydrocephalus monitoring
-Daily head circumference (occipitofrontal circumference) -Fontanel tension -Serial ultrasound examin of ventricle size
48
Initial mgmt of hydrocephalus
-Treat excessive CSF (VP shunt) -Prevent infections and malfxns
49
Headache
-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
Migraine
-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
Head injury
-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
Types of closed head injuries (CHI)
-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
Dx eval
-Detailed health hx -Initial assessment -Emergency assessment -Special test
54
Therapeutic mgmt of traumatic brain injury (TBI)
-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
TBI surgery
-Scalp lacerations are sutured --> topical anesthetic -Depressed fxs require surgical reduction and removal of bone fragment
56
TBI nursing mgmt
-Bed rest w/ HOB slightly elevated and head in midline position -Seizure precautions -Limit stimulation
57
Submersion injury
-s/s: duration of loss of consciousness and neurologic status after rescue and resuscitation -Highest mortality in children ages 1-4 yrs
58
Clinical death
-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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