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NUR 102 Pedi Assessment #2 > The Child with a Neurological Alteration > Flashcards

The Child with a Neurological Alteration Flashcards

1
Q

Review of the Central Nervous System (CNS)

* Composed of the __ and __

* Myelinization of the nerves begins approximately __th week of gestation and is completed by adolescence

* The axial skeleton protects the underlying structure of the CNS

A

brain; spinal cord

16th

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2
Q

> At birth, skull plates not fused but separated by non-ossified spaces - ___

> Posterior __ fuses by __ months

> Anterior __ fuses by __-__ months

> Allow cranium expansion due to rapid brain growth in infancy

> Brain growth measured by head circumference

* The brain and spinal cord are covered by the __

A

FONTANELS

fontanel; 2

fontanel; 16-18

meninges

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3
Q

The Brain

* Cerebrospinal fluid (CSF) surrounds the brain and spinal cord

> Infant has about __mL of CSF compared to an adult about __mL

> CSF acts like a “cushion” to reduce force trauma to the head

Functions of CSF
> Protects __, __, and __

> Maintains homeostasis

A

50mL; 150mL

brain, spinal cord, meninges

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4
Q

What are the 3 sections of the brain?

A

Cerebrum

Cerebellum

Brainstem

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5
Q

Cranial Nerves

12 pairs of cranial nerves (CN)

> Arise from the brain and brainstem

> Testing of the nerves can indicate location and degree of CNS injury

A
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6
Q

CN __, __, __, __

  • Blink reflex
  • Doll’s eye
A

II, III, IV, VI

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7
Q

CN __

  • Rooting
  • Sucking
A

V

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8
Q

CN __

  • Facial expressions
A

VII

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9
Q

CN __

  • Acoustic blink
  • Doll’s eye
A

VIII

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10
Q

CN __, __

  • Swallow, gag
A

IX, X

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11
Q

CN __

  • Suck, swallow
  • Tongue midline
A

XII

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12
Q

Spinal Cord

Regions

  • Cervical
  • Thoracic
  • Lumbar
  • Sacral

* Transmits signals to and from BRAIN through automatic motor responses
- REFLEXES (e.g., deep tendon reflexes)

A
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13
Q

?

* Also known as self-regulation

> Process allows cerebral arteries to change diameter in response to changes in cerebral perfusion pressure

* May be impaired by trauma, ischemia, increased intracranial pressure (ICP)

A

Autoregulation

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14
Q

↑ PaCO2 (above 40 mmHg) - cerebral vasodilation and ↑ cerebral blood flow (CBF)

A

↓ PaCO2 (25-30 mmHg) - cerebral vasoconstriction and ↓ CBF

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15
Q

Diagnostic Tests & Procedures

* CT scan
> If contrast need an IV line
> Check for allergies

* Angiography
> NPO
> Check for allergies
> Obtain consent

A

* Echoencephalopathy

* Electroencephalogram (EEG)

* Lumbar puncture

* MRI

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16
Q

?

Used to measure CSF pressure and obtain specimens

  • Explain procedure to child according to developmental stage
  • Obtain signed consent
  • Lay on side with knees to chin
  • Hold child by “hugging” knees to chin
  • Will feel cool liquid while washing
  • Feel “pinch” or “sting” while needle inserted
  • Child MUST REMAIN STILL…encourage relaxation by singing, taking deep breaths, guided imagery
  • MONITOR throughout procedure
    > Cardiorespiratory status
  • After procedure child lays FLAT
A

Lumbar puncture

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17
Q

Increased Intracranial Pressure

  • Pressure exerted by blood, brain, CSF, and any other space occupying fluid or mass
  • Results from a disturbance in autoregulation
  • Defined as pressure sustained at __ mmHg or higher for 5 minutes or longer
A

20 mmHg

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18
Q

Increased ICP - Manifestations: Infant

> Poor feeding or vomiting

> Irritability, restlessness, or lethargy

> Bulging fontanel

> High-pitched cry

> Increased head circumference

A

> Separation of cranial sutures

> Distended scalp veins

> Eyes deviated downward (“setting sun” sign)

> Increased or decreased response to pain

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19
Q

Increased ICP - Manifestations: Child

* Headache

* Diplopia

* Mood swings

* Slurred speech

A

* Papilledema (after 48 hours)

* Altered level of consciousness

* Nausea and vomiting, especially in the morning

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20
Q

ICP Neurologic Examination

* Level of consciousness (LOC)

> ___ (used to assess LOC)

  • Eye opening
  • Verbal response
  • Motor response

> Scores range from 15 (no change in LOC) to 3 (deep coma or poor prognosis)

A

Glasgow Coma Scale (GCS)

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21
Q

* Behavior
> Alterations in normal pattern of behavior
> Irritability, mild confusion, agitation - all need further assessment

* Pupil evaluation

A
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22
Q

* Motor function

> Flexion = ___ posturing

  • Flexion of upper extremities and extension of lower extremities

> Extension = ___ posturing

  • Extension of upper and lower extremities with internal rotation of upper arms and wrists and knees and feet
A

decorticate

decerebrate

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23
Q

Vital signs

  • Temperature ↑
  • Cushing’s response
    > Increased systolic BP with widening pulse pressure
    > Change in RR and pattern
A

Increased ICP - Diagnostic evaluation

  • CT scan
  • MRI
  • Lumbar puncture
  • Serum and urine electrolytes
  • ABG’s
    > ICP normal blood gases
    * PaO2 >80 mmHg
    * PaCO2 <45 mmHg
  • CBC
  • EEG
  • Radiography
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24
Q

Increased ICP - Therapeutic management

Goal is to reduce the volume of CSF, preserving cerebral metabolic function, and avoiding increased ICP

* Intraventricular catheter used to drain CSF, measure ICP, administer medications

* Elevate HOB at 30°

A

* Maintain normothermia

* Administer

  • osmotic diuretic
  • hypertonic saline
  • sedation and analgesia
  • anticonvulsants

* Monitor blood glucose levels

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25
Q

Increased ICP - Nursing considerations: Decreased cerebral tissue perfusion

* Determine baseline age and developmental level

* Perform a baseline neurological and LOC assessment

* Monitor factors that may increase cerebral edema and ICP

* Maintain HOB at 30-45° angle

* Avoid the prone or flat, supine position, neck flexion, or hip flexion

* Decrease stimulation

A

* Monitor pupil reactivity

* Monitor VS every 1-2 hrs

* Measure head circumference

* Palpate anterior fontanelle every 8 hrs and cranial suture line every 8 hrs

* Observe for irregularity, lethargy, eating intolerance, and decreasing GCS score

* Keep emergency equipment near the bedside

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26
Q

Increased ICP - Nursing considerations: Poor nutritional intake: less than required

* Determine LOC before giving liquids

* Daily weights

* Monitor skin turgor, mucous membranes, eye orbits, urine output, urine specific gravity, and serum and urine electrolyte values

* Referral to a dietician

A

* Always position in an upright position after feedings

* Flexible feeding schedules with small feedings at a time

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27
Q

Standard Terms for Level of Consciousness

* Full consciousness

* Confused

* Delirious

* Disoriented

* Obtunded

A

* Stupor

* Coma

* Lethargic

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28
Q

?

Requires stimulation to arouse

A

Stupor

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29
Q

?

Inability to think clearly and rapidly; oriented to person

A

Confused

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30
Q

?

Awake, alert, oriented; interacts with environment

A

Full consciousness

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31
Q

?

Inability to recognize place or person

A

Disoriented

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32
Q

?

Sleeps and, once aroused, has limited interaction with environment

A

Obtunded

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33
Q

?

Awakens easily but exhibits limited responsiveness

A

Lethargic

34
Q

?

Vigorous stimulation produces no response

A

Coma

35
Q

?

No orientation to person, place, or time; may have auditory or visual hallucinations

A

Delirious

36
Q

?

* Congenital neural tube defects (NTD) classified by incomplete closure of the vertebrae and neural tube

> __ __ occulta

> __ __ cystica

  • Meningocele
  • Myelomeningocele
A

Spina bifida

37
Q

Clinical manifestation

* Varies depending on degree of deficit

* Small tuft of hair or dimple in the lower lumbar sacral area

* Sac-like protrusion filled with spinal fluid and meninges - ___

* Sac-like protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord - ___

> High risk for developing latex allergies

A

meningocele

myelomeningocele

38
Q

Which condition is this?

A

myelomeningocele

39
Q

Which condition is shown here?

A

Spina bifida occulta

40
Q

Which condition is shown here?

A

meningocele

41
Q

Spina Bifida

Diagnostic tests
___ blood level at 16-18 wks

Therapeutic management
> Prenatal microsurgical repair of myelomeningocele at 19-25 wks gestation
> Immediate surgical repair after birth

Prevention
> Daily folic acid 0.4 mg for all childbearing age women

A

Alpha-fetoprotein (AFP)

42
Q

?

Develops as the result of an imbalance of production and absorption of CSF

> Most often congenital
> May lead to Arnold Chiari malformations
> Enlarged ventricles and ICP
> Head circumference abnormally large
> Treatment consists of ventriculoperitoneal shunt

A

Hydrocephalus

43
Q

Hydrocephalus - Manifestations: Infant

Early

* Rapid head growth - increased circumference
* Full, bulging anterior fontanel
* Irritability
* Poor feeding
* Distended, prominent scalp veins
* Widely separated cranial sutures

A

Late

> “Setting sun” sign
> Frontal bone enlargement
> Vomiting; difficulty feeding and swallowing
> Increased BP and decreased HR
> Altered respiratory pattern
> Shrill, high-pitched cry
> Sluggish or unequal pupillary response to light

44
Q

Hydrocephalus - Manifestations: Child

Early

* Strabismus
* Frontal headache occurring in the morning and relieved by emesis or sitting upright
* Nausea and vomiting - projectile
* Diplopia
* Restlessness
* Changes in ability to do schoolwork
* Behavior or personality changes
* Ataxia
* Irritability
* Papilledema
* Sluggish and unequal pupillary response to light
* Confusion
* Lethargy

A

Late

> Seizures
> Increased BP and decreased HR
> Altered respiratory pattern
> Blindness
> Decerebrate

45
Q

Hydrocephalus - Therapeutic management

> Bypass the blockage and drain the fluid from the ventricles to an area where it will be reabsorbed into circulation - ventriculoperitoneal shunt

A
46
Q

?

* Chronic, nonprogressive disorder of posture and movement

* Difficulty controlling muscles due to abnormality in the extrapyramidal or pyramidal motor system

* Comorbidities include
> Cognitive impairment
> Hearing and speech impairment
> Visual impairment
> Seizures

A

Cerebral palsy

47
Q

Cerebral palsy - Manifestations

* Persistence primitive reflexes
* Delayed gross motor development
* Abnormal muscle tone
* Lack of progression through developmental milestones
* Inability to maintain normal posture and balance
* Spasticity or uncontrollable movements in the extremities

A

* Ataxia or toe-walking
* Seizures
* ADD
* Sensory impairment
* Failure of automatic reactions (equilibrium) speech and swallowing impairments

48
Q

Cerebral palsy - Therapeutic management

> Multidisciplinary approach
- Pediatrician, neurologist, orthopedic surgeon, nurse, speech and hearing therapists, social worker, occupational therapist, physical therapist, psychiatrist, neurosurgeon, orthotist

> Early recognition and intervention

> Intrathecal baclofen

> Benzodiazepines

> Botulinum toxin

A
49
Q

Head Injury

* Skull fractures
* Contusion
* Concussion
* Intracranial hemorrhage
> Epidural hematoma: __ and __
> Subdural hematoma: __ and __

A

dura; skull

dura; cerebrum

50
Q

* Classified as minor, moderate, or severe

> Minor head injury - GCS with a 13 or >; change in LOC; periods of transient confusion; irritability; vomiting; somnolence; headache

> Moderate to severe head injury - decreased LOC; changes in VS; signs of increased ICP; retinal hemorrhage; hemiparesis; papilledema

A

* A concussion is a violent jarring or shaking that results in a disturbance of brain function

* A coup injury results from initial impact

* Contrecoup injury results from secondary impact as brain moves forward and then backward within skull

  • Bruising occurs as brain moves over skull floor
51
Q

?

* Convex, lens-shaped

* Middle meningeal artery

* “lucid interval”

A

Epidural hematoma

Epi = Pie = Lemon

52
Q

?

* Concave/crescent-shaped

* Bridging veins

* Elderly, alcoholics

A

Subdural hematoma

suB = Banana

53
Q

Classification of Severity of Head Injuries

Glasgow Coma Scale (GCS)

* Minor (mild) = score 13-15

* Moderate = 9-12

* Severe = 3-8

A

Head Injury - Therapeutic management

> Airway assessment
> Neurologic status
> In severe cases - craniectomy

Recommendation - stay home from school 1-3 days or until child can tolerate 30 minutes of cognitive activity without an increase in symptoms

54
Q

Head Injury - Nursing considerations

> Initial and ongoing assessment

> ABCDE = airway, breathing, circulation, disability, and exposure

> Immobilize neck

> Assess LOC using the GCS; assess PERRLA

A

> Check cranial nerve function and monitor for ICP

> HOB elevated 30-45°

> Monitor I&O carefully

55
Q

Spinal Cord Injury

Can result from any trauma or injury to the spinal cord and its vascular supply or venous drainage

> Motor vehicle or diving accidents
> Falls
> Sports injuries
> Tumors
> Gunshot or knife wound
> Sports injuries
> Congenital anomalies
> Attempted suicide

A

Spinal Cord Injury - Manifestations

> Loss of some or all movement or sensation below the level of injury
> Respiratory depression or apnea
> HTN and bradycardia
> Hypothermia
> Neck pain

Diagnostic Evaluation
> Complete neuro assessment
> Radiography or MRI

56
Q

Spinal Cord Injury - Therapeutic management

* Depends on the level of injury

* Assess for airway and breathing compromise

* Assess for pneumonia

* Risk for PE and DVT

* Surgical stabilization

A

* Bowel dysfunction requiring clean intermittent catheterization 4-6x/day and dietary modification and bowel regimen

* Pain and spasticity controlled with medications and PT

57
Q

Spinal Cord Injury - Nursing considerations

> Immobilization with tongs or halo traction

> Maintain proper alignment of traction and monitor every 1-2 hrs

> Motor and sensory assessments

> Respiratory status and pulse oximetry every 1-2 hrs
* O2 supplementation, nebulizer, incentive spirometry, intermittent positive pressure breathing
* Tracheostomy for prolonged mechanical ventilation

A

* Continuously monitor color sensation and movement

* Reposition every 1-2 hrs

* Assess hourly VS, color, core body temperature, skin, and I&O

* Intermittent catheterization

* Bowel training
> High fiber, stool softeners, increase water intake

* Monitor caloric intake
> Oral intake, tube feeding, TPN

58
Q

Seizure Disorders

Consists of brief paroxysmal behavior caused by excessive discharge of neurons

Classification of seizures

> Generalized
* Tonic, clonic, and tonic-clonic (grand mal seizure)

* Atonic

* Myoclonic

* Absence (petit mal seizures)

A

* Focal
> aware of impaired awareness (which you make mistakes)

* Unknown

59
Q

__ phase - generalized stiffness of muscles

__ phase - symmetric and rhythmic; alternating contraction and relaxation of major muscles; respirations irregular; incontinence

A

tonic

clonic

60
Q

* Tonic-clonic seizures cause abrupt arrest of activity and impairment of consciousness

* Post-ictal phase - follows a tonic-clonic seizure - period of confusion, lethargy, sleep

A

Febrile seizures

* Simple or complex

* Temperature elevated above 102°F

* Seizure occurs during temperature RISE

* Caused by otitis media, pharyngitis, or adenitis

61
Q

Simple or Complex ?

* <15 minutes

* 1 sz in 24 hrs

A

Simple (generalized)

62
Q

Simple or Complex ?

>15 minutes

>1 sz in 24 hrs

A

Complex (focal)

63
Q

Seizure Disorders - Therapeutic management

Goal is to identify and correct cause of seizure, eliminate the seizure with minimum side effects in the least amount of medication, and normalize the child’s and family’s life

A

* Anti-epileptic medications
> Numerous side effects
> CBC, liver enzymes, and medication levels must be monitored closely

* Ketogenic diet

64
Q

?

> Delivers electrical impulses to the brain at regular intervals through an implanted generator

> Side effects include

  • Tickling sensation in throat
  • Change in voice tone during stimulation
  • Slight coughing during stimulation
  • Vocal cord paralysis (rare) and infection of generator site
A

Vagus nerve stimulation (VNS)

65
Q

Seizure Disorders - Medications

?

Used for generalized or focal seizures

Side effects include drowsiness, dizziness, nystagmus, N/V, ataxia

Nursing implications - adjust dose according to renal function

A

Gabapentin

66
Q

?

Used for focal or generalized seizures

Side effects include sedation, cognitive deficits, behavior outbursts, weight gain, leukopenia

Nursing implications

  • Watch for behavior or decrease in school performance
  • Avoid erythromycin
  • Monitor blood tests for therapeutic levels
A

Carbamazepine

67
Q

?

Focal, generalized, or status epilepticus

Side effects include lethargy, nystagmus, ataxia, allergic reactions, hypertrophic gums, hirsutism, osteoporosis

Nursing implications
- Teach meticulous oral care to decrease gum hypertrophy

A

Phenytoin

68
Q

?

Generalized or focal seizures; broad spectrum use

Side effects include a rash, dizziness, headache, double vision, N/V, ataxia

A

Lamotrigine

69
Q

Guidelines for child or adolescent taking seizure medication

* Stress importance of oral care especially when taking phenytoin
* Dentist appointment every 3-6 mos
* Monitor blood levels frequently
* Never stop taking anti-epileptic medication abruptly
* Birth control pills may be less effective
* Review side effects of medications
* Alcohol, marijuana, and street drugs should be avoided

A

* Contact sports like football and wrestling are not advised
* Showers preferred over baths
* Report any symptoms of depression to physician
* Maintain a seizure diary
* Call 911 if seizure does not resolve after 5 minutes
* Wear a medical alert bracelet

70
Q

Observations and nursing care during a seizure

* Time the seizure
* Describe how long seizure activity lasts
* Protect from injury, loosen clothing at the neck, turn child on the side
* Remove obstacles away from the child, especially the head
* Do not restrain the child or insert anything into the child’s mouth
* When the seizure is over, allow child to rest and record behavior

A

In neonates if movement is initiated by stimulus such as a touch it is probably a tremor

If movement cannot be stopped or controlled with gentle restraint or passive flexion, it’s probably a seizure

71
Q

?

An inflammation of the meninges of the brain resulting from pathogens entering the brain

Most common infectious process affecting the CNS

Occurs as a primary disease process OR complication of neurosurgery, systemic infection, sinus or ear infection

A

Meningitis

Early diagnosis and prompt antibiotic therapy reduce morbidity and mortality

72
Q

Meningitis - Manifestations: Vary according to age…

Neonates

> Poor feeding; poor sucking; vomiting; diarrhea; poor muscle tone; weak cry; hypothermia or hyperthermia; apnea; seizures; sepsis; DIC; a full and tense bulging fontanel; and lethargy

Infants and preschoolers

> Fever; poor feeding; vomiting; irritability; seizures; high-pitched cry; bulging anterior fontanel; lethargy

A

Children and adolescents

> Severe headache; photophobia; nuchal rigidity (neck stiffness); fever; altered LOC; decreased appetite; V/D; agitation; drowsiness

* Muscle or joint pain
* Purpura
* Kernig sign and Brudzinski sign present (boths signs of meningeal irritation)
* Late signs = include decreased LOC and seizures

73
Q

?

Flexion of the hips and knees in response to neck flexion

A

Brudzinski’s sign (Brudzinski’s neck sign)

74
Q

?

Resistance to extension of the leg while the hip is flexed

A

Kernig’s sign

75
Q

Meningitis - Diagnostic evaluation

* Testing CSF - increased CSF pressure, cloudy CSF with bacterial meningitis, high protein concentration and low glucose level

Therapeutic management

* Acute bacterial meningitis - medical emergency
* Private room
* Droplet transmission precautions
* IV antibiotic therapy
* Monitor peak and trough antibiotic levels

A

For neonates = ampicillin and aminoglycoside or a third-generation cephalosporin

Older children and adolescents = ampicillin, penicillin G, or third-generation cephalosporin

> Immunization with meningococcal vaccine
* Ages 11-12 years and a booster dose at 16 yrs

* Or by the age of 23 if previously unvaccinated

76
Q

?

Autoimmune neurologic disorder of the peripheral nervous system

> Rapidly progressing limb weakness

> Loss of DTRs

> Acute demyelization of the nerves

> May originate as a viral infection or reaction to the influenza vaccine

A

Guillain-Barré Syndrome (GBS)

77
Q

Guillain-Barré Syndrome - Manifestations

* Limb paresthesia and/or pain

* Autonomic instability

* Cranial nerve dysfunction

* Respiratory failure

* Neuromuscular impairment

A

Guillain-Barré Syndrome - Therapeutic management

* Spontaneous recovery within 2-3 wks

* For rapidly progressing paralysis - treatment with high dose IV immunoglobulin for several days

* Respiratory support is critical

78
Q

Headache

International Headache Society has published criteria for classifying headaches:

?
> Pain is more generalized
> Band-like tightness or pressure
> Tight neck muscles
> Sore scalp

?
> Mild to incapacitating
> Depression and anxiety may co-exist
> Aura may precede headache onset

A

Tension-type headaches

Migraine

79
Q

?

  • Related to administration of aspirin to children with a viral disease*
  • Viral agent leads to liver cell damage and rising serum ammonia levels
A

Reye Syndrome

80
Q

Manifestations

* Antecedent viral infection, malaise, N/V, progressive neurologic deterioration

* Elevated serum ammonia levels, liver dysfunction with biopsy, hypoglycemia, altered coagulation times, increased ICP with respiratory dysfunction

A

Nursing considerations

> Hospitalization

> Continuous neurological and cardiorespiratory monitoring

> Fluid replacement

> Protect from coagulopathy-related injury

NUR 102 Pedi Assessment #2 (7 decks)

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