The Child with Alterations in Neurologic Function Flashcards
Anatomic Differences between Adult and Child
Child:
- top-heavy, head is large in proportion to body; neck muscles poorly developed; thin, cranial bones, not well developed; unfused sutures; skull expands until two years old. Prone to brain injury, and a skull fracture with falls.
- Excessive spinal mobility; immature muscles, joint capsule, and ligaments of cervical spine; wedge shaped, cartilaginous vertebral bodies; incomplete ossification of vertebral bodies. Greater risk for high cervical spine injury at C1-C2 level or vertebral compression fractures with falls
Adult:
- Head size proportional to body; neck muscles well developed; can reduce risk for brain injuries; sutures are ossified by age 12 years; no expansion of skull after five years.
- well developed muscles and ligaments, reduce spinal mobility; vertebral bodies completely formed and ossified
Alterations in Neurologic Function
Assessment
- Level of consciousness- Glascow Coma Scale
- Cognitive function
- Pupils
- Intracranial pressure: infection, trauma, crying, coughing, pooping
- Fontanelles
- Posturing & Movement
- Neck Stiffness
- Pain
- Cranial nerves
- Vital signs: fluctuate
- Labs and imaging exams: CT/MRI of the head, CBC, CSF, blood culture
Pupil findings in various neurologic
conditions with altered consciousness.
A. A unilateral dilated and reactive pupil is associated with an intracranial mass.
B. A fixed and dilated pupil may be a sign of impending brainstem herniation.
C. Bilateral fixed and dilated pupils are associated with brainstem herniation from increased intracranial pressure.
What causes:
Increased Intracranial Pressure
- Increased CSF Volume
- Decreased CSF Drainage
- Swelling
- Infection (meningitis)
Early signs of increased intercranial pressure
- Headache
- Visual disturbances, diplopia
- Nausea and vomiting
- Dizziness and vertigo
- Slight changes in vital signs
- Pupils not as a Reactive or equal
- Sunsetting eyes
- Slight change in level of consciousness
- Restlessness
- Irritability
- Bulging fontanelle
- Wide sutures, increased head circumference
- Dilated scalp veins
- High-pitched, cat like cry
Late signs of increased intercranial pressure
- significant decrease in level of consciousness
- Seizures
- Cushing’s triad
- fixed and dilated pupils, papilledema
*Cushing’s triad s/s
- Increased systolic blood pressure and widened pulse pressure
- Bradycardia
- Irregular respirations
Decorticate
Arms and feet flexed inward
brain injury/ swelling
Decerebrate
Arms and feet extended outward
severe brain damage
Kernig Sign
pain in neck upon extending leg= (+) Kernig sign = increased intracranial pressure
Brudzinski Signs
involuntary flex knees when putting chin to chest = (+) Brudzinski Sign= increased cranial pressure
Spinal Tap Positions
Brain Injury: Concussion
Alteration in mental status with or without loss of consciousness immediately after a head injury.
Brain Injury: Concussion
Nursing Considerations:
- Rule out Child Abuse
- VS
- Neuro Status
- Stabilize spine
- Ocular Assessment
- Prevent ICP
- keep calm
- ask parents if the kid has been behaving out of the norm
- Resolves 1-3 weeks; afterwards its known as post concussion syndrome
Post concussion syndrome: s/s
> 3 weeks:
- headaches
- Sleep problems
- Appetite changes
- Fatigue
- Trouble concentrating
- Memory problems
- Depression or anxiety
- Sensitivity to light and noise
- Dizziness
Concussion Clinical Manifestations
Less than 5% loss consciousness
Most common signs/symptoms:
- Headache
- Dizziness
- Difficulty concentrating
- Confusion Symptoms usually resolve within 1-3 weeks
Concussion theraputic management
- Mild to moderate concussion can be cared for at home or clinic
- **Strict bedrest and limited activity is contraindicated.
- Severe injuries are hospitalized until they stabilize or neuro symptoms have diminished
- Maintained on clear liquids - vomiting
- I.V. If child is comatose
- Careful monitoring of intake and output due to cerebral edema*
- Neuro checks q 2 to 4 hours only while awake
Submersion Injury
In children 1-4 yrs- leading cause of Accidental injury related death
- Can take place in any body of water
- Should be hospitalized for at least 24hrs Observation due to risk of respiratory compromise and cerebral edema (dry drowning)
- Management: oxygenation, thermoregulation, monitor glucose, seizure prevention
- Prognosis: depend on the length of submersion. Poor prognosis with Submersion greater than 5 min, no presence of sinus rhythm and poor neurologic assessment
Febrile Seizures
- most common type of childhood seizure
- Seizure occurring with febrile illness in the absence of CNS infection.
- The most important nursing intervention is to reassure parents of their benign nature and educate parents regarding protection of their child and meaningful observation during the event.
Questions to ask about seizures
Just before the seizure:
- What was the child doing?
- Did the child complain of not feeling well? (Headache, nausea, vomiting, muscle pain, fever)
- Did the child suffer any trauma? Did the child get into any medication or poisons?
During the seizure :
- What movement of the arms and legs were seen?
- On one or both sides of the body or in one extremity only?
- Did the child exhibit any chewing or other type of automatic behavior?
- Were the pupils dilated or the eyes deviated to one side?
- Did the child color change? (Pale, red, blue)
- What is the child incontinent of urine or stool?
- What is the child aware of surroundings or able to respond to questions?
After the seizure:
- how long did the episode last?
- What is the child lethargic, week, or uncoordinated when waking up?
- Did the child have loss of memory or confusion?
Hydrocephalus etiology
Etiology: *developmental malformation, CNS infection, cancer, trauma, myelomeningocele
Hydrocephalus Nursing Management
*Daily head circumference, monitor suture lines and fontanels, irritability, lethargy, feeding issues, VS, altered Mental Status or LOC
Hydrocephalus Treatment
- Surgically remove the obstruction
- Decrease swelling
- Place a Ventral peritoneal (VP) shunt in the ventricle to divert CSF to the peritoneal cavity or right atrium of the heart
Assessments of Shunt Function:
S/s of shunt not draining properly
- Early morning headache on awakening
- Vomiting with or without nausea
- Papilledema
- Lethargy and irritability
- Confusion
- Inability to follow commands
- Signs of infection: Fever
