TLO 2.9 Neurological/Sensory Motor Child Flashcards

1
Q

Glasgow Coma Scale

A
Standardized scale that assesses the LOC of infants and children
Assesses:
Eye opening: 1-4
Verbal response: 1-5
Motor response: 1-6
Higher score: intact infant
Lower score: coma
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2
Q

GCS

A

Patient with GCS of 3 is either dead or in vegetative state
GCS of 15 if normal
LOC is the best indicator to determine the depth of the comatose state
Children older than 3 should be able to state their name

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3
Q

Diagnostic test EEG

A

EEG identifies electrical activity of the brain

  • regular diet no caffeine or simulants
  • clean hair
  • sleep deprived night before test
  • painless
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4
Q

Diagnostic test CT scan

A

Identifies abnormal tissue structures, bleeding, hydrocephalus
IV if contrast used
Allergies
Sedate if necessary

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5
Q

Diagnostic test MRI of head

A

Sedated if agitated or afraid
Needs to lay still
Loud clicking noises
Head will be restrained, painless

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6
Q

Increased intracranial pressure IICP

A

A rise in pressure of the brain >20 mmHg.
Many causes of ICP
Brain tumor, hematoma
Infection, trauma
Overproductions of CSF, hypoxia (cause brain swelling)
Brain aneurysms
Brain damage prenatally or during birth (Cerebral Palsy)
Hydrocephalus, spina bifida, myelomeningocele

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7
Q

ICP assessment

A
Often have altered LOC with increased ICP. 
Use GCS
Nursing assessment:
LOC
Behavior
Pupil evaluation
Motor function
Vital signs
Developmental function, delayed milestones
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8
Q

Manifestations of ICP infant

A
Infant:
Poor feeding/vomiting
Irritability/restlessness
Lethargy
Bulging fontanel
High pitched cry
Increased head circumference
Cranial suture separation
Distended scalp veins
Eyes deviated downward
Increase/decrease pain response
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9
Q

Manifestation of ICP chidren

A
Child:
HA
Diplopia
Mood swings
Slurred speech
Altered LOC
N/V especially in AM
**head circumference is most significant neuro assessment for children <2
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10
Q

Assessment ICP Behavior

A

Behavior:
Behavior changes are important early signs of ICP
Involved parents ask questions
Inability to recognize parents, follow commands, minimal response to pain is deteriorating

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11
Q

Assessment ICP Pupils

A

Pupils:
ICP rises= 3rd cranial nerve compresses causing pupil dilatation and sluggish or absent constriction
Fixed dilated: bad suggests herniation of brains
Should be equal round reactive to light, accommodation (PERRLA)

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12
Q

Assessment ICP motor function

A

Motor function:
Purposeful movement will decrease

Abnormal posturing may be seen:
Decorticate: flexion upper extremities
Decerebrate: extension of upper extremities with internal rotation of upper are and wrist

Progression from decorticate to decerebrate indicates deteriorating neuro function

Flaccid paralysis indicates further deterioration in condition

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13
Q

Nursing interventions of ICP

A

HOB 30-40 degrees: facilitates venous draining reducing ICP
Avoid prone, supine position, hip flexion, neck flexion: this will increase ICP
Monitor for fever, seizures, hypotension, hypercapnia: this can increase ICP, avoid coughing
Block care reduces stimulation: too much stimulation can increase ICP, triggering seizure
Neuro checks: provides baseline
Monitor I/O: fluids affect ICP
Have emergency equipment: cardiac arrest

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14
Q

Seizures

three major classifications

A

Caused by excessive abnormal discharge of neurons
More than 2 seizures= epilepsy

Three major classifications of seizure:
Focal: 1 part of brain may/may not alter consciousness
Generalized: entire brain involved alters consciousness
Unknown

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15
Q

Seizures

Classified according to type

A

Tonic clonic (grand mal) generalized body involvement
Atonic: abrupt loss of postural tone drop head or drop to floor and get back up like nothing happened
Myoclonic: contraction and relaxation of muscles
Absence (petit mal): no muscle activity instead eyes roll upward
Focal: symptoms on one side of body often aura present prior to

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16
Q

Seizures predisposing factors

A
Predisposing factors:
Genetic defects
Strokes, trauma
Infections
Fevers >102
Hypoglycemia
Drug withdrawal
Intrauterine and perinatal infection
17
Q

Seizures diagnosis

A
Diagnostic
Family history
EEG, most helpful
Labs to rule out infection
CT
MRI
18
Q

Seizure assessment

A

Assessment
Body parts involved
Begin and end time of seizure

19
Q

Seizure NI

A
Nursing Interventions
Protect safety
NPO
Place side lying
Seizure precautions
STay with child
Call doc if over >5 min
Do not restrain
Loosen clothing
Teach caregiver about meds
20
Q

Seizure med

A
Medications:
Carbamazepine (tegretol)
Gabapentin
Phenobarbital
Phenytoin
Valproic acid
Levetiracetam (Keppra)
21
Q

Seizure treatment, daily meds

A
Phenytoin (Dilantin):
Oral care important
Causes gingival hyperplasia
Soft toothbrush
Floss after each meal
See dentist 3-6 mo

Valproic Acid (Depakote):
Monitor for generalized weakness
Do not crush/split med
Effects platelets, monitor for bleeding

  • *Most meds cause dizziness/drowsiness
  • *Do not stop med abruptly
  • *Monitor liver function
22
Q

meningitis

A

Inflammation of the meninges of the brain
Results from pathogen entering CNS and causing toxic response

Bacterial: medical emergency, droplet precautions 24 hour of antibiotic treatment

Viral: self limiting, lasts 7-10 days

Diagnosis: Lumbar puncture to obtain CSF

23
Q

Meningitis lumbar puncture

A
Insertion of spinal needle into subarachnoid space of lower spinal canal
Purpose:
Detect infection
Detect increase pressure
Insertion of medication

CSF findings:
Clear/colorless: normal
Cloudy/milky yellow: bacterial meningitis

24
Q

Lumbar puncture Nursing responsibilities

A

Informed consent
Child lying on side, knees to chest
Practice position with child
Monitor cardiorespiratory status during procedure
Lay flat 8-12 hours after to avoid spinal HA
Label specimens 1, 2, 3
Walk to lab

25
Meningitis manifestations Infants/preschool
``` Poor feeding/poor sucking Irritability/lethargy Bulging anterior fontanel V/D Bulging fontanels/high pitched cry Hyperthermia or hypothermia Seizures ```
26
Meningitis manifestations Children/adolescent
``` Severe HA Photophobia Nuchal rigidity Fever Altered LOC Lethargy Irritability Anorexia/V/D Drowsiness ```
27
Meningitis Kernig and Brudzinski sign
Kernig: leg easily extended in supine position but when flexed toward abdomen pain presents Brudzinski: supine child bends head forward to chest hip and knee flexion will involuntarily occur in meningitis
28
Meningitis nursing care
``` Assist with LP VS, neuro checks q 15 min S/S of increase ICP I/O NPO if decrease LOC Droplet precautions ``` ``` Potential complications: Hydrocephalus Vision/hearing loss Delayed G&D Seizures ``` Prevention: Meningococcal vaccine age 11-12 or by age 18 H. Influenzae B (Hib) vaccine as part of normal routine
29
Viral meningitis
Most common type of meningitis Less severe than bacterial Self limiting, usually resolves by 7-10 days, some receive antiviral meds S/S same as bacterial but less severe
30
Common viruses that cause vial meningitis
``` Non-polio enteroviruses: Mumps Measles Influenza West Nile ```
31
Spina Bifida what it is? types? risks?
Congenital neural tube defect where there is an incomplete closure of the vertebrae and neural tube during fetal development Two types: Spina bifida cystica (more severe) Spina bifida occulta Risks Genetic predisposition Folic acid deficiency
32
Spina bifida results in?
90% lesions at or below L2 ``` Results in: Paralysis, partial paralysis Varying sensory defects Clubfeet, scoliosis, contractures and hip dislocations may also be seen r/t impaired intrauterine development Hydrocephalus also can occur 73% develop latex allergies ```
33
Spina bifida Occulta
Occurs between L5-S1 usually Vertebrae fail to completely close Usually no sensory or motor deficits Clinical manifestation in lower lumbar or sacral area: Dimple or small tuft of hair Hemangioma or lipoma
34
Spina bifida Cystica
More extensive defect with sensory and motor impairments Visible defect seen on infant r/t failure of vertebrae to completely fuse Meningocele: Saclike protrusion containing meninges and CSF Myelomeningocele: Saclike protrusion filled with CSF, meninges, nerve roots and spinal cord (more extensive)
35
Spina bifida Cystica nursing care
Sac protrusion measured and assessed Head circumference, palpate fontanel (increased ICP risk) Avoid pressure on sac, infant in prone position Maintain foot and leg alignment, reduce tension on sac
36
Spina bifida surgical care
``` Pre-op: Prevent infection, cover sac Prone position Avoid fecal contamination Maintain warmth Adequate hydration (until NPO) ``` ``` Post-op: Monitor for hydrocephalus Respiratory status Wound care as ordered Monitor incision s/s infection ```
37
Hydrocephalus what is it?
Caused by imbalance between production and absorption of CSF Excess CSF accumulates causing brain to be compressed against the skull Skull becomes enlarged if sutures are open and s/s of increased ICP if sutures are closed
38
Hydrocephalus risk factors
``` Risk factors: Myelomeningocele Neonatal meningitis Intrauterine infection Older children: tumor, hemorrhage, meningitis ```
39
Hydrocephalus assessment infant
``` Infant assessment: Rapid head growth Bulging anterior fontanel Irritability Poor feeding Distended scalp veins Widely separated cranial sutures ```