TLO 2.9 Neurological/Sensory Motor Child Flashcards
Glasgow Coma Scale
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
GCS
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
Diagnostic test EEG
EEG identifies electrical activity of the brain
- regular diet no caffeine or simulants
- clean hair
- sleep deprived night before test
- painless
Diagnostic test CT scan
Identifies abnormal tissue structures, bleeding, hydrocephalus
IV if contrast used
Allergies
Sedate if necessary
Diagnostic test MRI of head
Sedated if agitated or afraid
Needs to lay still
Loud clicking noises
Head will be restrained, painless
Increased intracranial pressure IICP
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
ICP assessment
Often have altered LOC with increased ICP. Use GCS Nursing assessment: LOC Behavior Pupil evaluation Motor function Vital signs Developmental function, delayed milestones
Manifestations of ICP infant
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
Manifestation of ICP chidren
Child: HA Diplopia Mood swings Slurred speech Altered LOC N/V especially in AM **head circumference is most significant neuro assessment for children <2
Assessment ICP Behavior
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
Assessment ICP Pupils
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)
Assessment ICP motor function
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
Nursing interventions of ICP
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
Seizures
three major classifications
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
Seizures
Classified according to type
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
Seizures predisposing factors
Predisposing factors: Genetic defects Strokes, trauma Infections Fevers >102 Hypoglycemia Drug withdrawal Intrauterine and perinatal infection
Seizures diagnosis
Diagnostic Family history EEG, most helpful Labs to rule out infection CT MRI
Seizure assessment
Assessment
Body parts involved
Begin and end time of seizure
Seizure NI
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
Seizure med
Medications: Carbamazepine (tegretol) Gabapentin Phenobarbital Phenytoin Valproic acid Levetiracetam (Keppra)
Seizure treatment, daily meds
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
meningitis
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
Meningitis lumbar puncture
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
Lumbar puncture Nursing responsibilities
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
Meningitis manifestations Infants/preschool
Poor feeding/poor sucking Irritability/lethargy Bulging anterior fontanel V/D Bulging fontanels/high pitched cry Hyperthermia or hypothermia Seizures
Meningitis manifestations Children/adolescent
Severe HA Photophobia Nuchal rigidity Fever Altered LOC Lethargy Irritability Anorexia/V/D Drowsiness
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
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
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
Common viruses that cause vial meningitis
Non-polio enteroviruses: Mumps Measles Influenza West Nile
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
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
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
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)
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
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
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
Hydrocephalus risk factors
Risk factors: Myelomeningocele Neonatal meningitis Intrauterine infection Older children: tumor, hemorrhage, meningitis
Hydrocephalus assessment infant
Infant assessment: Rapid head growth Bulging anterior fontanel Irritability Poor feeding Distended scalp veins Widely separated cranial sutures
