Week 5 Chapter 38 Flashcards
Any environmental substance that can cause physical defect in developing embryo and fetus.
Teratogens
Premature infants are at greater risk for brain damage and intracranial hemorrhage/ bleeding
True
More premature the infant, greater the risk
What makes up the central nervous system?
Brain and spinal cord.
Development occurs at __ to___ weeks gestation from the neural tube.
3-4 weeks
What can affect normal CNS development?
Infection, trauma, teratogens, and malnutrition can cause physical defects and may affect CNS development.
At birth the cranial bones are well developed.
False
Increased risk for infection.
What is highly vascular organ?
Brain.
Increased risk for intracranial hemorrhage.
_____________ and ______ provide for brain growth.
Sutures and fontanels.
In a child the spinal cord is_________.
Mobile. High risk for cervical spine injury.
What is large to proportion to the body?
Head of the infant.
Head of infant accounts for ___ of the body height.
1/4.
Adults is 1/8th.
Child’s neck and muscles are ________ developed.
Not well developed.
Leads to increased incidence of head injury from falls.
PMH related to Neurologic Disease in Children
Prematurity
Difficult birth
Infection during Pregnancy
Falls
Recent Trauma
Common S/S related to Neurological Disease in children
Nausea, vomiting
Headaches
Changes in gait
Loss of motor function
Visual disturbances
Recent Trauma
Poor feeding
Lethargy
Fever
Pain
Changes in LOC
Increased irritability
Altered muscle tone
Inspection an observation with a Neurologic Disorder
LOC
VS
Head, face, and neck
Cranial Nerve Function
Motor Function
DTR
Sensory Function
Increased ICP
Earliest indicator of improvement or deterioration of neurologic status.
Loss of consciousness
Lack of response to painful stimuli is abnormal and can indicate life threatening condition. Report finding immediately to HCP.
5 States of Consciousness
Full
Confusion
Obtunded
Stupor
Coma
Child can’t be aroused even with painful stimuli.
Coma
Child responds to vigorous stimuli
Stupor
Child has limited responses to the environment and falls asleep unless stimulation is provided.
Obtunded
Disorientation exists, child may be alert but responds to inappropriately to questions
Confusion
Child is awake and alert, is oriented to time, place, person, and exhibit appropriate age behaviors.
Full Consciousness
Objective measure of child’s LOC by assigning numeric values to the presence of developmentally appropriate cues(eye opening, verbal response, and motor response.)
Pediatric Glasgow Coma Scale
Alterations in CN function can be result of
Compression of nerve, infection, or trauma leading to brain injury.
When assessing oculomotor function be sure to note…
Nystagmus or sunset appearance of the eyes. ( Sclera of eyes showing over the top of iris)
May indicate increased ICP as seen in hydrocephalus. Pupillary response is abnormal when neuro disorder is present.
How do we evaluate brainstem function in patients who are comatose.
Doll’s Eye Maneuver
Tests cranial nerves III, IV, VI and VIII.
Ensure the patient has a stable cervical spine without c spine precautions or neck injuries.
Doll’s Eyes Maneuver
Brainstem is intact when?
Head turned quickly in one direction, eyes move to opposite like Doll’s Eyes.
Possible Lesion of the Midbrain or Pons
Eyes continue to look straight (midline) without movement relative to head position, negative for doll’s eyes
This reflexed is suppressed in a conscious patient normal neurologic function function .
Damage to the cerebral cortex.
Decorticate Positioning
Occurs with damage at the level of the brainstem.
Decerebrate Posturing
Because cortical control of motor function is lost in certain neurologic disorders postural reflexes re emerge and are directly related to the area of the brain that is damaged.
True. Both have extremely rigid muscle tone
Carries out essential functions of your brain
Memory, thinking, learning, reasoning, problem solving, emotions, consciousness and sensory functions.
Cerebral Cortex
Sends messages to the rest of the body
Brainstem
Regulates balance, breathing, heart rate, sleep)
CNS has a dynamic balance of fluid (CSF) that bathes the brain and spinal cord at a specific pressure called
ICP
Possible Causes of ICP
Head Trauma, birth trauma, birth trauma, hydrocephalus, brain tumors
IICP shows what triad?
Cushing’s
Increase Systolic BP
Decreased in Pulse and Respirations
Shock Symptoms
Decreased B/P
Increased in Pulse and Respirations
How can you decrease ICP?
Elevate 30 degrees and use mannitol
Changes in LOC - Flat affect, decreased orientation and attention, coma
Eyes- papilledema, pupillary changes, impaired eye movement
Posturing- Decerebrate, decorticate, flaccid
Decreased motor function- Change in motor ability and posturing
Headache and Seizures- Impaired sensory and motor function
Changes in VS- Cushing’s Triad
Vomiting- No nausea, may be projectile
Changes in Speech
Infants show- Cranial Suture separation, Increased Head Circumference, High pitched cry.
IIP
Early Signs of ICP
Headache
Vomiting
Visual Change
Dizziness
Decreasing HR and RR
Sunset eyes
Changes in LOC
Seizures
Bulging Fontanel and increasing head circumference - infants
Eyes are focused downward, visible white space between the sclera and the iris
Sunset Eyes
Late Signs of ICP
Decreased LOC
Depressed motor, sensory responses
Bradycardia
Irregular respirations
Cheyne Stokes Respirations
Decerebrate, decorticate postures
Fixed and dilated pupils
Nursing Assessment Reminders
Alterations in VS and check frequently
All Children younger than 3 and any head size that is questionable should have their head circumference and plotted on growth chart
Important to assess cranial nerve function and motor function as part of neuro assessment
Assessing reflexes in infants, primitive reflexes should be assessed
Palpation is used to assess the infant skull and fontanels
Common Lab and Diagnostic Tests
LP and CSF analysis
ICP Measurements
EEG
Head and Neck Radiograph
Ultrasound
Fluoroscopy
CT, MRI, PET, SPECT
Other procedures and treatments for Neurological Disorders
Ventricular Shunt
Hyperventilation
PT,OT, ST therapists
EVD
Ventricular tap
Vagal Nerve Stimulator
Ketogenic diet
Nerve stimulator is implanted and a lead wiring running under the skin is wrapped around the vagus nerve.
Vagal Nerve Stimulator
Used in children older than 12 years of age.
Hyperventilation can due what?
Decrease PaCO2 results in vasoconstriction and decrease ICP.
High in fat and protein, low carbs to prevent, control and reduce seizures.
Keto Diet
_____________ is available in rectal form to stop prolonged seizures.
Diazepam
Useful for home management
Nurses must educate parents on administration and when to call 911.
Medications used to treat Neurological Disorders
Antibiotics
Anticonvulsants
Benzodiazepines
Analgesics
Osmotic Diuretics
Corticosteroids
Types of Neurological Disorders in Children
Structural Disorders
Seizure Disorders
Infectious Disorders
Trauma to Neurological System
Blood flow disruption Disorders
Chronic Disorders
Common Types of Structural Defects
Neural Tube Defects
Microcephaly
Arnold- Chiari Malformation
Hydrocephalus
Intracranial Arteriovenous Malformation
Craniosynostosis
Account for majority of congenital anomalies and defects the spine and brain
Neural Tube Defects
- Spina Bifida Occulta
Myelomeningocele
Anencephaly - small or missing brain, skull or scalp
Encephalocele- Protrusion of brain and meninges through a skull defect
Microcephaly- Head circumference more than 3 standard deviations
Folic acid supplementation can decrease of NTD by 50%- ).4 mg PO Daily
Type I and Type II are under what catergorical disease?
Chiari Malformation
Cerebral tonsils displacing into the upper cervical canal
More benign
Symptoms:
Seen in teens and adults
Neck pain
Recurrent Headaches that increase with physical activity and laughing, sneezing, and crying
Lower Extremity spasticity
Type I
Cerebellum, medulla oblongata and 4th ventricle displace into the cervical canal and most common
Usually associated with hydrocephalus and myelomeningocele
Symptoms
Detected prenatally or at birth
Weak cry
Stridor
Apnea
Surgical Decompression
Type II- Arnold Chiari
Results from an imbalance in production and absorption of CSF
CSF causes the ventricles to enlarge and increases ICP
Hydrocephalus
S/S of Hydrocephalus
2 years or less:
High pitched cry, bulging fontanels, irritability and changes in LOC, vomiting and poor feeding, frequent seizures and sunset eyes
Congenital- Present at birth:
Myelomeningocele
NTD
Intrauterine Infections
Hydrocephalus acquired after birth
Intentional or nonintentional trauma
IVH in premature infants
Neoplasms
Infections
Mlaformations
Maintaining Cerebral perfusion
Minimizing Neurologic Complications
Recognizing and Preventing shunt infection and malfunction
Maintaining adequate nutrition
Promoting growth and development
Supporting and educating the child and family
Nursing Management of Hydrocephalus
Diverts the flow of CSF to the peritoneum where it is absorbed across the peritoneal membrane
Ventriculoperitoneal Shunt
VP Shunt
Will be need to be replaced as the child grows ( shunt revision)
- Post Op Care- Measure Head Circumference
Symptoms of Shunt Infection
Elevated vital signs (fever), poor feeding, vomiting, decreased responsiveness, seizures, local inflammation, along shunt tract
Symptoms of Shunt Malfunction
Vomiting, Drowsiness, headache
Normally the capillaries connect the arteries to veins, in ___________ happens when what is missing?
AVM; capillaries
Nursing interventions for AVM
BP, pulse, assess pain, neuro status, focal deficits, maintain airway, administer oxygen to prevent hypoxia, maintain BP
Rare congenital disorder caused by an abnormal development of blood vessels ; “tangle of blood vessels”
Intracranial Arteriovenous Malformation
AVM
Blood from artery flows under high pressure then_____ then______ vessels swell____then _____ and __________
vein then blood and then burst and bleed
AVMs that ____________ can lead to neurological defects
Hemorrhage
Symptoms of AVM
Sudden onset, severe headache, N/V, slurred speech, confusion, paralysis, seizures
Premature closure of the cranial sutures and can inhibit brain growth and show a distorted skull appearance
Craniosynostosis
When 2 or more sutures fused Hydrocephalus with increased ICP more likely to occur
Requires Surgical Correction
Treatment Options for AVM
Surgical Excision and Endovascular embolization
Asymmetry in head shape without fused sutures
Increase in incidence in “ back to sleep”
Results from gravitational force on developing cranium
Positional Plagiocephaly
Therapeutic Management
Tummy time
Molding Helmet
Common types of seizures include
Infantile spasms
Absence
Tonic- Clonic
Myoclonic
Atonic
Simple Partial
Complex Partial
Status Epilepticus
Usually by age 4 or 5 more than half of children who have IS will develop other types of seizures
True
Higher risk of developing Autism
Infantile Spasms Characteristics
Waking from sleep common but can happen during any moment in the day
Often happen in clusters or back to back. Clusters last several minutes
Often occur at ages 3 - 12 months and continue
Treatment for Infantile Spasms
ACTH
Anti Seizure drug vigabatrin
Surgery if in brain lesion
Criteria for Febrile Seizures
Convulsion with temperature greater than 38
Child older than 3 months younger than 6 years
Absence of CNS or inflammation
Absence of acute systemic metabolic abnormally that may produce convulsions
No history of previous afebrile seizures
Type of seizure that is in ages of 6 months to 5 years
1 seizures that lasted less than 15 minutes and is a tonic Clonic seizure
Simple Febrile
Less than 6 months or greater than 5 years
More than 1 seizure in a 24 hour period that are longer than 15 minutes and is a focal seizure
Complex Febrile
Higher incidence in neonates due to immature brain
Metabolic, infectious, structural, and toxic diseases are likelyy to be seen in this group
Neonatal Seizures
Associated with: Hypoxic Ischemia
Hypoglycemia and hypocalcemia
Infection
Intracranial Hemorrhage
Neonatal Seizures
May causes ____________ with neonatal seizures
Neurodevelopmental Problems
Tx is Phenobarbital and correct underlying cause
Common neurological emergency in children and can occur with any seizure activity
Status Epilepticus
Can be life threatening
Prolonged or clustered seizures where consciousness does not return between seizures
Age, cause, an duration influence prognosis
Requires prompt medical attention
Status Epilepticus
Tx of Status Epilepticus
Basic life Support- ABCs
Administration of anticonvulsants to cease seizure ex: lorazepam, diazepam, fosphenytoin
Blood glucose levels and electrolytes, evaluate the underlying cause
Tonic and Clonic Seizures Interventions
Maintain Airway
Protect from harm
No objects in mouth
Observe and record event
Note the:
Onset, LOC, Muscle tone, pupils, cyanosis, incontinence, altered salivation
Antiepileptic Drugs include
Phenytoin, Carbamazepine, Valproic Acid
Selective inhibition of sodium channels and is an antileptic drug
Phenytoin
Suppresses high frequency neuronal discharge and is an antileptic drug
Carbamazepine
Blocks sodium and calcium channels to prevent neuron firing
Valproic Acid
What to watch for Antileptic Drugs?
Dilantin- gingival, hyperplasia, bradycardia, rash
Tegretol- visual problems, leukemia, anemia, thrombocytopenia
Valproic Acid- GI upset, hepatoxicity, pancreatitis
Need to do levels on these drugs
Noncompliance is frequently responsible for Tx failure
Padding of side rails and other hard objects
Side rails always raised when child is in bed
Oxygen and suction at bedside
Supervision, especially during bathing,
ambulation, and other potential hazards
Use of protective helmet
Child should wear medical alert bracelet
Seizure Precautions
Nursing management of Seizures
Maintain Airway
Administer appropriate medication
Help family cope with challenges of chronic seizures
Types of Infectious Disorders
Bacterial Meningitis
Aseptic Meningitis
Encephalitis
Reye Syndrome
Rigid and arches their head back ( severe backward arching)
Opisthotonic Position
Infection of the meninges, the lining that surrounds the brain and spinal cord
Can Lead to brain damage, nerve damage, deafness, stroke and death
Bacterial Meningitis
Decreases with Hib vaccine
Bacterial Meningitis and Hib
Bacterial Meningitis is a medical emergency that needs what two things started right away?
IV antibiotics
Corticosteroids
Opithotonic position for infants and positive kernig and Brudzinski signs
Bacterial Meningitis
Preceding URI or sore throat
Fever Chills
Headache
Vomiting
Rash
Irritability
Drowsiness, lethargy
Muscle rigidity
Seizures
Common S/S of Bacterial Meningitis
Infants display poor sucking and feeding, weak cry, lethargy, vomiting
Bulging fontanel is late sign
Bacterial Meningitis
Group Strep, S. pneumoniae, L. montocytogenes, E. Coli
Common bacterial for bacterial meningitis in NEWBORNS
S. pneumoniae, N. meningitis, H influenzae, Group B strep, M. tuberculosis
Common bacterial for bacterial meningitis in Babies and young children
N. Meningitis and S. pneumoniae
Common bacterial for bacterial meningitis in Teens and Young adults
Labs and Diagnostic Testing for Bacterial Meningitis
LP
CBCs and WBCs
Blood, urine, and NP culture
Nursing management of bacterial Meningitis
Administer antibiotics ASAP
Supportive measures to reduce ICP
Control Seizures
Reduce fever
Prevention includes:
Treat pregnant mothers who are GBS+
Vaccines:
Hib, pneumococcal, meningococcal
Most common and affects children younger than 5 years of age
S/S include same as bacterial and is less ill and it is self limiting lasting 3-10 days
Aseptic Meningitis
Viral
Tx of Aseptic Meningitis
Antivirals
Supportive Measures - reduce pain and fever
Stay home if neuro status is stable and tolerating
Discharge teaching to include parental administration of over the counter analgesics
Inflammation of the brain, often due to infection or unknown
Encephalitis
S/S of Acute Encephalitis
Fever Headache
Bulging fontanels
Neck Stiffness
Sleepiness
Lack of energy
Increased irritability
Tx of Encephalitis
Bed rest
Plenty of fluids
Corticosteroids
Prescription based anti-inflammatory drugs to fight fever
Very rare and shows vomiting, diarrhea, rapid breathing, severe fatigue
Reyes Syndrome
Symptoms requiring emergency Tx include confusion, seizures, and LOC
Tx is supportive care and aggressive monitoring of complications
Progressive encephalopathy with hepatic dysfunctions
Risk Factor is aspirin use and in born metabolism errors
Reye Syndrome
Closed Head Injuries are graded on ?
Severity
Mild
Moderate
Severe
May occur with an accident or injury
Nonpenetrating injury to the head
Normal behavior before the injury, may or may not lose consciousness
Leading cause of child mortality in the US
Trauma or Injury
Common Causes of Head Trauma in Children
Falls
Motor Vehicle Accidents
Sports Injuries
Pedestrian and Bicycle Injuries
Child Abuse
Causes of Nonaccidental Head Trauma
SBS
Blows to the Head
Intentional cranial impacts against the wall furniture, or the floor.
2nd leading cause of unintentional injuries between ages 1-14 years of age
Drowning
Preventable by proper fencing around pool
Water safety training
Swimming Lessons
Never leave without direct supervision
Proper floating devices
Learn CPR
Know water depth
Near drowning
- Hypoxia
- Promotion of oxygenation and monitoring for infection related to aspiration
Occurs less often than adults and many children will develop lifelong cognitive an motor impairments
cute Stroke in Children
Ischemic or Hemorrhagic
More common stroke
Cardiac disorders, coagulation abnormalities, sickle cell, infection, arterial dissection, genetic disorders
Ischemic
AVMs, aneurysms, coumadin, malignancy, trauma, hemophilia, liver failure, leukemia, intracranial tumors
Hemorrhagic
S/S of Acute Stroke in Children
Weakness on one side
Facial Droop
Slurred Speech
Speech deficits
What is important in reducing the risk of injury in children?
Safety
Having a neurological disorder can lead to lifelong impairment of individual’s physical, cognitive, and psychosocial functioning
Assess the child and family in their willingness to learn
Provide family time to adjust with diagnosis
Repeat info
Teach in short sessions
Gear teaching to understanding level of family/ child
Provide Reinforcement and rewards
Use multiple modes of learning involving many senses
Promoting Child and Family Teaching
