Week 5 TUES Flashcards
peds neuro
6 y.o. has hx of febrile seizures and is admitted w/ a temperature of 102.2 degrees F. What is the highest priority?
institute safety (seizure) precautions
What statement indicates child most likely had an absence seizure?
“He was just staring into space and was totally unaware”
What finding is consistent w/ increasing ICP in an infant
bulging fontanels
The nurse suspects the child may have hydrocephalus. Which s/s was observed?
Dramatic increase in head circumference
What is a first change noted in the presence of increasing ICP?
change in LOC
The nurse observes for what reponse for the child’s eye reflex exam that would indicate potential increase ICP?
- pupils will not change in diameter in response to light
Glasgow coma scale assesses what?
- eye opening, verbal response, and motor response
What information will the nurse address when teaching the child and parent about living with this condition (chronic epilepsy)?
- support for maintaining self-esteem because of the child’s altered lifestyle
place the folling orders in the order they should be completed?
- conduct neuro assess q2hr
- complete pre-op checklist
- consult social work
- administer IV phenytoin
- Implement seizure precautions
- obtain IV access
- implement seizure precautions
- obtain IV access
- administer IV phenytoin
- neuro assess q2hr
- complete pre-op checklist
- consult social work
What assessment findings are effective, ineffective, or unrelated after a VP shunt placement
- HR 108 bpm
- resp 36 breaths per min
- increased head circumference
- temp 99.1
- alert
- bulging fontanels
Effective: resp 36 bpm, Alert
Ineffective: increased head circumference, bulging fontanels
unrelated: HR 108bpm, temp 99.1
What VS’s are most concerning for ICP?
- temp 991.
- pulse 76
- resp 24
- BP 97/66
- O2 sats 95%
- Pulse 76 (100-120)
- resp 24 (30-60)
The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply.
A. increased head circumference
B. Pulse rate of 60 beats/min and regular
C. vomiting
D. Blood pressure decreased from baseline
E. Parent states ‘my infant is not acting right’
A, B, C, E
A nurse is caring for a patient who is on ICP monitoring. At the previous assessment the ICP level was 13 mm/Hg. The nurse checks on the patient who is sleeping lying flat in bed and find the most current ICP level is 18 mm/Hg. Which of the following is the first thing the nurse will do?
A. Notify the provider
B. Reassess in 1 hour
C. Consult the charge nurse
D. Elevate the head of the bed to 30 degrees
D.
- try elevation first to drain fluid!
Which of the following is/are a part of seizure precautions? Select all the apply.
A. Padded side rails
B. Side rails raised on the bed at all times
C. Oxygen and suction at bedside
D. Medic alert bracelet
E. Lay patient flat on their back
F. Supervision during bathing and ambulating
A, B, C, D, F
- always lay the person to the side!
You are taking care of a 6-month-old who has a VP shunt that was placed shortly after birth to manage hydrocephalus. Your assessment includes to the following findings:
HR: 72 RR: 22 BP: 88/52 Temp: 36.9C
Pupils are sluggish
Head circumference 18.2cm (previous 17.5cm)
Shunt incision site is clean, dry, and intact. When you leave the room patient starts vomiting.
Which of the following are you most likely cause of the symptoms?
A. Shunt infection
B. Shunt malfunction
C. Shunt replacement due to growth
D. Head injury
Shunt malfunction
- infection occurs 1-2 months after placement> too late for infection
You just received a patient in the emergency department with possible non-accidental head trauma. Place the following items in order of priority for the nurse to complete:
A. Consulting social work
B. Assess airway
C. Conduct a neuro assessment
D. Stabilize the patient’s head
E. Obtain a head CT
D, B, C, E, A
- always stabilize the neck first!
- stabilizing the neck protects airway
The 3-year-old child is admitted to the hospital with headaches, irritability, and dizziness. The child has a history of hydrocephalus and a ventriculoperitoneal shunt that was placed when the child was 8 months old. Which of the following is the most likely cause of the symptoms?
A. Head Injury
B. Shunt infection
C. Shunt malfunction
D. Need for shunt revision
C. Shunt malfunction
- Most shunt malfunctions occur within the first 2-3 years of life when a baby has them placed when they are little because of the head growth and dependent on the age of shunt placement
What concept refers to compensatory mechanisms in the brain that operate to maintain pressure w/in the cranial cavity in a safe range
intracranial regulation
Definition: The process that impacts the brain’s state of equilibrium to ensure overall neurological function
intracranial regulation
Cheyenne Stokes respirations
- also called neuro breathing
- periods of apnea
- late stage of IICP
Why is increased ICP/ IR significant or concerning?
disruption/ alteration IR in children can lead to severe complications which may have long term impacts
When does CNS development occur?
- 4 weeks in gestation
Cranial nerve development
- cranial nerves are not fully developed and not fused at birth
- myelin not fully formed
- large head size and shape, center is gravity is off
T or F: Children are top heavy and fall a lot which increases the risk of ICP/ IR impairment
True!
- more likely for head trauma
T or F: the brain is highly vascular, and there is a decrease in hemorrhage risk
FALSE,
there is more of a risk for potential hemorrhage because the brain is so vascular
Risk factors for altered intracranial regulation
- prematurity
- difficult birth/ trauma
- maternal infection during pregnancy, maternal drug or alcohol use, carcinogen exposure
- family hx of neuro disorders
nursing interventions for altered IR risk factors
- folic acid during pregnancy
- well-child checks
- safety education about head trauma
- prenatal care and education to reduce risks
What are the big 3 symptoms when assessing for altered IR in peds
- headache/ irritability
- vomiting
- lethargy> hard to arouse
What is included in a neuro assessment for assessing intracranial regulation
- LOC
- glasgow coma scale
- vital signs
- cranial nerves/ reflexes
- posturing/ motor function
Decerebrate posturing
- extend/ pronated extremities
- Brain stem damage/ injury
- More concerning
Decorticate posturing
- flexed extremities
- extremities towards the core
- cerebral cortex damage
Early signs of ICP
- headache
- vomiting> projectile
- change in vision
- dizziness
-low pulse and resp, elevated BP - sunset eyes
- change in LOC
- irritability
- bulging fontanels
Late signs of ICP
- decreased LOC
- motor and sensory responses diminished
- bradycardia
- fixed and dilated pupils
- posturing: decerebrate or decorticate
The earliest and #1 s/s of changing ICP
LOC change
the 12 cranial nerves
- olfactory
- optic
- oculomotor
- trochlear
- trigeminal
- abducens
- facial
- acoustic
- glossopharyngeal
- vagus
- accessory
- hypoglossal
What CSF reading warrants treatment
> 20 mmHg> need treatment
5-15 mmHg> is normal
nursing interventions to decrease ICP
- HOB elevated 15-30 degree
- routine ICP monitoring
- reduce environmental stimuli
- reduce risks for infection, bleeds, and drainage
What is the criteria for a pt to be diagnosed with epilepsy
a pt MUST have recurrent seizures ( 2 or more in greater than 24hrs)
What is happening (patho)to the brain during a seizure
disrupted electrical communication in the brain neurons, imbalance in excitatory and inhibitory mechanisms, neurons fire when they shouldn’t or do not fire when they should
seizure categories
focal and generalized and unknown
Focal seizures
one hemisphere, majority of case of epilepsy
Generalized seizures
both hemispheres
seizure type> sustained rigidity followed by the jerking of extremities, altered mental status, pallor, eye deviation, incontinence, most common type of seizures
generalized clonic-tonic seizures
seizure type> sustained muscle contractions/ stiffening, awake
tonic seizures
seizure type> legs and arms spasm, jerk, and relax
clonic seizures
seizure type> loss of awareness, less than 10 seconds, blank facial expressions, usually fast and hard to diagnose
Absence seizure
A feeling, subjective, lasting 1-2 minutes, before onset of seizure
Aura
period after seizure last 1-2 hours
postical period
What to document or know about a child’s seizure
- where? when?
- how long it lasted?
- how frequent are they?
- any triggers?
- description and progression of mov’t
- resp effort/ apnea
- changes in color
- posturing changes
- loss of bowel/ bladder control
What labs and diagnostic tests to order for a child w/ epilepsy
- glucose
- urea and creatinine
- anticonvulsant levels
- LP > assess CSF
- eeg
- MRI/ CT
The most common medication for epilepsy
Levetiracetam (Keppra)
What is the first line of treatment for epilepsy?
anticonvulsants
What anticonvulsant do you need to wean off and watch for withdrawal
phenobarbital
Other treatments for epilepsy
- surgery
- ketogenic diet
- vagal nerve stimulator> seizure management
epilepsy nursing interventions
- emphasis on preventing injury during seizures
- seizure precautions and ABCs, stay w/ pt during seizures - administering appropriate meds and treatment to reduce seizures> anticonvulsants (when to take, adherence)
- providing education and support; loosen clothing jewery, what to document, when to call ems, know triggers and prevention methods
T or F prognosis for children w/ epilepsy is typically good
True!
- many children outgrow epilepsy
T or F; anticonvulsant med should NOT be crushed
TRUE!!
What are seizures that last longer than 5 minutes or have more than 1 seizure w/out returning to a normal level of consciousness between
Status epilepticus
- neuro emergency!
- same treatment and interventions as normal seizures
A result of other neurological disorders; neural tube defects, injury, or disease
- increased level of CSF in the ventricles
hydrocephalus
genetic or environmental factors during fetal development> neural tube defects, intrauterine infections causing increased CSF
congenital hydrocephalus
at or after birth, from injury or disease> trauma, neoplasm, infection causing increased CSF
Acquired hydrocephalus
What is the patho of hydrocephalus
imbalance of CSF production and absorption leading to altered intracranial regulation
categories of hydrocephalus
obstructive and nonobstructive
obstructive hydrocephalus
- noncommunicating
- most common form
- CSF flow is blocked W/ IN the ventricels impeding the flow
- tumors, trauma
non obstructive hydrocephalus
- communicating
- bloacked AFTER leaving the ventricles
S/S of hydrocephalus
- big head> macrocephaly
- bulging fontanels
Nursing assessment for hydrocephalus
- health hx; pregnancy/ intrauterine hx/ infections,
- physical assess; size/ symmetry of skull, LOC, motor function, palpate fontanels, personality changes
hydrocephalus labs and tests
- ultrasound during pregnancy
- skull x-ray> suture separation
- MRI/CT scan
- Ventricular catheter placed to allow CSF flow
- most common
- permanent till taken out
Ventriculoperitoneal (VP) Shunt
- drain CSF via gravity and intracerebral pressure, ICP monitoring; usually used in emergency situations
- temporary
External ventricular drainage device (EVD) drainage
alternative to shunt placement for obstructive hydrocephalus; small perforation in the third ventricle for CSF to drain to the subarachnoid space
Endoscopic third ventriculostomy
When does a VP Shunt infection most commonly occur
within 1-2 months of placement
When is the most common time for a child to get a shunt revision?
between 0-2 yrs old
- all dependent on each kid and valves
Hydrocephalus nursing interventions
- maintain cerebral perfusion; monitor neuro status, minimize environmental stimuli, measure head circumference
- minimize neurological complication; monitor shunt infection/ malfunction, monitor neuro status, vs, icp
- maintain adequate nutrtion
- promote growth and development
- ## pt and family education and support
What is the number one cause of morbidity and mortality in children
trauma and injury
T or F the patho of head trauma is solely dependent on the injury
TRUE
- depending on the injury the patho will change
T or F babies are less at risk for head trauma
FALSE
- the are more at risk due to there bigger heads and less awareness in space
- Most common skull fracture, is a break in the skull, generally straight line
- not usually serious… require followup
- can impact the brain if there is tissue damage or bleeding in the skull
Linear skull fracture
- most common head injury
- results in disruption of electrical activity of the brain
- mva, sports accidents, falls
concussion
What sign is most concerning with a head trauma, or any neuro issues?
- fixed and dilated pupils
- sluggish pupils
Skull not compromised and brain not exposed but injury did occur
closed head injury
Skull compromised and brain exposed injury
open head injury
Head injury lab and diagnostics
- x-ray
- CT/MRI
- stabilize spine
Head injury nursing interventions
- stabilize spine and neck
- ABC’s
- pain management
- rest is important, closely monitor
- quiet environment
- preventing further head injuries; helmets, safety and supervision
- nonaccidental head trauma; monitor for inconsistencies, mandatory reporters, risk factors> single parents, external stressors, ect.
What is the leading cause of traumatic death and morbidity in infants
Nonaccidental head trauma
When should you intubate a pt based on the GCS?
<8 intubate!!!
