Week 7 Flashcards
main differences between adults and children - cranium
CHILD
- skull and brain grow rapidly during early childhood = increased risk for brain injury
- top heavy as a child (head large in proportion to body)
- neck muscles not well developed
- thin cranial bones not well developed until 2
main differences between adults and children - cervical spine
- excessive spinal mobility (immature muscles, joint capsule, ligaments, cartilagenous vertebral bodies, incomplete ossification
- greater risk for high cervical spine injury at C1-C2 level OR compression fractures with falls`
3 meninges
- dura mater
- arachnoid membrane
- pia matter
Dura mater - two spaces (2)
- epidural space - between 2 dura mater layers
- subdural space - between dura mater and arachnoid
Arachnoid mater - space
- subarachnoid space - filled with CSF
Pia mater - what
- contains arteries and veins that supply the brain
Cerebral blood flow - 3 characteristics
- auto-regulation
- oxygen
- blood brain barrier
Cerebral blood flow - autoregulation
- intracranial pressure –>
- cerebral arteries change their diameter in response to fluctuating cerebral perfusion
- Cerebral Perfusion Pressure (CPP) = MAP (mean arterial pressure) - Intracranial Pressure
- CPP = MAP - ICP
- IE - increased ICP = blood pressure must increase for perfusion
Cerebral blood flow - oxygen
- needs alteration with temperature (ex fever = needs more oxygen)
- brain sensitive to PaO2 and PaCO2
Cerebral blood flow - blood brain barriers
- at birth, it is indiscriminate = allows passage of protein as well as oxygen and glucose (why meningitis is prevalent in this age group)
Neuro assessment - what (3)
- level of consciousness
- basics + more complex elements
- head circumference
- fontanels
- suture lines in infants
- Pupil size, shape, equality, light
- developmental milestones
- posture/movement
- neck stiffness - meningitis ?
Neuro assessment - level of consciousness
- Glasgow coma scale - Kidz edition
- recognize caregiver?
- irritable, difficult or calm to console
- range is 3-15 (anything below an 8 you lose ability to protect airway effectively )
Neuro assessment - basics
- allertness
- ability to keep up with other children vs tires easliy with feeding or activity
- sleep patterns
- concentration, attention span, hyperactivity, memory or learning problems
Neuro assessment - more complex elements
- seizures
- fainting spells
- dizziness
- numbness
- brain injuries
Neuro assessment - head circumferance (3)
- hydrocephalus?
- fontanels and sutures
- palpation
Neuro assessment - fontanells (4)
- closed?
- flat and soft?
- sunken?
- full and bulging?
Neuro assessment - suture lines in infants
- separated?
- overriding?
Neuro assessment - pupils (4)
- pupillary size
- shape
- equality
- reqctive to light
- PERRL
Neuro assessment - posture and movement
- infant posture and movement = test via primitive reflexes
- observe patient doing spontaneous activity
Neuro assessment - neck stiffness
meningitis ?!!!`
Elevated ICP
- potentially devastating complication of neuro injury
- often complication of traumatic brain injury
- may occur in children with hydrocephaly, brain tumours, infectious hepatic encephalopathy, impaired central nervous system venous outflow (tumours)
Management of elevated ICP
- early recognition and prompt management
- TREAT = reduce ICP, correct original cause
- ex a VP shunt
Pupils - coning
- unequal size and shape of pupils
Pupils - bilateral dilation
- can be from something as simple as a pupil dilator (ophthalmology)
Pupils - bilateral pinpoint
- very sedated/high kids
Pupils - blown
can indicate brain death
Pupil - Unilateral dilated and reactive to light
can in indicate an intracranial mass
Pupil - Unilateral fixed and dilated
impending brainstem herniation
Pupil - Bilateral fixed and dilated
brainstem herniation from ICP
Flexor or Decorticate posturing (what, neuro associations)
- characterized by rigid flexion (arms in, feet in)
- associated with lesions above the brainstem int he corticospinal tracts
- “decorticate = bring towards ‘Cort’’
extensor or decerebrate posturing (what, neuro associations)
- characterized by rigid extension
- associated with lesions of the brainstem
Causes of decreased LOC (10)
- hypoxia
- trauma
- infection
- poisoning
- seizures
- endocrine or metabolic disturbances
- electrolyte or biochemical imbalance
- acid base imbalance
- cerebrovascular pathology
- congenital structural defect
Traumatic head injury (4)
- TBI is the leading cause of death or severe disability in children older than 1 year
- most common cause of traumatic brain injury is fall
- 61% children with moderate to severe TBI experience
- even children without overt neuro deficits resulting from TBI can show impairment in academic performance, attention and concentration, memory, and executive function
Mild TBI
- manifests as a concussion = biomechanically induced alteration of brain function affecting memory and orientation, may involve loss of consciousness
- loss of consciousness sis not required for a diagnosis of concussion
- a GCS of 14-15
- computed tomography cannot be used to diagnose concussion and should generally be avoided to prevent unnecessary radiation exposure (can be used to rule out a more severe TBI)
Traumatic head Injuries - COACHV
- C - cognitive function
- O - oculomotor dysfunction
- A - affective disturbances
- C - cervical spine disorders
- H - headaches
- C - cardiovascular anomaly
- V - vestibular dysfunction
Traumatic head Injuries - cognitive symptoms (3)
- memory impairment
- decreased attention and concentration
- slowed processing speed
Traumatic head Injuries - ocular dysfunction (4)
- convergence insufficiency
- blurred vision
- abnormal saccades/smooth pursuit
- photophobia
Traumatic head Injuries - cervical spine disorders (4)
- neck pain
- headaches
- dizziness
- balance difficulty
Traumatic head Injuries - cardiovascular anomaly (4)
- exercise intolerance
- heart rate variability or elevation
- postural orthostatic tachycardia syndrome
- autonomic dysfunction
Traumatic head Injuries - affective disturbances (6)
- fatigue
- sadness
- irritability’
- sleep disturbances
- poor concentration
- emotionality
*could also indicate depression
Traumatic head Injuries - vestibular dysfunction
- dizziness
- vertigo
- balance difficulties
Post-concussion syndrome - what (2)
- sequela to brain injury with or without loss of consciousness
- typically occurs after mild head injury (may also occur after moderate or severe)
Post-concussion syndrome - what (2)
- sequela to brain injury with or without loss of consciousness
- typically occurs after mild head injury (may also occur after moderate or severe)
Post-concussion syndrome - symptoms
at least 3 of the following (typically develop within days and resolve within 3 months:
- headaches (most common)
- dizziness
- light sensitivity
- fatigue
- nausea
- irritability
- restlessness
- difficulty concentrating memory impairment
Return to play progression: post concussion - stages
- no activity
- nonaerobic activity
- light aerobic activity
- moderate activity
- heavy noncontact activity
- full contact
- competitive activities
Return to play progression: post concussion - no activity
complete physical and cognitive rest for 24-48 hours
Return to play progression: post concussion - nonaerobic activity
normal daily activities that do not provoke symptoms (reintegrate into work and school)
Return to play progression: post concussion - light aerobic activity
- exercise bike, walking, light jogging at slow pace (no weights, jumping, running) (5-10 mins)
Return to play progression: post concussion - moderate activity
- jogging, brief running, moderate intensity stationary bike, light resistance activities (limit body and head movement)
Return to play progression: post concussion - heavy noncontact activity
running, noncontact drills, weight lifting, stationary biking (cognitive activity during exercise can be added)
risk with getting concussion before 8
if a child experiences the first concussion before 8 their is twice the risk of sustaining a second concussion before 18
Moderate and severe TBI - classification
- GCS - moderate - GSC score of 9-13
- GCS - severe - less than 8
- more severe injuries differentiated from mild based on clearer imaging findings
Differences between pediatric brain adult brain in and head trauma (3)
- pediatric brain is more resilient to focal lesions (stroke, surgical excisions) due to plasticity
- the younger a child is when experiencing a severe TBI the longer the take to recover
- the morbidity from TBI seems to be significantly higher in children than adults (due to high water content and incomplete myelination)
Space-occupying traumatic brain injuries (3)
- the most urgent clinical factor associated with TBI
- rapid expansion of space-occupying lesions (ex bleeds, progressing edema)
- post traumatic hydrocephalus is much less common in children than adults and can often be managed conservatively (negative need for decompression or evacuation)
Epidural hemorrhage (what)
bleed between skull and dura mater
subdural hemorrhage (what)
bleed under dura layer
subarachnoid hemorrhage (what)
bleed in subarachnoid space
Epidural hemorrhage - clinical picture (2)
- low velocity falls, child abuse, motor vehicle accidents
- clinical picture = momentary unconsciousness, followed by period of lethargy and coma (cushing triad: hypertension, widening pulse pressure bradycardia, respiratory depression)
Cushing triad
- bradycardia
- irregular respirations
- widened pulse pressure
Subdural hemorrage - clinical picture
- develop slow, spread thinly and widely
- birth trauma, falls, violently shaking infants
- irritability, vomiting, increased head circumferance, bulging anterior fontanelle, lethardy coma seizure
Monro-Kellie doctrine (3)
- cranial cavity is a rigid sphere
- filled to capacity with non compressible contents
- increase int he volume of one of the constituents results in a rise in pressure
Monro-Kellie doctrine - compensation
- may lose venous volume and CSF to compensate
- once you run out of fluid you compress structures = they want a way out = impinge on brainstem = braindeath
Monro-Kellie doctrine - stages (4)
- high compliance = compensation
- decreasing compliance = compensatory reserve gradually depleted
- minimal compliance = increased risk of cerebral ischemia and herniation
- no compliance = collapse of cerebral microvasculature
Monro-Kellie doctrine - progression of ICP
NON-LINEAR - ICP increases rapidly
Measuring ICP - in the ICU
- ICP monitor
- EVD (extra-ventricular drainage device)
Increased intracranial pressure - early warning signs (10)
- change in behaviours
- irritability
- high pitch cry
- headaches
- vomiting
- dizziness
- slight change in LOC
- pupils slightly sluggish
- sunsetting eyes
- bulging fontanel/wide sutures
Increased intracranial pressure - late warning size
- significant decrease in LOC
- change in pupil response (ex fixed and dilated, pailledema
- change in vital signs
Normal CSF pressures in children at time of lumbar puncture
12-28 centimetres of water
- ICP of 20 for greater than 5 minutes with signs and symptoms is threshold of treatment
- sneezing, coughing can cause transient increase, but sustained is abnormal
dont know #
Cushings triad
- change in vitals = hypertension (change in pulse pressure, widening distance between systolic and diastolic pressures()
- bradycardia
- irregular respirations
Nursing care for TBI - acute (7)
- doctor set parameters to slow down body and brain metabolism
- pain control
- sedation
- quiet dark room
- temperature control (decrease)
- HR and BP parameters
- constant neurovitals and monitoring
Nursing care for TBI - chronic (3)
- all of the same for acute plus
- treatment at rehab facility and support from PT/OT/Speech-language
- psych consult for the new normal (HR increases, BP changes, metabolic requirements, cerebral perfusion pressures etc)
Bacterial Meningitis - common population
- seen in infancy, pre school aged
Bacterial Meningitis - symptoms
- prolonged fever
- rash (non-blanchable)
- irritability
- decreased appetite
- neck stiffness
Bacterial Meningitis - common bacteria infants
- group B strep
Bacterial Meningitis - common bacteria other age groups
streptococcus pneumoniae
Bacterial meningitis - prevention
- VACCINATION
- antibiotics (if mom is carrier for strep B)
Bacterial meningitis - testing
lumbar puncture
- identify meningitis + which bacteria
Epilepsy -
seizures
Seizures types (3)
- simple partial vs complex partials
- generalized seizures (bilateral),
- myoclonic, tonic clonic, atonic etc
Seizures types (3)
- simple partial vs complex partials
- generalized seizures (bilateral),
- myoclonic, tonic clonic, atonic etc
Neural tube defects - what
- congenital malformation of the central nervous system and surrounding tissue
- occurs early in embryonic development (completed by day 26)
- often results in miscarage or stillbirth
Neural tube defects - prevention
- folic acid supplementation **
- more common if mothers drink excessively during pregnancy or if the mother is on anticonvulsants for seizure control
Infant mortality risk with spina bifida
10%
spina bifida - common population
hispanic mothers
Types of neural tube defects
- ancencephaly
- encephalocele
- spina bifida (3 types)
Anencephaly
no development of the brain above the brainstem
Encephalocele
protrusion of meningeal tissue or meningngeal-covered brain througha defect in the skull
Spina bifida - types
- occulta
- meningocele
- meningomyelocele
Normal care of infant - considering neural tube defects
- monitor for CSF leakage
- integrety of sac
- assess extremities for deformities
- monitor vitals for s/s of infection (meningitis)
- monitor for wound healing
- measure head circumference daily (monitor hydrocephaly)
Spina bifida - thoracic lesion
thoracic - sensory loss in legs, bowel and bladder incontinence, may stand with braces
Spina bifida - Lumbar L1-L2 lesion
lumbar L1-l2 - may have hip flexion and adduction, can stand with braces, bowel bladder incontinence
Spina bifida - L3 lesion
- hip extension, may be able to extend their knees but nothing below (crutches and braces below)
- bowel and bladder incontinence
Spina bifida - L4-L5 lesion
- flex hips extend knees
- week or absent ankle/toe flexion/extension (need braces)
- bowel and bladder incontinence
Spina bifida - sacral lesion
- mild weakness in ankles and toes
- may walk 2-3 years, may need ankle braces
- bowel and bladder MAY be affected
Microcephaly - what
- small brain with a head circumference greater than 3 standard deviations below the mean for age and sex (below 3rd percentile)
- intellectual disability is common
Microcephaly - cause
- it may be caused by a genetic disorder
- destructive insult during infancy, such as infection, metabolic disorder, hypoxia/ischemia
Cerebral Palsy
- describes a group of permanent disorders of movement and posture development
- causes activity limitation (attributed to non-progressive disturbances that occur in developing fetal or infant brain
- may also have disturbances in sensation, perception, cognition, communication, behaviour
Cerebral Palsy - four types of motor dysfunction
- spastic
- dystonia
- athetosis
- ataxic
- related to location of brain insult
Cerebral Palsy - etiology (4)
- abnormal muscle tone, lack of coordination
- symptoms depend on age, pattern in extremities may very
- (diplegia, hemiplegia, quadriplegia)
- spasticity of muscles inhibits muscle growth
- leads to contracture that limits joint movement, or deformities such as scoliosis or hip displacement
Diplegia
- both legs affected
hemiplegia
one side of the body is involved
(in CP, the arm is usually more severely affected than the leg)
quadraplegia
all four extremities are affected
Cerebral Palsy - diagnostics (6)
- clinical findings (delayed development, increased or decreased muscle tone)
- difficult to diagnose early in life (must be different than other neuro conditions, s/s may be subtle)
- ultrasound of head
- neuromotor tests
- genetic and metabolic tests (if anomalities are present)
- CT and MRI to identify areas + determine cause (once CP is the likely cause)
Spastic cerebral palsy - what (2)
- cerebral cortex or pyramidal tract injury
- 75% of cases
Spastic cerebral palsy - symptoms
- increased muscle tone through a joints ROM
- positive babinski reflex
- exaggerated deep tendon reflexes (clonus)
- persistence of primitive reflexes
- leads to contractures and abnormal curvature of the spine
Dyskinetic Athetosis cerebral palsy - what (2)
- extrapyramidal, basal ganglia injury
- 10-15% of cases
Dyskinetic Athetosis cerebral palsy - symptoms (3)
- slow involuntary writhing motions that interfere with ability to maintain a stable posture
- abnormalities of muscle tone that affect the entire body
- difficulty with fine and purposeful movements or coordinating the timing of movement; tremors
Dyskinetic Dystonia cerebral palsy - what (1)`
basal ganglia, extrapyramidal injury
Dyskinetic Dystonia cerebral palsy - symptoms (3)
- involuntary sustained muscle contractions leading to sustained or intermittent exaggerated and distorted posturing, twisting, repetitive movements
- develops 5-10 years after myelination
- rigid muscles when awake, normal or decreased muscle tone when asleep
Ataxic cerebral palsy - what (2)
- cerebellar (extrapyramidal) injury
- 5%-10% of cases
Ataxic cerebral palsy - symptoms (7)
- irregularity in muscle coordination, tone, balance
- abnormalities of voluntary movement involving balance, position of trunk and limbs, maintaining posture
- difficulty controlling hand and arm movements during reaching (overshoot, past pointing)
- increased or decreased muscle tone
- hypotonia in first couple of years
- muscle instability and wide based unsteady gait
- intellectual disability
Mixed Cerebral palsy (2)
- injuries to multiple areas
- no dominant motor pattern; may have mild spasticity, dystonia and/or athetoid movement
Cerebral palsy - therapy goals (8)
- half of infants suspected to be at risk for CP at age 1 are unimpaired neurologically by age 2
- careful monitoring, early referral
- goal = promote max level of independence and perform ADLs
- referrals for PT, OT, SLP
- prognosis depends on level of physical disability and presence of intellectual, visual, hearing deficits (early intervention)
- some children can ambulate, others need assistance
- swallowing and aspiration can be an issue (feeding is a challenge, may need G tube)
- these children are usually cared for in their homes, some cases receive care in LTC facilities
Cerebral palsy - nursing management
- listen to caregivers
- meds (clonazepam, Baclofen)
- hydration/nutrition (feeds, IV)
- skin - reposition q3Hr (air mattress, CHAIR)
Febrile seizures
- seizures in young ones triggered by fever (either occurs concurrently or fever onset after)
- does not mean epilepsy
- use fever lowering drugs (acetaminophen)
- scares TF out of parents
Epilepsy (3)
- disorder of CNS
- tendency for recurrent and spontaneous seizures
- diagnosed when person experiences two or more seizures where the seizure is not result of a temporary known cause
Seizure (3)
- brief disturbance in the electrical activity of the brain
- excessive and simultaneous firing of action potentials in brain
- manifestation: alter in persons behaviour (depends on location in brain)
Epilepsy - pathophysiology (3)
- fast or long acting activation of excitatory receptors = increased neuronal signalling
- dysfunctional GABA receptors –> less able to inhibit neuronal signals
-RESULT = excess depolarization and hypersynchonization of neurons (seizure threshold exceeded)
Categories of epileptic seizures (3)
- focal/partial
- generalized
- secondary generalized
Types of focal/partial seizures (5)
- simple partial seizure
- complex partial seizure
Types of generalized seizures (5)
- absence seizure
- tonic/clonic seizure
- myoclonic seizure
- tonic seizure
- atonic seizure
Simple partial seizure
- no loss of consciousness, symptoms based on brain location
Partial complex seizure
-` loss of consciousness, symptoms based on brain location
Absence seizure (3)
- loss of consiousness
- staring
- behavioural arrest`
Tonic/clonic seizure (2)
- tonic period (rigid muscles) AND
- clonic period (contracting muscles)
Myoclonic seizure
sudden brief muscle contractions
Tonic seizure (2)
muscle stiffening, loss of consiousness
Atonic seizure
- sudden loss of muscle tone (aka “drop seizures”)
Seizure in parietal lobe (3)
affects touch, taste, temperature
Seizure in occipital lobe (1)
affects vision
Seizure in cerebellum (2)
affects balance, coordination
Seizure in frontal lobe (1)
affects executive functions
Seizure in temporal lobe (3)
affects hearing, memory, language
Seizure in brainstem (3)
affects breathing, HR, BP
Diagnosis of epilepsy (7)
- medical history
- bloodwork
- neuro exam
- EEG (electroencepholagram)
- Brain imagine
- MRI
- seizure descriptions
Diagnosis of epilepsy - age details
- commonly diagnosed in early childhood, or over age 65
- 50-60% of children will outgrow their seizures as an adult
Treatment of epilepsy
- meds (antiepileptic, AEDs)
- medical devices to prevent and control seizures (3)
- dietary therapies (2)
- resective brain surgery
Treatment of epilepsy - medical devices
- vagal nerve stimulator
- responsive neurostimulator
- deep brain stimulator
Treatment of epilepsy - dietary therapy
- low glycemic index treatment
- ketogenic diet
Antiepileptic drugs - mechanism of action (4)
- block sodium channels (phenytoin)
- block VG calcium channels
- glutamate antagonists
- potentiate actions of GABA
Antiepileptic drugs - side effects (4)
- nausea
- dizziness
- sleepiness
- double vision
Nonpharmacological treatments for epilepsy
- surgery
- medical devices
- lifestyle modifications (diet, aerobic exercise, music therapy, acupuncture, herbal remedies, etc)
Nursing interventions during seizure (4)
- recovery position
- prevent injury
- patent airway
- comfort and safety
Bacterial Meningitis - what
- infection of meninges by a bacterial origin
Bacterial meningitis - risk factors (4)
- young age
- group settings
- preexisting medical conditions
- travel
Bacterial meningitis - complications (4)
- seizures
- brain damage
- hearing loss
- death
Bacterial meningitis - symptoms (12)
- fever
- headache
- stiff neck
- non-blanchable rash
- seizures
- nausea
- vomiting
- photophobia
- altered mental status
- irritability
- poor feeding
- bulging fontanel in babies
Assessment/diagnosis for meningitis (7)
- vitals
- neuro assessment
- CBC
- blood cultures
- MRI/CT scan
- CSF tap
- Skin assessment
Treatment for meningitis (4)
- antibiotics
- anticonvulsants
- pain meds
- corticosteroids
Meningitis - inadequate tissue perfusion - assessments (4)
- vitals
- neuro status (signs of high ICP)
- s/s of excess fluid
- measure head circumference
Meningitis - inadequate tissue perfusion - management (6)
- monitor ABGs and O2 saturation
- keep head/neck along midline
- elevate bed to 30 degrees
- administer O2 as needed
- mannitol
- anticonvulsants
Meningitis - health history questions for the mother (9)
- vaccination status
- allergies
- recent infections (UTIs)
- birth/prenatal history
- medical history
- travel history
- previous experience with meningitis
- predisposing risk factors
Pathophysiology of spina bifida
- occurs in utero, evident at birth
- spine does not form or close properly
- presents with or without a herniated sac filled with spinal fluid
- results in neuro defects
Spina bifida oculta
- neural tube defect, but spinal cord and meninges remain int he spinal column
spina bifida cystica
meninges extend out of spinal column
meningocele spina bifida
a sac with spinal fluid protrudes through spinal column
Myelomeningocele spina bifida
a spinal fluid filled sac extends out of the vertebral column, containing the spinal cord
Diagnosis of spina bifida (3)
- ultrasound (can be suspected at second trimester fetal anatomy scan)
- blood tests (can be suspected with elevated maternal serum alpha-fetoprotein [MSAFP])
- if suspected, mother is referred to tertiary care centre for further imaging
Spina bifida - nursing focuses (6)
- mobility
- hydrocephalus
- GI
- GU
- integumentary
- emotional support
SPina bifidaMobility - complications (5)
- alignment, muscle imbalance, sensory, hip problems, scoliosis
Spina bifida mobility - treatment
- braces, walkers, WC, PT, OT, etc.
Spina bifida - growth and development - mobility (3)
- delay in gross motor skills
- increased weight gain and growth in adolescence
- trend of increased WC reliance in adolescence
Nursing role - spina bifida mobility (5)
- promote safety and independence
- functional equipment
- good skin care
- discus para sport (promote physical activity)
- advocate for accessibility
- health teaching
Hydrocephalus - pathophysiology (4)
1) imbalance of CSF absorption/production
2) CSF volume increased in ventricals
3) increased intracranial pressure
4) brain damage
Hydrocephalus - treatment
1) ventriculoperitoneal shunt placement
2) rapid surgical decompression
3) prophylatic antibiotics (prevent shunt infection
Hydrocephalus - nursing role (5)
-vitals
- signs of ICP
- inspect shunt resevoir/tubing for s/s of infection
- neuro assessment, GCS
- measure head circumference
Signs if ICP (5)
- headache
- nausea
- vomiting
- irritability
- decreased LOC
Gastrointestinal health - spina bifida - treatment
- meds (fiber, stool softeners, etc)
- nutrition
- sacra nerve stimulation (prevent incontinence)
- enema (malone aterogade enema)
- diversion colostomy
Gastrointestinal health - spina bifida - nursing role (4)
- daily bowel movements
- good nutrition and med admin
- stoma care education/independence/self esteem/ decrease infection
- emotional support
Genitourinary Health - spina bifida - meds (4)
- anticholinergic meds (kidney function)
- alpha-adrenerguc antagonists (increase urin flow rate)
- antibiotics (treat bladder/kidney inffections)
- botulinum toxin injection (paralize external bladder sphincter to improve continence)
Genitourinary Health - spina bifida - surgical procedures
- stoma in umbilicus (for catheter)
- bladder neck reconstruction
