Peds Neuro - Overview and Structural Defects

What are newborns’ brains more prone to (especially if immature) and why?

intraventricular hemorrhage, due to highly-vascular brain

When is an increased head circumference concerning?

if increased or decreased by 10%

How can you assess an infant’s sensory function?

if they’re pulling away from uncomfortable stimuli (abnormal = not pulling away)

At what point on the GCS scale is a severe head injury expected?

12 or below

At which point on the GCS scale is intracranial pressure monitoring likely required?

6 or below

Early physical signs of increased ICP in babies

• bulging fontanel

• increased head circumference

• dilated scalp veins

• high-pitched cry

Early signs of increased ICP in kids

• altered LOC (irritability, confusion)

• headache w/ vomiting

• blurred vision

• dizziness

Late signs of increased ICP in kids

• seizures

• cushing’s triad

• lowered LOC

• cheyne-stokes respirations

• posturing

• fixed/dilated pupils

What does a safe environment look like for a kid with an increased ICP risk?

lowered bed w/ all four side rails up (not a restraint for kids!) and adult at bedside

Nursing priorities for kids at risk of increased ICP

• maintain body equilibrium

• head + body alignment

• decrease stimulation

• monitor UOP

• prevent coughing, gagging, pain, or anything that will increase ICP

How can you maintain body equilibrium to prevent an increased ICP?

• stable temperature

• treat pain and discomfort quickly

• watch electrolytes, ABGs

How should patients at risk of increased ICP be positioned?

HOB at 30 degrees, w/ neck and head aligned

Can you suction patients at risk of increased ICP?

only when absolutely necessary

Why is it important to monitor UOP in kids with increased ICP?

the increased pressure may affect the pituitary gland, causing SIADH or diabetes insipidus from abnormal ADH release

How is increased ICP treated?

removal of CSF via EVD, mannitol, hypertonic saline, and seizure prophylaxis (e.g. benzos)

Hydrocephalus

imbalance of CSF in the brain, causing increased ICP

Signs of hydrocephalus

• widening sutures (causing a rapid increase in head circumference)

• bulging fontanels

• change in developmental progression

• sunsetting eyes (lower pupils)

• dilated scalp veins

What is a short-term way to decrease ICP in hydrocephalus?

EVD placement

What is a long-term way to monitor/decrease ICP in hydrocephalus?

VP shunt

How does a VP shunt work?

it connects the brain’s ventricles to the peritoneal cavity to allow drainage and absorption of excess CSF

What should a VP shunt incision look like?

clean, dry, and intact

What happens if a VP shunt is not dry and is leaking?

that means that CSF is coming out, causing a huge risk of infection

Which signs of systemic infection should you look for with a VP shunt?

vital changes, poor feeding, and fever

Which signs of localized infection with a VP shunt should you look for?

redness, warmth, and swelling along the track of the shunt (which usually goes behind the ear)

Aside from infection, what is another sign of a VP shunt malfunction?

increased ICP

What happens if a VP shunt malfunctions and ICP starts increasing?

the shunt will be turned into an external shunt (similar to an EVD) until it can be replaced to accommodate the child’s growth

What education should you give parents of a child with hydrocephalus?

no contact sports!

Nursing care for an EVD

• keep device level w/ tragus and popoff level at MD ordered level

• monitor volume and character of CSF

• clamp drain when moving, then unclamp!!

• keep dressing sterile and occlusive

What does normal EVD drainage look like?

clear and straw-colored

Should blood be present in EVD drainage?

no; only blood-tinged within 24-48hrs after initial insertion

When should you notify the neurosurgeon about EVD drainage?

if drainage is cloudy or bloody, or if the drainage significantly increases or decreases

How often should you document the volume and characteristics of EVD drainage?

every hour

Craniosynostosis

premature closure of the skull sutures, causing increased ICP

What could craniosynostosis lead to if untreated?

seizures, cognitive delays, and brain damage

What is the primary sign of craniosynostosis?

decreased head circumference by at least 10%

When is surgery typically done for craniosynostosis?

before 6 months

Surgical options for craniosynostosis

endoscopic surgery → minimally invasive + uses a molding helmet afterward for 3-4 months

open surgery → increased blood loss but doesn’t use a molding helmet afterward

What should you monitor after a craniosynostosis surgery?

• bleeding (H&H)

• increased ICP

• infection

• pain

• watch neuro baseline!!!!

What should you educate patients on regarding craniosynostosis surgical recovery?

severe facial swelling is common post-op but will resolve

Positional plagiocephaly

asymmetry in head shape, often due to laying on the back too frequently

Torticollis

shortening of the neck muscles on one side, causing positional plagiocephaly

How often should a molding helmet be worn for positional plagiocephaly?

23hrs/day for 2-6 months