Neuro - Quiz 2

Describe A&P of the neuro system in children

• First 3 to 4 weeks’ gestation: Infection, trauma, teratogens,

  and malnutrition can cause physical defects and may affect normal CNS development.

• Birth

  • Cranial bones not well developed and not fused: increased risk for fracture

  • Brain is highly vascular: increased risk for hemorrhage

• Child: spinal cord is mobile, high risk for cervical spine injury

What factors are associated with neuro diseases in children?

• Prematurity

• Difficult birth

• Infection during pregnancy

• Falls

• Recent trauma

What are common S&S related to neuro disease in children?

• N/V

• Headaches (frequent or persistent)

• Changes in gait

• Loss of motor function

• Visual disturbances

• Changes in LOC or confusion

• Altered muscle tone

List the common laboratory and diagnostic tests used for neuro conditions

• Lumbar puncture (LP)

• Intracranial pressure (ICP) monitoring

• EEG = records electrical activity in brain to find abnormalities

• Head and neck xray

• Ultrasound

• Fluoroscopy

Describe lumbar puncture

• Withdrawal of CSF for analysis

  • Can measure pressure

• Diagnoses hemorrhages, infections or any obstruction

• Implications:

  • Help position properly and maintain it

  • Monitor respiratory status, LOC, HR, and pain level

  • Keep child flat for 1 hr

Describe a head and neck x ray

• Takes an image of the skull and spine

• Detects fractures and shows info about inc ICP and skull defects

• Implication:

  • Allow parents to accompany to ease child’s worry so they can cooperate and stay still

Describe fluoroscopy

• Continuous x rays showing live up to date images

• Assesses cervical spine for instability during movement

• Implications:

  • Try to get child cooperation

Describe an ultrasound when used for neuro conditions

• Assesses intracranial hemorrhage in newborns and ventricular size

• Better tolerated by children compared to CT or MRI

List the medications used to treat neuro conditions

• Antibiotics

• Anticonvulsants

• Benzodiazepines

• Analgesics

• Osmotic diuretics

• Corticosteroids

Describe antibiotics and nursing implications

• Actions:

  • Treats bacterial meningitis and shunt infections

  • Kills and prevents bacterial growth

• Implications:

  • Check for allergies

  • Monitor serum levels for therapeutic levels

  • Follow prescription

Describe anticonvulsants and nursing implications

• Action:

  • Dec nerve hyperexcitability

  • Treats and prevents seizures

• Implications:

  • Seizure precautions and activity

  • Monitor drug interactions and adverse effects

  • Stopping abruptly = precipitate seizures or status epilepticus

Describe benzodiazepines and nursing implications

• Minor sedative that prevent/stops seizures

• Treats status epilepticus

• Implications:

  • Diazepam = educate family how to administer rectal form to stop prolonged seizures

  • Monitor sedation level and cessation of seizure activity

Describe analgesics and nursing implications

• Block pain impulse

• Helps avoid inc ICP

• Implications:

  • Monitor for pain improvement, sedation, neuro status and resp status w/ narcotics

Describe osmotic diuretics and nursing implications

• Inc plasma osmolarity = reduces ICP

• Implications:

  • Monitor electrolytes, I&O, VS and s/s of inc ICP

Describe corticosteroids and nursing implications

• Suppresses inflammation and normal immune response

• Reduces cerebral edema

• Implication:

  • Give oral doses w/ food

  • Dosage must be tapered before d/c

What are other treatments for neuro conditions?

• Ventricular shunt placement

• Hyperventilation

• Physical, occupational, or speech therapies (PT/OT/ST)

• External ventricular drainage (EVD)

• Ventricular tap

• Vagal nerve stimulator

• Ketogenic diet (high fat, low carb)

Describe ventricular shunt placement

• Drains excess CSF from the brain into another part of the body to relieve pressure and improve brain function

• Use: for hydrocephalus, increased ICP

• Implications:

  • Monitor for s/s of inc ICP

  • Monitor neuro status, LOC, VS, infection

Describe hyperventilation when used for neuro conditions

• Hyperventilation inc RR & pH to calm pt

  • Deceases PaCO2 = vasoconstriction to decrease ICP

• Use: for inc ICP

• Implication:

  • Monitor ABGs, s/s of inc ICP, pulse ox

Describe an external ventricular drainage

• Temp catheter to drain CSF from the ventricles = typically used in surgery

• Use: for shunt infections, treats acute hydrocephalus, meningitis

• Implication:

  • Monitor for s/s of inc ICP, LOC, level of collection container when drain is unclamped

Describe a ventricular tap

• Drains CSF and dec ICP

• Use: for inc ICP

• Implication:

  • Monitor LOC and neuro status

Describe vagal nerve stimulator

• Provides stimulation to the vagal nerve

• Use: for short/long term seizure management in children 12+

• Implication:

  • Monitor for s/s of infection and seizure activity

Describe a ketogenic diet

• High fat, low carb

• Use: prevents, controls, and reduces seizures

• Implications:

  • Monitor I&O’s, seizure activities, growth and nutritional status

What are prenatal risk factors for neuro conditions?

• Prematurity

• Maternal drug or alcohol use during pregnancy

• Maternal infection during pregnancy

• Maternal ingestion of teratogens

• Fetal malnutrition in utero

What are the common types of seizures?

• Infantile spasms

• Absence

• Tonic–clonic

• Myoclonic

• Atonic

• Simple partial

• Complex partial

• Status epilepticus

Describe infantile spasms

• Occurs btw 3-12 months

  • Peaks at 3-7 months

• Arms and legs flail up in clusters or head nods repeatedly

Describe absence seizures

• Causes you to blank out or stare into space for a few seconds

• May go unrecognized or mistaken for inattentiveness due to subtle change

Describe tonic clonic seizures

• Involves a loss of consciousness and violent muscle contractions = two phases in total

• Causes cyanosis due to apnea, saliva pools due to inability to swallow, tongue biting

Describe myoclonic seizures

• Brief, involuntary muscle jerks that can affect any part of the body

Describe atonic seizures

• Sudden and brief loss of muscle tone, causing person to fall or slump forward

• Can result in injury related to fall

Describe simple partial seizures

Affects a specific area of the brain without causing LOC = pt can rmr event

Describe complex partial seizures

Causes a loss of awareness or consciousness

Describe status epilepticus

• A life-threatening medical emergency characterized by prolonged or recurrent seizures that do not stop on their own

  • Longer than 5 mins or multiple seizures without regaining consciousness btw them

• Treatment:

  • ABCs, anticonvulsants, check BG levels and electrolytes

List the common types of structural defects

• Neural tube defects

• Microcephaly (abnormally small head)

• Arnold–Chiari malformation

• Hydrocephalus

• Intracranial arteriovenous malformation

• Craniosynostosis

Describe neural tube defects

• Affect the brain and spinal cord, causes defects = spina bifida

• An opening in the spine remains open and does not close like it should

Describe microcephaly

• Abnormally small head = more than 3 standard deviations below mean for age and sex of infant

• Results in intellectual disability due to lack of functioning brain tissue

Describe Arnold–Chiari malformation

• Where the lower part of the brain pushes down into the spinal canal

• Associated w/ hydrocephalus and myelomeningocele (severe form of spina bifida = part of spinal cord and nerves are contained in a sac which is visible in the back)

Describe hydrocephalus

• Extra CSF in the ventricles of the brain

  • Caused by an imbalance in the production and absorption of CSF

• May see signs of ICP including increase in head size and loss of developmental milestones or changes in personality in older children

• May require surgical intervention to relieve pressure with a ventricular shunt (temporary or permanent)

Describe intracranial arteriovenous malformation

• Occurs when arteries in the brain connect directly to nearby veins without having the normal small vessels (capillaries) between them

• Increased risk of hemorrhage

Describe craniosynostosis

• Where the bones of the skull fuse together prematurely, before the brain has finished growing = neuro complications

What are the different types of infectious disorders of the neuro system?

• Bacterial meningitis

• Aseptic meningitis (viral)

• Encephalitis

• Reye syndrome (rare)

Describe bacterial meningitis

• Inflammation of the membranes (meninges) that cover the brain and spinal cord, caused by a bacterial infection

Describe aseptic meningitis

• Inflammation of the membranes (meninges) that cover the brain and spinal cord, without the presence of bacteria or other identifiable infectious organisms

  • Usually viral

Describe encephalitis

• Inflammation of the brain, can be due to bacterial or viral infection

• Can be mild to life threatening

Describe Reye syndrome (rare)

Serious condition that causes brain swelling, liver failure, and death in a few hrs if not treated

Describe intracranial pressure (ICP)

• CNS has a dynamic balance of fluid (called CSF) that bathes the brain and spinal cord at a specific pressure called intracranial pressure (ICP)

• Elevated ICP is a sign of a neurologic disorder

• Possible causes: head trauma, birth trauma, hydrocephalus, infection, brain tumors

Describe Cushing’s Triad

• Signs that indicate increased ICP

• Three classic signs:

  • HTN, Bradycardia, and Irregular respirations = typically decreased, bradypnea

• Medical emergency = if left untreated can result in brain herniation and death

What are early signs of increased ICP?

• Change in LOC (drowsy, irritable, confused)

• Headache (worse in the morning)

• Projectile vomiting without nausea

• Blurred vision

• Sunset eyes (eyes deviate downward)

What are late signs of increased ICP?

• Cushing’s Triad

• Fixed, dilated pupils (no response to light)

• Decerebrate posturing (severe brainstem damage)

• Decreased response to pain

What are the S&S of a shunt infection?

• Elevated vital signs

• Poor feeding

• Vomiting

• Decreased responsiveness

• Seizure activity

• Signs of local inflammation along the shunt tract

What are the common causes of head trauma in children?

• Falls

• Motor vehicle accidents

• Sport injuries

• Pedestrian and bicycle accidents

• Child abuse

What are causes of nonaccidental head trauma?

• Violent shaking: shaken baby syndrome (SBS)

• Blows to the head

• Intentional cranial impacts against the wall, furniture, or the floor

Describe acute stroke in children

• Ischemic or hemorrhagic types

• Risk factors in children are different than in adults

• Same S&S

  • Weakness on one side or hemiplegia

  • Facial droop

  • Slurred speech

  • Speech deficits

What do we observe in a child with a neuro condition?

• LOC

• VS

• Head, face, and neck

• Cranial nerve function

  • Motor and sensory function

• Reflexes

• Increased ICP

How do you manage disturbed sensory perception?

• Assess for any changes

• Monitor child for risk of injury due to changes in sensory perception

• Notify MD or NP

• Assist child to learn adaptive methods to live with permanent changes (ex: use of eyeglasses) and maximize use of intact senses

• Provide familiar sounds (voices, music)

Describe the eye opening portion of the pediatric glascow coma scale (GCS)

• Eyes open:

  • Spontaneously = 4

  • To speech = 3

  • To pain = 2

  • None = 1

Describe the motor response portion of the peds GCS

• Obeys commands = 6

• Localizes pain = 5

• Flexion withdrawal = 4

• Flexion abnormal = 3

• Extension = 2

• None = 1

Describe the response to auditory or verbal stimulus portion of the peds GCS

• < 2 years

  • Smiles, listens, follows = 5

  • Cries, consolable = 4

  • Inappropriate, persistent cry = 3

  • Agitated, restless = 2

  • None = 1

  • Tracheal tube = T

• >2 years

  • Oriented = 5

  • Confused = 4

  • Inappropriate words = 3

  • Incomprehensible words = 2

  • None = 1

  • Tracheal tube = T

Describe the five states of consciousness

• Full consciousness: a&o x4, and exhibits age-appropriate behaviors

• Confusion: disorientation exists; alert but responds inappropriately to questions

• Obtunded: limited responses to the environment and falls asleep unless stimulation is provided

• Stupor: only responds to vigorous stimulation

• Coma: cannot be aroused, even with painful stimuli

What are closed head injuries?

• Nonpenetrating injury to the brain but skull is hit hard

• Can happen with an accident or intentional injury

How do we promote child and family teaching?

• Assess child’s and family’s willingness to learn

• Provide family with time to adjust to diagnosis

• Repeat information

• Teach in short sessions

• Gear teaching to a level of understanding for the child and family

• Provide reinforcement and rewards

• Use multiple modes of learning involving many senses