The Child with Neurologic Concerns

What is the fluid that fills the ventricles and canals of the brain and spinal cord?

cerebral spinal fluid

What is the function of the cerebral spinal fluid?

bathing the external surface, protect the brain form hitting the cranium, rinse metabolic waste from the nervous tissues, and regulate the chemical environment

What happens as the intracranial pressures increases?

LOC deteriorates

What assessments are needed to assess ICP?

LOC, pupillary reaction, vital signs

What are the manifestations of increased ICP in infants?

irritability, poor feeding, high pitched cry, difficult to soothe, tense and bulging fontanels, separated cranial sutures, sun setting eyes, distended scalp veins

What are s/s of increased ICP in children?

HA, projectile vomiting, drowsiness, lethargy, diminished physical activity, inability to follow simple commands

What is sunsetting sign?

eyes bulging and deviated down

What are late signs of increasing ICP?

bradycardia, decreased motor response to command, decreased sensory response to painful stimuli, alterations in pupil size and reactivity, extension, posturing, decreased LOC, coma

What is an abnormal build of CSF in the cavities, or ventricles deep within the brain over a long period of time?

hydrocephalus

What must be enlarged for increased ICP to cause hydrocephalus?

ventricles

What condition is when extra CSF is over the spinal cord?

myelomeningocele

What is the surgical treatment for hydrocephalus?

ventriculoperitoneal shunt

What is the earliest indicator of changes in neurological status?

Level of consciousness

What are the components of level of consciousness?

motor activity, reflexes, and vital signs

What level of consciousness is when the patient is awake and alert?

full consciousness

What level of consciousness is when the patient has impaired decision making?

confusion

What level of consciousness is when the patient doesn’t know time and place?

disorientation

What level of consciousness is when the patient has sluggish speech?

lethargy

What level of consciousness is when the patient only arouses with stimulation?

obtundation

What level of consciousness is when the patient only responds to repeated and vigorous stimulation?

stupor

What level of consciousness is when the patient has no motor or verbal response to noxious stimuli?

coma

What level of consciousness is when the patient has permanent loss of function of cerebral cortex?

persistent vegetative state

What are the components for GCS?

eye, verbal, and motor response

What does brain death require?

complete cessation of brain function and irreversibility of condition

What are the components of neuro exam?

VS, skin, eyes, motor fx, posturing, reflexes

What are the diagnostic test used for increased ICP?

lab tests, EEG, lumbar puncture, assessment of evoked potentials, imagining

What is the emergency management of unconscious children?

airway, reduction of ICP, treatment of shock

What is the respiratory management of a comatose child?

airway management

Cerebral hypoxia lasting longer than what many cause irreversible brain damage?

4 minutes

What does CO2 retention cause?

vasodilation, increased cerebral blood flow, increased ICP

What reflexes may be minimal in a comatose child?

gag and cough

What are some indications a patient may need ICP monitoring?

GCS less than 8, abnormal CT post traumatic event, deterioating neuro condition

What are the nursing activities for increased ICP?

avoid neck vein compression, provide alternating pressure mattress, elevated HOB 30 degrees, avoid increasing ICP activities, eliminate environmental noise

What nutrition and hydration is needed for increased ICP?

IV admin of fluids and parental nutrition, g/ng feedings

What care management is needed for increased ICP?

thermoregulation, elimination, hygienic care, positioning and exercise, stimulation, regain consciousness, and family support

What is a drain that is placed in the ventricles of the brain and descends down towards the ear and then into the abdomen to drain fluid?

VP shunt

What are s.s of VP shunt maldunction?

buldging fontanel, poor feeding, irritablity, HA, v/, increased sleepiness, swelling on shunt track, chnages in balance/coordination, eyes deviated down, subtle changes in behavior

What period is the risk for shunt infection greatest?

1-2 months after placement

What is the treatment for shunt infection?

ATBs or removal

What are the 3 major causes of brain damages in childhood?

falls, being struck by or striking an object, MVA

How do you prevent head injury in childhood?

safety gates/fall prevention, seat belt use, helmet use

What is the pathophysiology of head injury?

force of intracranial contents that cannot be absorbed by the skull and musculoligamentous support of the head

Why is a child response to a head injury different to adults response?

larger head to body relationship

What are injuries occur at the same time as physical trauma?

skull fractures, contusions, intracranial hematoma, diffuse injury

What are the complications of head injuries?

hypoxic brain injury, increased ICP, cerebral edema

What is an alteration in neurolgic or cognitive function w or w/o loss of conciousness?

concussion

What a concussion usually followed by?

amnesia and confusion

What head injury has visible bruising?

contusion

What head injury is the tearing of tissue?

laceration

What head injury is bruising at the point of impact?

coup

What head injury is bruising at a site far removed from the point of impact?

countercoup

Why are children at lower risk for skull fracture?

flexibility

What are the possible complications of head trauma?

epidural hemorrhage, subdural hemorrhage and cerebral edema

What are the components needed for the diagnostic evaluation of head trauma?

detailed hx, assessment of airway, breathing and circulation, evaluation for shock, neuro exam, LOC assessment, assessment of VS

What is inflammation of the meninges of the brain cause by bacterial or viral infection that moves into the cerebral spinal fluid?

meningitis

What type of meningitis is more severe?

bacterial

What may meningitis cause first?

sinus infection

What is available to prevent meningitis?

vaccines

What are the s/s of meningitis in infants?

irritability, fever, sleeping more than usual, poor feeding, crying that can’t be soothed, high pitch cry, seizures, vomiting positive Kernig and Brudzinski signs

What are the s/s of meningitis in children older than one?

neck and back pain, HA

What is needed to diagnose meningitis?

lumbar puncture, CT

What is a seterile procedure that is done either in IR or on the floor where you you pull CSF out from the spinal cord than send to lab count cells, cell types and be cultured ?

What is the nursing care required during a spinal tap?

maintain pt positioning

What is the nursing care required after a spinal tap?

maintain occlusive dressing, lay pt flat on back for at least one hour, and neuro checks and check ability of pt to void

What is the treatment for meningitis?

antivirals, ATBs, dexamethasone

What is the inflammation and swelling of the brain?

encephalitis

What are the causes of encephalitis?

viral (animal to human), lyme disease (tick bite), rabies, autoimmune - NMDA

What are the s/s of encephalitis?

fever, seizures, change in behavior, confusion, disorientation, problems with speech or hearing, double vision, hallucinations, personality changes, loss of sensation in part of body, muscle weakness, impaired judgement

What is the treatment for encephalitis?

antivirals, immunosuppressant drugs - steroids, IVIG, antibodies

What is a disorder defined as toxic encaphalopathy associated with other characteristic organ involvements?

reye’s syndrome

What are s/s of reye’s syndrome?

fever, impaired consciousness, and disordered hepatic fx

What is the treatments for Reyes Syndrome?

early diagnosis and aggressive therapy

What is a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change in a person’s movement, behavior, level of awareness, and or feelings?

seizure

What is a spectrum disorder where you have surges of electrical activity in your brain can cause recurring seizures?

epilepsy

What are the risk factors for epilepsy?

genetic causes, head injury, infections of the brain and coverings, lack of oxygen to the brain, hydrocephalus, disorders of brain development

What are seizures that affect both sides of the brain or groups of cells on both sides of the brain at the same time?

generalized seizures

What are seizures that can start in one of area or group of cells in one side of the brain?

focal seizures

What are spasms in infants that start around 6-8 months of age that consist of sudden stiffening only lasting a second or two and is a neurological emergency?

infantile spasms

What do infantile spasms look like?

jackknife seizures or crunch

What types of seizures is generalzied by abrupt onset between 4-12 years of age where a person suddenly stops all activity without warning where they may stare off into space or just have a blank look?

absence seizure

What seizure involves a momentary loss of consciousness where one of all of the body may before limp, eyelids may droop, the head may nod or drop forward and the person may drop things?

atonic seizure

What type of seizure has 2 phases where the first stage last about 10-20 seconds where all the muscles stiffen and there is a loss of consciousness, the second phase lasts about 30 seconds when the arms and legs begin to jerk rapidly, during this time the face may look dusky or a bit blue and the person may loose control of their bladder?

tonic-clonic seizure

What type of seizure is triggered by a fever above 101 degrees and does not indicate that a child may have epilepsy?

febrile seizure

What type of febrile seizure lasts less than 15 minutes?

simple febrile seizure

What type of febrile seizure last longer than 15 minutes and occurs more than once in a 24 hour period?

complex febrile seizure

What are the risk factors for a febrile seizure?

children between the ages of 6 months and 5 years,

When should pts with seizures take their ASM?

same time each day

When can pts be weaned off their ASM?

when they are seizure free for 2 years

What diet could be used to prevent seizures?

ketogenic diet

What are 2 other treatments for seizures other than meds and diet changes?

surgery and neuromodulation devices

What is a condition when a seizure lasts too long or when seizures occur close together and the person doesn’t recover between each seizure?

status epileptics

Seizures longer than 30 minutes are dangerous why?

increase risk of brain injury and death

What seizure rescue med is considered for older kids, teens?

intranasal - midazolam

What seizure rescue med is easiest to use in todderl/infants?

rectal - diazepam

What seizure rescue med is used if atomizer or nasal spray device is unavailable?

buccal - midazolam