Peds Test 3: Neurological

Central nervous system

brain and spinal cord, created by the neural tube in utero

Peripheral nervous system

sensory-somatic, autonomic

Cerebrum functions

motor, cognitive, and sensory

Cerebrum divisions

right and left hemispheres; frontal, parietal, temporal, and occipital lobes

When is the nervous system developing?

first 3-4 weeks of gestation

What are maternal components that can cause physical defects and impact CNS development?

infection, trauma, teratogens (toxic exposure to chemicals), malnutrition

Pediatric differences - birth

cranial bones are soft and have not yet fused, brain is highly vascular with immature vessels

Pediatric Differences - child

head is heavy and disproportionately sized

What are 3 things an infant is at high risk for in the first few weeks after birth?

stroke d/t immature and fragile blood vessels (evidenced by seizure); cervical spine injury r/t head control; skull fractures

What age groups can state of consciousness assessed like adult patients?

older children and adolescents

Confusion

impaired decision making

Disorientation

4 factors (A&Ox4)

Obtundation

arouses with verbal stimulation

Stupor

arouses with vigorous painful stimulation

Coma

cannot be aroused

Components of state of consciousness assessment for an infant

muscle tone, reflexes, characteristics of cry, sleep/wake pattern, pupils, fontanels, vital signs

Assessing LOC - infant muscle tone

normal - level of resistance when repositioning. Abnormal - no resistance, hypotonia

Assessing LOC - infant characteristics of cry

abnormal - high pitched, shrill cry

Assessing LOC - infant sleep/wake pattern

typically have a predictable routine

Assessing LOC - infant fontanels

normal - gentle palpation, soft and flat. Abnormal - bulging and tense

Causes of unequal pupils

increased ICP, trauma, brain herniation

Causes of dilated pupils

brain herniation, increased ICP, drug intoxication, hypoxia

Causes of pinpoint pupils

opioid OD, stroke, poisoning

ICP

pressure of CSF in subarachnoid space

Causes of increased brain volume

cerebral swelling r/t trauma, infection, etc.

Causes of increased CSF

r/t hydrocephalus - body might be creating CSF or not able to regulate flow due to underlying condition (blocked circulation, malabsorption)

Causes of increased blood volume in brain

(infant) if BP increases (could be d/t temp, trauma, fever, etc.), brain cannot efficiently restrict and regulate blood flow to those blood vessels

Increased ICP infants S/S

irritability, poor feeding, high-pitched cry, vomiting, spitting up, vitals - decreased RR and HR, increased temp and BP (identify cushing’s triad!), bossing of forehead (protruding), hyperactive reflexes

3 unique s/s of increased ICP in infants

setting sun sign - eyes deviated down, assess for bulging or tense fontanels; cranial suture ridge - spread of cranial bones; distended scalp veins

Increased ICP children S/S

HA, vomiting (w/ or w/o nausea), seizures, diplopia (double vision, may need to explain to kids), irritability, personality changes, balance/gait problems, difficulty remembering, difficulty waking/staying awake

Increased ICP tx for congenital cause

shunt placement

Increased ICP tx for trauma or infection

osmolar agents, sedatives/analgesics, NMBs, stool softeners

Osmolar agents

hypertonic fluids, mannitol

Sedatives and analgesics

control pain and agitation

Neuromuscular Blockaders

vecuronium, pt will need mechanical ventilation

Seizures

malfunction of brain’s electrical system, determined by site of origin

Seizure manifestations

change in LOC, involuntary movements, posturing, changes in perception, behaviors, or sensations

Febrile seizure duration

15-20 seconds

Febrile seizure occurs in temperatures above

101.8

Febrile seizure occurs when

temp is rising, NOT after

When to call 911 in the event of febrile seizure

if gen seizure lasts longer than five minutes

Parent education for febrile seizures

side lying position, head protection, med admin safety

Epilepsy

2 or more unprovoked seizures due to excessive neuronal charges

Major causes of epilepsy

Birth injuries (anoxia), congenital defects to the brain, acute infections in late infancy and early childhood, genetic causes

Seizure classifications

focal or generalized

Focal seizure

abnormal elec activity is coming from part of the brain; hemibody convulsions or stiffening, eye deviation to one side, facial twitching or rhythmic movements only, can rarely retain awareness

Generalized seizure

abnormal elec activity is coming from all of the brain; Involves the whole body, typically causes impaired awareness

Types of generalized seizures include

absence, myoclonic, tonic-clonic, atonic, febrile, status epilepticus

Absence Seizures

Sudden onset, lasts 5 to 10 seconds, can have 100 daily, precipitated by stress, hyperventilation, hypoglycemia, fatigue, differentiated from daydreaming

Absence seizures S/S

Loss of responsiveness but continued ability to maintain posture control and not fall, twitching eyelids, lip smacking, no postictal symptoms

Myoclonic Seizures

Movement disorder (not a seizure); seen as the child awakens or falls asleep; may be precipitated by touch or visual stimuli; focal or generalized; symmetrical or asymmetrical

Myoclonic S/S

No loss of consciousness; sudden, brief, shocklike involuntary contraction of one muscle group

Tonic-Clonic seizures

Violent total body seizure

Tonic-Clonic S/S

Aura, tonic first (20 to 40 seconds), clonic next, postictal symptoms

Atonic seizure

Drop and fall attack, needs to wear protective helmet

Atonic S/S

loss of posture tone

Status Epilepticus

Prolonged or frequent repetition of seizures without return to baseline, may result in anoxia and cardiac and respiratory arrest.

Status epilepticus S/S

Consciousness not regained between seizures; lasts more than 30 minutes

Infantile spasms onset

first 3-7 months

Infantile spasms - prior to seizure

normal development

Infantile spasms - initiation of seizure

arrest of psychomotor development; results in lifelong developmental delay and intellectual disability

Infantile spasms tx

ACTH

Infantile spasms assessment findings

aura (child reports unusual tastes, feelings, odors), eyes deviating to one side or blinking, muscle contractions, irregular breathing with spasms, incontinence, postictal phase (disoriented, drowsy, uncoordinated)

Priority nursing diagnoses for the child experiencing a seizure

1. Ineffective airway clearance 2. Risk for injury 3. Disturbed sensory perception

Convulsive seizure first aid DO

side-lying position, apply O2 and suction if safe, prepare to give abortive seizure meds (be mindful of route)

Promoting patient safety during a seizure

protect the head, seizure pads on bed, loosen tight clothing, reduce external stimuli, stay with child

Nursing documentation for seizures

time the seizure, follow facility guidelines, notify HCP of characteristics

Convulsive seizure first aid AVOID

putting anything in mouth, interrupting seizure, using tongue blades

Nonpharm epilepsy management

vagal nerve stimulator activated by a magnet, brain surgery to remove seizure foci, ketogenic diet (high fat, no carb, normal protein)

Principles of epilepsy med management

monitor therapeutic levels and side effects, weight-based, avoid disrupt discontinuation

How is a medication chosen for epilepsy?

based on type of seizure, age, medication interactions

Daily seizure meds

valproic acid/depakote, phenytoin/dilantin, carbamazepine/tegretol

abortive/emergency seizure meds

rectal diazepam/diastat, intranasal diazepam/valtococ, lorazepam iv/ativan, intranasal midazolam/nayzilam (versed)

Seizure education

Take medication at the same time every day, most require blood monitoring (liver and kidney function, among others), abortive medication for home use is administered for convulsive seizures lasting longer than 3-5 minutes (can cause respiratory depression), safety measures at home

Seizure potential triggers

changes in dark-light patterns, sleep deprivation, skipping seizure medication, hyperventilation, dehydration, elyte imbalances (low na or ca), toxins/drugs/lead poisoning, fever, infection, hypoglycemia

Which type of meningitis is more severe?

bacterial - pt needs immediate IV abx

Which vaccines protect against meningitis?

HIB vaccine and pneumococcal

Most common cause of meningitis

maternal group b strep infection

Meningitis high risk populations

newborns and immunocompromised

Protocol for any fever in an infant under 28 days old

treat as meningitis

Meningitis transmission

droplet infection from nasopharyngeal secretions, organisms spread through CSF

Meningitis diagnostics

CSF analysis and culture via lumbar puncture, blood culture, CBC

What is unique about early meningitis presentation?

vague or subtle symptoms

Meningitis early S/S

HA, poor feeding, fever, irritability/high-pitched cry, diarrhea, Projectile N/V

Meningitis late S/S

poor muscle tone, weak cry, lethargy, petechial or purpuric rash (end sign), seizure. Kernig & brudzinski’s are mid to late signs

Kernig & Brudzinski’s signs

indicative of meningitis, most reliable when performed on pt age 2+. Kernig = pain on extension; Brudzinski’s = passive flexion of neck elicits hip and knee flexion

Lumbar Puncture RN responsibility

positioning child. RN holding infant/child determines success of procedure

Lumbar puncture positions

lateral decubitus or sitting

Lumbar puncture 2 most common indications

active infection requiring CSF or septic workup

Most common lumbar puncture complications

hypoxia (r/t positioning), bloody tap, unsuccessful attempt (only attempt twice at one time, if unsuccessful do not attempt for another 24 hours)

What should the nurse avoid when positioning child for lumbar puncture?

do not flex the neck (instead put hands on back of shoulders and hips), do not take hands off until cleared by physician

Meningitis safety precautions

droplet with private room, seizure precautions

What should be monitored in the plan of care for meningitis?

look for anything that might indicate increased ICP - vitals, UOP (drastic drop could mean low ADH, dilutional hyponatremia, increased cerebral edema, and increased ICP), fluid status, pain level, neuro status

Meningitis tx principles

treat fever, assess fontanels, measure head circumference, maintain NPO if decreased LOC, decrease environmental stimuli, comfort measures

Meningitis meds

abx and corticosteroids

Encephalitis

affects brain and spinal cord tissue

Which type of encephalitis is most frequent?

viral encephalitis

Encephalitis vector reservoir in the US

mosquitos and ticks

Encephalitis presentation

altered mental state - slurred speech, memory and mood issues

Encephalitis medications

antivirals, abx, antipyretics, anticonvulsants, analgesics, antiinflammatories