neuro

what is microcephaly

abnormally small head with resultant cognitive impairments, from mild to severe

what is the primary cause of microcephaly

genetic, chromosomal, or hereditary problems

what is the secondary cause of microcephaly

exposure to radiation, maternal infection (TORCH), maternal alcohol or tobacco, zika virus

what are clinical presentations with microcephaly

global delays in cognitive and motor development

how is microcephaly diagnosed

MRI of brain; may be detected upon fetal ultrasound

is there a cure for microcephaly

no, nursing care is supportive

early intervention services

what is hydrocephalus

when CSF collects in the brain causing an enlargement in the ventricles thereby causing harmful pressure on the other fragile brain tissues

what can cause hydrocephalus

brain tumors, head injury, bleeding, infection, arnold chiari malformations

symptoms of hydrocephalus

rapid increase in head circumference

dilated scalp vein and/or separation of cranial sutures

sun setting eyes

abnormal pupillary responses

difficulty holding head upright

bulging fontanel

vomiting, poor feeding

lethargy, irritability

headaches in AM

what are some symptoms of shunt malfunction in hydrocephalus

leaking CSF at the head along the shunt area

halo sign on linens (blood tinged spot encircled by lighter ring = CSF leakage)

diagnosis of hydrocephalus

MRI of brain

cisternogram (study of CSF flow dynamics)

what is cisternogram

study of CSF flow dynamics

what is the treatment for hydrocephalus

surgical ventriculostomy with placement of ventriculoperitoneal (VP) shunt

what is preop care for hydrocephalus

frequent position changes of the head, IV antibiotics, diuretics, baseline HC, baseline abd circumference

post op care of hydrocephalus

immediate - lay flat, do not elevate higher than 30 degrees to prevent rapid ventricular decompression

position on non ope side, frequent changes

close neuro assessment and incision checks

daily HC and abd circumference (girth and BS)

monitor for changes in fontanel or change in behavior

complications: paralytic ileus, peritonitis, infection, shunt malfunction

what are some post op complications for hydrocephalus

paralytic ileus, peritonitis, infection, shunt malfunction

why should you not elevate HOB for immediate post op for hydrocephalus

rapid ventricular decompression can occur

what is meningitis

infection affecting the meninges of the brain and spinal cord

medical emergency and is life threatening

how is meningitis classified

septic (bacterial) and aseptic (viral)

how is meningitis spread

close contact with respiratory secretions

what are the symptoms of meningitis

severe headache, stiff neck (nuchal), sudden high fever, photosensitivity, nausea, purpuric rash

is septic or aseptic meningitis less severe and self limiting

aseptic (viral)

what will the nurse see on assessment of a child greater than 2

kernig’s and brudzinski’s signs

may also see a petechiae or purpuric rach

what will the nurse see on assessment of a child less than 2

will usually present with fever, seizures, high pitched cry, irritability, sleepiness, bulging fontanels (infants), poor feeding, and vomiting

how do you diagnose meningitis

CBC and lumbar puncture

what is the nursing care for meningitis

administer antibiotics (only for septic), supportive care, seizure precautions, close monitoring to recognize subtle changes or complications of increased ICP, infection control measures (droplet)

what is important during lumbar puncture

positioning (lateral recumbent, prone, or sitting upright)and maintaining sterile field

what is the post op nursing care for lumbar puncture

pressure to puncture site, place pt flat on bed for 4-6 hours, monitor VS, neuro status, I&Os, monitor puncture site for signs of CSF leakage and blood

how is encephalitis different from meningitis

it is also characterized by an infection surrounding the meninges but with subsequent cerebral edema

what is encephalitis associated with

mosquito born viruses or herpes virus

systemic illnesses such as polio, mono, and rabies

what is the clinical presentation of encephalitis

lethargy, nuchal rigidity, photophobia, and behavioral changes that rapidly progress to a decreased level of consciousness, flaccid paralysis, and seizure activity

what are the diagnostic tests for encephalitis

lab work, LP, head MRI

how to prevent encephalitis

routine vaccinations, mosquito mitigation

what is the nursing care for encephalitis

aimed at cause with antivirals, antipyretics, antiinflammatories, and antiepileptics, seizure precautions, close neuro monitoring, and fluid and electrolyte monitoring

what are the long term deficits of encephalitis

cognitive, neurological, and physical

is encephalitis viral or bacterial

often viral

presents as an acute febrile illness that may progress within hours

what is reye’s syndrome

serious illness defined by rapid progression, subsequent multiorgan failure with a poor outcome

when does reye’s syndrome occur

when aspirin is administered to a child during a viral illness which leads to cascade of events resulting in acute noninflammatory encephalitis and fatty degenerative liver failure

how many stages of reye’s syndrome are there

0-6 with rapid progression

what happens in stage 4 of reye’s syndrme

deep coma

how do you diagnose reye’s syndrome

liver biopsy, LP, lab tests

what is the treatment of reye’s syndrome

collaborative in a PICU, bleeding and seizure precautions, steroids to decrease cerebral edema, diuretics to decrease ICP, electrolytes to correct imbalances

how to prevent reye’s syndrome

avoid aspirin in children

why is prevention of reye’s so important

by the time the child has sx, the body has already been severely compromised

what is epilepsy

condition in which seizures are recurrent and unprovoked

what are focal seizures

abnormal electrical activity is one hemisphere (partial)

simple focal seizures

unlikely to lose consciousness, may smell or taste something strange and may see flashes of light, may hear a buzzing sound, feel tingling or feel anxious or dizzy

complex focal seizures

begins as a simple focal and may include lip smacking, gagging, or rhythmic movements or inappropriate mannerisms

there is impairment of consciousness

generalized seizures

abnormal electricity in both hemispheres

may manifest as loss of consciousness and may present with motor or nonmotor activity and have a postictal state afterward

what should parents do for seizure lasting >2 mins with loss of awareness

administer rectal diazepam or intranasal midazolam at home

what may lengthy seizures require

resp support and IV meds

absense seizure

(generalized)

loss of consciousness with vacant stare or unresponsiveness; may have lip mvmts, chewing, fluttering, eyelids

often misdiagnosed as ADHD or day dreamer

myoclonic seizure

(generalized)

sudden forceful contractions of single or multiple groups of muscles

can be brief and may be mistaken for tics, tremors, or clumsiness

tonic-clonic seizures

(generalized)

combo of body stiffening (tonic) and clonic rhythmic activity with loss of consciousness

as child begins to relax, may lose control over bowel/bladder

atonic

(generalized)

loss of muscle tone, person suddenly drops. Known as drop attacks - complete loss of tone as muscles become limp, child falls. Brief attacks. Protective headgear recommended

common seizure triggers

sleep deprivation, drugs and alcohol, increased stress, not eating well, flashing bright lights or patterns, illness or fever, changes in hormones (menstrual cycle)

status epliepticus

brain in state of constant seizure

children who experience this in early life are at risk for hippocampal and temporal lobe sclerosis

lasts 5 mins or longer or is recurrent seizures without regaining consciousness between seizures for >5 minutes

medical emercency

febrile seizures

convulsions triggered by rise in body temp >101.2

common in children 6 months to 3 years

lasts a few mins

have not been found to cause brain damage

nursing interventions for seizure

turn on their side

protect head from injury

do not put anything in the mouth

do not restrain

loosen clothing around the neck

\

what are the commonly prescribed meds for seizures

phenytoin, carbamazepine, valproic acid, fosphenytion, topiramate, gabapentin, and ethosuximide

education for seizure meds

take at the same time every day; labs are often required at frequent intervals, do not stop abruptly

what is valproic acid for

used for both focal and tonic clonic seizures

there are loading doses and maintenance doses

this requires serum drug monitoring

\

what is dilantin for

focal and tonic clonic

requires serum drug monitoring

what are the adverse effects of valproic acid

confusion, nystagmus, nausea, bleeding, gingival hyperplasia

what are the adverse effects of dilantin (phenytoin)

dizziness, drowsiness, uncoordinated movements, gingival hyperplasia

what is phenobarbital for

focal and tonic clonic seizures

loading and maintenance doses

requires serum drug monitoring

what are adverse effects of phenobarbital

hyperactivity, inattentiveness, dizziness, fever, rash, slurred speech

what are examples of primary TBI

skull fracture

bleeding

concussion

contusion

what are examples of secondary TBI

tissue ischemia and hypoxia

cerebral edema

increased ICP

early signs of TBI

photophobia, n/v, headaches, vertigo, shrill or high pitched cry, irritability, lethargy, difficult to wake up, poor feeding (infant), amnesia/confusion, altered LOC, leakage of CSF from ears nose, changes in behavior

late signs of TBI

increased ICP, increased head size in kids

what are symptoms of epirual hematoma

(bleeding between the dura and skull)

short period of unconsciousness followed by normal period for several hours, then lethargy or coma due to accumulation of blood

what are symptoms of subdural hemorrhage

(bleeding between dura and arachnoid membrane)

irritability, vomiting, increased head circumference, lethargy, seizures, coma

what can subdural hemorrhage be from

birth injuries, falls, or violent shaking

what are symptoms of brain herniation

(downward shift of brain tissue)

loss of blinking, loss of gag reflex, lack of PERRLA, systemic HTN, bradycardia, coam, respiratory arrest

what is decorticate positioning

upper limbs flex and lower limbs extend - less severe and indicates damage to one or both corticospinal tracts

what is decerebrate positioning

upper and lower limbs extend - damage to the upper portion of the brainstem and has a poor outcome

what is cerebral palsy

results from developing brain either failing to form correctly or receiving some type of injury causing permanent damage to the brain with an inability to control one’s muscles and movements

what are risk factors for cerebral pulsy

low birth weight, premature, multiple births, use of infertility procedures, maternal infections of thyroid/seizure disorder, jaundice or kernicterus, birth complications

causes of cerebral palsy

acquired within first 28 days of life, meningitis, head trauma, sickle cell disease, stroke, AV malformation, bleeding disorder

what are the four type of cerebral palsy

spastic, dyskinetic, ataxic, mixed

spastic CP

most common

stiff, rigid, muscles, difficult to move

increased muscle tone makes performing smooth, coordinated movements difficult

presentation of spastic CP

developmental delay, gross and/or fine motor delay, increased/decreased muscle tone

feeding difficulties with potential FTT due to gagging, choking, tongue thrust, chewing, and swallowing difficulties

predisposed to seizures or cognitive delay - often phsyically but not intellectually disabled

interventions for spastic CP

OT, PT, speech therapist

meds for CP

baclofen, diazepam, botulinum toxin A

baclofen

for CP, skseltal muscles relaxant to decrease muscle spasm and severe spasticity

diazepam

for CP, skeletal muscle relaxant, often used in older children and adolescents - monitor for drowsiness and fatigue

botulinum toxin A

for CP, reduces spasticity in specific muscle groups; lasts 3-6 months

neural tube defects

two most common are spina bifida and anencephaly

spina bifida cystica (myelomeningocele)

section of the spinal cord and nerves are exposed and visible on the outside of the body

causes partial or complete paralysis below the spinal opening

spina bifida occulta

section of the spinal vertebrae is malformed but the cord and nerves are normal

no visible defect but usually dimpling, hair tufts, or a hemangioma in the lumbar sacral area

found incidentally and does not result in physical deficits

spina bifida

may have paralysis of the legs or may have flaccid muscles with sensory loss. Problems with bowel and bladder control are also common

preop nursing care for spina bifida cystica

protect sac from injury

place infant in radiant warmer without clothing

apply a sterile, non adherent dressing with NS on the cyst, rewetting as needed to prevent drying

inspect cyst closely for signs of leakage

assess for signs of infection

avoid rectal temps

avoid putting pressure on the sac

post op nursing care for spina bifida cystica

monitor VS, weight, I&Os, head circumference

assess for s/sx of infection

pain management

assess for leakage of CSF

maintain prone position until other positions are rxd

resume oral feedings

provide ROM to extremities

assess fontanels for bulging

education on post op care

what is muscular dystrophy

progressive muscle weakness due to muscle fiber degeneration and muscle wasting

duchene muscular dystrophy (DMD)

x linked, affect only males

genetic defect affects the protein dystrophin - this normally provides muscles the ability to be strong and stable over time

clinical presentation of DMD

generalized muscle weakness first noticed in the proximal muscles of the arms and legs

overly clumsy, difficulty climbing stairs

calf muscle hypertrophy, toe walk

inability to keep up with peers in age appropriate activities

gower sign

as disease progresses, loss of ambulation and impairment in respiratory and cardiac function

what are the labs for DMD

elevated creatinine kinase

what is gower sign

sitting on floor to standing - will use arms to help them up

DMD interventions

early diagnosis and initiation of therapy are essential

progressive loss of function

PT help maintain muscle strength and prevent contractures

frequent resp infections common

important to monitor PFTs

usually treated with steroids but at high risk for fractures

encourage routine immunizations