Family Nursing Exam 2

What does the frontal lobe control in children?

Personality development.

What does the parietal lobe control in children?

Spatial awareness.

What does the temporal lobe control in children?

Sensory, and emotions.

What does the cerebellum control?

Balance.

What does the occipital lobe control?

Vision.

What are the contents of the brain?

• 80% brain content

• 10% cerebrospinal fluid (CSF)

• 10% blood

What is true of the volume in the brain?

It must remain the same at all times.

What does increased blood in the brain do to the brain and what becomes displaced?

Increased blood compresses the brain and CSF becomes displaced.

How do infants with open fontanels compensate for adjustments in brain volume?

They expand and widen their sutures.

How do fontanels appear in babies in response to increased ICP?

Bulged and tight.

Which fontanel closes first: the anterior or posterior?

Posterior.

How long does the posterior fontanel take to close?

2 to 4 months.

What are some signs of increased intracranial pressure in infants?

• Tense, bulging fontanels

• Separated cranial sutures

• MacEwen (cracked pot) sign

• Irritability, restlessness, drowsiness.

• Increased sleeping.

• High-pitched cry, unconsolable.

• Increased head circumference.

• Distended scalp veins.

• Crying when disturbed.

• Poor feeding.

• Setting sun sign.

What is the cracked pot (MacEwen) sign?

The brain pulls apart and sutures open.

What is the setting sun sign?

You can’t see the baby’s pupil, only their sclera.

What are some signs and symptoms of increased ICP in children?

• Headache

• Nausea

• Forceful vomiting

• Diplopia

• Blurred vision

• Seizures

• Drowsiness

• Indifference

• Decline in school

• Diminished physical activity and motor performance.

• Inability to follow simple commands.

• Lethargy

What can intracranial hypertension lead to?

Papilledema (the optic nerve becomes compressed).

When doing a health history on a newborn with a fever, what is an important question to ask the mother?

What is their Group B Strep (GBS) status?

What is true of the symptoms of GBS?

They can show early and late.

What questions should be asked to the mother of a newborn upon admission?

• How was the delivery?

• What were the APGARS?

• Was the baby in the NICU?

• Were there any complications?

GBS primarily affects what body system?

Neurologic.

THC ingestion in children can lead to what issues?

Airway and vision problems.

What is a pupillometer?

A device that measures pupillary size and response. It picks up subtle changes that the human eye cannot.

What is true of a fixed and dilated pupil?

It is an immediate medical emergency.

What is true of head movement when patients show abnormal CNS symptoms?

Keep the head immobilized until a spine injury is ruled out.

What should you be monitoring for in the neuro exam on a child?

• LOC

• Complete set of vitals

• Pupillary response

• Nystagmus

What sense should always be assessed after trauma?

Smell.

What are the 12 cranial nerves?

1. Olfactory

2. Optic

3. Oculomotor

4. Trochlear

5. Trigeminal

6. Abducens

7. Facial

8. Acoustic

9. Glossopharyngeal

10. Vagus

11. Accessory

12. Hypoglossal

What does the olfactory nerve control and how can it be tested?

• It controls smell.

• Have patient identify a familiar scent with eyes closed.

What does the optic nerve control and how can it be tested?

• It controls visual acuity and field.

• Have patient perform confrontation visual field test and test visual acuity with a snellen chart.

What does the oculomotor nerve control and how can it be tested?

• It controls pupil size and reactivity and eyelid movement.

• Use penlight to assess patient for PERRLA.

What does the trochlear nerve control and how can it be tested?

• It controls eye movement down and laterally.

• Hold the penlight and ask patient to follow the movement of the penlight down and sideways.

What does the trigeminal nerve control and how can it be tested?

• It controls chewing and facial sensation.

• Have patient close eyes and take a cotton ball and touch the face at the cheeks, chin, and forehead. Instruct patient to verbalize when they feel sensation.

What does the abducens nerve control and how can it be tested?

• It controls lateral eye movement.

• Hold penlight and ask patient to follow movement side to side and diagonally.

What does the facial nerve control and how can it be tested?

• It controls facial expressions.

• Ask patient to frown, smile, raise eyebrows, puff cheeks, and close eyes tightly.

What does the vestibulocochlear nerve control and how can it be tested?

• It controls hearing and balance.

• Have patient occlude one ear and whisper in other ear. Have patient repeat phrase.

• Ask patient to walk and assess their gait.

What does the glossopharyngeal nerve control and how can it be tested?

• It controls the gag/swallow reflex.

• Ask patient to say “an” and have patient yawn.

• Assess upward movement of the soft palate and ask patient to swallow.

Does trigeminal nerve damage always occur bilaterally?

No. It can be unilateral.

What is the three part assessment of the pediatric coma scale?

1. Eye opening response

2. Verbal response

3. Motor response

If a patient has a score of 3 on the GCS, would they be comatose or alert?

Comatose.

A score below what on the GCS is considered comatose?

8.

What score of 3 indicates what on the GCS?

Deep coma or death.

What is true of oxygenation in patients with a GCS under 8?

They may need to be intubated.

When can hyperactivity in the reflexes occur?

In acute febrile and toxic states.

The absence of what reflex on a neuro exam is associated with severe brain damage?

Corneal reflex.

What is a positive Babinski reflex indicative of?

Pyramidal tract lesions.

Decorticate posturing is also known as what?

Flexion posturing.

What is flexion posturing usually associated with?

Severe cerebral cortex dysfunction.

What is unilateral extension posturing usually associated with?

Tentorial herniation.

Where does the pyramidal tract originate from and what is it responsible from?

It originates from the cortex and is responsible for voluntary movement.

What are the 2 tracts of the pyramidal tract?

• Corticospinal tract

  • For skeletal muscle voluntary movement.

  • 25% ipsilateral, 75% contralateral.

• Corticobulbar tract

  • For face, head, neck voluntary movement.

Where does the extrapyramidal tract originate from?

The Brainstem.

What is the extrapyramidal tract responsible for?

Involuntary movement.

What are the 4 tracts of the extrapyramidal tract?

• Rubrospinal: Fine movement control

• Reticulospinal: Tone control and automate breathing

• Vestibulospinal: For balance and posture

• Tectospinal: For head, eye, and body coordination.

What criteria needs to be met for someone to be considered brain dead?

• Fully dilated pupils in both eyes that don’t respond to light.

• Absence of spontaneous eye movements and those induced by oculocephalic and caloric testing.

• Absence of facial and oropharyngeal muscles.

• Absence of corneal, gag, cough, sucking, and rooting reflexes.

• Absence of respiratory movements when removed from respirator.

What is the apnea test?

A patient is taken off a ventilator for a certain amount of time and left on oxygen. Every time this is done, CO2 levels are checked in the body. Low respiratory drive would lead to increased CO2.

What is true of body tone in brain death?

It is flaccid.

What ages require 2 separate exams in a 24 hour period for brain death?

Newborn to 37 weeks and up to 30 days of age.

What ages require 2 separate exams separated by at least a 12 hour period for brain death

Ages 31 days to 18 years old.

Are electrolyte abnormalities present in brain death?

No.

What is done if there is concern of the validity of a brain death exams?

An EEG and/or cerebral blood flow test.

What is true of the exams for brain death?

They are done by two different providers.

What brainstem reflexes are tested in brain death?

• Pupillary

• Corneal

• Gag

• Cough

What is another name for the Doll’s Eye Reflex?

Vesibulo-Ocular Reflex (VOR).

What do you do for a Doll’s Eye Reflex Test?

Turn the head side-to-side.

If the brainstem is intact, what would be seen on a Doll’s Eye Test?

If the head is turned to the left the eyes move to the right and vice versa.

Failure of the Doll’s Eye indicate an issue with which cranial nerve?

Cranial nerve III (oculomotor)

What is another name for the oculovestibular response/caloric test?

Ice water test.

What is done during a caloric test and what do you monitor for?

Ice water is instilled into the ear of a comatose child. If nystagmus occurs, the child is not brain dead.

What is true of the tolerance of the caloric test?

It is not well tolerated.

What patients would never have a caloric test?

Patients who are awake or who have a ruptured eardrum.

From least sedated to most sedated how would brain waves appear on an EEG?

• Awake

• Beta activation

• Slowing (delta shift)

• Near burst suppression

• Isoelectricity

Which patients can have slowing (delta shift)?

Post-arrest/seizure patients.

What is done on a cerebral blood flow test?

A radioactive isotope is injected and timed throughout your body.

If a patient shows any sign of _____________, do not do a brain flow tes

consciousness

What is stupor?

A state in which someone remains in a deep sleep and is responsive only to vigorous and repeated stimulation.

What needs to be done to confirm stupor?

Sternal rubs or pinching feet.

What is obtundation?

A level of consciousness in which the child can be aroused with stimulation.

What is a coma?

A state in which no motor or verbal response occurs from painful stimuli.

What is a persistent vegetative state?

The permanent loss of function of the cerebral cortex.

What is a concussion?

A transient, reversible neuronal dysfunction.

What is confusion?

Impaired decision making.

What is disorientation?

Confusion regarding time and place.

What is the number one neurological issue you will see in pediatrics, and is it reversible?

Concussions; yes.

What should be done in the nursing care of an unconscious child?

• Observe, record, and evaluate changes in objective signs.

• Ongoing neuro checks

• AVOID hyperthermia → increased metabolic demand on brain

• Monitor ABC’s

• Manage pain

What should you know about room temperature and nursing care of unconscious children?

They take the temperature of the room.

After how long does cerebral hypoxia lead to brain damage?

4 minutes.

When are fluids avoided in the nursing care of an unconscious child?

If there is a risk for cerebral edema.

Children with NG and NJ feedings are at risk?

Aspiration and vomiting.

Why are NJ tubes more beneficial than NG tubes?

They have a lower vomiting risk.

When are steroids used in the nursing care of unconscious children?

In brain tumors.

How many times a day is Keppra administered, and children with what condition have symptoms exacerbated by it?

It is administered twice a day; children with ADHD have exacerbated symptoms when taking Keppra.

What is the first line pain medication for care of an unconscious child?

Morphine.

What can happen if fentanyl is pushed too fast through an IV?

Chest wall rigidity.

Why is versed used less in children?

It has a higher risk of causing delirium.

What can precedex lead to in children?

Bradycardia

Paralytics paired with what drugs have a prolonged recovery period?

Steroids or aminoglycosides.

Which is more common SIADH or DI?

DI.

What is SIADH?

A syndrome if inappropriate antidiuretic hormone (too much of it).

SIADH or DI: Decreased urine output.

SIADH