NSG 3107: Neurological Conditions

Increased intracranial pressure

Raised level of pressure within the skull above the normal and healthy level

ICP signs in infants

Bulging fontanels, separated cranial sutures, irritability, drowsiness, high-pitched cry, setting sun sign

ICP signs in children

Headache, nausea, forceful vomiting, blurred vision, seizures, indifference/drowsiness, diminished physical activity

Late ICP signs

Bradycardia, decreased motor response to commands, decreased sensory response to painful stimuli, alterations in pupil size, flexion/extension, Cheyne-Stokes respirations, papilledema, decreased consciousness, coma

Consciousness

Term that implies awareness; 2 components: alertness and cognitive power

Awareness

Ability to respond to sensory stimuli and have subjective experiences

Alertness

Arousal-waking state, including the ability to respond to stimuli

Cognitive power

Ability to process stimuli and produce verbal and motor responses

Altered state of consciouness

Refers to varying states of unconsciousness that may be momentary or may extend for hours, days, or indefinitely

Unconsciousness

Depresses cerebral function; the inability to respond to sensory stimuli and have subjective experiences

Coma

State of unconsciousness from which the patient cannot be roused even with powerful stimuli

True

True or false? The earliest indicator of changes in neurological status is levels of consciousness

Full consciousness

Awake and alert; oriented to person, place, and time; behavior is appropriate for age

Confusion

Impaired decision making

Disorientation

State of mental confusion to time, place, or identity

Lethargy

Limited spontaneous movement, sluggish speech, drowsy, falling asleep quickly

Obtundation

Severe reduction in LOC; child arouses with very strong stimulus but is close to comatose state

Stupor

Remaining in a deep sleep, responsive only to vigorous and repeated stimulation or moaning responses to stimuli

Persistent vegetative state

Permanently lost function of the cerebral cortex, eyes following objects only by reflex or when attracted to direction of loud sounds; all limbs spastic but can withdraw from painful stimuli; hands showing reflexive grasping, face grimacing, some food swallowed, groaning or crying without uttering words

Pediatric GCS

3-part assessment of eyes, verbal response, and motor response

8

A score of __ or below on the pediatric GCS is generally defined as a coma

3

A score of __ indicates extremely decreased LOC and is the worst possible score on the pediatric GCS

Opiate or barbiturate poisoning

What condition are pinpoint pupils commonly observed in?

After seizures, eye trauma, or during atropine poisoning

When might widely dilated pupils be observed?

Lesion on same side

What does a unilateral fixed pupil usually suggest?

Cranial nerve VI damage

What can post-traumatic strabismus indicate?

Decorticate

Flexion posturing; seen with severe dysfunction of the cerebral cortex or with lesions to corticospinal tracts above brainstem

Decerebrate

Extension posturing; sign of dysfunction at level of midbrain or lesions to brainstem

Electroencephalogram

An amplified recording of the waves of electrical activity that sweep across the brain's surface; measured via electrodes placed on the scalp

4 minutes

Cerebral hypoxia lasting more than ______ may cause irreversible damage

Indications for ICP monitoring

GCS of <8 OR GCS eval >8 but with respiratory assistance, deteriorating neurological condition, subjective judgement regarding clinical appearance and response

Intraventricular catheter

Gold standard of ICP monitoring; burr hole in skull allows entry into lateral ventricle on nondominant side; provides means for recalibration when measurement drift occurs

Subarachnoid bolt

Device placed in subarachnoid space and epidural sensor is placed between dura and skull

Epidural sensor

Provides readout of ICP with a stopcock assembly and transducer

Anterior fontanel pressure monitor

Detects impulses from pressure sensor and converts them to electrical energy which is then converted to visible waves or numeric readings on a oscilloscope; may be inaccurate if poorly placed

Head injury

Pathological process involving scalp, skull, meninges, or brain as a result of mechanical force

Primary head injury

Head injuries that occur at the time of trauma and include skull fracture, contusions, intracranial hematoma, and diffuse injury

Acceleration-deceleration injury

Head injury typical of a car crash in which the head comes to a sudden stop, but the brain continues to move back and forth inside the skull, resulting in bruising to the brain

Coup

Bruising at the point of impact

Contrecoup

Injury to the brain at a point directly opposite the point of contact

False (children present with increased blood volume)

True or false? Children with an acceleration-deceleration injury demonstrate diffuse generalized cerebral swelling produced by increased water content rather than by increased blood volume as seen in adults

Shearing stress

Effect of brain movement which may tear small arteries and cause subdural hemorrhages (letter D in the image)

Concussion

Transient disturbance of brain function often traumatically induced that involves a complex pathophysiological process

Contusion and laceration

Terms used to describe visible bruising and tearing of cerebral tissue

Occipital, frontal, temporal lobes

What are the 3 areas of the brain susceptible to contusion or laceration?

Traumatic head injury due to child maltreatment

Previously known as shaken baby syndrome or abusive head trauma; violent shaking that may occur as a result of the inconsolable infant crying; results in lifelong complications; brain rotates within skull which tears neurons and BVs

Skull fractures

Result from direct blow or injury to skull and often associated with intracranial injury; immature skull can withstand greater increase in deformities before fracture, so the force must be extreme

Linear fractures

Single fracture line that starts at the point of maximal impact but does not cross suture lines; overlying hematoma or soft tissue swelling

Depressed fractures

Bone is broken into several irregular fragments that are pushed inward; direct underlying parenchymal damage; suspected when heads appears misshapen

Comminuted fracture

Multiple associated linear fractures; usually result from intense impact such as repeated blows against an object; may suggest child maltreatment

Basilar fractures

Involve bones at the base of the skull in either the posterior or anterior region; usually result in a dural tear; fracture line is very close to brainstem, so this type of fracture is considered a serious head injury

Open fracture

Fracture that causes communication between skull and scalp or surfaces of upper respiratory tract; increase risk of cNS infection

Growing fracture

Skull fractures with underlying dural tear that fails to heal properly; enlargement caused by leptomeningeal cyst, dilated ventricles, or herniated brain

Epidural hemorrhage

Bleeding between dura and skull to form a hematoma; causes dura to be stripped from bone = underlying brain contents forced downward and inward as brain expands

Subdural hemorrhage

Bleeding between dura and arachnoid membrane as a result of rupture of cortical veins that bridge the subdural space; spreads thinly and widely until it is limited by dural barriers

24-72 hours

When does cerebral edema peak after a traumatic head injury?

ABC assessment, evaluation for shock, spinal cord injury assessment

A child falls on her head at home an sustains a head injury. What are your priority assessments?

Rest until the patient is asymptomatic

What is the hallmark treatment for concussions?

True

True or false? A sleeping patient with a head injury should be awakened every 2 hours to reassess for changes in responsiveness

Submersion injury

Injury occurring up until the time of drowning-related death; includes any person who experiences distress from near-drowning submersion or immersion in liquid that results in death

Bacterial meningitis

Acute inflammation of meninges and CSF; medical emergency; vascular dissemination from a focus of infection elsewhere

Hemophilus influenzae type B

Which vaccine has dramatically decreased the amount of cases of meningitis in Canada?

Lumbar puncture

What is the definitive diagnostic test for bacterial meningitis?

S&S of bacterial meningitis

Fever, chills, headache, vomiting, photophobia, nuchal rigidity

Nursing care for bacterial meningitis

Quiet with minimal stimuli, HOB elevated, side-lying position, monitor pain, family support

Nonbacterial meningitis

Aka aseptic; causative agents are principally viruses

Enteroviruses

What are the most common cause of viral meningitis?

Encephalitis

Inflammatory process of the CNS that is caused by a variety of organisms; result of direct invasion of CNS by virus or postinfectious involvement of CNS after viral disease

Reye syndrome

Disorder defined as toxic encephalopathy associated with other characteristic organ involvement; fever, impaired consciousness, and disordered hepatic function

Acetylsalicylic acid

There is a potential association between ____ therapy for treatment of fever in children and development of RS

Excessive and disorderly neuronal discharges

What causes a seizure?

True

True or false? Seizures are a symptom of an underlying disease process

Epilepsy

Condition characterized by 2+ unprovoked seizures more than 24 hours apart; caused by variety of pathological processes in the brain

Acute symptomatic seizure

Seizure disorder associated with head trauma or meningitis

Remote symptomatic seizure

Seizure disorder caused by brain injury such as encephalitis, meningitis, or stroke

Cryptogenic seizure

A seizure disorder with no clear cause

Idiopathic seizure

Seizure disorder that is genetic in origin

Focal seizures

Local onset and start in an area of cells on one side of the brain; person maintains awareness although may not be able to talk during the seizure

Generalized seizures

Seizures which involve both hemispheres of the brain and are without local onset; loss of awareness; aka tonic-clonic seizures

Tonic phase

Lasts 10-20 seconds/2-3 minutes; immediate loss of consciousness followed by contraction of entire body musculature; apneic - may become cyanotic

Clonic phase

Lasts 30 seconds to 30 minutes; violent jerking movements as trunk/extremities undergo rhythmic contraction/relaxation

Status epilepticus

Seizures occur at intervals too brief to allow child to regain consciousness between seizures; requires emergency intervention, can lead to exhaustion, respiratory failure, death

Seizure management

Medication therapy, ketogenic diet, vagus nerve stimulation, surgical therapy, treatment for status epilepticus

Sudden unexpected death in epilepsy

Refers to the death of someone with epilepsy, usually during or immediately following a seizure; most common epilepsy-related cause of mortality

False

True or false? Restraining the child's arms in an important step in injury prevention when caring for a child who is seizing

Febrile seizures

Seizures that result from sudden high fevers, particularly in children

True

True or false? Tepic sponge baths are not recommended to treat febrile seizures

8 weeks

By when should the posterior fontanel close?

6 months

By when should the fibrous suture lines and interlocking of serrated edges occur?

18 months

By when should the anterior fontanel close?

Craniosynostosis

Premature closure of cranial sutures; inhibits perpendicular growth and skull is forced to grow in a direction parallel to fused suture = distorted head shape

Positional plagiocephaly

Flattening of one side of an infant's head from prolonged lying in one position; teach parents to position infant's head to side when lying them on their back

10-15 minutes TID

What is the recommended amount of tummy time for infants?

Hydrocephalus

Condition caused by imbalance in production and absorption of CSF in ventricular system; communicating and noncommunicating types

Communicating hydrocephalus

Impaired absorption of CSF fluid within the subarachnoid space, obliteration of the subarachnoid cisterns, or malfunction of the arachnoid villi

Noncommunicating hydrocephalus

Obstruction to the flow of CSF through the ventricular system

Ventriculoperitoneal shunt

Tube used to drain fluid from brain ventricles into the abdominal cavity; treatment for hydrocephalus; risk of infection greatest 1-2 months after placement