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330 Peds > Neurological Disorders > Flashcards

Neurological Disorders Flashcards

1
Q

What is the CNS

A
  1. Brain, spinal cord and the related nerves
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2
Q

What are the different parts of the CNS?

A
  1. Cerebrum
    a. Connected R and L hemispheres, top of the cranium
    b. Responsible for the main activities of our body, behavior and cognition
  2. Cerebellum
    a. Under the cerebrum
    b. Back of the cranial vault
    c. Responsible for our bigger movements like posture, initiating and maintaining movement, balance
  3. Brainstem
    a. Base of the skull
    b. Protected because it is made of midbrain, pons and medulla which are critical for our life (breathing and heart)
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3
Q

Protection

A
  1. Skull, skin and 3 layers of meninges (see picture)
  2. Arachnoid (cobweb where fluid and blood to flow through
  3. Pia mater-thin and sensitive, right beside the brain
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4
Q

Assessment

A
  1. LOC
    a. Most important indicator of neurologic dysfunction
    b. Describing LOC
    i. Conscious vs unconscious
    ii. Alertness-the ability to react to stimuli
    iii. Cognitive power-processing of data. Can they answer questions, look at noises etc.
  2. ICP
  3. Head circumference
  4. Vital signs
  5. Pediatric assessment is limited by the developmental stage of the child so we need help from family and friends
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5
Q

Types of LOC

A
  1. Full consciousness
    a. Patient alert to person, place and time if developmentally appropriate
    b. Do they smile when a familiar face is present
  2. Confusion
    a. Disorientation to time, place or person
  3. Delirium or obtundent
    a. Characterized by confusion, fear, agitation, hyperactivity or anxiety
    b. Some stimulation needed to stay awake
  4. Stupor
    a. Response to vigorous stimuli only
    b. Loud noises, sternal rub
  5. Coma
    a. Severely diminished response
    b. Not responding to vigorous stimuli
    c. Part of our assessment needs to look at our posture
    i. Decorticate where they are flexed and wrists and hands are turned in and feet are extended
    ii. Deserigrit-extremities are extended and hands and feet are pronated
    iii. See more often in longer coma
    iv. PT/OT needs to do an assessment so they don’t have complications r/t their positioning
  6. Bring in family member because we are going based on their reported baseline
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6
Q

Intracerebral Pressure, cerebral spinal fluid

A
  1. Measured mmHg, created by the things in the skull (brain, blood and CSF)
  2. The pressure within the skull
  3. Normal CSF
    a. Clear, odorless
    b. Wbc 0-5
    c. Protein 15-45
    d. Glucose 50-80
    e. Pressure 50-180
  4. Abnormal CSF
    a. Turbid, cloud, bloody (infection or trauma)
    b. WBC 1000-2000 esp. bacterial infection
    c. Protein 100-500 (bacteria or blood)
    d. Glucose lower than blood sugar esp. bacterial infection because the bacteria is ingesting the glucose
    e. Pressure 180 or greater (tumor, trauma or infection)
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6
Q

Pediatric Glasgow coma scale

A
  1. Designed as a standardized assessment of the patient with disturbed consciousness
  2. The lower the score at time of admission the poorer the outcome
  3. Takes into account the age of the child
  4. We look at their baseline and track changes as they occur
  5. Lowest score is 3 and highest is 15
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7
Q

Common cause in change of LOC

A
  1. Trauma (head injury, car accident, poisoning)
  2. Most common is infection (meningitis and encephalitis)
  3. Seizure
  4. Hypoxia
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8
Q

What may account for an increase in brain volume

A
  1. Edema
  2. Blood flow
  3. Bleed within the brain
  4. Tumor (cancerous or benign)
    a. They grow and change the brain volume
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9
Q

If we don’t catch changes in ICP fast enough

A
  1. Trauma to the brain causing brain tissue death and long-term outcomes
  2. Specific things that can happen from ICP
    a. Brain can shift from edema
    b. Injury to brain tissue, then necrosis (irreversible)
    c. Older than 2 when there is no way to accommodate expansion is brain herniation that causes injury, ischemia and necrosis of the brain
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10
Q

What to assess with an increased ICP

A
  1. LOC and pediatric Glasgow coma scale
  2. Head circumference under 2 years on admission and if hospitalized for something neuro BID, OD, q48h
  3. Known as Cushing’s triad (seen in response to ICP)
    a. Hypertension
    b. Bradycardia
    c. Irregular respirations
    d. The sympathetic NS is stimulated so vasoconstriction occurs and an increase in cardiac output so the baroreceptors are triggered and heart rate decreased
    e. Pressure on the brain stem leads to irregular and slow respirations
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11
Q

Vital signs tips

A
  1. Warm stethoscope
  2. Get the patient asleep when possible
  3. Start with RR and HR, then temperature calm them and BP
  4. RR and HR need to be done for a full minute
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12
Q

Measure Head circumference

A
  1. Start just above ears to occipital prominence (largest part on the back of the head) and move around the front to the largest part (frontal prominence) and match the tape together
    a. Front between the hairline and eyebrows
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13
Q

Common Pediatric alterations in neurologic function

A
  1. Hydrocephalus
  2. Meningitis
  3. Encephalitis
  4. Seizures
  5. Traumatic brain injury
  6. Cerebral palsy
  7. Spinal cord injury/trauma
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14
Q

Hydrocephalus

A
  1. Dilation of the ventricles
  2. Develops as a result of an imbalance between the production and absorption of CSF
  3. CSF builds up causing abnormal enlargement of the ventricles in the brain
  4. 1/500 children in Canada will develop this
  5. 2 primary causes
    a. Congenital, uncommon. Means the infant or newborn is born with and it occurred in utero
    b. Acquired through lesions, tumors, infection, intracranial bleed, myelomeningocele. Trauma during the birth process
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15
Q

Hydrocephalus signs and symptoms

A
  1. Increased head circumference
  2. Bulging fontanelle
  3. Gaping sutures (being pushed apart)
  4. Veins are more prominent on the scalp
  5. Eyes deviated downward (sunsetting eyes) because of the pressure being put on the eyes
  6. Vomiting
  7. Poor feeding
  8. Nausea
  9. Infants are irritable and uncomfortable
  10. Children can tell you about pain
  11. Blurred vision or changes in vision
  12. Late signs
    a. Change in LOC
    b. Cushing Triad (impending sign of respiratory arrest)
16
Q

Causes of hydrocephalus

A
  1. Obstructive (noncommunicating)
    a. Results from an obstruction within the ventricular system of the brain that prevents CSF from flowing or “communicating” within the brain
    b. More common
    c. No absorption of CSF in to the subarachnoid space
    d. Seen with tumors, infection and trauma due to structural changes
  2. Non obstructive (communicating)
    a. Results from problems with the production or absorption of CSF
    b. Seen more in preterm babies with intraventricular hemorrhage in the birth process
16
Q

Interventions for hydrocephalus

A
  1. Are aimed at re establishing the balance between CSF production and reabsorption
    a. Lumbar puncture esp. with suspicion of infection
    b. Ventriculoperitoneal shunt insertion
    i. Patient put on NPO so they can get this shunt and the lumbar puncture
17
Q

VP shunt complications

A
  1. Infection
    a. Seen with any foreign body
    b. Very common within first year of insertion, every subsequent year families come in for treatment of infection too
    c. 40%-staph epidermitis
    d. 20%-staphorius
    e. 40%-strep and other
    f. Need to teach family about identifying infection
    g. It can be localized to behind the ear where you can palpate the pump
    h. Systemic infection (fever, increased HR, RR and irritability
    i. When they come with infection they get blood work, and signs and symptoms the internal shunt is removed, external shunt placed, antibiotics, once infection is clear they have a new shunt then they can go home (6-8 weeks).
    j. Infection is gone when CSF is clear and WBC are lowered
  2. Mechanical failure
    a. The pump is broken, the one in the ventricle gets clogged or the distal end is locked with debris or it grows into the epithelial tissue of the peritoneum
    b. Signs and symptoms of ICP seen
    c. 40% of shunts fail in 1st year
    d. 5-20% of shunts fail every subsequent year
    e. When children grow the catheter end (distal) can get displaced out of the perineal space
18
Q

Blocked Shunt

A
  1. An MRI or CT scan is often used to determine the cause and confirm the diagnosis
  2. Intracranial pressure may be measured during a spinal tab (lumbar puncture)
  3. It may also be measured by an intraventricular catheter inserted into the anterior fontanelle
    a. The normal ICP pressure is 1-10mmhg
  4. A level of over 15mmhg is considered abnormal
  5. Draining the ventricle isn’t often done because it is high risk
19
Q

External ventricular drains

A
  1. Clamp shunt every time child is picked up
    a. Should be as least often as possible to decrease risk of all CSF draining
  2. Head must remain at same level as the body
  3. Sterile technique when accessing the shunt for specimens
    a. Often CSF is taken daily for Culture and sensitivity to see if the infection is clear
  4. Measure CSF output q1h
20
Q

Potential nursing diagnoses for hydrocephalus

A
  1. Risk for infection
  2. Pain
  3. Risk for ineffective cerebral tissue perfusion
  4. Potential for seizures
  5. Potential for fluid volume deficit
21
Q

Meningitis

A
  1. An inflammation of the meninges
  2. The most common infectious process affecting the CNS system
  3. Many of the bacteria or viruses that can cause meningitis are family common and are more often associated with other everyday illnesses
  4. The infection can start anywhere including the skin, GI tract, or urinary system, ear or sinus infection but the most common source is the respiratory tract
  5. Infants can get it in the birth canal in the endothelial cells and then transfers through the BBB
  6. Can be caused through trauma if BBB is compromised
  7. Sinus and ear infection
22
Q

3 many ways - Meningitis

A
  1. Through BBB
  2. Trauma
  3. Localized infection (ear and sinus infection)
  4. See point 5-7 above
23
Q

Types of Meningitis

A
  1. Bacterial
    a. Neisseria meningitides (meningococcus) causes the majority of cases, together with streptococcus pneumoniae (pneumococcus)
    b. 95% of meningitis cases are caused in children ages 3 months-12 (or 16) years of age in Canada
    c. Group B strep and E coli are largely responsible for neonatal meningitis (birth-3months) due to birthing process
  2. Viral or aseptic
    a. Viral is relatively common and is typically far less serious than bacterial meningitis
    b. Bacteria do not grow in cultures of cerebrospinal fluid
    c. Most cases of viral meningitis are associated with enteroviruses
    i. Viruses that typically cause stomach flu (kosaki, endovirus)
    d. However, many other types of viruses such as the herpes and mumps virus can also cause meningitis
  3. Seen because kids are in big groups of people and are much more contagious
24
Q

Symptoms of Meningitis

A

a. Fever
b. Lethargy (decreased consciousness), confusion or irritability
c. Bulging fontanelles, poor feeding or sucking, high pitched cry, hypothermia (we don’t know why but is serious), apnea, seizures
d. Older children may complain of a headache, photophobia (eye sensitivity to light), stiff neck or skin rash
e. Seizures, fever, agitation or drowsiness

25
Q

Classic signs of meningitis

A
  1. Brudzinski’s neck sign
    a. They flex the neck of the child and there is severe discomfort so the child flexes their hips and knees
  2. Kernig’s sign
    a. Practitioner lays the child down and extend their hip at 90 degree trying to extend the knee will cause extreme discomfort
26
Q

Meningitis Diagnosis

A
  1. Lumbar puncture
    a. Usually done in OR but occasionally done on the floor
  2. Lab work
    a. CSF and blood work
    b. Culture and sensitivity from urine, blood and CSF
27
Q

Types of Seizures

A
  1. Partial seizures (focal seizures)
    a. Complex
    b. Simple
  2. Generalized seizures
    a. Generalized tonic clonic
    b. Myoclonic
    c. Absence
    d. Atonic
    e. Infantile spasms
28
Q

Partial seizure

A

The electrical disturbance is limited to a specific area of one cerebral hemisphere. Can spread to generalized

29
Q

What is a seizure?

A

An involuntary contraction of muscles caused by abnormal electrical discharges

30
Q

Causes of Seizures

A

Fever
Genetic Factor or benign seizures of the newborn
Cerebral lesions
Progressive brain disease
Head Trauma
Infections

30
Q

Epilepsy vs status epilepticus

A

a seizure that lasts seconds to minutes

a seizure that lasts more than 5 minutes is considered status epilepticus

31
Q

Diagnosis of seizures disorders

A
  1. Primarily based on description of events from child and family
  2. CBC, liver function tests
  3. Blood glucose
  4. LP
  5. CT head
  6. Electroencephalogram (EEG)
  7. MRI
    a. Done if the patient is decreasing in cognitive functioning

330 Peds (2 decks)

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