Test 3 Flashcards
Basic Components of Neuro Assessment
LOC
pupil response (2-6)
motor function
VS’s
GCS
Best response:
- eye opening
- verbal response
- motor response (decoriate, decerebrate)
Minimum score is 3, max is 15, < or = 8 is coma
LOC
- Full consciousness-Awake and oriented
- Confusion
- Disorientation
- Lethargy
- obtundation (arousable with stimulation)
- stupor
- persistent vegetative state=permanently loss funtion of the cerebral cortex, eyes follow objects by reflex, can withdraw from painful stimuli, hands show reflexive grasping, face can grimace, some food may be swallowed, my cry/grown, but no words
Microcephaly
- primary-genetic, autosomal recessive or chromosomal
- secondary-not genetic…infection, trauma, etc., has neuro manifestations
not all children with microcephaly have cognitive delays
Hypoxic-Ischemic
Brain Injury
complication of prematurity
long term sequelae=
cognitive impairment
seizures
CP
Hypoxic-ischemic Encephalopathy-cellular damage from hypoxic-ischemic injury
Intraventricular Hemorrhage
(IVH)
extremely common in preterm infants, espcially ELBW and VLBW infants <32 weeks gestation
50% of preemies that die in first few days have hemorrhage
subsequent neurological handicap is not uncommon
- etiology: BP flucts, mech vent, asphyxia, rapid infusion volume, NaHCO3 or hyperosmolar solns, coagulopathy, pneumothorax
- S/S=sudden deterioration, brady, acidosis, fall in H/H, shock, hyperglycemia, tense anterior fontanel; or may be gradual
Later-tense, bulging fontanel, incr vent support, sz, apnea, coma
-hydrocephalus
Nursing procedures that increase ICP
- ET suctioning
- head positioning (lowest when head is midline and elevated 30 degrees)
- crying, cough, sneeze, strain, shivering
- normal is 80-110 mmHg
Plagiocephaly
asymmetric head
Craniosynostosis
(Craniostenosis)
- premature closure at birth of one or more cranial sutures (usually sagital suture–results in elongation of skull in anterior-posterior direction)
- increased ICP-with or without mental retardation; progressive papilledema, optic atrophy, eventual blindness
- Sx correction at 6-9 months (post-op observe for hemorrhage and infection)
Increased ICP
- S/S-increased BP, decreased pulse (opposited of shock)
- diminishes cerbral perfusion, leads to brain ischemia and infarction=poor prognosis
- if sustained-brainstem compression and herniation of cerebellum and brainstem…respiratory arrest
- clinical manifestations: anterior fontanel bulging, absence of normal pulsations; increased OFC, HA (increased pain with valsalva), altered mental status (irritable, fatigued), vomiting, VS’s (brady is late sign), altered vision (diplopia, stting sun, restricted fields, papilledema), pupillary changes (normal…sluggish…fixed and dilated (blown)), altered LOC, high pitched cry
- increased BP and decreased HR (opposite of shock)
- increased temp increases O2 needs
Brain Tumor
- most common solid tumor of childhood
- manifestations: *HA on awakening, vomiting (with/without nausea, progressively more projectile, more severe in AM, relieved by position change), neuromuscular change (clumsiness, loss of balance, + Babinski, paralysis), behavioral change, cranial nerve neuropathy (head tilt, visual), VS disturbances (decreased pulse and respiration, increased BP, hypo/hyperthermia), seizures, cranial enlargement, bulging fontanel, nuchal rigidity, papilledema
- surgery (VS and pupil checks q1h), infection-meningitis, drainage (colorless=CSF), do not position on side of tumor, fluid regulation, pain control (narcan available); DI and SIADH
- radiotherapy
- chemotherapy (intrathecal chemo, or resevoir in brain)
- Later children may develop another CA, thyroid issues, cognitive changes, radiation somnolence syndrome
Myelodysplasia
(spina bifida)
(neural tube defects)
Types:
- anencephaly-absence of brain tissue above rudimentary brainstem
- encephalocele-external mass/sac that may occur at any place above the skull
- spina bifida cystica-sac is present at some point along the spine. myelomeningocele-contains meninges, spinal fluid, neural tissue; spinal nerve roots may end at the sac, sensory/motor function end here; meningocele-contains meninges and CSF, less neuro involvement
- spina bifida occulta-may have no signs externally-defect of vertebrae only–bowel and bladder problems may occur
**ALWAYS screen for latex allergies**
- prevention-folic acid
- Associated-flaccid paralysis (no feeling below the defect), head circ no normal, hydrocephalus (90% of those with myleomeningocele), neurogenic bladder, poor anal sphincter tone, congenital dislocated hips, club feet, skin problems from anesthesia below defect, scoliosis
Orthopedic Problems associated with NTDs
- club feet
- contractures
- dislocated hips
- scoliosis
Mitrofanoff Procedure
(NTDs)
- appendix is used as route for intermittent catheterization
- q4-5 h to prevent fluid stasis (microo’s)
- if appendix won’t work-use Monti tube-part of the intestine, ileum or colon is used to create a conduit.
Hydrocephalus
- abnormal accumulation of CSFwithin the ventricles of the brain
- most often associated with spina bifida; can be a complication of meningitis
- communicating=impaired absorption of CSF within the subarachnoid space
- non-communicating=obstruction to the flow of CSF through the ventricular system-usually developmental malformation, apparent at birth
- S/S=head growth abnormal, bulging anterior fontanel, setting-sun sign, poor feeding, irritable, lethargy, changes in LOC, opisthotonos (arching=severe CNS irritablility), lower extremity spasticity
- Tx-ventriculoperitoneal shunt (VP), rarely ventriculoatrial shunt; complications=malfunction (increased ICP, vomit, HA, irritability, pupillary response, increased BP, decreased HR, setting sun sign.
Meningitis
- source-usually bacterial invasion of middle ear/nasopharynx, other sources=wounds including skull fx, lumbar punctures and shunts
- LP shows increased WBCs, decreased glucose, increased protein, increased ICP, positive culture
- peak incidence is between 6-12 months
- S/S=infants & young children-fever, poor feeding, vomit, irritability, restless, sz, bulging fontanel, nuchal rigidity, + Brudzinski and Kernig; older child-sz, irritable, photophobia, nuchal rigidity, opisthotonis, + Brudzinski and Kernig, hyperactive reflexes, signs of cardiovascular collapse, petechiae or purpura
- complications=obstructive hydrocephalus, subdural effusions, thrombosis in meningeal veins or venous sinuses, brain abcess, deafness, blindness, paralysis, Waterhouse-Friderichesen Syndrome (shock, DIC, massive bilateral adrenal hemorrhage, purpura), SIADH (90% of children with bacterial meningitis), seizures
Treatment-respiratory/droplet precautions for first 24h, antimicrobial therapy, hydration, ventilation, reduce ICP, control sz, temperature, anemia
Rifampin-orange urine
Hib vaccine!!!
Seizures
- more common in children under the age of 2
- causes=immaturity of CNS, fever, infection,neoplasms, cerebral anoxia, metabolic disorders
- Partial (focal/local)=simple partial, complex partial
- Generalized=absence, myoclonic, tonic, tonic-clonic, atonic
- infantile spasms (infantile myoclonus)-more often in boys, no post-ictal drowsiness, poor outlook for intelligence, may or may not include loss of consciousness
- Febrile-more in boys
- status epilepticus-Ativan, Dliantin, Valium