The Child with a Neurological Alteration Flashcards
(80 cards)
1
Q
Review of the Central Nervous System (CNS)
* Composed of the __ and __
* Myelinization of the nerves begins approximately __th week of gestation and is completed by adolescence
* The axial skeleton protects the underlying structure of the CNS
A
brain; spinal cord
16th
2
Q
> At birth, skull plates not fused but separated by non-ossified spaces - ___
> Posterior __ fuses by __ months
> Anterior __ fuses by __-__ months
> Allow cranium expansion due to rapid brain growth in infancy
> Brain growth measured by head circumference
* The brain and spinal cord are covered by the __
A
FONTANELS
fontanel; 2
fontanel; 16-18
meninges
3
Q
The Brain
* Cerebrospinal fluid (CSF) surrounds the brain and spinal cord
> Infant has about __mL of CSF compared to an adult about __mL
> CSF acts like a “cushion” to reduce force trauma to the head
Functions of CSF
> Protects __, __, and __
> Maintains homeostasis
A
50mL; 150mL
brain, spinal cord, meninges
4
Q
What are the 3 sections of the brain?
A
Cerebrum
Cerebellum
Brainstem
5
Q
Cranial Nerves
12 pairs of cranial nerves (CN)
> Arise from the brain and brainstem
> Testing of the nerves can indicate location and degree of CNS injury
A
6
Q
CN __, __, __, __
- Blink reflex
- Doll’s eye
A
II, III, IV, VI
7
Q
CN __
- Rooting
- Sucking
A
V
8
Q
CN __
- Facial expressions
A
VII
9
Q
CN __
- Acoustic blink
- Doll’s eye
A
VIII
10
Q
CN __, __
- Swallow, gag
A
IX, X
11
Q
CN __
- Suck, swallow
- Tongue midline
A
XII
12
Q
Spinal Cord
Regions
- Cervical
- Thoracic
- Lumbar
- Sacral
* Transmits signals to and from BRAIN through automatic motor responses
- REFLEXES (e.g., deep tendon reflexes)
A
13
Q
?
* Also known as self-regulation
> Process allows cerebral arteries to change diameter in response to changes in cerebral perfusion pressure
* May be impaired by trauma, ischemia, increased intracranial pressure (ICP)
A
Autoregulation
14
Q
↑ PaCO2 (above 40 mmHg) - cerebral vasodilation and ↑ cerebral blood flow (CBF)
A
↓ PaCO2 (25-30 mmHg) - cerebral vasoconstriction and ↓ CBF
15
Q
Diagnostic Tests & Procedures
* CT scan
> If contrast need an IV line
> Check for allergies
* Angiography
> NPO
> Check for allergies
> Obtain consent
A
* Echoencephalopathy
* Electroencephalogram (EEG)
* Lumbar puncture
* MRI
16
Q
?
Used to measure CSF pressure and obtain specimens
- Explain procedure to child according to developmental stage
- Obtain signed consent
- Lay on side with knees to chin
- Hold child by “hugging” knees to chin
- Will feel cool liquid while washing
- Feel “pinch” or “sting” while needle inserted
- Child MUST REMAIN STILL…encourage relaxation by singing, taking deep breaths, guided imagery
- MONITOR throughout procedure
> Cardiorespiratory status - After procedure child lays FLAT
A
Lumbar puncture
17
Q
Increased Intracranial Pressure
- Pressure exerted by blood, brain, CSF, and any other space occupying fluid or mass
- Results from a disturbance in autoregulation
- Defined as pressure sustained at __ mmHg or higher for 5 minutes or longer
A
20 mmHg
18
Q
Increased ICP - Manifestations: Infant
> Poor feeding or vomiting
> Irritability, restlessness, or lethargy
> Bulging fontanel
> High-pitched cry
> Increased head circumference
A
> Separation of cranial sutures
> Distended scalp veins
> Eyes deviated downward (“setting sun” sign)
> Increased or decreased response to pain
19
Q
Increased ICP - Manifestations: Child
* Headache
* Diplopia
* Mood swings
* Slurred speech
A
* Papilledema (after 48 hours)
* Altered level of consciousness
* Nausea and vomiting, especially in the morning
20
Q
ICP Neurologic Examination
* Level of consciousness (LOC)
> ___ (used to assess LOC)
- Eye opening
- Verbal response
- Motor response
> Scores range from 15 (no change in LOC) to 3 (deep coma or poor prognosis)
A
Glasgow Coma Scale (GCS)
21
Q
* Behavior
> Alterations in normal pattern of behavior
> Irritability, mild confusion, agitation - all need further assessment
* Pupil evaluation
A
22
Q
* Motor function
> Flexion = ___ posturing
- Flexion of upper extremities and extension of lower extremities
> Extension = ___ posturing
- Extension of upper and lower extremities with internal rotation of upper arms and wrists and knees and feet
A
decorticate
decerebrate
23
Q
Vital signs
- Temperature ↑
- Cushing’s response
> Increased systolic BP with widening pulse pressure
> Change in RR and pattern
A
Increased ICP - Diagnostic evaluation
- CT scan
- MRI
- Lumbar puncture
- Serum and urine electrolytes
- ABG’s
> ICP normal blood gases
* PaO2 >80 mmHg
* PaCO2 <45 mmHg - CBC
- EEG
- Radiography
24
Q
Increased ICP - Therapeutic management
Goal is to reduce the volume of CSF, preserving cerebral metabolic function, and avoiding increased ICP
* Intraventricular catheter used to drain CSF, measure ICP, administer medications
* Elevate HOB at 30°
A
* Maintain normothermia
* Administer
- osmotic diuretic
- hypertonic saline
- sedation and analgesia
- anticonvulsants
* Monitor blood glucose levels
25
Increased ICP - Nursing considerations: *Decreased cerebral tissue perfusion*
\* Determine baseline age and developmental level
\* Perform a baseline neurological and LOC assessment
\* Monitor factors that may increase cerebral edema and ICP
\* Maintain HOB at 30-45° angle
\* Avoid the prone or flat, supine position, neck flexion, or hip flexion
\* Decrease stimulation
\* Monitor pupil reactivity
\* Monitor VS every 1-2 hrs
\* Measure head circumference
\* Palpate anterior fontanelle every 8 hrs and cranial suture line every 8 hrs
\* Observe for irregularity, lethargy, eating intolerance, and decreasing GCS score
\* Keep emergency equipment near the bedside
26
Increased ICP - Nursing considerations: *Poor nutritional intake: less than required*
\* Determine LOC before giving liquids
\* Daily weights
\* Monitor skin turgor, mucous membranes, eye orbits, urine output, urine specific gravity, and serum and urine electrolyte values
\* Referral to a dietician
\* Always position in an upright position after feedings
\* Flexible feeding schedules with small feedings at a time
27
Standard Terms for Level of Consciousness
\* Full consciousness
\* Confused
\* Delirious
\* Disoriented
\* Obtunded
\* Stupor
\* Coma
\* Lethargic
28
?
Requires stimulation to arouse
Stupor
29
?
Inability to think clearly and rapidly; oriented to person
Confused
30
?
Awake, alert, oriented; interacts with environment
Full consciousness
31
?
Inability to recognize place or person
Disoriented
32
?
Sleeps and, once aroused, has limited interaction with environment
Obtunded
33
?
Awakens easily but exhibits limited responsiveness
Lethargic
34
?
Vigorous stimulation produces no response
Coma
35
?
No orientation to person, place, or time; may have auditory or visual hallucinations
Delirious
36
?
\* Congenital neural tube defects (NTD) classified by incomplete closure of the vertebrae and neural tube
\> __ \_\_ occulta
\> __ \_\_ cystica
- Meningocele
- Myelomeningocele
Spina bifida
37
Clinical manifestation
\* Varies depending on degree of deficit
\* Small tuft of hair or dimple in the lower lumbar sacral area
\* Sac-like protrusion filled with spinal fluid and meninges - \_\_\_
\* Sac-like protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord - \_\_\_
\> High risk for developing latex allergies
meningocele
myelomeningocele
38
Which condition is this?
myelomeningocele
39
Which condition is shown here?
Spina bifida occulta
40
Which condition is shown here?
meningocele
41
Spina Bifida
Diagnostic tests
\_\_\_ blood level at 16-18 wks
Therapeutic management
\> Prenatal microsurgical repair of myelomeningocele at 19-25 wks gestation
\> Immediate surgical repair after birth
Prevention
\> Daily folic acid 0.4 mg for all childbearing age women
Alpha-fetoprotein (AFP)
42
?
Develops as the result of an imbalance of production and absorption of CSF
\> Most often congenital
\> May lead to Arnold Chiari malformations
\> Enlarged ventricles and ICP
\> Head circumference abnormally large
\> Treatment consists of ventriculoperitoneal shunt
Hydrocephalus
43
Hydrocephalus - Manifestations: Infant
Early
\* Rapid head growth - increased circumference
\* Full, bulging anterior fontanel
\* Irritability
\* Poor feeding
\* Distended, prominent scalp veins
\* Widely separated cranial sutures
Late
\> "Setting sun" sign
\> Frontal bone enlargement
\> Vomiting; difficulty feeding and swallowing
\> Increased BP and decreased HR
\> Altered respiratory pattern
\> Shrill, high-pitched cry
\> Sluggish or unequal pupillary response to light
44
Hydrocephalus - Manifestations: Child
Early
\* Strabismus
\* Frontal headache occurring in the morning and relieved by emesis or sitting upright
\* Nausea and vomiting - projectile
\* Diplopia
\* Restlessness
\* Changes in ability to do schoolwork
\* Behavior or personality changes
\* Ataxia
\* Irritability
\* Papilledema
\* Sluggish and unequal pupillary response to light
\* Confusion
\* Lethargy
Late
\> Seizures
\> Increased BP and decreased HR
\> Altered respiratory pattern
\> Blindness
\> Decerebrate
45
Hydrocephalus - Therapeutic management
\> Bypass the blockage and drain the fluid from the ventricles to an area where it will be reabsorbed into circulation - ventriculoperitoneal shunt
46
?
\* Chronic, nonprogressive disorder of posture and movement
\* Difficulty controlling muscles due to abnormality in the extrapyramidal or pyramidal motor system
\* Comorbidities include
\> Cognitive impairment
\> Hearing and speech impairment
\> Visual impairment
\> Seizures
Cerebral palsy
47
Cerebral palsy - Manifestations
\* Persistence primitive reflexes
\* Delayed gross motor development
\* Abnormal muscle tone
\* Lack of progression through developmental milestones
\* Inability to maintain normal posture and balance
\* Spasticity or uncontrollable movements in the extremities
\* Ataxia or toe-walking
\* Seizures
\* ADD
\* Sensory impairment
\* Failure of automatic reactions (equilibrium) speech and swallowing impairments
48
Cerebral palsy - Therapeutic management
\> Multidisciplinary approach
- Pediatrician, neurologist, orthopedic surgeon, nurse, speech and hearing therapists, social worker, occupational therapist, physical therapist, psychiatrist, neurosurgeon, orthotist
\> Early recognition and intervention
\> Intrathecal baclofen
\> Benzodiazepines
\> Botulinum toxin
49
Head Injury
\* Skull fractures
\* Contusion
\* Concussion
\* Intracranial hemorrhage
\> Epidural hematoma: __ and \_\_
\> Subdural hematoma: __ and \_\_
dura; skull
dura; cerebrum
50
\* Classified as minor, moderate, or severe
\> Minor head injury - GCS with a 13 or \>; change in LOC; periods of transient confusion; irritability; vomiting; somnolence; headache
\> Moderate to severe head injury - decreased LOC; changes in VS; signs of increased ICP; retinal hemorrhage; hemiparesis; papilledema
\* A concussion is a violent jarring or shaking that results in a disturbance of brain function
\* A coup injury results from initial impact
\* Contrecoup injury results from secondary impact as brain moves forward and then backward within skull
- Bruising occurs as brain moves over skull floor
51
?
\* Convex, lens-shaped
\* Middle meningeal artery
\* "lucid interval"
Epidural hematoma
Epi = Pie = Lemon
52
?
\* Concave/crescent-shaped
\* Bridging veins
\* Elderly, alcoholics
Subdural hematoma
suB = Banana
53
Classification of Severity of Head Injuries
Glasgow Coma Scale (GCS)
\* Minor (mild) = score 13-15
\* Moderate = 9-12
\* Severe = 3-8
Head Injury - Therapeutic management
\> Airway assessment
\> Neurologic status
\> In severe cases - craniectomy
Recommendation - stay home from school 1-3 days or until child can tolerate 30 minutes of cognitive activity without an increase in symptoms
54
Head Injury - Nursing considerations
\> Initial and ongoing assessment
\> ABCDE = airway, breathing, circulation, disability, and exposure
\> Immobilize neck
\> Assess LOC using the GCS; assess PERRLA
\> Check cranial nerve function and monitor for ICP
\> HOB elevated 30-45°
\> Monitor I&O carefully
55
Spinal Cord Injury
*Can result from any trauma or injury to the spinal cord and its vascular supply or venous drainage*
\> Motor vehicle or diving accidents
\> Falls
\> Sports injuries
\> Tumors
\> Gunshot or knife wound
\> Sports injuries
\> Congenital anomalies
\> Attempted suicide
Spinal Cord Injury - Manifestations
\> Loss of some or all movement or sensation below the level of injury
\> Respiratory depression or apnea
\> HTN and bradycardia
\> Hypothermia
\> Neck pain
Diagnostic Evaluation
\> Complete neuro assessment
\> Radiography or MRI
56
Spinal Cord Injury - Therapeutic management
\* Depends on the level of injury
\* Assess for airway and breathing compromise
\* Assess for pneumonia
\* Risk for PE and DVT
\* Surgical stabilization
\* Bowel dysfunction requiring clean intermittent catheterization 4-6x/day and dietary modification and bowel regimen
\* Pain and spasticity controlled with medications and PT
57
Spinal Cord Injury - Nursing considerations
\> Immobilization with tongs or halo traction
\> Maintain proper alignment of traction and monitor every 1-2 hrs
\> Motor and sensory assessments
\> Respiratory status and pulse oximetry every 1-2 hrs
\* O2 supplementation, nebulizer, incentive spirometry, intermittent positive pressure breathing
\* Tracheostomy for prolonged mechanical ventilation
\* Continuously monitor color sensation and movement
\* Reposition every 1-2 hrs
\* Assess hourly VS, color, core body temperature, skin, and I&O
\* Intermittent catheterization
\* Bowel training
\> High fiber, stool softeners, increase water intake
\* Monitor caloric intake
\> Oral intake, tube feeding, TPN
58
Seizure Disorders
*Consists of brief paroxysmal behavior caused by excessive discharge of neurons*
Classification of seizures
\> Generalized
\* Tonic, clonic, and tonic-clonic (grand mal seizure)
\* Atonic
\* Myoclonic
\* Absence (petit mal seizures)
\* Focal
\> aware of impaired awareness (which you make mistakes)
\* Unknown
59
\_\_ phase - generalized stiffness of muscles
\_\_ phase - symmetric and rhythmic; alternating contraction and relaxation of major muscles; respirations irregular; incontinence
tonic
clonic
60
\* Tonic-clonic seizures cause abrupt arrest of activity and impairment of consciousness
\* Post-ictal phase - follows a tonic-clonic seizure - period of confusion, lethargy, sleep
Febrile seizures
\* Simple or complex
\* Temperature elevated above 102°F
\* Seizure occurs during temperature *RISE*
*\** Caused by otitis media, pharyngitis, or adenitis
61
Simple or Complex ?
\* \<15 minutes
\* 1 sz in 24 hrs
Simple (generalized)
62
Simple or Complex ?
\>15 minutes
\>1 sz in 24 hrs
Complex (focal)
63
Seizure Disorders - Therapeutic management
*Goal is to identify and correct cause of seizure, eliminate the seizure with minimum side effects in the least amount of medication, and normalize the child's and family's life*
\* Anti-epileptic medications
\> Numerous side effects
\> CBC, liver enzymes, and medication levels must be monitored closely
\* Ketogenic diet
64
?
\> Delivers electrical impulses to the brain at regular intervals through an implanted generator
\> Side effects include
- Tickling sensation in throat
- Change in voice tone during stimulation
- Slight coughing during stimulation
- Vocal cord paralysis (rare) and infection of generator site
Vagus nerve stimulation (VNS)
65
Seizure Disorders - Medications
?
Used for generalized or focal seizures
Side effects include drowsiness, dizziness, nystagmus, N/V, ataxia
Nursing implications - adjust dose according to renal function
Gabapentin
66
?
Used for focal or generalized seizures
Side effects include sedation, cognitive deficits, behavior outbursts, weight gain, leukopenia
Nursing implications
- Watch for behavior or decrease in school performance
- Avoid erythromycin
- Monitor blood tests for therapeutic levels
Carbamazepine
67
?
Focal, generalized, or status epilepticus
Side effects include lethargy, nystagmus, ataxia, allergic reactions, hypertrophic gums, hirsutism, osteoporosis
Nursing implications
- Teach meticulous oral care to decrease gum hypertrophy
Phenytoin
68
?
Generalized or focal seizures; broad spectrum use
Side effects include a rash, dizziness, headache, double vision, N/V, ataxia
Lamotrigine
69
Guidelines for child or adolescent taking seizure medication
\* Stress importance of oral care especially when taking phenytoin
\* Dentist appointment every 3-6 mos
\* Monitor blood levels frequently
\* Never stop taking anti-epileptic medication abruptly
\* Birth control pills may be less effective
\* Review side effects of medications
\* Alcohol, marijuana, and street drugs should be avoided
\* Contact sports like football and wrestling are not advised
\* Showers preferred over baths
\* Report any symptoms of depression to physician
\* Maintain a seizure diary
\* Call 911 if seizure does not resolve after 5 minutes
\* Wear a medical alert bracelet
70
Observations and nursing care during a seizure
\* Time the seizure
\* Describe how long seizure activity lasts
\* Protect from injury, loosen clothing at the neck, turn child on the side
\* Remove obstacles away from the child, especially the head
\* Do not restrain the child or insert anything into the child's mouth
\* When the seizure is over, allow child to rest and record behavior
In neonates if movement is initiated by stimulus such as a touch it is probably a tremor
If movement cannot be stopped or controlled with gentle restraint or passive flexion, it's probably a seizure
71
?
An inflammation of the meninges of the brain resulting from pathogens entering the brain
Most common infectious process affecting the CNS
Occurs as a primary disease process OR complication of neurosurgery, systemic infection, sinus or ear infection
Meningitis
Early diagnosis and prompt antibiotic therapy reduce morbidity and mortality
72
Meningitis - Manifestations: Vary according to age...
**Neonates**
\> Poor feeding; poor sucking; vomiting; diarrhea; poor muscle tone; weak cry; hypothermia or hyperthermia; apnea; seizures; sepsis; DIC; a full and tense bulging fontanel; and lethargy
**Infants and preschoolers**
\> Fever; poor feeding; vomiting; irritability; seizures; high-pitched cry; bulging anterior fontanel; lethargy
**Children and adolescents**
\> Severe headache; photophobia; nuchal rigidity (neck stiffness); fever; altered LOC; decreased appetite; V/D; agitation; drowsiness
\* Muscle or joint pain
\* Purpura
\* _Kernig_ sign and _Brudzinski_ sign present (boths signs of meningeal irritation)
\* Late signs = include decreased LOC and seizures
73
?
Flexion of the hips and knees in response to neck flexion
Brudzinski's sign (Brudzinski's neck sign)
74
?
Resistance to extension of the leg while the hip is flexed
Kernig's sign
75
Meningitis - Diagnostic evaluation
\* Testing CSF - increased CSF pressure, cloudy CSF with bacterial meningitis, high protein concentration and low glucose level
Therapeutic management
\* Acute bacterial meningitis - medical emergency
\* Private room
\* Droplet transmission precautions
\* IV antibiotic therapy
\* Monitor peak and trough antibiotic levels
For neonates = ampicillin and aminoglycoside or a third-generation cephalosporin
Older children and adolescents = ampicillin, penicillin G, or third-generation cephalosporin
\> Immunization with meningococcal vaccine
\* Ages 11-12 years and a booster dose at 16 yrs
\* Or by the age of 23 if previously unvaccinated
76
?
Autoimmune neurologic disorder of the peripheral nervous system
\> Rapidly progressing limb weakness
\> Loss of DTRs
\> Acute demyelization of the nerves
\> May originate as a viral infection or reaction to the influenza vaccine
Guillain-Barré Syndrome (GBS)
77
Guillain-Barré Syndrome - Manifestations
\* Limb paresthesia and/or pain
\* Autonomic instability
\* Cranial nerve dysfunction
\* Respiratory failure
\* Neuromuscular impairment
Guillain-Barré Syndrome - Therapeutic management
\* Spontaneous recovery within 2-3 wks
\* For rapidly progressing paralysis - treatment with high dose IV immunoglobulin for several days
\* Respiratory support is critical
78
Headache
International Headache Society has published criteria for classifying headaches:
?
\> Pain is more generalized
\> Band-like tightness or pressure
\> Tight neck muscles
\> Sore scalp
?
\> Mild to incapacitating
\> Depression and anxiety may co-exist
\> Aura may precede headache onset
Tension-type headaches
Migraine
79
?
* Related to administration of aspirin to children with a viral disease*
- Viral agent leads to liver cell damage and rising serum ammonia levels
Reye Syndrome
80
Manifestations
\* Antecedent viral infection, malaise, N/V, progressive neurologic deterioration
\* Elevated serum ammonia levels, liver dysfunction with biopsy, hypoglycemia, altered coagulation times, increased ICP with respiratory dysfunction
Nursing considerations
\> Hospitalization
\> Continuous neurological and cardiorespiratory monitoring
\> Fluid replacement
\> Protect from coagulopathy-related injury
