UNIT 4 NEURO Flashcards
1
Q
What famiy hx would be important when doing a neuro assessment?
A
Family hx of…
1. Intellectual & developmental disability
2. Deaf/blind
3. Epilepsy
4. Stroke
2
Q
What health hx would be important to gather during your neuro assessment?
list 5.
A
- Injury w/loss of consciousness
- Febrile illness
- Encounter with animal or insect (rabies, Mosquitos)
- Ingestion of neurotoxic substance (tiki torch fluid)
- Past illness (Time Frame important esp. after having a viral infection)
3
Q
During our physical exam portion of a neuro exam what features/structures are we looking at or observing for?
A
- Size/shape of head
- Awake & alert vs. drowsy/lethargic
- Activity
- (spontanous or only responsive to certain stimuli)
- Tone
- Hypertonic vs. hypotonic
- Symmetry
- Movements equal and bil?
- Facial features
- Can clue us into different syndromes
- High-pitched cry “Neuro cry”
- Respiratory Pattern
- Periods of apnea? or hyperventilation?
- Muscular activity/coordination
- Twiching or ticks? Unusal movements?
- Reflexes/strength
4
Q
What is our earliest indicator of improvment/deterioration?
A
Level of consciousness
5
Q
True or false: It important in neuro to know what the patients “baseline” is?
A
true
6
Q
What are the purpose of coma scales?
A
- quick, practical, standardized system to assess LOC
7
Q
True or false: Assessing impairment in infants and very young children is no harder than assessing an adult patient. Just more time consuming?
A
False. It can be very problematic to assess infants and very young children.
There are pedicatric coma scales for ages 2 and younger for this reason
8
Q
When reassessing the neuro status at the end of a shift a good practice is to…
A
Grab the TPCN taking over and do together so that there is consistency and agreement when transferring care
9
Q
Who can we utilize when using a pediactric coma scale when we suspect the child may be acting different due to unfamiliarity of the situation?
A
Parents– family at bedside can be very helpful in determining if a seen behavior is a patients baseline before or not
10
Q
What is the most commonly used coma scale?
A
Glasgow Coma Scale (GCS)
11
Q
What 3 parts does the GCS examine?
A
- Eye opening
- Verbal response
- Motor
Uses best response
12
Q
What makes a pediatric coma scale different than an adults coma scale?
A
The pediatric coma scale takes in consideration the different motor and verbal responses
13
Q
How is the GCS graded?
A
Number scale
Highest grade is a 15 and lowest is a 3.
14
Q
A GCS score of 8 or less is typically accepted as…
A
Coma
15
Q
A GCS of 3 would indicate….
A
Lowest score: Deep coma/Death
16
Q
If its under 8 we….
A
Intubate
17
Q
Just review: Eye opening responses for all ages on the GCS… how are the scored
A
4: Spontanous
3: Too speech
2: To pain/pressure
1: None
18
Q
Just review
Verbal responses using the GCS are graded how for child/adult?
A
5: Oriented
4: Confused
3: Inappropriate words
2: Incomprehensible
1: None
T: Endotracheal tube or trach
19
Q
Just review
Verbal responses on the GCS are graded how for children less than 2 years old?
A
Biggest take away: Are they doing things developmentally appropriate for their age?
5: Coo’s, babbles, smiles
4: Irritable cry, consolable
3: Inappropriate crying/screaming
2: Moans/grunts
1: None
20
Q
Just review
Motor responses on the GCS are graded how for child/adults?
A
6: Obeys commands
5: Localizes pain
4: Flexion withdrawl
3: Flexion abnormal
2:extension abnormal
1: None
21
Q
Just review
Motor responses on the GCS are graded how for children less than 2 years old?
A
6: Spontaneous/purposeful
5: Withdrawls to touch
4: Withdraws to pain
3: Flexion abnormal
2: Extension abnormal
1: None
22
Q
When assessing pupils what are we looking for?
A
- Size using the pupil scale 1-8mm or a pupillometer
- Reaction… noting if
- brisk
- sluggish
- no reaction
- eyes closed by swelling
23
Q
If pupils are fixed and dilated for longer than 5 mins this could inidcate….
A
brain stem damage which is an emergency situation
24
Q
Certain medication like…._____ can cause pinpoint pupils…
A
Barbiturate poisioning
25
What could cause pin point pupils?
1. Certain medications
2. Heavily sedated vent patients
26
What medication can cause the pupils to dilate?
1. Atropine
27
True or false: unequal pupil size is a red flag of a neuro emergency and a HCP should be notifed immediately?
True
28
When assessing a childs pupils you notice that one pupil has become fixed and dilated you recongize as the nurse that this......
A neuologic emergency... we will remain with the child and notify the HCP via vocera.
29
A child experiencing an neruologically emergency whose pupil has been fixed and dilated is at high risk for?
Resp. Arrest
30
What the two types of posturing?
1. Decorticate (Flexion)
2. Decerebrate (extension)
31
What is decorticate (flexion) posturing?
It is the dysfunction of the cerebral cortex ABOVE the brainstem
Decorticate: Think de**"cor"**ticate bring arms into **core**
32
What is decerebrate (extension) posturing?
Dysfunction at the midbrain/brainstem
Worse than decorticate
De"cere"brate thing cerebellem... and de and away.. so away from brain...
33
Where are you going to see the biggest difference in what type of posturing a child is experiencing?
Upper extremities
34
True or false: Posturing is present even when a child is resting?
False-- It is not alway present when the child is resting... most often present when the child becomes stimulated
35
When assessing a child you notice posturing on only one side of the body... your next action is...
The is a neurlogical emergency. Usually means the child is heirniating... notify HCP immediately.
36
The brain accounts for ____% of the craniums total volume
80
37
CSF accounts for _____ % of the craniums total volume
10
38
Blood accounts for _____% of cranial volume?
10%
39
40
A change in one of the 3 components of the craniums total volume must be.....
Compensated by a change in another to maintain a constant volume and pressure
41
____ fontenals allow for more compensation?
Open
42
Common ICP patients include
1. Head trauma
2. Brain bleeds
3. Hydrocephalus
4. Cerebral edema
43
Increased ICP clinical manifestations typically present as...
Subtle to more pronouced as the pressure increases
44
What are generalized s/s of increased ICP
1. Headache
2. vomiting
3. personality changes
4. Irritability
5. fatigue
45
What are s/s of increased ICP in infants?
List 10
1. Tense, bulging fontanel
2. seperated cranial sutures
3. irritable and restless
4. Drowsy
5. Increased sleeping
6. High-pitched cry
7. increased head circumference (FOC)
8. Distended scalp veins
9. Poor feeding
10. Setting sun syndrome
46
What is setting sun syndrome?
Causes eyes to rotate downward
47
How often is the FOC measured?
DUring inital assess. each shift or more often depending on orders or if the status of child changes
48
What are s/s of increased ICP in children?
1. Headache
2. Nausea
3. Forceful vomiting
4. Diplopia, blurred vision
5. Seizures
6. indifference, drowsiness
7. increased sleeping
8. inability to follow simple commands
9. Lethargy
49
What are late s/s of increased ICP in infants and children?
1. Bradycardia (Serious... at this point you need to be moving faster)
2. decreaed motor response to command
3. Decreased sensory response to painful stimuli
4. Alteration in pupil size and reactivity
- as the pressure increases the pupils will become more sluggish and eventually progress to fixed and dilated
5. Posturing (flexion or extention)
6. Altered resp. pattern
7. Decreased consciousness which will progressively deterioriate
8. Coma
50
What are some indication for invasive ICP monitoring?
1. GCS 8 or lower
2. GCS of 8 with resp assistance
3. Traumatic brain injury with abnormal CT
4. Deterioration of condition
5. Subjective judgement by neurosurgeon
51
Which ICP monitoring site is considered gold standard?
Ventricular-- esp for extremely increased ICP- able to place catheter down into the ventricles and able to connect that to a drainage device with a transducer to monitor
52
What should we know about the intraparenchymal ICP monitor site?
by draining off some of the cerebral spinal fluid we are able to lower ICP temporarly
53
Nursing care for children with increased ICP include
1. Familiarity with the monitoring and drainage system and insertain procedure
- sometimes Done at bedside in emergent situations
2. Monitoring and interpreting readings and patient symptoms
**2. Mannitol
3. Hypertonic saline**
**4. Positioning
5. Pain control**
6. Environmental maintenance/minimal stimulation.
7.** Sedate/paralizye**
8. Continual observation of LOC, Pupils and VS
**9. Suction only as needed
10. Thermoregulation
11. Bowel elimination
12. Eye lubercating ointment
13. Room set up***
Bolded are asked talked about later in slides.
54
What medications might be used in the nursing care of increased ICP?
1. Mannitor: osmotic diuretic used to decrease ICP. Works quickly within 1-5 mins and is rapidly excreted by the kidneys so it carries lots of sodium and water with it. CAUTION: HYPOVOLEMIC RISK
2. Hypertonic solutions: Increases sodium level and pulls fluid into the vascular system. MOst helpful in patients who are hypotensive and hypervolemic
55
What positioning techniques might we use in our nursing care to help decrease ICP?
1. Elevate HOB and keep head MIDLINE to help facilitate venous drainage
56
Why is pain control important to increased ICP?
If you are hurting your ICP is elevated. If we can control the pain we can work on bringing down the ICP
57
What can we have a family member do to help try and bring down ICP?
Sometimes a family member just placing a hand on the patient can soothe them and decrease the ICP. If we utilize this method it is important that we teach the family member not to rub.. as this could stimulate and increased ICP
58
What sedation/paralytic medication might we use when caring for a patient with increased ICP?
1. Midazolam (sedative
2. Fentanyl(sedative+ analgesic)
3. Vecuronium (paralytic)
These medications are used to help keep child in a relaxed state
59
Never use a paralytic without a....
sedative
60
When a child with increased ICP is intubated you should suction when?
ONly when neccessary
61
Why is thermoregulation important in the nursing care of a patient with increased ICP?
These children are typically hyperthermic and dont normally respond to antipyretics so we must cool them with other methods.. body working harder could increase ICP
62
What are other methods of cooling a patient with increased ICP? and what must you be careful about when cooling a patient?
1. Cooling blankets
2. Ice packs
Avoid cooling the patient to the point they start to shiver as this will have defeted the purpose
63
Why is bowel elimination important in the nursing care of a patient with increased ICP?
We want to avoid having the child strain as this can increase ICP. They may become constipated so we should see about getting them a stool softner or enema
64
Why is eye lubercaiting oinment important in the care of a patient with increased ICP?
Important esp. for the kids that are intubated and sedated. Eyes tend to dry out quickly... so we want to alternate artifical tears w/lubercants
65
Why is room set up important in the care of a patient with increased ICP?
Important to make sure that you have all the equipment you need and that it works properly in case of an emergency
66
What is a head injury?
Damage to brain or surrounding structures
67
Head injuries can occur as result of.... list 3
1. Fall
2. MVC
3. Bike accidents
68
Why are infants & young children at highest risk for head injuries?
1. Large head compared to their body
2. Immature neck muscles
3. Thin skill bones
4. Fontanels (open fontenal open brain)
69
What are s/s of a minor head injury?
1. may have loss of consciousness
2. Temporary confusion
3. Lethargy
4. Drowsiness
5. Irritablility
6. Pallor
7. Vomiting
70
What are s/s that a head injury is progressing from minor to severe?
1. ALtered mental stauts
2. Increased agitation
3. Marked changes in VS
Bradycardia is a late and dangerous sign
71
What are s/s of a severe head injury?
1. Signs of increased ICP
2. Bulging fontenel(s)
3. Retinal hemorrhages
4. Pupillary changes
5. Hyperthermia
6. Unsteady gaint
7. Seizures
8. Posturing
9. Resp depression
72
How is a head injury diagnosed?
1. History and physical
- Preexisting conditios: Bleeding disorders could put children at higher risk
2. History of injury.... if it doesnt make since investigate
3. Assessment of ABC's, then neuro
4. Baseline vitals
5. Radiography exams
73
What diagnostic exams can be done to determine a head injury?
1. x-ray: confirms fractures
2. CT: R/o bleed
3. MRI: typically not done initally... if we need structural details we may come back for one
74
When the brain strikes the skull what is the point of impact called?
Coup
75
When the brain strikes the skull the point of impact is called the coup. What is the injury opposite from impact called?
Contrecoup
76
What is acceleration and deceleration in head injuries?
Acceleration: Stationary head recieves blow (blunt hit like a baseball to the head)
Deceleration: Head in motions comes to abrupt stop (car accidents, falls)
77
How do you recieve a skill fracture?
Direct blow or injury to skulll associated with a intracranial injury
78
What are the most common causes of skull fractures?
Falls
In children younger than 2 yo these fractures usually occur from falling from a short distacnce
79
What does it mean when they say kids have a more flexible skull than an adult?
It takes a greater amount of force to fracture their skull so anytime there is an infant with a skull fracture it is a huge red flag
80
What is a basilar skull fracture?
Facture to the bones at the base of the skull...
1. Ethmoid
2. Sphenoid
3. Temporal
4. Occipital
This type of fracture typically results in a dural tear and is considered a serious injury due to the proximity to the brainstem
81
Why is a basilar skull fracture a serious injury?
Due to its proximity to brianstem
82
Children with a basilar skull fracture at higher risk of...
developing an infection... recommended to get pneumovax prophalactically
83
What are some s/s of a basliar skull fracture?
1. Battle sign: Subcutaneous bleding in the back of the neck area kinda over the mastiod process
2. Bleeding around the eyes "racoon eyes"
3. Bleeding behind the tempanic membrane "hemotempanum"
4. Cerebral spinal fluid leaking out from ears/nose
84
What is a quick way to test draininage from ears or nose for CSF?
Glucose test...
Halo sign is also a good indicator
85
What are some complications of head injuries?
1. Hemorrhage
2. Infection esp. with open injuries
3. Edema-- can peak 24-72 hours post injury
4. Herniation-- r/t compression of the brain... this can be fatal quickly
86
What is the patho of a epidural hemorrhage?
1. Blood accumulates rapidly between the skull & dura
2. Formation of a hematoma
3. Froces brain tissue downward and inward
Because bleeding is generally arterial the brain can be compressed pretty rapidly parital and temporal region are most common
87
Is an epidural bleed venous or arterial blood?
Arterial
88
What should we know about the meningeal artery in an epidural hemorrhage?
1. It becomes embedded into the skull itself so a break in that bone can tear the artery which causes the arterial bleed.
2. However, this is not often seen in kids under 2 since it not yet embeded into bone.
89
What are the classic signs of an epidural hemorrhage?
1. Momentary unconsciousness followed by a normal period
2. Few hours later they will have an altered mental status and become lethargic or end up in coma
If not recognized it can progress rapidly and cause dealth
90
True or false? Classic signs of an epidural hemorrhage are not often evident in children?
True
They frequently have no unconscious period instead their normal period frequently has symtoms
91
Since children do not experience the classic signs of an epidural hemorrhage what signs might we expect to see?
1. Irritability
2. Headache
3. Vomiting
4. pallor
5. buldging fonanel
92
How is an epidural hemorrhage detected?
CT SCAN
93
What is the patho of a Subdural hemorrhage?
1. Vascular injury that leads to
2. Bleeding between the dura and cerebrum
3. Spreads slowly through the dural space
Spreads more around brain because it is inside the dura... this is a venous bleed... which bleeds more slowly
94
What are the presenting sings of a subdural hemorrhage?
1. Irritability
2. Vomiting
3. Increased FOC
4. Bulging anterior fontanel (infant)
5. Lethargy
6. Coma
7. Seizure
95
True or false: Infants with open fontenals can lose alot of blood and end up in shock before we ever see any neuro changes?
True
96
Anytime a child comes in with a subdural hematoma and retinal hemorrhages we should?
Evaluate for possiblilty of child abuse indicative of abusive head trauma
97
What is the treatment of a subdural hematoma?
1. Observation
2. Subdural taps infants
3. subdural drains
4. burr hole
5. surgical evacuation of hematoma
98
What are some general therapeutic management measures we can take for MILD head injuries?
| Think least invasive
1. Cared for/observed at home
2. Family education on what to watch for and when to bring them back in
3. Watch for signs of SIADH
99
What are some general theraputic management measure we can take for SEVERE head injuries?
1. Admitted for observation/treatment
2. possible prep for surgery
100
What are some general theraputic managment measures we can take for any severity of head injuries?
1. Rehab for residual symptoms
2. Comfort care and consults
Sometimes head injuries are going to be so severe that the only thing they can offer is comfor care because the child will not be able to survive
101
What age range is at the highest risk of a submersion injury?
0-4 years old
102
Where can submersion injuries occur?
1. Bathtub
2. bucket
3. swimming pool
4. lakes,ponds, rivers, oceans
103
What should we know about bathtub submersion injuries?
1. Most common in 1 years old and younger
2. Teach parents not to leave child unattended for any amount of time.
104
What should we know about submersion injuries that occur in a bucket?
1. Only takes 1 inch of water to drown
2. Toddlers at most risk due to being so top heavy
105
What should we know about submersion injuries that happen in swimming pools?
| age group?
1. Most common in preschool age and up
106
What age group do we see most of the submersion injuries caused by lakes, ponds, rivers, oceans?
1. Adolecents
107
What three adverse effects are we worried about with submersion injuries?
1. Hypoxia
2. Hypothermia
3. Aspiration
108
Hypoxia related to a submersion injury can happen within...
minutes
109
What happens when a child suffers hypoxia r/t a submerssion injury?
| Patho like anwser?
Lack of oxygen ---> loss of consiciousness ---> progressive decline of cardiac output----> leads to apnea/cardiac arrest
110
Time it takes for Irreversible damage from hypoxia r/t submersion injury occurs...
after 4-6 mins
Heart & lung can survive up to 30 mins
111
Aspirated fluid quickly absorbed in the pulmonary circulation results in...
R/T subermersion injuries
1. Pulmonary edema
2. Atelectasis
3. Airway spasms
All of which aggravates hypoxia.. Doesnt matter how much fluid is aspirated
112
Who is at most risk of developing hypothermia as a results of a submersion injury?
1. Children due to their large surface area, decreased subq fat and limited thermoregulation
113
What is the driving reflux?
Cold water decreased the metabolic demands and activates the diving reflex which shunts blood away from the peripheray and toward vital organs
114
What is our priority when treating submersion injuries?
Retore oxygen delivery/prevent futher damage
115
How do we treat submersion injuries?
1. Airway
- Even if spontanous respiratory effort happens we will still apply o2
- No spontanous resp. effort we will intubate as they may require mechanical ventilation
2. ABG's
3. Rewarm if hypothermic
4. monitor for/treat seizures-- can happen due to hypoxia and cerebral edema... treat quickly seizures consume alot of oxygen and can worsen condition
5. Monitor blood glucose
- hypo or hypo can be harmful to the brain
6. IVF- Correct electrolyte imbalances
7. Admit to PICU
116
What are some complications r/t submersion injuries?
1. Respiratory compromise
2. Cerebral edema
3. Aspiration pneumonia
4. Other: Bronchospasm, alveolar-capillary membrane damage, atelectasis, abcess formation, acute respiratory distress syndrome
117
In submersion injuries when is respiratory compromise pose the highest risk (timeframe)
Highest risk is between 4-8 hours but can happen up to 24 hours after incident
118
In submersion injuries when are kids most at risk for developing cerebral edema?
| Time frame
Highest risk: 4-8 hours and up to 24 hours after incident
119
In submersion injuries when are kids at most risk for developing aspiration pneumonia as a complication? (timeframe)
48-72 hours after incident
120
What is the prognosis of a submersion injury?
Best outcome: Submersion less than 5 mins with sinus rhythm, reactive pupils and neuologic responsivemess at the scene
Worst outcome: Submerssion longer than 10 mins & unresponsive to advanced life support within 25 mins
All children w/o spontaneous, purposeful movement and normal brainstem function 24 hours after submersion injury suffered severe neuologic deficts or death
121
How can we prevent submersion injuries?
1.Adequate supervision
2.Pool covers, fencing, lifegaurd
3.Basic CPR skills, water safety/survival training
122
What is bacterial meningitis?
1. Inflammation of the membranes covering the brain and spinal cord
MEDICAL EMERGENCY
123
What is the patho of bacterial meningitis?
1. Bacteria invades from a focus of infection
2. Bacteria crosses the blood brain barrier (BBB)
3. Spreads into the CSF and subarachnoid space
4. Brain swells
5. Brain surface is covered with purulant exudate
6. Infection spreads to ventricles
7. Pus may obstruc narrow passages
8. Obstruction of CSF
124
What are the s/s of bacterial meningitis in infants/young child?
1. Fever/hypothermia
2. poor feeding
3. vomiting
4. marked irritability
5. restlesslness
6. Seizures
7. bulging/tense fontanel
8. high pitched cry
125
What are s/s of bacterial meningitis in older children and adolescents?
Abrupt onset or may take 1 to several days to appear
1. Fever/chills
2. headahe
3. vomiting
4. altered mental status
5. lethargy
6. irritability/agitation
7. nuchal rigidity (neck stiffness)
8. Poor perfusion
9. May develop: seizures, photophobia, confusion, hullucinations, agressive behaviors, drowsiness, stupor, coma
126
How do you test for a postive Kernig sign?
1. Child is supine
2. Flex the knee
3. Extend the leg at the knee
4. Resistance or pain in hamstring indicates a postive Kernig sign
127
How do we test for a positve Brudzinski sign?
1. Flex head while in supine postion
2. If the knee or hips flex involuntary this a postive result
128
How is bacterial meningitis diagnosed?
Lumbar puncture
Sometimes done under moderate sedation but sometimes just given versed and fentynal
129
Where is the needle inserted in a lumbar puncture?
1. L3-L4 or L4-L5 vertebral spaces into subarachnoid space
130
What is the purpose of a lumbar puncture in bacterial miningitis?
1. Measure CSF
2. Collect CSF sample for culture and gram stain
131
What is a contraindication of doing a lumbar puncture?
Increased ICP- risk of herination if pressure is released to quickly.
132
How do you prep for a lumbar puncture?
1. Obtain consents
2. Educate family
- most common questions-- Will it hurt or will i become paralyzed as a result of this procedure.... inform them that sedation can help with pain and the needle is inserted below the spinal cord which decreases risk of paraylis. More risky not to do procedure than to not.
3. EMLA?-- sometimes done emergent and wont have time
4. Lidocaine locally
133
What are the anatomical landmarks for the lumbar puncture?
Locate top of illiac creast and draw line straight up
134
How do you position a child for a lumbar puncture?
1. Close to edge of exam table
2. Side-lying (infants and small children)
3. Bedside table (children & adolescents)
4. Head flexed
5. Knees drawn up toward chest
6. Immbolize childs spine in flexed position
135
CSF Analysis of bacterial meningitis.... the WBC will be
Elevated
Increased neutrophils
136
CSF analysis of Viral meningitis ... the wbc will be...
slightly elevated
increased lymphocytes
137
The CSF analysis of Bacterial meningitis will have protien counts that are....
elevated
138
The CSF analysis of viral meningititis will show protient counts as...
normal or slightly increased
139
The CSF analysis of bacterial meningitis will show glucose content as...
decreased
140
The CSF analysis of viral menigitis will show glucose content that is
normal
141
The CSF anaylsis of bacterial meningitis will show a gram stain bacterial culture that is.....
postive
142
The CSF analysis of viral meningitis will show a gram stain bacterial culture that is
Negative
143
The CSF fluid will be what color in bacterial meningititis?
Turbid or cloudy
144
The CSF color will be.... in viral meningitis?
Clear
145
What are acute long term complications of bacterial meningitis?
1. SIADH
2. Cerebral edema/herniation
3. Subdural effusion
4. Seizures
5. Septic shock
6. Disseminated intravascular coagulation
7. Hydrocephalus
146
What are some long-term complications of bacterial meningitis?
1. Deafness-- most common
2. Hydrocephalus
3. Cerebal palsy
4. Cognitive impairments
5. Learning disorders
6. ADHD/Hyperactivity
7. Seizures
147
What is unique about meningococcal meningitis?
Purpalic rash
148
How are we going to treat bacterial meningitis?
1. Isolation-- on iso protocols until meningitis is ruled out or for a set time.
2. Antibiotics
- Typically broad specture until culture comes back and organism is identifed. May or may not switch depending on those results
3. Maintain hydration
4. Manage airway and shock
5. Reduce ICP (Raise HOB, keep midline)
6. Seizure control
7. Thermal regulation
149
Nursing care of bacterial meningitis includes?
1. Minimal stimulation
2. position of comfort
- Obastagnose position help relieve pain
3. pain management
4. ensure safety
5. family support
150
The prognosis of bacterial meningitis is dependant on...
1. Time from onset to antibiotic therapy
2. Type of organism
3. Prolonged/complicated sizures
4. Low CSF glucose
151
Who has the highest mortality rate for bacterial meningitis?
Pneumococcal meningitis and infants less than 6 months
152
How can we prevent bacterial meningitis?
1. Vaccination
- Haemophilus influenzae type b (HIB), pneumococcal, meningococcal
153
What are the patient outcome goals for bacterial meningitis?
1. Early reogniation
2. Antibiotics-- ASAP after obtaining usually within the hour
3. Prevent cerebral edema
4. Prevents spread (isolation) DROPLET
5. Manage symptoms
6. Prevent neuologic complications
154
What are the clinical manifestations of nonbacterial (aspetic) meningitis
AKA Viral meningitis?
1. Headahe
2. Fever
3. Photophobia
4. Nuchal rigidity
155
What virus is a common cultrupt of viral meningitis?
Entero Virus
156
How is viral meningitis dx?
1. Clinical manifestations
2. CSF finding
3.
157
How do we treat viral meningitis
Primarly symptomatic
1. Acetaminophen
2. Hydration
3. Positioning for comfort
4. Possible antibiotics/isolation until definitive dx.
Antibiotics d/c once they rule out bacterial meningitis
158
What is Reye's syndrome?
Acute illness causing encephalopathy & liver dysfunction
159
Reye's syndrome is characterized by?
1. Fever
2. Impaired consciousness (profoundingly impaired)
3. Liver dysfunction
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How is Reyes syndrome diagnosed?
1. Liver biopsy
Cerebral edema and fatty changes in live are s/s
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What causes Reye's syndrome?
1. Usually follows a viral infection
2. Flu and varicella are known culprets
3. Asprin
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What is the nursing managment of reye syndrome?
1. Manage ICP (cerebral edema risk)
2. Accurate/frequent monitoring of I&Os- adjust fluids according to prevent cerebral edema but still preveniting dehydration
3. Lab studies
- Impaired coagulation r/t liver dysfunctions
4. Family support/teaching
- avoid salicylate medications (asprin/pepto)
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Reyes syndrome recovery is usually?
Rapid with no long term complications
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Increased ammonia levels+ cerebral edema + increased ICP is worst out come for....
Reyes syndrome-- risk of death increased
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True or false: It is important to ask patient about factors that may have precipitated seizures and what postical feeling and behaviors they had?
True
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What diagnostic tests might we see ordered or done for a patient with seizures?
1. Lab studies- drug toxicity, glucose, ammonia levels
2. Lumbar puncture to r/o infection
3. CT or MRI to r/o cerebral hemorrhages/tumors
4. EEG- confirms abnormal electrical discharge and what part of the brain
5. Split Screen EEG- Tracing + video on child because sometimes you may have seizures w/out being able to physical see them
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what do we need to know about neonatal seizures?
1. Usually a clinical manifestation of serious underlying disease
- Typically, hypoxic ischemic encephalopathy
- Rarely, well organized tonic-clonic seizures
2. Clinical manifestions subtle in newborns
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Treatment infludes what for neonatal seizures?
1. Treat underlying cause
2. Resp. Support
3. Medication
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What is is an infantile spasm?
1. Sudden, brief, symmetric muscular contractions that occur in clusters
2. May have altered consciousness
3. Over time, seizure activity increases in severity
4. Regression of developmental milestones
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What is the common time frame for infantile spasms?
1. 1st 4-8 months usually stops at age of 2
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Why is it important to gain control of infantile spasms quickly?
Can decrease the risk of intellectual disabilities and decrease the mortalilty rate
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What is a febrile seizure?
1. Most common seizure type
2. Associated with febrile illness without CNS infection
3. No hx of afebrile seizures, temp at least 38c, age 6-60months
4. Genetic/family history
5. Typically self-resolve
6. Parental education and support
7.
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What are clinical manifestations of neonatal seizures?
1. Frequent blinking
2. smaking of tongue
3. excessive sucking
4. chewing movements
5. spasms/jerky movements
6. lip smaking,
7. tongue thrusting
8. eye deviation
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What education can we provide for febrile seizures?
1. Ensure that parents know the correct dose of acetaminophen and tylenol
2. Inform patients to call ambulance if seizure last longer than 5 mins
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Safety percautions for seizures include?
1. If standing or sitting, ease to floor
2. Position on side
3. Protect from injury
4. Do not force anything in mouth
5. Do not try to forcibly stop the seizures
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What precautions for seizures should we take in the hospital?
1. Padded side rails
2. Child should not be left unattended
3. Oxygen set up with everything working and extension tubing
4. Suction set up-- making sure everything works and extension tubing is present
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What precautions should be set up for seizures at home?
1. Waterproof mattress or pad r/t incontience
2. Hard objects removed or padded
3. Showers prefered
4. Swimming with a compainion
5. use of protective gear
6. carry or wear med ID
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What is hydrocephalus?
Imbalance in production & absorption of CSF in the ventricular system.
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What is the etiology of hydrocephalus?
1. Often congenital
- Commonly associated with myelomeningocele
2. Complications of illness
- Meningitis
- Brain tumor
3. Complications
- Intraventricular hemorrhage
- Brain injury
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What are the two types of hydrocephalus?
1. Communicating/nonobstructive hydrocephalus
2. Non-communicating/obstructive hydrocephalus
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What is communicating/nonobstructive hydrocephalus?
Imparied absorption of CSF within the subarachnoid space
Ventricles communicate
Problem is outside the ventricular system
increased production of CSF or impairment of absorption of CSF
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What is non-communication/obstructive hydrocephalus?
Obstruction to the flow of CSF within the ventricles
Ventricles do not communicate
1. Developmental malformation: Myelomingeocele
2. Chari Malformation
3. Turmors, trauma (bacterial meningitis)
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How is hydrocephalus diagnosed in infants, older infants/ children?
Infants:
1. Head circumference
- Increase of at least 1 percentile line within 2-4 weeks
2. Progressive associated neurologic signs
Older infants/children
1. CT & MRI: Can show us that they have dilated ventricles
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What are the clinical manifestation of hydrocephalus when there is open fontanels & suture lines?
1. Rapidly increasing head circumference
2. Tense,full, bulging fontanel
3. Bulging scalp veins
4. Shrill, high-pitched cry
5. setting sun syndrome
6. Irritability or lethargy
7. Poorfeeding
8. Vomiting
9. change in LOC
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What are the clinical manifestations of hydrocephalus when there is a closed fontanel and suture line?
1. Headache upon awakening
2. Irritability or lethargy
3. Poor appetitie
4. Strabismus
5. Personaility change, apathy
6. Alterations in motor skills
7. Confusion
8. Vomiting
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How do we treat hydrocephalus?
Surgical correction
1. Remove obstruction if present
2. Placement of shunt
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What is the most common shunt placement?
1. Ventriculoperitoneal VP shunt
consists of
1. Ventricular catheter
2. flush pump
3. unidirectional flow valve
4. distal catheter
shunts are coiled to allow for growth
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Placement of a reservior requires....
Requires tapping of reservioir
Not Permenant
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Post operative VP shunt for the treatment of hydrocephalus care includes?
1. Position on non-operative side
- Keep flat initally
2. Assess for signs of increasing ICP
- Neuro checks
3. Monitor for infection
- Surgical sites & shunt tract
4. Pain management
5. FOC
6. Abdominal assessment
7. Family support
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Shunt malfunction is a VP shunt complication what do we need to know
Shunt malfunction which can cause s/s of increased ICP
Caused by kinking, plugging, serparation or migration of tubing which can lead to a mechanical obstructions such as
1. Particulate matter (tissue/exudate)
2. Thrombosis
3. Displacement as a result of growth
This will require a shunt revision
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Shunt infection is a complication of a VP shunt... what do we need to know about his complication
1. Most serious complication
2. Generally the result of an intercurrent infection at the time of placement
3. Treatment- MASSIVE doses of IV antibiotrics
4. For persistant infection
- Shunt removal
- placement of external ventricular drain (EVD)
- Continue IV antibiotics
- Daily CSF cultures until infection clears
- Replace VP shunt
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What are some alternatives to shunts used to tx hydrocephalus?
1. EVD
2. Endoscopic 3rd ventriculostomy
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Our discharge teaching of hydrocephalus should include?
1. Teaching to notify HCP immediately if
- Signs of shunt malfunction
- Signs of infection
- Seizures
2. Infants with large head & poor head control should not be placed in forward facing care safety seat regardless of age
3. Appropriate referrals: Helmet during play, no contact sports if severe
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What is cerebral palsy?
1. Nonprogressive impairment of motor function
- Muscle control, coordination, posture
- can have hearing impairments, speech impairments, seizure disorders, abnormal sensation and perception
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What is the leading cause of cerebral palsy?
1. Asphyxia at birth vs. prenatal brain abnormalities
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What are some prenatal causes of cerebral palsy?
1. Maternal infection
2. Maternal substance abuse
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What are some PERINATAL causes of cerebral palsy?
1. Nuchal cord
2. Ischemic stroke
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What are some postnatal causes of cerebral palsy?
1. Meningitis/encephalitis
2. MVC
3. Child abuse
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What are the 3 types of cerebral palsy?
1. Spastic
2. Dyskinetic
3. Ataxic
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What is spastic cerebral palsy?
1. Hypertonicity- muscle stiffness & permanent contractions
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What is dyskinetic cerebral palsy?
1. Abnormal movement-uncontrolled,slow writhing movements
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What is ataxic cerebral palsy?
1. Poor coordination, balance & posture
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What are some abnormal motor performance clincal manifestations seen in cerebral palsy?
1. Abnormal crawl
2. very early unilateral hand preference
3. standing or walking on toes
4. Uncoordinated/involuntary movements
5. Poor sucking/feeding difficulties
6. Persistent tongue thrust
More obvious as growth advances
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What alteration in muscle tone are manifestations of cerbral palsy?
1. Hypertonicity/hypotonicity
2. Opisthotonicposturing (arching of back)
3. Feels stiff on handling or dressing
4. Difficulty in diapering
5. Rigid & unbending at hip and knee joints when pulled to sitting position (early sign of spasticity)
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High risk populations for cerebral palsy?
Preterm
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What are some reflex abnormalities seen in cerebral palsy's clinical manifestations?
1. Persistent primitive reflexes
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What abnormal postures can be seen as a clincal manifestation of cerebral palsy?
1. Scissoring and extension of legs with feet plantar flexed in supine position
2. arms aducted at shoulders
3. elbows flexed, hands fisted
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True or false: A clinical manifestation of cerebral palsy is failure to meet developmental milestones?
True
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In cerebral palsy head lag and clenched 1st persist after
3 months
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What are some associated disabilities seen in children with cerebral palsy?
1. Seizures
2. cognitive deficits: Altered learning/reasoning
3. Behavioral problems
4. speech impairment
5. sensory impairment (vision/hearing)
6. Feeding issues/gastroesophageal reflux
7. orthopedic complications r/t contractures
8. constipation r/t meds
9. poor bladder control/urinary retnention
10. cavities, gingivitis
11. skin breakdown
12. chronic resp tract infection
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What are some oral meds that can decrease spasticity in cerebral palsy?
1. Dantrolene sodium
2. Baclofen
3. Diazepam
4. Gabapentin
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What are some injectable medication used to decrease spasticity in cerebral palsy
1. Botulinum toxin A(botox)
in targeted muscles in upper & lower extremeities
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What is a impantable medication that can decrease muscle spasticity in cerebral palsy?
1. Baclofen pump- tube inserted into the intrathecal space
Usually do a test dose..
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What other meds may be used in cerebral palsy?
1. Antiepileptic drugs
2. drugs to tx dystonia
3. drugs to tx hyperkenitic movement disorders
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What treatments may we see to help with mobilization in a child with cerebral palsy?
1. Ankle-foot braces/orthotics
2. wheelchairs
3. surgery
4. physical therapy
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What are our nursing interventions with cerebral palsy kids?
1. Airway
- airway needs to be clear of secreations to help prevent aspiration pneumonia
2. Monitor for seizures
3. admin antiepileptic drugs
4. dental care
5. bowl and bladder care
6. support therapy
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What should we know about hippo care?
1. helps physially, cognitively, increases attention, visual coordination, social interaction, self-esteem and hlep build core muscles.
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What is spina bifida?
1. failure of neural tube to close during early development of embryo
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What causes spina bifida?
Multifactorial
1. genetic
2. environment: Material drug use, radiation use, hot tub use,
3. syndromes- trisomi 18
Also associated with a folic acid dificiency
- Recommended 0.4mg daily for prevention 50-70% cases are prevented by this alone
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What are the 2 types of spina bifida and how are they "characterized"
1. Spina bifida occulta
- Not visible externally
2. Spina bifida cystica
- Visible externally
2 forms
- Meningocele or myelomeningocele/meningomyelocele
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What is Spina Bifida Occulta
Spinal vertabrae does not completely encase cord usually effects the lumbar and sacral areas of the spine
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Since the skin is closed in spina bifida occulta what else may be present to clue us in that the child may have spina bifida?
1. Skin dimple about gluteal cleft
2. tuff of hair
3. port wine nevi (redish rash)
4. Depression of skin
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What is spina bifida cystica meningocele?
Herniation of delicate sac containing spinal fluid that protrudes outside of the body but is NOT associated with neuro deficits
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What is spina bifida cystica myelomeningocele?
Herniation of delicate sac containing spinal fluid and spinal cord that protrudes outside of the body and IS associated with neuro deficits occuring in varying degress
80% develop type II chiari malformation
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How is a myelomeningocele dx
| Spina Bifida Cystica
1. Prenatal detection
- ultrasound
- Alpha fetoprotien done during 16-18 weeks gestation. can indicate a dx but it is not accurate after 18 weeks
2. Postnatal
- CT, MRI, ultrasound
- clinical manifestation
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What are some associated problems with a myelomeningocele?
- Hydrocephalus
- Pneumonia
- Paralysis and/or orthopedic deformities
- neurogentic bladder
- bowel incontinence
Really depends on where on the spine and the defiects is at on the spine
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What is included in preoperative care of a myelomeningocele?
1. Sterile, mosit, nonadherent dressing
- Normal saline
- Change every 2-4 hours
2. Incubator/warmer
- Caution can causes sterile dressing to dry out
3. Antibiotics prophalactically
4. Early detection of hydrocephalus
5. Assess sac for leaks, abrasions, irritation, signs of infection
6. Prevent fecal contamination
7. no rectal temps
8. monitor frontal-occipital circumerene (FOC)
9. Observe for CSF leakage
10. Prone position initally but done forget to provide tactile stimulation (keep pressure off sac)
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What position should we keep the child in with a myelomeningocele in preoperatively?
1. Hips slightly flexed
2. abduction w/pad between knees
3. small roll under the ankles
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Myelomeningocele- Post op care should include?
1. Routine postop care
2. Prone position initally to keep pressure off surgical site
3. monitor FOC
Encourage breastfeeding
4. No rectal temps
5. High risk for latex alleragies
6. Urinary/bowel independance
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What is anencephaly?
Most serious neural tube defect
Both cerebral hemispheres are absent
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What is the treatment of anencephaly?
1. No specific treatment for those who survive
2. A portion of the brainstem may be able to maintain vital functions for a few hours to several weeks before ultimately the baby passess
3. Treat symptoms
- Temp
- Cardiac function
- Resp function
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What is Guillain-barre syndrome
Autoimmune disorder affecting the peripheral nervous system resulting in a progressive, usually asceniding flaccid paralysis
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What is the hallmark symptom of GBS?
1. Acute peripheral motor weakness
2
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When does paralysis usually occur in GBS?
Occurs 10 days after a nonspecific viral infection
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What is the patho of GBS?
1. Viral or bacterial infection
2. Infalmmation & edema of spinal cord & cranial nerves
3. Rapid segmented demyelination of compressionof nerve roots
4. Impaired nerve conduction
5. Asending partial or complete muscle paralysis
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GBS affects what age groups the most?
4-10 yo
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What are the 3 phases of GBS?
1. Acute
- Symptoms begin
- continues until new symptoms stop appearing or deterioration ceases
- Can last up to 4 weeks
2. Plateau
- symptoms remain constant
- Few days to weeks
3. Recovery
- Improvement begins
- progression to optimal recovery can take few weeks to months
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How is GBS dianosied?
1. Clinical manifestations
- Ascending paralysis
- Acute peripheral motor weakness (symmetric)
2. CSF anaylsis
3. EMG findings (TENS UNIT)
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Treatment of GBS includes?
1. Airway support (may need trach or intubation if paralysis moves up neck)
2. IVIG
3. Plasmapheresis
- expensive and can cause hypotention but can help with recovery
4. stool softeners
5. GABAPENTIN
6. Rehab
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True or false: GBS effects the patient cognitively so you do not have to talk to your patient?
False-- they are cognitively away and scared so talking is encouraged
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What can contribute to best possible outcome for GBS?
1. Younger age
2. No mechanical resp. assistance needed
3. slower progression
4. normal peripheral nerve function (EMG)
5. Treatment with IVIG or plasmaphersis
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Recovery of GBS occurs...
in reverse order
rate r/t degree of involvement-- weeks to monthss
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