1
Q
Basic Structures of the Neurologic System
A
- Brain
- Spinal Cord
- Nerves
2
Q
Nervous System at birth…
A
complete but immature at birth
-infant is born with all nerves they will have
3
Q
Myelination of nerves
A
- incomplete until age 4 years
- progresses in a cephalocaudal direction
- responsible for progressive development of fine and gross motor skills
- need fat in diet for myelin
4
Q
Pediatric Differences and Risks for Neuro
A
- head is top heavy
- neck muscles weak
- thin cranial bones
-excessive spinal mobility, immature muscles and ligaments or cervical spine
5
Q
LOC
A
- most important indicator of neuro dysfunction
- conscious (awareness of stimuli)
6
Q
Altered Levels of Consciousness
A
- confusion
- delirium
- lethargy
- stupor
- coma
-in this order
7
Q
Confusion
A
slight disorientation to time, place, or person
8
Q
Delirium
A
restless, fussy, irritable
9
Q
Lethargy
A
-profound slumber, responds to loud commands, painful stimuli
10
Q
Stupor
A
-non-purposeful response to moderate stimulation, decorticate or decerebrate posturing
11
Q
coma
A
no response
12
Q
Causes of altered LOC
A
- infection of brain and meninges
- trauma
- hypoxia
- poisoning
- seizures
- DKA
- electrolyte or acid-base imbalance
- congenital structural defect
13
Q
Any of causes of altered LOC can result in..
A
- increased ICP
- decreased cerebral perfusion pressure
14
Q
increased ICP
A
force exerted by brain tissue, CSF, blood
15
Q
decreased CPP
A
amount of pressure needed to perfuse brain
16
Q
increased ICP can lead to…
A
decreased cerebral perfusion pressure
17
Q
Pediatric Glasglow coma scale
A
- 3 part assessment
- eyes
- verbal response
- motor response
- score 15: unaltered LOC
- score of 3: extremely decreased LOC; worst possible score on the scale
18
Q
Pediatric Neuro Assessment Guidelines
A
- LOC
- VS
- pain
- cognition
- head
- eyes
- neck
- posture/movement
- reflexes
- cranial nerves
19
Q
Bacterial Meningitis
A
- inflammation of the meninges
- newborns and infants at greatest risk
- higher morbidity and mortality than viral meningitis
20
Q
Newborns to 1 month
A
- group b strep
- e. coli
- listeria monocytogenes
21
Q
Over 1 month of age
A
- streptococcus pneumoniae most common
- neisseria meningitidis
- haemophilus influenzae type B
22
Q
Pathophysiology of Bacteria Meningitis
A
- often secondary to OM, sinusitis, pharyngitis, cellulitis, pneumonia, or brain trauma
- bacteria enter bloodstream “bacteremia”
- bacteria cross BBB and enter CNS
- inflammation occurs: WBCs accumulate and cover brain with purulent exudate
- brain swells can lead to increased ICP and hydrocephalus
23
Q
Clinical Manifestations
A
Classic Triad:
- fever
- nuchal rigidity
- HA or change in mental status
24
Q
Clinical Manifestations of Neonates
A
- nonspecific
- fever or hypothermia
- poor feeding or suck
- V/D
- fontanel bulging
- irritable or lethargic, weak cry
- poor tone
- seizures
25
Clinical Manifestations of Infants and Young Children
- fever
- vomiting
- nuchal rigidity
- opisthotonos
- bulging fontanel
- irritable or lethargic
- difficult to console
- high pitched cry
- seizures
26
Clinical Manifestations of Older Children and adolescents
- classic signs: fever, HA, nuchal rigidity
- photophobia, opisthonotonos
- positive Kernig and Brudzinski signs
- confusion, delirium, irritable, lethargic
- vomiting
- petechial rash
27
Diagnosis of BM
- based on hx, clinical presentation and labs
- lumbar puncture (LP)
- CBC, blood cultures, serum electrolytes and clotting factors, UA with C&S
- CT scan for increased ICP or suspected brain abscess
28
Antibiotic Tx of BM
- antibiotics administered as soon as blood, LP, urine obtained
- IV antibiotics for 7 to 21 days
- may be changed when culture results available
- contacts may need prophylactic antibiotics (Cipro or Rifampin)
29
General Tx of BM
- NPO, IVF (2/3 maintenance initially)
- Tx of increased ICP with mannitol and furosemide
- Tx seizures
- Tx shock to maintain CPP
- Tx fever/isolation
30
Nursing Management of BM
- Monitor VS, LOC, pupils, neuro status, I and Os, labs, ICP, CPP
- Assist with LP: position after LP, supine to prevent HA
- Seizure precautions
- Antibiotics, antipyretics
- measure head circumference
- promote comfort and quiet environment with minimal stimulation: reduce noise, light
- isolate first 24-48 hours
31
Sequelae
- most common: 8th cranial nerve, hearing loss
- seizures
- hydrocephalus
- developmental delay
- learning problems
- severe: septic shock, stroke, death
- EBP: study indicates that heparin and ASA may discourage stroke in pediatric bacterial meningitis
32
Preventative Measures for BM
- HIB vaccine
- Pneumococcal vaccine
- Meningococcal vaccine
33
Microcephaly
- small brain
- head below 3rd percentile
- due to:
- fetal insult such as maternal rubella, Zika
- genetic disorder
- chromosomal
- insult during infancy
-associated with DD
34
Hydrocephalus
- water on the brain
- imbalance b/w production and absorption of CSF
- body produces 500 mLs CSF/day
- CSF cushions brain from injury, delivers nutrients, remove wasate and maintains normal ICP
- circulates throughout ventricular system
- absorbed within the subarachnoid spaces
35
Etiology/Pathophysiology with hydrocephalus
- congenital or acquired
- congenital: present at birth, may not be apparent, may be assoc. with other CNS abnormalities (spina bifida)
- acquired: may be result of illness (tumor) or trauma
36
Most common type of hydrocephalus
non-communicating
caused by: obstruction to flow of CSF through ventricular system, ventricles enlarge
- infection
- hemorrhage
- tumor
- congenital defect
37
Clinical Manifestations of Hydrocephalus in infant
- vary with age of the child
- rapidly increasing head circumference, decreased LOC, vomiting, irritability, sunset eyes, bulging fontanel, distended scalp veins, bossing of frontal skull
38
Clinical Manifestations of Hydrocephalus in older child
signs of increased ICP
- HA in AM with vomiting
- ataxia (loss of body control)
- strabismus (abnormal alignment of eyes)
39
Diagnosis of Hydrocephalus
- prenatally ultrasound
- clinical manifestations after birth
- head circumference
- CT scan
- MRI
- U/S of infant head, open fontanel
40
Clinical Therapy of Hydrocephalus
- removal of obstruction
- creating a new CSF pathway to divert excess CSF (VP shunt)
- tx of complications
- manage problems related to psychomotor development
41
VP Shunt Complications
- infection
- malfunction (blocking or kinking of tube)
- increased ICP
- worsening neurological status/altered LOC
42
Nursing care for hydrocephalus
- measure head circumference (infants)
- observe for signs of increased ICP, may indicate shunt malfunction
- positioning: usually supine, HOB is raised gradually (post op)
- provide emotional support to child, parents
- teaching about medications, signs of shunt malfunction
43
Neural Tube Defects
NTDs
- neural tube is structure in embryo that becomes CNS - brain and spinal cord
- neural tube fused by 28th day of gestation
- if neural tube does not fuse properly, a NTD forms at open location
44
Spina bifida occulta
spinal cord not completely fused, but does not protrude: tuft of hair or sacral dimple seen
- mildest form of spina bifida
- usually no problems with nervous system
```
-skin indicators:
sacral dimple
port-wine nevus
sacral tufts of dark hair
sacral lipoma
```
45
spina bifida cystica
definition: visible defect with external saclike protrusion
two types:
- meningocele: fluid filled sac protrudes from back, but spinal cord in normal position
- meningomyelocele: fluid filled sac with spinal cord
46
Causes of NTDs
- 50% or more: folic acid deficiency
| - other cases: multifactorial - environment, chemical, medications, genetic, maternal obesity
47
Prenatal diagnosis of NTDs
- amniocentesis: elevated alpha-fetoprotein in amniotic fluid (16-18 wks)
- uterine ultrasound
48
Prevention of NTDs
- folic acid supplementation (0.4mg/day)
- if history of NTD: 4 mg/day
- 1998 FDA fortifies cereal grains with folic acid
- begin at preconception
49
Meningocele
sac contains meninges and spinal fluid but no neural elements
- spinal cord in normal position
- no neurologic deficits
50
Myelomeningocele
sac contains meninges, spinal fluid, and nerves
51
With Myelomeningocele: if defect below 2nd lumbar vertebra:
- flaccid paralysis of lower extremities
- sensory deficit
- orthopedic braces, walkers, crutches, and wheelchairs
- bladder and bowel sphincters may be affected
52
Clinical Therapy for spina bifida cystica
- prevent infection of sac
- assessment of neurologic and associated anomalies
- early closure in 24-48 hours after birth
- prevent stretching of other nerve roots and further damage
- Hydrocephalus - VP shunt placement
- braces to support joint mobility
- neurogenic bladder - clean intermittent catheterization q 3-4 hrs
53
Nursing management of spina bifida cystica
cover sac with sterile saline dressing
- place infant prone
- assess infant for motor, bladder, and bowel deficits
- monitor VS
- observe for signs of infection
- comfort infant
- create a latex-safe environment
54
Latex Allergy
- SB patients at high risk for latex allergy due to repeated exposure to latex products from multiple surgeries and repeated urinary cath
- 73 percent of SB patients have latex allergy
- anaphylactic rxns possible
- recommend that SB patients avoid latex from birth
55
Discharge teaching for SB patients
- symptoms of increased ICP, hydrocephalus, shunt malformation, UTIs
- splints, wedges
- ROM exercises
- clean intermittent cath q 3-4 hrs
- community based care
- braces, walkers, wheelchairs
- monitor adolescents for mental health issues
- teach to self-cath when old enough
56
Cerebral Palsy
- most common chronic disorder in childhood
- disorder of impaired movement and posture
- 2-3 per 1,000 live births
- non-progressive, may have perceptual problems, language deficits, and intellectual impairment
- most cases have abnormal muscle tone and lack of coordination with spasticity
57
Etiology/Patho for CP
- congenital
- damage to the brain before or during birth
- hypoxia, infection, abnormal brain structure
- birth asphyxia accounts for only 6-7 percent of cases
- preterm, twin, and LBW increase risk
- very low Apgar score increases risk
- multifactoral, unknown
- infant/child develops CP from asphyxia, near drowning, choking, poisoning, head trauma
58
Clinical Manifestations of CP
- spastic most common clinical type (75percent of cases)
- persistent hypertonia and rigidity
- impairment of fine and gross motor skills
- contractures and abnormal curvature of the spine
- exaggerated DTRs, positive babinski
- classic gait: intoeing
59
Possible Motor Signs of CP
- poor head control after age 3
- persistent premature reflexes
- stiff or rigid limbs
- arching back/pushing away
- floppy tone
- unable to sit without support at age 8 months
- clenched fists after age 3 months
- excessive irritability
- no smiling by age 3 months
- feeding difficulties (persistent tongue thrusting, freq gagging or choking with feeds)
60
Diagnosis of CP
- based on clinical findings
- failure to achieve milestone may be the first sign
-suspect CP if:
small for age, H/O prematurity, low apgar score, traumatic, inflammatory or anoxic event
61
Clinical Therapy for CP
- tx focuses on helping the child to develop to his/her maximum potential
- referrals for PT, OT, speech therapy
- special education to improve motor function and ability
- braces, splints, serial casting to prevent contractures, increase ROM
- mobilizing devices: wheelchairs, scooters
62
Surgical intervention for CP
- lengthening of the achilles tendon
| - dorsal rhizotomy to decrease spasticity
63
Medications for CP
- anti-seizure
| - muscle relaxants
64
Prognosis for CP
-depends on the severity and presence of deficits
65
Seizure Disorders
- abnormal electrical discharges in brain
- one in 20 children will have a seizure
- most children who have one seizure will never experience a second
- epilepsy
66
epilepsy
chronic disorder characterized by recurrent, unprovoked seizures, secondary to an underlying brain abnormality
67
Etiology/Patho for Epilepsy
-result from abnormal excessive electrical discharges from the brain
may occur due to:
- infection
- brain trauma
- hypoxia
- brain tumor
- structural defect/electrolyte disturbance
- most common in children
68
Types of Seziures
1. simple partial
2. complex partial
3. absence
4. tonic-clonic
69
simple partial
-focal
- no aura
- less than 30 seconds
- no postictal confusion
70
complex partial
- aura
- LOC
- automatisms (smack lips)
- may progress to generalized, postical confusion
71
absence
- petit mal
- no aura
- lasts 5-10 seconds
- hyperventilation
- staring
- brief LOC
- postictal amnesia
72
tonic-clonic
- grand mal
- LOC
- aura
- stiffness F/B rhythmic jerking
- eyes roll back
- postictal confusion
73
Status Epilepticus
- continuous or recurrent seizure, 20 min or longer
- may become hypoxic or hypoglycemic
- emergency: airway, suction, oxygen, monitoring, neuro assessment
- IV line for fluids and meds
- blood glucose: admin glucose as indicated
- protect child from injury
- administer benzodiazepines
74
Benzodiazepines
- diazepam
- lorazepam
- midazolam
- phenytoin
- phenobarbital
75
Clinical Therapy for seizures
- thorough hx and physical
- EEG
- antiepileptic drugs (AEDs)
- monotherapy preferred
- serum drug level
- sx if indicated
- trial of med withdrawal attempted for children who are seizure-free for at least 2-5 years
76
Nursing Assessment for Seizures
- monitoring of:
- seizure activity
- LOC
- VS/neuro checks
- signs of hypoxia
- safe environment
- family adaptation and coping with uncertainty of when next seizure will occur
77
Antiepilepsy Drugs
* Phenobarbital
* Phenytoin (Dilantin)
* Carbamazepine (Tegretol)
* Valproic acid (Depacon, Depakote)
* Levetiracetam (Keppra)
* Gabapentin (Neurontin)
* Topiramate (Topramax)
* Benzodiazepines-Diazepam, Lorazepam
78
Planning for Safety
- do not leave alone in pool
- use shower instead of bathtub
- life vest when boating
- helmet if freq. to protect the head
- wear a form of medical identification, such as medical alert bracelet
79
Febrile Seizures
- sensitivity of brain to fever
- run in families, benign
- 30-40 percent change of having future febrile seizures
- peak incidence between 18-24 months
- generalized tonic-clonic movements with eyes rolling back
- last 1-2 minutes followed by postictal period
- acetaminophen or ibuprofen
80
Pulsing fontanel
normal finding
81
Checking LOC while chemically paralyzed
-check pupils is the only way to check LOC
Peds Exam 1
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