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The Child with Neurological Dysfunction
Terms in this set (48)
increased pressure or tissue hypoxia or ischemia.
Sudden appearance of a fixed and dilated pupil
-Any time a patient puts in the VS in a computer/system, it is a basis on whether treatment should be done. Hence, they should be accurate
-Vital Signs changes
-Dilated or pinpoint pupils that don't react to light can indicate what?
-What appearance of the pupils will indicate a neurosurgical emmergency?
to prevent complications by assessing for alterations in cerebral tissue perfusion:
Vital signs: monitor blood pressure and pulse
Overall fluid status: urine output
In an unconscious child, I&O must be carefully monitored to avoid fluid overload and cerebral edema
A patient comes in with a head injury. What is the nurse's goal? How can this be done?
Level of Consciousness (LOC)
Level of alertness and
This is most sensitive early indicator of a change in neurological status
What are the 2 aspects of this tool?
Levels of Consciousness includes:
1. Full consciousness
2. ________________- impaired decision-making
3. __________________- time (x1), place (x2), person (x3), situation/event (x4)
4. _________________- arouse with stimulation
5. ____________- deep sleep, responds vigorous and repeated stimuli
6. ___________- no motor or verbal response
7. Persistent _______________ state - some responses but only reflexes
Glascow Coma scale
This grading scale that consists of 3 parts - eye opening, verbal response, and motor response
What score indicates normal neurological function?
The lower the score, the deeper the ?
Know the difference between a high score and low score
Normal, hypotonic, hypertonic
This diagnostic tool assesses the spontaneous movement, response to painful stimuli, and posturing of the muscles
What terms are used to define muscle tone?
It involves three distinct components: spreading out the arms (abduction) pulling the arms in (adduction) crying (usually)
-This is an infantile reflex normally present in all infants/newborns up to 3 or 4 months of age as a response to a sudden loss of support, when the infant feels as if it is falling
What three distinct components does this reflex involve?
Positive: big toe then moves upward or toward the top surface of the foot. The other toes fan out.
Negative: toes curl inward
Positive babinski if under the age of 2. This is good!
After the age of 2 when they start walking
The adult is not able to stand on their own 2 feet. Their feet can't stand and stay stable because they won't grip the earth to stabilize
This is one of the normal reflexes in infants. Reflexes are responses that occur when the body receives a certain stimulus
-occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.
What is a positive Babinski sign? Negative?
Will infants have a positive or negative babinski?
When should the Babinski sign be absent?
Why is not good for an adult to have a Babinski sign that is positive?
asymmetrical tonic neck reflex (ATNR)
This is a primitive reflex found in newborn humans that normally vanishes around 6-7 months of age
-is also known as the "fencing reflex" because of the characteristic position of the infant's arms and head, which resembles that of a classically trained fencer.
If this reflex continues after 6-7 months, what could be the reason?
We want to make sure we have a baseline and continuing the measurement of the infant head growth.
When measuring head circumference, we are using a tape measure, feeling the fontanels and the suture lines to see where they lie.
The suture lines and fontanels should be coming IN closer to protect the brain. If they start to SEPARATE...that's a problem
Cerebral vasodilation and edema due to cerebral tissue hypoxia from a decreased CBF and increase pressure
Increased Intracranial Pressure (IICP)
How/Why does this occur?
What is a s/s of IICP?
decrease (acidosis); increase (acidosis)
IICP Produces Cerebral Ischemia and Hypoxia
-Because there is an increase in P, blood flow to the brain is decreased
-Waste products are not removed causing a ____________ in ph and an ______________ in PC02
-The blood vessels respond to the hypoxia and acidosis by dilating to try and get more blood flow, but this dilation can cause edema and increase the intracranial pressure
Priority is good respiratory status since acidosis and hypoxia produces IICP
Intubation and mechanical ventilation
Maintaining normal body temperature b/c a high temperature increases the body's needs for oxygen
Caring for the Child with IICP
What is the priority goal when treating?
What invasive tools may be required to support the respiratory status?
What is the next priority goal when treating IICP?
acidosis, acidosis, hypoxia
Interpretation of (ABG) Results
Will find the following:
-pH < 7.33 (___________)
-PCO2 >45 mm Hg (________)
-PO2 < 80 (___________)
Importance of Proper Positioning for child with respiratory support
-Head of the bed should be _________
Prevent head from being _____________ prevent any increase in pressure
Keep in a ____________ position so that there are no pressure points that may cause an increase in irritability
Care with turning to prevent ?
Infants: tense bulging fontanel, separated cranial sutures, increased head
vomiting (often without nausea), diplopia, blurred vision, seizures.
Differences in Symptoms with IICP Infants/Children
What are the s/s of IICP in infants?
Large head size (macrocephaly) is commonly defined as more than two standard deviations above the mean. Baby Sarah's head is large and becoming larger. The head circumference is rising across percentile lines and exceeds 2 standard deviations (the 98th percentile). This child should be evaluated.
Small head size (microcephaly) is most often defined as more than two standard deviations below the mean. Depending on head size at birth, microcephaly may be classified as congenital or acquired, the two types tending to have different causes. Baby Jared's head has grown too slowly and its circumference is now below. This child deserves evaluation.
Two 4-month-old infants are seen in the pediatric clinic. Baby Sarah's head circumference is plotted well above the 95th percentile, while Baby Jared's plots out well below the 5th percentile. How would you interpret these findings?
Sunken = dehydration
Bulging = IICP
The nurse working in an ER assesses an 8-month-old with vomiting. Among the findings is a sunken fontanel. A little later, another 8-month-old is seen with the same complaint of vomiting, but this infant's fontanel is bulging and tense. How do interpret these findings?
-Change in child's behavior such as extreme irritability (child is cranky, cannot be consoled or comforted)
-Increased sleepiness (does not act as usual when you offer a favorite toy, or is difficult to wake up)
-Shrill or high-pitched cry
-Vomiting (throwing up)
-Complaint of a headache or stiff neck when waking up
-Complaint of nausea or throwing up in the morning
-Weakness of one side of the body
-Trouble walking or uncoordinated movement (staggering or swaying)
-Eye changes (crossed eyes, droopy eyelids, blurred or double vision, trouble using eyes, unequal size of eye pupils, or continuous downward gaze)
The nurse is caring for two children, both at risk for increased intracranial pressure: a 15-year-old with a brain tumor and a 2-month-old with hydrocephalus.
What symptoms would you expect to find in the 15-year-old?
What symptoms would be consistent with increased ICP in a 2-month-old?
RD S20...too many symptoms to write
Pediatric Neurological Disorders includes:
This is Increased amounts of cerebrospinal fluid (CSF) within the ventricles, due to either a blockage of the flow of CSF, or impaired absorption of CSF
Misnomer: "water on the brain"
Infants: increase in head size of the forehead due to the swollen brain, bulging fontanels, sun setting eyes on the right side...continuous downward eye gaze, frontal bossing (prominent, protruding forehead often associated with a heavy brow ridge.)
Early on, these physical appearances are not seen..if not treated early or no treatment, then that is when those late symptoms occur
If oxygen to brain is disturbed for a long period of time, then the child will suffer brain damage if they survive
Children: typical signs of increased ICP
Early signs in either age group would be increased size of brain ventricles only
What are the s/s of hydrocephalus for infants? Children?
Surgery to drain the fluid: ventriculo-peritoneal (VP) shunt
What treatment would be used for Hydrocephalus?
Rd 24....whole paragraph written
frequent vital signs, neuro assessments, pain management, incisional care, etc.
Post-op care for shunt revision
Like all implanted devices, shunts can become blocked or infected. In the early stages of VP shunt blockage, a child who is old enough to communicate will complain of a __________________.
A blocked VP shunt will need to be replaced or revised, surgically.
Post-op nursing care includes ?
This is termed as the most severe form of Spina Bifida (SB)
Occurs due to failure of vertebral body to close over the intraspinal contents
Lift the baby up gently to decrease pressure put on that sac
Occurs around 4 weeks gestation
alpha fetoprotein (AFP) test shows AFP in mother's blood, other blood tests (HCG, Inhibin A, Estriol), ultrasound, and amniocentesis are also used to confirm
Babies born with Myelomeningocele have a sac over defect; contents in the sac include: CSF, spinal nerves, possibly part of spinal cord itself
What could they do to prevent irritation of that sac?
When does this occur?
What dx tools can be used to identify this disorder?
There are 2 main types of Myelomeningocele/SB.
What are they?
SB Oculta—most common/least severe; not visible, externally, except for a tuft of hair, a dimple or a 'birth mark'; may be asymptomatic
SB Cystica—Visible with an external saclike protrusion;
could include meningocele and myelomeningocele
Meningocele (also called meningeal cyst; only meninges protrude; not spinal nerves)
Myelomeningocele (meninges and spinal nerves protrude; sometimes without a sac-like covering)
Neurologic deficit occurs in varying degrees in myelomeningocele (location on spine; covered by sac vs. open)
Hydrocephalus most frequently associated anomaly
What is the difference between Meningocele and myelomeningocele?
Surgery can be performed pre- or post-natally
Risk factors - folate deficiency (B9); obesity; poorly controlled diabetes; antiepileptic drugs (AEDs) - interfere with folate metabolism
Cause is unknown
Surgical repair of myelomeningocele
When can surgery be performed?
What are risk factors to myelomeningocele?
What causes this?
-Motor and sensory impairment
-Lower extremity paralysis
-Elimination issues due to Neurogenic bowel & bladder
What are the s/s of myelomeningocele?
There is a disruption of nerves to the bowel and bladder due to the location of the sac/SB
pressure sores, burns and other injuries
to repeated exposure to latex products during surgery and numerous bladder catheterizations.
Neurogenic bowel & bladder = elimination issues..how?
-Establish regular bowel pattern: suppositories, enemas, diet
-Clean, intermittent catheterization
-Urinary diversion procedures: suprapubic catheter; urostomy
Children with this disorder have Decreased sensation. This places the child at risk for what?
Most children with myelomeningocele are on latex precautions. Why?
This is a bacterial, viral, or fungal infection of the meninges that surround the brain and spinal cord, and CSF
could be bacterial, virus, or fungi
note that abx are only given for bacterial infection
Irritability and unable to console
For older childrens:
sudden onset headache** fever
severe headache with irritability**
S/S of meningitis includes:
CSF analysis via the Lumbar puncture
How is meningitis diagnosed?
Isolation until 24 hours of antibiotics
Nursing Care for meningitis
-Frequent neurological assessments
-Keep room _______ and dim (decr. stimuli)
-Antibiotics: ampicillin; vancomycin
-Isolation for how long?
Meningococcal meningitis patients should be placed on ___________ precautions (private room, mask for all entering the room). Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.
This occurrence results from disturbance in the brain's electrical system
1. Focal (formerly called partial: affects one side of the brain)
2. Generalized (affects both sides of the brain)
3. Unknown onset
look at the link
The type of seizure will depend upon the area of the brain affected
What are the 3 seizure classifications?
1. Describe and record/document awareness in focal seizures: The level of awareness is of practical importance because it is one of the main factors affecting a person's safety during a seizure.
2. Describe and record/document what their motor and other symptoms in focal seizures are: Motor = twitching, jerking, or stiffening movements of a body part or automatisms (automatic movements such as licking lips, rubbing hands, walking, or running);
Non-motor = changes in sensation, emotions, thinking, or experiences.
3. Describe and record/document generalized onset seizures: Seizures that start in both sides of the brain, called generalized onset, can be motor or non-motor
RD S9 notes
Important to document all of this so that healthcare providers will know how to medicate and treat the seizure
Nursing interventions when caring for a child having a seizure..
What are they?
Why is it important to document?
Frequent follow-ups are needed so dose can be adjusted
Ketogenic diet: protein, high fat, low carb
Treatment of Seizures:
1. Describe and record/document seizure activity observed
2. Administer AED drugs
What important parent teaching should be done to kids on Carbamazepine drug?
3. Ketogenic diet: which includes:
4. Vagal nerve stimulator therapy
(this is like a pacemaker for the brain)
5. Surgical treatments
antiseizure drugs, antiepileptic drugs (AEDs), or anticonvulsant drugs.
Medications used to prevent seizure are called ?
Most medications are started at ________does and slowly ___________ until seizures are no longer occur
The dose of the medication will be adjusted as the child grows and weight increases or as new medications are added for other problems (e.g., asthma).
IT IS IMPORTANT THAT PARENTS COME BACK REGULARLY FOR dose adjustment based on child growth
Meds need to be _____________ off, not ___________ discontinued.
Rd notes in S10 for surgical interventions and vagus nerve stimulator
This is termed as Two or more unprovoked seizures
Emphasis on reducing and avoiding harm
-wear medical identification bracelet or necklace
-sleep well and take medications on time
-supervise child around water; wear life jacket
-avoid biking, skating, and skateboarding in traffic; wear helmet
-avoid climbing a tree or rope
-restrict driving, per state law
-restrict video games if photosensitivity exists
have parent accompany child on school bus/trips
What is the goal in treatment of epilepsy?
What are the interventions to accomplish that goal?
Nursing care management for epilepsy would be:
-Seizure precautions, prevent injury
-Long-term care and support to child and family
-Education and anticipatory guidance
-Medication compliance and administration
-Prevention of triggers
-School plans to ensure safety and medication
Main cause is an infection with a fever
Medical emergency that may lead to permanent brain damage or death
-Maintain patent airway
-Diazepam administration (buccal, nasal, rectal, IV)
This is termed as a seizure that lasts greater than 30 minutes.
What is the main cause?
Why is this condition dangerous?
What would the nursing care management include?
children who are between 6 months and 5 years-of-age. The majority of febrile seizures occur in children between 12 and 18 months of age
Having a febrile seizure does not mean that a child has epilepsy; remember, epilepsy is defined as having two or more seizures without fever present.
These type of seizures occur when child has a fever (>100.40F)
What age group is more at risk for this?
These seizures can be frightening to watch, but do ________ cause brain damage or affect intelligence.
If a child has a febrile seizure, does it mean that a child has epilepsy? Why/Why not?
falls, motor vehicle crashes (MVCs), bicycle injuries, sports injuries and gunshot wounds.
Cerebral edema peaks 24-72 hours after the injury.
Head injuries are caused by any mechanical force that leads to pathology of the brain, skull or scalp.
What are common causes?
When will cerebral edema peak?
This results from bleeding between the dura and the cerebrum generally from rupture of the cortical veins.
-Monitor BP, pulse,
-Fluid intake and urinary output -Looking for any alteration in cerebral tissue perfusion
-Avoiding fluid overload and worsening of cerebral edema
What would nursing interventions for head injury include?
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