Peds Exam 3: Neuro Conditions in Children

which congenital anomaly is the leading cause of death in the first year of life
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which congenital anomaly is the leading cause of death in the first year of life
neuro anomaly
When does the neural tube form?
3 weeks
what could cause issues with neural tube formation
Related to infection, trauma, teratogens, malnutrition
when should most infant reflexes be gone by
around 4 mo of age
differences in neuro between adults and peds
§ Top heavy, head is large in proportion to body; neck muscles poorly developed; thin cranial bones not wall developed; unfused sutures; skull expands until age 2 years. Prone to brain injury and skull fracture with falls.
§ Excessive spinal mobility; immature muscles, joint capsule, and ligaments of cervical spine; wedge-shaped, cartilaginous vertebral bodies; Incomplete ossification of vertebral bodies. Greater risk for high cervical spine Injury at C1-C2 level or vertebral compression fractures with falls (level of brain stem)
when does the expansion of the skull stop
at 5 years of age
Is brain development complete by birth? What other processes are going on
o Development is complete but immature at birth
--Myelination is incomplete (Proceeds in a cephalo-caudal direction- head and neck control before trunk and extremities)
what does an open fontanelle allow for
allows for head to expand without increasing ICP in the infant
Neuro HPI
-N/V esp. if persistant
-vision changes (hard to identify in infants)
-headache/ photophobia
-neck stiffness
-poor feeding
-inconsolability
-lethargy
-fever
-ataxia
-trauma history
difference between adult and pediatric GCSscale
Still same scoring (max 15, normal between 12-15)

Ped scale is more appropriate for infant behaviors and developmental age
where should an infants head be measuredMeasure just above eyebrows and around the occiput on the back of the headWhy is measuring head circumference importantthis is important in detecting potential neurologic conditions · Acute changes/changes over timeunilateral plagiocephalybrachycephalic head shapeearly signs of increased ICP in infantsirritability, high-pitched cry, bulging fontanel, persistent vomiting, delay or loss of developmental milestones, sunset eyes, seizuresearly signs of increased ICP in children-Headache, nausea, vomitting -Irritability or change in personality -Seizures -gait disturbances, vertigo -blurred vision, sunset eyes -worsening school performanceLate findings of increased ICPContinuing decrease in LOC progressing to coma -Abnormal posturing -Fixed and dilated pupils -Cushings triadCushing's triadSigns of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirationsDecorticate posturing· flexed towards the core of the body - Indicative of: damage at the cerebral cortex levelDecerebate postureWhen the upper extremities are stiffly extended and internally rotated Palms are pronated Lower extremities are stiffly extended with plantar flexion Indicative of damage to the brain stemAcute nursing management of a child with increased ICP-Frequent neuro assessment including GCS -Frequent vital signs -Elevate HOB 30+ degrees -Have emergency equipment readymedications to give a patient with increased ICPAcute diuretics, mannitol, and 3% hyper saline to pull fluid from the brain8 month old is admitted with head injuries. The nurse monitors for signs of increased ICP. She should expect an 8 mo old with increased ICP to have? - Diplopia - Headache - PERRLA - A bulging fontanellea bulging fontanellestructural neuro disorders in childrenhydrocephalus and myelomengoceledefinition of hydrocephalusAccumulation of fluid (CSF or blood) in the ventricles of the brain "water on the brain"Most common infant brain surgeryhydrocephalusTypes of hydrocephalus and the differences bw themCommunicating: too much CSF flowing (impaired absorption) Non-communicating: anatomical obstruction or blockage of CSF flow (narrowing between 3rd and 4th ventricles)causes of hydrocephaluscan be aquired or congenitalhow can hydrocephalus be acquired- Trauma - Intraventricular hemorrhage, infection, tumors, etcTreatment for Non-Communicating or "Aqueductal stenosis"Endoscopic third ventriculostomyEndoscopic third ventriculostomyMove away tissue between the ventricles and make a hole in bottom of 3rd ventricle to promote flow of CSF (Avoids need for a shunt)Treatment for Communicating Hydrocephalus(too much CSF flowing) Ventriculoperitoneal (VP) ShuntVentriculoperitoneal (VP) Shunt- Thread catheter from the ventricles in the brain down under the skin through to the peritoneal cavity - One way valve: as pressure builds up the fluid will flow down to the peritoneal cavity - Relieves pressure when the fluid builds up in the brainpost op care of VP shunt- measure head circumference - assess for bulging fontanels and widening cranial suture lines - monitor the temperature (easily infected) -VS + Pain -S/s inc. ICP -Monitor neuro -Observe surgical siteswhen should parents call provider following the placement of a VP shuntParents should call provider immediately for fevers, headaches or vomitingMyelomeningocele akaspina bifidacause of myelomeningoceleNeural Tube fails to close at the end of the 4th week of gestation (typically occurring in lumbar)etiology of myelomeningocelecombination of genetic (family history of neural tube defects) and environmental factors (folic acid deficiency)Types of Spina Bifidaspina bifida occulta, meningocele, myelomeningocelespina bifida occultamost common and least severe form of spina bifida without protrusion of the spinal cord or meninges · can be a dimple or dark spot (cord and nerves in tact)Meningoceleopening or sac full of CSF and meninges, cord in tactmyelomeningoceleo Spinal cord tissue, nerves, and fluid in the sac o Damage to the spinal cord with this conditionlong term complications of spina bifida- Paralysis - Orthopedic deformities: club foot, dislocated hip - Bowel and bladder incontinencecan spina bifida be repairedfetoscopic repair: Repair 24-26 weeks in utero or after birthpre op nursing care before fetoscopic repair-Protect the sac with saline moistened dressing -Keep legs abducted with cushions/padding (prevent hip dislocation) - Prepare for multiple surgeries - Prepare for many complications -Supportive care to families -Emphasize the infant's normal and positive featuresseizureabnormal electrical discharge of nerve cells in the brain (occur in 10% of children)What causes a seizure in childreno Fever, infection, trauma, hypoxia, toxins, cardiac arrhythmia's o Familial tendency o Unknown cause o Chronic seizures or epilepsy: often familial2 major categories of seizuresgeneralized and partialsimple partial seizureOccurs in one area of the brain and is localized to one body partSimple partial seizure: -LOC? -Aura? -Post-ictal? -duration?· No LOC; No post-seizure confusion; no aura · ~30 secs.complex partial seizurea partial seizure, starting from a focus and remaining localized, that produces loss of consciousness, may progress to a generalized seizureComplex partial seizure: -LOC? -Aura? -Post-ictal? -duration?-Impaired consciousness -YES aura -Anxiety and or fear afterwards -30 sec to 5 mincomplex partial seizures are associated with __________automatisms (lip smacking, chewing, screaming, eye movements)Types of generalized seizures• Absence (formerly called "petit mal"): • Tonic-clonic: stiffening → jerking (start tonic eg. pt w/ seizures in the hospitalist shadowing)characteristics of tonic clonic seizures- Involved both sides of the brain and sends throughout the brain - Associated with an aura and Post-ictal phase **May also be associated with loss of phincter and bladder controlPost-ictal phaseThe final phase of a generalized seizure, during which the patient becomes extremely fatigued.major complications of tonic clonicairway compromise!absence seizureSudden cessation of motor activity or speech - often a staring spell Only lasts 10 secmost common type of seizure in childhoodfebrile seizureswhat predisposes a child to a febrile seizurefamilial predispositionwhat type of seizure is a febrile seizure in childrenUsually a simple seizure that is not associated with CNS changeintervention of febrile seizureNo interventions needed - must look for source of fevertreatments for seizuresAnticonvulsants, ketogenic diet, vagal nerve stimulator (pacemaker for the brain to stop seizure), surgery (extreme cases: left hemispherectomy)Nursing implications for seizures#1: maintain patent airway and adequate oxygenation -Maintain sage environment during event -Do not place anything in the patients mouth -monitor post ictal phase -admin meds appropriately DOCUMENT! -- date, time, natureetiology of bacterial meningitisInfection of the meninges, the lining the surrounds the brain and spinal cord which Can lead to brain damage, stroke, deafness, and deathprevalence in the US of bacterial meningitisDecreased dramatically due to HIB vaccine in USs/s bacterial meningitis in older childrenneck stiffness, headache, fever, photophobias/s bacterial meningitis in babies and young children-Opisthotonic position: extreme form of hyperextension and spasticity - Bulging fontanelle - Inconsolable high pitched cry - Purpuric rashtreatment of bacterial meningitis-Complete sepsis workup (inc. lumbar puncture, blood cultures, and CBC) -Need prompt IV antibioticsnursing implications of bacterial meningitiso Educate patients on preventing Meningitis Importance of vaccination (HIB, meningococcal, pneumococcal vaccines)What is cerebral palsy?· Abnormal development or damage to the motor areas of the brain, resulting in a lesion Causes a disruption in the brain's ability to control movement, often Non-progressive and may be associated with sensory, intellectual, emotional or seizure disorders.Etiology of Cerebral Palsy-Anoxic brain injury -Premature birth or intrapartal asphyxia -Congenital or perinatal infections -congenital brain anomaliesclassifications of cerebral palsySpastic (75%) Dyskinetic (15%) Ataxic (10%) Mixedcharacteristics of spastic cerebral palsyHypertonicity, poor control of posture, balance and coordinated movements, contracturescharacteristics of athetoid/dyskinetic cerebral palsyabnormal involuntary movements- disappear during sleep, increase with stressAtaxic Cerbral Palsywide-based gait, rapid repetitive movements performed poorlyMajor assessment findings in a child with cerebral palsy-*Delayed gross motor development identified at around 6 mo -Abnormal posturing -Persistence of infantile reflexes and or reflex hyerpsensitivitypotential accompanying health problems with cerebral palsyo Contractures r/t hypertonicity o Pain o Feeding problems/ swallowing/ reflux/ nutrition o Respiratory problems o Dental disease o Hearing impairment (can be related to anoxia) o Delayed Speech o Intellectual Delay: occurring in about 30-50% of children with CP o Seizures o Visual impairment (i.e. Strabismus) o Functional abilities to perform ADL's o ImmobilityManagement of Cerebral Palsy**early recognition to promote optimum development - physical therapy - occupational therapy - speech therapy - mobility devices, ankle-foot orthotics - promote self care activities to maximize ability - medications/ anti spasmodics - surgical interventionsWhat is the leading cause of head injury in children under age 5? - Non accidental trauma - Falls - Motor vehicle accidents - Trauma caused by siblingFallsleading cause of death in children 0-19 yearsunintentional injuries#1 cause of unintentional injuriesMVCleading cause of death under 1suffocationleading cause of death 1-4Drowningleading cause of death 5-19vehicle passanger#1 cause of non fatal injuries in children 0-15fallsTraumatic Brain Injurymild or severe trauma that can result from a violent impact to the head can be due to sports, MVC, and/or fallschronic traumatic encephalitisbrain swelling and atrophy of the brain tissue resulting from any hits to the head even if these do not result in a concussionconcussion symptoms-Difficulty thinking and remembering - feeling slowed down and having trouble concentrating -Physical: headache, nausea, vomitting, balance, dizziness, fuzzy or blurry vision, feeling tired, having no energy, sensitivity to light and noise -Emotional: irritable, sad, more emotional, nervousness, anxiety -Sleep disturbances: sleeping more or less than usual, trouble falling asleepred flags with concussions-Looking very drowsy and cannot be awakened -unequal pupils -seizures -cannot recognize people or places -increased confusion and agitation -LOC -Inconsolability in young children -clear fluid drainage from ears or nosemild TBI treatment- Restful sleep - Light cognitive activities if they don't increase symptoms - No physical or recreational activities until cleared - Return to school once able to tolerate light activitymoderate to severe TBI treatmentHospitalization, CT, MRI to r/o bleed to the brain, malformation, and tumorswhich ages are most susceptible to brain injury and whyIn children <12 years their brains are not fully developed and therefore more susceptible to injury due to brain not being fully developedprevention strategies to reduce TBI in children- Proper use of car seats - Helmets for sport activitiesharm reduction strategies in peds to reduce TBI- Safety gates and window guards for young children to prevent falls in young children - Safe, absorbent playground surfaces