NUR 412: Exam 3

Nursing interventions for ICP:

**Early recognition is key •Decrease cerebral blood volume •Decrease metabolic rate •Decrease CSF volume •Maintain cerebral perfusion pressure -Oxygenate: Intubate and ventilate -IV fluids: To help with blood pressure -Drugs: Epi and isotropes, Mannitol/Lasix, Anticonvulsants -Extra ventricular drain -Head midline and HOB 15 to 30 degrees -Decrease metabolic rate

2nd line medications for continuing seizures

-IV Fosphenytoin (Cerebyx) -IV phenobarbital -Phenytoin (Dilantin): Not preferred in children

When caring for a patient with increased intracranial pressure (ICP), the nurse knows that cerebral blood volume must be decreased. How is this achieved?

-Maintain head midline -Elevate head of bed 15-30 degrees to enhance venous drainage (prevents pressure on jugular veins) -Restore normocarbia by giving oxygen or possible intubation

Signs and Symptoms of ICP in children

-Nausea and vomiting -Slight change in vital signs -Sunset eyes -Seizures -Restlessness, irritability -Papilledema -Changes in respiratory patterns SIGNS SPECIFIC TO CHILDREN: -Visual disturbances, diplopia -Dizziness or vertigo -Headache -Slurred speech

Late signs of ICP

-Significant decrease in LOC: Decrease motor response to command, decreased sensory response to painful stimuli. -Cushing's Triad -Fixed and dilated pupils

Characteristics of head and neck development in infants and children

-Top heavy head -Excessive spinal mobility -Head circumference increases in size until age 5 -Myelination is incomplete at birth which accounts for the primitive reflexes present at birth. As myelination progresses, fine & gross motor control is established. -Cranial vault is able to expand more in the presence of intracranial pressure due to the open sutures -Muscles and ligaments of the cervical spine are immature, the veritable bodies are not ossified

Signs and symptoms of ICP in infants

-vomiting -Slight change in vital signs -Sunset eyes (white sclera above eyes) -Seizures -Restlessness, irritability -papilledema (optic disk swelling) -Changes in respiratory patterns -Poor feeding SIGNS SPECIFIC TO INFANTS -Poor feeding -Bulging fontanel -Wide sutures -MacEwen (Cracked pot): occurs when ICP has caused the sutures to separate forming a cracked pot resemblance -increased head circumference -Dilated scalp veins -High-pitched cat-like cry

How much blood does the brain use in comparison with the rest of the body?

10x more, 17% of the bodies cardiac output

Febrile seizures, which are unique to pediatric patients, are commonly seen in children between ___ months and ___ years.

3 months-5 years

Increased intracranial pressure (ICP) is defined as an increase greater than ___ mmHg for more than ___ minutes.

>20mmHg for more than 5 minutes

The nurse walks into the room of a 1-year-old patient who is screaming. She cannot be soothed by either the nurse or her parents and the boisterous crying continues. She would receive which of the following scores for best verbal response? A. 2 (grunts) B. 3 (inappropriate screaming/crying) C. 4 (irritable crying) D. 5 (cries appropriately, coos)

B. 3 (inappropriate screaming/crying)

The nurse caring for a 4-year-old child is using the Modified Glasgow Coma Scale. The child answers questions, but frequently uses curse words. He would receive which of the following scores for best verbal response? A. 5 (appropriate words) B. 4 (inappropriate words) C. 3 (screams) D. 2 (grunts)

B. 4 (Inappropriate words)

The nurse caring for a 7-year-old patient who is postop after a car accident is using the Glasgow Coma Scale. The child can correctly state her name and birthdate, but tells the nurse that she is "in bed at home right now." She would receive which of the following scores for best verbal response? A. 5 (oriented) B. 4 (confused) C. 3 (inappropriate) D. 2 (incomprehensible)

B. 4 (confused)

Which of the following is NOT a symptom of increased intracranial pressure (ICP) in infants? A. Macewen B. Diplopia C. High-pitched, cat-like cry D. Bulging fontanel E. Sunset eyes

B. Diplopia

A child who's experienced abnormal stimulation of the respiratory center in the medulla would likely have a respiratory rate that is: A. Slow & shallow B. Hyperventilation C. Periodic or irregular D. Slow & deep

B. Hyperventilation

Which of the following is NOT a symptom of increased intracranial pressure (ICP) in children? A. Headache B. Increased head circumference C. Vomiting D. Visual disturbances E. Papilledema

B. Increased head circumference

Bilateral pupillary deviation is a(n) ___ sign of change in intracranial pressure. A. Early B. Late

B. Late

A child remains in a deep sleep, has slow response to vigorous and repeated stimuli, and has a moaning response to stimuli. The nurse charts these findings as: A. Obtundation B. Stupor C. Lethargy D. Coma

B. Stupor *responsive only to vigorous and repeated stimulation, deep sleep, as in conscious sedation (Able to breath on their own but in deep sleep) *Sternal rub, rub pen to the side of finger nail

A nurse is caring for a 2-year-old patient when she begins having a seizure. Which of the following should be the nurse's initial action? A. Do nothing B. Take music box toy away from child C. Have mother hold and soothe child D. Ensure bed rails are padded

B. Take music box toy away from child * decrease stimulation, remove hard surfaces

Causes of meningitis include:

Bacterial Viral (Aseptic meningitis-> non-bacterial) Fungal

First line medications for seizures

Benzodiazepines -Rectal diazepam: profiled syringe w/ gel may be given pre-hospital or in hospital -Intranasal Midazolam (versed): at home, pre-hospital, hospital -IV diazepam (Valium) -IV lorazepam (Ativan) *Administer IV doses very slowly, may need to assist with ventilations

Which of the following is the most common shunt placed in pediatric patients with increased intracranial pressure (ICP) in attempt to decrease cerebrospinal fluid volume? A. Ventriculoatrial B. Lumboperitoneal C. Ventriculoperitoneal D. Ventriculopleural

C. Ventriculoperitoneal Usually placed on right side (if right handed or if dominant hand unknown) since left brain is associated with logical function

When caring for a patient with increased intracranial pressure (ICP), the nurse knows that cerebrospinal fluid (CSF) volume must be decreased. How is this achieved?

CSF diversion (temporary external ventricular drain) Shunt placement (ventriculoperitoneal most common) *Hydrocephalis

Hypocapnia

Constricts cerebral blood vessels (Vasoconstriction) and decreased blood flow

The nurse is caring for a 9-year-old patient and evaluating him using the Glasgow Coma Scale. The child continuously speaks in gibberish. He would receive which of the following scores for best verbal response? A. 5 (oriented) B. 4 (confused) C. 3 (inappropriate) D. 2 (incomprehensible)

D. 2 (incomprehensible)

A nurse picks up a 1-year-old child and he begins crying. He would receive which of the following scores for best verbal response? A. 2 (grunts) B. 3 (inappropriate screaming/crying) C. 4 (irritable crying) D. 5 (cries appropriately, coos)

D. 5 (Cries appropriately, coos)

A child has no motor or verbal response or extension posturing to noxious (painful) stimuli. The nurse charts these findings as: A. Obtundation B. Stupor C. Lethargy D. Coma

D. Coma *cannot arouse, no motor or verbal response to noxious or painful stimuli

Which of the following is NOT a symptom of increased intracranial pressure (ICP) in infants? A. Wide sutures B. Increased head circumference C. Poor feeding D. Headache E. Dilated scalp veins

D. Headache

A child who has experienced seizures or cerebral infections would likely have a respiratory rate that is: A. Slow & shallow B. Hyperventilation C. Periodic or irregular D. Slow & deep

D. Slow and deep

Which of the following is NOT a symptom of increased intracranial pressure (ICP) in children? A. Diplopia B. Vertigo C. Slurred speech D. Wide sutures E. Restlessness

D. Wide sutures

Significant decrease in level of consciousness is a late sign of increased intracranial pressure (ICP). What two manifestations are often present when this occurs?

Decreased motor response to command Decreased sensory response to painful stimuli

If a febrile seizure lasts more than 5 minutes, the provider may administer:

Diazepam or Lorazepam

Why would an infant have a lower intracranial pressure (ICP) even when it is increased?

Fontanels adapt to decrease ICP

When caring for a patient with intracranial hypertension, the nurse is aware that what interventions are necessary?

Hyperventilation (PCO2 <30 mmHg) Osmotic therapy (Mannitol) Barbiturates/pentobarbital - artificial coma (decreases brain activity & BMR, requiring less O2/nutrients) Corticosteroids Hypothermia (temp <35 C)

What conditions can cause a seizure?

Hypoglycemia Hyponatremia Stroke, CNS infection (Meningitis) Closed head injury Hypoxia Fever

Why are children more susceptible to meningitis?

Immature blood-brain barrier

Hypercapnia (increased CO2)

Increased levels of lactic acid, which causes dilation of cerebral blood vessels resulting in increased blood flow and blood volume, thus also increasing ICP due to the 80 10 10 rule. -Brain is very sensitive to this and the metabolic damage to the brain tissue caused by an inadequate supply of well oxygenated blood can often exceed the effects of the trauma itself.

Decreased respirations cause hypoxia which causes hypercapnia which results in vasodilation and increased ICP.

Increased respirations (giving oxygen in the presence of ICP) cause hyperventilation which causes hypocapnia which results in vasoconstriction and decreased ICP

Definition of Meningitis

Inflammation of the meningies

What is the earliest indicator of improvement or deterioration of neurologic function?

LOC

Why are IV diazepam & lorazepam most commonly given for seizures in the hospital setting?

Longer duration of action Less side effects

What can cause an altered mental status

MITTEN: Metabolic (hypoglycemia, DKA) Infections (meningitis) Toxins (alcohol, lead, narcotics, toxins from parasites) Trauma (traumatic brain injury, Submersion injury) Endocrine (hypothyroidism) Neurological/Neoplasm (seizure, myelomenigocele, tumor)

When caring for a patient with increased intracranial pressure (ICP), the nurse knows that cerebral perfusion pressure (CPP) must be maintained. How is this achieved?

Maintain O2 level Fluids to maintain normal BP (if BP drops, CSF will be disproportionate)

When caring for a patient with increased intracranial pressure (ICP), the nurse knows that metabolic rate must be decreased. How is this achieved?

Maintain normothermia: antipyretics for infections, tepid sponge bath Avoid noxious stimulation/pain Sedation & analgesia Prevent seizures

Hypothermia

decreases the need for oxygen by the brain

Increased Intracranial Pressure (ICP)

defined as the total pressure exerted by the brain, blood, and CSF in the intracranial vault. When one of these components increase, another one must decrease to keep the total volume the same; the blood and/or CSF are the only two that can do this because the brain is a fixed amount. CSF can compensate by decreasing production and/or increasing absorption of CSF -Brain 80% -Blood 10% -CSF 10%

What does the Glascow Coma Scale evaluate?

eye opening motor response verbal response *the lower the score the deeper the coma

Hyperthermia

increases the need for oxygen by the brain

Cushing's Triad presents with what three manifestations?

Widened pulse pressure (HTN) Bradycardia Respiratory depression * Late sign of impending brainstem herniation

The nurse is assessing a 6-year-old patient using the Glasgow Coma Scale. The child can state her name, date of birth, and tells the nurse that she is in the hospital. She would receive which of the following scores for best verbal response? A. 5 (oriented) B. 4 (confused) C. 3 (inappropriate) D. 2 (incomprehensible)

A. 5 (oriented)

Alteration in level of consciousness, resulting in restlessness or irritability, is a(n) ___ sign of increased intracranial pressure (ICP) in infants and children. A. Early B. Late

A. Early

Which of the following is a clinical manifestation of increased intracranial pressure in infants? A. Irritability B. Photophobia C. Vomiting and diarrhea D. Pulsating anterior fontanel

A. Irritability

Which of the following is the correct chronological order for an intracranial assessment of a 2-year-old child? A. LOC, fontanels & sutures, RR, motor, pupils B. LOC, head circumference, pupils, RR, motor C. LOC, fontanels & sutures, RR, pupils, motor D. LOC, head circumference, RR, motor, pupils

A. LOC, fontanels & Sutures, RR, Motor, pupils

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care should include which of the following? A. Monitor closely for signs of infection. B. Place child with operated side of the head on the bed. C. Pump the shunt reservoir often to maintain patency. D. Maintain Trendelenburg position to decrease pressure on the shunt.

A. Monitor closely for signs of infection

A child is arousable only with stimulation. The nurse charts these findings as: A. Obtundation B. Stupor C. Lethargy D. Coma

A. Obtundation *aroused by stimulation; lessened interest in their environment

A child who has been sedated would likely have a respiratory rate that is: A. Slow & shallow B. Hyperventilation C. Periodic or irregular D. Slow & deep

A. Slow & shallow

Brain volume, which is often measured by head circumference in children, grows to ___% of its adult size in the first year, ___% by 3 years, and ___% by 6 years. A. 25%, 50%, 75% B. 50%, 75%, 90% C. 50%, 90%, 100% D. 30%, 50%, 75%

B. 50% (Age 1) 75% (Age 3) 90% (Age 6)

What three factors regulate intracranial pressure?

Blood, CSF, Brain

The nurse goes into the room of a 4-year-old patient and she is screaming and refuses to answer any questions. She would receive which of the following scores for best verbal response? A. 5 (appropriate words) B. 4 (inappropriate words) C. 3 (screams) D. 2 (grunts)

C. 3 (screams)

The nurse is assessing a patient and notes pupils that are fixed and dilated. What is the priority nursing action? A. Chart the finding. B. Attempt to stimulate the child. C. Call the neurosurgeon. D. Assess level of consciousness.

C. Call the neurosurgeon. Brainstem will herniate through foramen, blocking off blood supply to the brain, resulting in lack of oxygen/nutrients to brain cells

Which of the following is a clinical manifestation of increased ICP in children? A. Low-pitched cry B. Sunken fontanel C. Diplopia, blurred vision D. Increased blood pressure

C. Diplopia, blurred vision

At any point in time, a child without intracranial pressure variations has: A. More CSF than blood B. More blood than CSF C. Equal amounts of CSF and blood D. Varying levels of CSF and blood

C. Equal amounts of CSF and blood

A child has limited spontaneous movement, sluggish speech, is drowsy, and falls asleep quickly. The nurse charts these findings as: A. Obtundation B. Stupor C. Lethargy D. Confusion

C. Lethargy *Sleep more than normal, drowsy, sluggishness, inactivity, apathy

A child who has been diagnosed with brainstem dysfunction would likely have a respiratory rate that is: A. Slow & shallow B. Hyperventilation C. Periodic or irregular D. Slow & deep

C. Periodic or irregular

The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain: A. Cannot occur if the child is comatose. B. May occur if the child regains consciousness. C. Requires astute nursing assessment and management. D. Is best assessed by family members who are familiar with the child.

C. Requires astute nursing assessment and management

A child is brought to the emergency department after experiencing a seizure at school. He has no history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is which of the following? A. "Epilepsy is easily treated." B. "Very few children have actual epilepsy." C. "The seizure may or may not mean that your child has epilepsy." D. "Your child has had only one convulsion; it probably won't happen again."

C. The seizure may or may not mean that your child has epilepsy

___ is defined as recurrent (two or more), unprovoked seizures secondary to a CNS disorder unrelated to alternate conditions.

Epilepsy

Emergency management of continuing seizures includes:

Establish IV to administer fluids/meds Check blood glucose & administer glucose if low NG tube to prevent aspiration Seizure meds (IV, PR) Manage Thermoregulation (Tylenol) Maintain airway, pulse ox

Fontanels and sutures should be assessed for all children under ___ years, whereas head circumference should be assessed for all children under ___ years.

F/S = < 2 HC = < 5

(True/false) A 1-year-old has a hypoglycemic fever. Two weeks later, she has a febrile seizure. The nurse would expect the physician to diagnose the child with epilepsy.

False

(True/false) Potential negative outcomes of febrile seizures include impaired IQ and academic performance later in life.

False, No negative outcomes relating to intelligence, behavior or academic performance

(True/false) Papilledema is a late sign of increased intracranial pressure (ICP) in infants and children.

False, early sign

(True/false) Acetaminophen can be used to prevent febrile seizures.

False, it may treat symptoms related to the fever but can not prevent a febrile seizure

(True/false) Seizure medications may be administered routinely in the hospital setting to prevent seizure onset.

False, not given unless repeated seizures

(True/false) Febrile seizures are typically a chronic condition; many children with febrile seizures develop epilepsy.

False, typically not chronic, 1% develop Epilepsy

(True/false) A majority of seizures that occur in children are due to epilepsy.

False, unknown in 75% of cases

Are tepid sponge baths effective in febrile seizures?

NO, they do not reduce the temperature and the shivering effect further increases metabolic output and causes discomfort to the child

Nursing priorities after a seizure:

Notify primary care provider Provide emotional support Reposition, provide for sleep and rest Reorient to what has happened Document

What infections are associated with febrile seizures?

Otitis media Pharyngitis Adentitis

Nursing preventative measures for seizures:

Padded side rails O2 Setup and Suction equipment at bedside

Febrile seizures

Seizure activity related to fever (above 38. 8C or 101.8 F) -occurs during the temperature rise rather than after a prolonged elevation, esp if it rises rapidly, -Fever caused by an infection -familial susceptibility

___ are defined as periods of abnormal electrical discharges in the brain that cause involuntary movement, as well as behavioral and sensory alterations.

Seizures *These neurons may be triggered by either environmental or physiologic stimuli such as stress, anxiety, fatigue, Infection, or metabolic disturbances.

What causes ICP

So too much blood due to a hemorrhage, too much tissue due to tumor or swelling, too much CSF due to hydrocephalus, will increase intracranial pressure!

___ ___ is defined as a continuous seizure that lasts for more than 30 minutes or a series of seizures during which consciousness is not regained.

Status Epilepticus *Can result in hypoxia and cardiac arrest

(True/false) Increased intracranial pressure is a life-threatening emergency.

TRUE

When do a child's cranial bones ossify and completely fuse?

The 8 bones of the skull ossify and close at various times but by the age of 8 they are all ossified, and by age 12 they are all completely sutured.

Why are children more prone to neck injuries.

The muscles and ligaments of the cervical spine are immature, and the vertebral bodies are not yet ossified. This results in a greater risk for high cervical spine injury at the C1 to C2 level or compression of vertebrae and fractures with falls

Autoregulation

The unique ability of the cerebral arterial vessels to change their diameter in response to fluctuating cerebral perfusion pressure or CPP (the pressure at which the cells are perfused). This allows the brain to continue recieving constant blood flow even in the presence of fluctuating BP and perfusion caused by body posture,increased intracranial pressure, decreased cardiac output or narrowing or occlusion in the major blood vessels of the neck. -Autoregulation fails when blood vessels can dilate no further or ICP has increased too much.

Causes of ICP include:

This is a MEDICAL EMERGENCY!! -Trauma -Lesions -Hydrocephalus -Meningitis -DKA -Hypoxic-ischemic injury -Status epilepticus -Aneurysm -Stroke

(True/false) If cerebral perfusion pressure (CPP) is adequate even if intracranial pressure (ICP) is increased, it is likely that cells are receiving sufficient oxygen and nutrients.

True

(True/false) Medications and organisms can be transferred into the intracranial space more easily in the first year.

True, (Immature blood brain barrier)

Reduced cerebral perfusion due to ICP results in:

ischemia, nausea, fainting, dizziness, dim vision -The MAP falls causing hypotension

When do the fontanels close?

o Posterior closes by 2-4 months o Anterior closes by 18-24 months

Assessment for motor function in ICP

observation for spontaneous activity, posture and response to painful stimuli; As motor function is lost due to brain dysfunction, primitive postural reflexes emerge. -2 Kinds of posturing: Decorticate or flexion: rigid flexion of the arms held tightly to the body, feet flexed, legs extended and internally rotated; This occurs with dysfunction of the cerebral cortex or lesion above the brainstem Decerebrate or extension: rigid extension and pronation of arms and legs, flexed wrists and fingers, clenched jaw, extended neck and arched back. This occurs with dysfunction at the midbrain or lesion to the brainstem.

What is involved in the emergency management of a seizure?

observe/record time, onset, actions-> the longer the seizure lasts the harder it is to stop, Remain calm Maintain airway - O2 (Non rebreather mask, jaw thrust, suction as necessary for secretions and vomiting, no tongue blade (added stimulation) Monitor vitals and circulation with pulse ox and cardiac monitor Protect child from injury - position on side, remove or pad hard surfaces, don't restrain, clear environment Stay at bedside and call for assistance Decrease external stimuli Loosen tight clothing Provide emotional support to family: what is happening, what to expect

Postictal state

the period following the seizure; the child may be drowsy, uncoordinated, be confused, have aphasia or have some sensory or motor impairment.

Assessment ICP:

•Level of Consciousness (LOC) o Lethargy o Obtundation o Stupor oComa •Fontanels (Assess only if <2) o Posterior closes by 2-4 months o Anterior closes by 18-24 months •Sutures •Head Circumference: assessed < 5 years old - Respiratory rate (cheyne stokes breathing) o Slow & deep o Slow and shallow o Hyperventilation o Periodic or irregular •Pupils o Pinpoint (Poisoning, barbiturates or opiate overdose) o Widely dilated and reactive (after seizures, may be 1 sided) o Widely dilated and fixed (Pressure from herniation of the brain, hypothermia, anoxia, ischemia, use od mydriatic drugs) o Unilateral fixed (lesion on the same side) o Bilateral and fixed (brainstem damage if present >5 mins. **Medications can change the pupil size, don't always jump right to intracranial pressure