NURS 449- Neurologic Disorders

increased intracranial pressure (ICP)

- Early signs and symptoms may be subtle - As pressure increases, signs and symptoms become more pronounced and the level of consciousness (LOC) deteriorates

cerebral palsy: nonsurgical

-PT/OT -bracing -botox -nutrition -exercises

bacterial meningitis: nursing care

-Quiet room and minimal environmental stimuli as patients are sensitive to noise, bright lights, etc. -Side lying position due to nucchal rigidity. -Avoid actions that cause pain or increase discomfort. -Evaluation for pain and implement appropriate relief measures. -Fluids and nourishment. -Family support

concussion: treatment

-Rest- cognitive and physical (brain rest) -Reading, writing, homework, computers, -Impact testing prior -Avoid bright lights -Avoid noise and stimuli

bacterial meningitis

-acute inflammation of the meninges as well as the CSF -decreased incidence following use of Hib vaccine

diagnostic procedures

-lab tests: glucose, CBC, electrolytes, blood culture if fever; evaluation for toxic substances, liver function -fundoscopic exam to r/o papilledema -imaging: CT, MRI, echoencephalogaphy, USG, nuclear brain scan -lumbar puncture -EEG -xray (r/o skull fractures, dislocations; evaluate degenerative changes, suture lines

increased ICP: late symptoms

-lowered LOC -change in pupils (dilated) -lowered motor and sensory responses -papilledema -Decerebrate or decorticate posturing

cerebral palsy: interdisciplinary interventions

-medical/surgical -neurosurgical -pain management -PT and OT -nutrition -Speech and language -vision and hearing support -psychosocial support -special education

spina bifida: nursing care

1. Skin care - prevent decub and infection 2. Prevent neuro injury/infection 3. Prevent ortho injury: -Contractures -Determine functional expectations -Promote best locomotor function 4. Promote bowel elimination -regime-diet -regular toileting -prevent constipation/impaction 5. Manage neurogenic bladder -clean caths -? antispasmotics

meningitis: prognosis

10 to 15 % of cases of bacterial meningitis are fatal. Important prognostic factors: -Child's age -Duration of illness before antibiotic therapy -Type of organism -Adequacy of therapy -Quickness of diagnosis after onset of symptoms Result in brain damage, nerve damage, hearing loss, learning disability, stroke, and death.

Reye Syndrome

A disorder defined as toxic encephalopathy associated with other characteristic organ involvement Characterized by fever, profoundly impaired consciousness, and disordered hepatic function Affects children < 15 years of age who are recovering from a viral illness

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? A. "Did you use any medications like aspirin for the fever?" B. "Did you give your child any acetaminophen, such as Tylenol?" C. "What type of fluids did your child take when he had a fever?" D. "How high did his temperature rise when he was ill?"

A. "Did you use any medications like aspirin for the fever?" Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands that after this treatment: A. PaCO2 levels decrease, causing vasoconstriction. B. drainage of cerebrospinal fluid occurs C. activity is controlled via a stimulator D. hyperexcitability of the nerves is reduced.

A. PaCO2 levels decrease, causing vasoconstriction. Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity. Anticonvulsants decrease the hyperexcitability of nerves.

A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery device would the nurse most likely expect to be used? A. Simple mask B. Venturi mask C. Nasal cannula D. Oxygen hood

A. Simple mask A simple mask would be used to deliver a flow rate of 8 liters per minute. A Venturi mask would be used to deliver a specific percentage of oxygen, from 24% to 50%. A nasal cannula would be used to deliver no more than 4 liters per minute. An oxygen hood requires a liter flow of 10 to 15 liters per minute.

The nurse caring for a neonate experiencing seizures asks the charge nurse: "How can I tell if a baby is having a seizure or is just crying for attention?" Which response would be most appropriate? Select all that apply. A. "You will not be able to stop a seizure with gentle restraint." B. "The baby experiencing a seizure will be tachycardic." C. "Stimulating the baby by singing to him will not stop a seizure." D. "There will be no changes in the baby's vital signs with a seizure" E. "The baby will become more active with sensory stimulation with a seizure." F. "The baby will stop the seizure activity when swaddled in a blanket."

ABC With seizure activity, the neonate experiences tachycardia and increased blood pressure, and movements are not suppressed by general restraint and are unchanged by sensory stimuli. With nonepileptic movements, there is no change in vital signs, the movement is suppressed easily with gentle restraint, and movements are enhanced with sensory stimuli.

Bacterial Meningitis: management

Acute meningitis is a medical emergency and requires immediate intervention. -Isolation precautions -Initiate antimicrobial therapy -Maintain hydration -Maintain ventilation -Reduction of ICP (May give steroids) -Management of systemic shock -Control of seizures (May give anticonvulsants) -Control of temperatures -Treat complications

bacterial vs viral meningitis

Also: color is negative (? cloudy from book p.1082) in bacterial; clear or slightly cloudy in viral

Reye Syndrome: Nursing Management

Assess for cerebral edema with increased ICP Assess neuro status. Safety re: seizures Monitor I&O (prevent dehydration/overhydration) Monitor lab studies (LFTS) Education about salicylate containing products and OTC medications: Alka-Seltzer Pepto-Bismol

neonatal bacterial meningitis: causative agents

GBS gram negative (E coli)

health history for altered neurologic status

Interview the child and parents; review medical records. Use developmental and biologic milestones to determine whether the child's patterns of development are normal, delayed, or demonstrate regression. Health history data collection guided by: -Urgency of the child's problem -Child's age -Availability of reliable historians

Opisthotonic positioning

Opisthotonus Arching of the back Brain injury, cerebral palsy, tetanus

cerebral palsy: RF

Perinatal factors: -intrauterine infection -fetal/placental dysfunction -maternal pre-eclampsia -complications of birth and labor -prematurity -asphyxia -sepsis Childhood factors: -respiratory distress -TBI -near drowning -anything causing hypoxia to developing brain

concussion: s/s

Physical - H/A, N,V, fatigue, visual disturbance, balance problems, sensitivity to light or noise, numbness/tingling Cognitive - mental fog, problems concentrating or remembering, feeling slowed down, slow response to questions Emotional - instability, sadness, nervousness, emotional Sleep - drowsiness, changes in sleep pattern, trouble falling asleep

Brudzinski's sign

Positive Brudzinski Sign= pain or resistance when lying supine and flexing neck

Reye Syndrome: Clinical Manifestations

Severe and continual vomiting Changes in mental status Lethargy Irritability Confusion Hyperreflexia

Pediatric Glasgow Coma Scale

Three part assessment: Eyes Verbal response Motor response Score of 15: unaltered LOC Score of 3: extremely decreased LOC (worst possible score on the scale)

tonic clonic phases

Tonic-clonic seizures consist of four stages: -the prodromal period, which can last for days or hours (may be drowsy, dizzy or have lack of coordination); -the aura, which is a warning immediately before the seizure (may be related to sensory signs) -the tonic-clonic movements (generalized jerking of muscle); -the postictal stage (child may sleep soundly and may have a period of stupor or confusion)

SMA: 3 types

Type I: Fatal Type II: 6mo-24 mo -not as severe as type I -may learn to walk before complications noted Type III: Juvenile 3-17 yo -delayed developmental milestones -often noted to be clumsy -atrophy of proximal muscles

spina bifida

a NT defect that affects a small area of the spinal cord or the entire length abnormal development or incomplete closure

bacterial meningitis: signs and symptoms

abrupt, with fevers, chills, h/a, vomiting, can be associated with or followed by change in mental status

nursing priority in a child with suspected meningitis

administer abx as soon as ordered and received from pharmacy. obtain cultures first- dont wait for results

confusion

alert, but responds inappropriately to questions; impaired decision making

concussion: deterioration

any deterioration- seek medical care -Worsening headaches -Seizures -Cant awaken -Repeating vomitting -Slurred speech -Increased confusion -Neck pain -Significant irritability

obtundation

arouses with stimulation

Sport concussion assessment tool (SCAT)

athletes should not be returned to play on the same day as injury A structured, graded exertion protocol should be developed; individualized on the basis of sport, age and the concussion history of the athlete. Exercise or training should be commenced only after the athlete is clearly asymptomatic with physical and cognitive rest. Final decision for clearance to return to competition should ideally be made by a medical doctor

full consciousness

axo, awake, age appropriate behavior

At birth, the ________ is 25% of adult size; at age 1, 50% of adult size; at age 5, 90% of adult size- rapid growth during younger years

brain

Retained newborn reflexes are suggestive of

cerebral palsy

Reye Syndrome: Diagnosis

definitive diagnosis by liver biopsy

cerebral palsy

disorder of movement or posturing caused by any defect or lesion of that developing brain

levels of consciousness

earliest indicator of improvement or decline in neurological status

head injury in infants

fall off bed, stairwells, trauma Vomiting Headache Crying Inconsolable Seizures Change in personality

SMA: diagnosis

genetic testing (chromosome 5) muscle biopsy EMG

bacterial meningitis: neonates signs and symptoms

harder to assess and diagnose -well at birth but within a few days begin to look and behave poorly -refuses feedings, poor sucking ability -neck usually supple -vomiting or diarrhea -poor muscle tone, lack of movement -weak cry -full, tense and bulging fontanel which can appear late

Kernig's sign

inability to extend legs fully when laying down supine positive Kernig sign= pain along vertebral column when flexing legs at hip and knee

ICP: causes

includes: -tumors or other space occupying lesions -accumulatin of fluid w/in ventricles, bleeding or edema of cerebral tissues

Reye Syndrome: Therapeutic Management

key is early dx and aggressive therapy

communicating hydrocephalus

lack of absorption: -surgery to repair myelomeningocele, adhesions b/w meninges at the base of the brain or meningeal hemorrhage

skull fractures

linear/depressed basilar

SMA: pathology

loss of muscle function no cardiac involvement normal IQ

coma

no motor or verbal response to noxious (painful) stimuli

noncommunicating hydrocephalus

obstruction of flow of CSF -congenital anomalies -infection -tumor -blood clot

head injury: pathology

r/t force of impact ***Think about development

stupor

responds only to vigorous and repeated stimulation, state of deep sleep

linear/depressed skull fracture

s/w scalp lacerations good prognosis

dexamethasone

steroids like dexamethasone are used primarilty to reduce edema surrounding mass lesions in ICP

Nucchal rigidity

the inability to flex the neck forward due to rigidity of the neck muscles; if flexion of the neck is painful but full range of motion is present, nuchal rigidity is absent.

hydrocephalus: goal

to relieve hydrocephalus, bypass blockage and drain fluid from ventricles to area where it can be reabsorbed

meningitis: prevention

vaccines- pneumococcal and H influenza droplet precautions early medical care

Lumbar puncture is contraindicated in patients

with brain abscess because increased ICP creates a risk of cerebral herniation

Reye Syndrome: Pathophysiology

-Cerebral edema -Fatty liver changes -> liver failure -Neurologic changes (irritability, confusion, hyperreflexia)

components of neurologic assessment

-Cerebral function, vital signs, level of consciousness, mental status, and verbal response -Cranial nerves, usually CNs II, III, IV, and VI, for pupil reactivity, cardinal fields of gaze, and eye movement -Motor system: strength, movement, and symmetry -Sensory system: tactile and pain sensation in extremities -Reflexes: deep tendon and superficial reflexes -Presence of decorticate or decerebrate posturing

Spinal Muscular Atrophy (SMA)

-Degeneration of anterior horn cells of spinal cord and cranial nerves -Weakness and wasting of voluntary muscles -Most common autosomal recessive neruomuscular disorder -CF and SMA are the most common recessive conditions leading to death in pediatrics

transmission of bacterial meningitis

-Droplet infection from nasopharyngeal secretions -Appears as extension of other bacterial infection through vascular dissemination -Direct implantation after penetrating wounds, skull fractures, lumbar puncture, surgical procedures, anatomic abnormalities, or foreign bodies -Organisms then spread through CSF -Increased risk with the number of contacts -Seasonal variation: late winter and early spring

hydrocephalus: infected shunt manifestations

-Elevated vital signs -Poor feeding -Vomiting -Decreased responsiveness -Seizure activity -May be signs of local inflammation at shunt site or along tract

bacterial meningitis: causative agents

-H flu type B (decreased b/c HiB vaccine) -streptococcus pneumoniae -neisseria meningitis (miningococcus)

bacterial meningitis: diagnosis

-Lumbar puncture is the gold standard test. -Opening pressure is obtained as are cultures, gram stain, cell count and glucose and protein. -Spinal fluid pressure if often elevated, but if infant/child is crying hard to interpret. -White count usually elevated, glucose is reduced in proportion to duration and severity of the infection. Protein is increased.

assessment parameters for child with altered neurologic status

-Observe how the child interacts with parents and examiner. -Assess muscle strength. -Evaluate child's intellectual and language skills during play. -Assess child's behavior and how the parent deals with it. -Inspect the child's head for disproportionate growth and unusual shape. -Perform a brief screening examination, acute neurologic check, and comprehensive neurologic assessment.

clinical manifestations of hydrocephalus: early infancy

-abnormally rapid head growth -bulging fontanels (especially anterior)- tense, non pulsatile -dilated scalp veins, serated sutures -thinning of skull bones

mechanisms causing pediatric head injury

-blunt or nonpenetrating injuries -penetrating or open injuries -compression injuries -coup and contrecoup

nurse's role in preparing the child for diagnostic testing

-consider developmental level, cognitive ability, and physical status- include levels of consciousness and pain threshold -in emergency situations, offer child comfort measures during the study and support the family until the child is stabilized -minimize painful interventions: may require premedicating child (if allowed) to reduce anxiety

spina bifida: teaching

-coping, self esteem -folic acid 400 mcg/day for women (multivitamin) -latex allergy -family support

bacterial meningitis: clinical manifestations

-dependent largely on child's age -influenced by organism, the effectiveness of therapy for the antecedent illness, whether it occurs as an isolated entity or as a complication of another illness

spina bifida: S/S

-depends on degree of defect -many systems can be involved -sensory and motor dysfunction

ICP: early symptoms

-distended scalp veins -HA -nausea -fatigue -personality changes -vomiting -seizures -bulging fontanel -high pitched cry -Macewen's sign -sun setting eyes -diplopia -Decreased pupil reaction -decreased respirations -dizziness -irritability

spina bifida: diagnosis

-examine sac to determine extent of involvement -may dx in utero with AFP testing or ultrasound

skull fractures: RF

-falls -MVA -assaults -sports -shaken baby syndrome

head injury: etiology

-falls -MVC: < 2 years passengers; > 2 years pedestrian/cyclists -bicycle

spina bifida: treatment

-fetal surgery -C section delivery -surgical closure w/in 1-3 days after birth -medical-prevent infection -multidisciplinary team approach

bacterial meningitis: infants and young chidren signs and symptoms

-fever -poor feeding -vomiting -marked irritability -frequent seizures (often accompanied by a high pitched cry) -bulging fontanel -nucchal rigidity (may or may not be present)

clinical manifestations of hydrocephalus: later infancy

-frontal enlargement or bossing -depressed eyes -setting sun sign (sclera visible above iris) -pupils sluggish with unequal response to light

different levels of consciousness

-full consciousness -confusion -obtundation -stupor -coma -persistent vegetative state

clinical manifestations of hydrocephalus: childhood

-headache on waking and gets better with upright positioning; -papilledema, stabismus, ataxia (involuntary movements), irritable, -lethargic, confused, vomiting (may be projectile, incoherence

spina bifida: complications

-hydrocephalus -GU (neurogenic) -CV -altered development of upper and lower extremities -contractures

head injury

-injury as a result of mechanical force -degree of injury depends on force of impact -leading cause of death in children over 1 year

clinical manifestations of hydrocephalus: infancy (general)

-irritability, lethargy -infant cries when picked up or rocked, quiets when still -early infantile reflex acts may persist -normally expected responses fail to appear -opisthonos -may display LOC -lower extremity spasticity -vomiting

goal of care with increased ICP

-keep level down -decreased stimuli -quiet environment -control hyperthermia -neutral head position

basilar skull fracture

-most severe -battle sign and raccoon eyes -CSF leaks- nares/ears

concussion: diagnosis

-no imaging -history -Any amnesia?- predictive of severity -Acute concussion evaluation tool (ACE) -LOC? - 90% do not!! -Early signs observed by others -Seizures? -Previous concussion?? Impact studies SCAT

bacterial meningitis: children and adolescent signs and symptoms

-often abrupt onset -fevers, chills -HA, altered sensorium -vomiting -seizures -nucchal rigidity -positive kernig and brudzinski signs -irritability, agitation

hydrocephalus: treatment

-placement of ventriculoperitoneal (VP) shunt drains fluid from the ventricles to peritoneal cavity -alternative: ventriculoatrial (VA) shunt drains fluid to right atrium of heart

cerebral palsy: surgical interventions

-prevent fixed contractures (tendon release) -manage spasticity -hip osteotomy -scoliosis repair

infected VP shunt management

-remove shunt -externalize shunt to extra ventricular drainage system -treat with IV abx -place new shunt

concussion

-reversible -instantaneous loss of awareness/responsiveness **Confusion and amnesia post-head trauma Contusion & laceration -bruising and tearing of tissue Skull fracture

cerebral palsy: complications

-scoliosis -contractures -seizures -visual -speech -feeding/nutrition

hydrocephalus: late signs

-seizures -increased pulse pressure, decreased HR -altered respiratory pattern -blindness from herniation of optic disc -decerebrate rigidity

types of NTD

-spina bifida occulta -spina bifida cystica (meningocele, myelomeningocele) -encephalocele -anencephaly

SMA: treatment

-supportive -nutrition (prevent obesity) -monitor respiratory -prevent complications like contractures and scoliosis

Macewen sign

A sign to detect hydrocephalus (and brain abscess). Percussion (tapping) on the skull at a particular spot (near the junction of the frontal, temporal and parietal bones) yields an unusually resonant sound in the presence of hydrocephalus or a brain abscess.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. A. Eye opening B. Verbal response C. Motor response D. Fontanels E. Posture

ABC The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

battle sign

Bruising behind an ear over the mastoid process that may indicate a skull fracture.

hydrocephalus: etiology

not a specific disease-> results from underlying brain d/o results from an imbalance in the production and absorption of CSF in the ventricular system

Reye Syndrome: etiology

not well understood believed to be mitochondrial insult induced by different viruses, drugs, exogenous toxins, and genetic factors potential associated b/w aspirin therapy for fever

persistent vegatative state

permanently lost function of cerebral cortex

causes of NTD

poor nutrition: -folic acid deficiency -vitamin deficiencies -maternal obesity maternal age pregnancy history birth order SES

When do the fontanels close?

posterior: 2-3m anterior: 12-18m

hydrocephalus

ventricles fill with fluid, pushing the brain outward