Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
97 Cards in this Set
- Front
- Back
|
What are pedi variations in neuro fx?
|
Brain dev. & growth until 4-6 yrs
Myelination occurs until 6 yrs (sensation>movement) Sutures expand anterior fontanel closes by 18 mos., posterior fontanel closes by 3 mos. Primitive reflexes disappear by 6 mos. Fat needed for myelin sheath development reflects brain growth (within normal guidelines) Brain has higher metabolic demands (glucose and O2... 20% of cardiac output goes to the brain) BBB less discriminate in infants Development of sulci (furrows) and gyri (folds)... a smooth brain has no conductivity Neuro big difference btwn. adults and kids... growth until age 30 |
|
|
What are the layers of the brain?
|
3 Layers:
Meninges: Dura mater, Arachnoid and pia mater |
|
|
What is CSF and what does it do?
|
CSF=Cerebral spinal fluid
Fills subarachnoid space Cushions the brain Balance between absorption and secretion |
|
|
What is Falx Cerebri?
|
A sheet of dura which separates the cerebral hemispheres
|
|
|
What is Falx Cerebelli?
|
A sheet of dura which separates the cerebellar hemispheres
|
|
|
What is the CNS composed of?
|
Two cerebral hemispheres
The brainstem The cerebellum The spinal cord |
|
|
What is the Corpus Callosum, and what does it do?
|
The largest fiber bundle in the brain, it connects the two hemispheres centrally and allows cross communication
|
|
|
What is cerebral blood flow?
|
The blood supply to the brain tissue is carried by the internal carotid arteries, which branch to supply the various brain segments
|
|
|
How does cerebral blood flow work?
|
It is controlled by arterial pressure primarily
Provides needed nutrients for metabolic fx Elevated temp, seizure increase metabolic needs ex: cancer,meningitis, encephalitis increase need for sugar and 02 |
|
|
What is autoregulation?
|
It is the ability of cerebral arteries to change diameter
Allows constant brain blood flow during changes, but has a limit to its abilities Blood 02 and C02 levels effect as well as B/P (important to keep B/P in normal range since HTN will cause blood in brain to change |
|
|
What is cerebral perfusion pressure?
|
It is the mean arterial pressure (MAP) minus the intracranial pressure (ICP)
|
|
|
What can have a profound effect on the autoregulation system of the brain?
|
Changes in arterial oxygen pressure (PA02) or arterial carbon dioxide pressure (PAC02).
|
|
|
What is the most important physiologic determinant of autoregulation?
|
The cerebral perfusion pressure (CPP), because the brain relies on the delivery of oxygen and nutrients to function
|
|
|
What is the Blood Brain Barrier?
|
BBB is an anatomic-physiologic feature of the brain tha separates the brain parenchyma from the blood
The BBB is impermiable to Protein, and does not permit passage of many active substances |
|
|
What is responsible for the selective nature of the BBB?
|
Tight junctions of the vascular endothelium
|
|
|
Does the BBB work the same in the fetus, infant, child and adult?
|
NO. The BBB of the fetus and newborn is normally indiscriminantly permeable, allowing protein and other large and small molecules to pass freely between the cerebral vessels and the brain
|
|
|
What is the total volume enclosed in the cranium?
|
Brain 80%
CSF 10% Blood 10% These volumes need to remain relatively constant... if there is an increase in one factor, there must be a decrease in another |
|
|
What is intracranial pressure (ICP)?
|
This is when the capacity for spatial compensation is exhausted, so any further increase in volume results in a rapid rise of ICP
|
|
|
What are manifestations of increased intracranial pressure in infants ?
|
Infants:
Tense, bulging fontanel Separated cranial sutures Macewen sign (crkd pot) Irritability High-pitched cry setting sun sign poor feeding increased frontooccipital circumference |
|
|
What are manifestations of increased intracranial pressure in children?
|
headache
nausea forceful vomiting diplopia, blurred visiion seizures |
|
|
What are late signs of ICP?
|
Bradycardia
Decreased motor response to commands Decreased sensory response to painful stimuli Alterations in pupil size and reactivity Extension or flexion posturing cheyne-stokes respirations papilledema decreased consciousness coma |
|
|
Complete neuro hx
|
Prenatal: maternal infection in 1st Tri, substance abuse, environmental exposure to toxins (pesticides have a high affinity for fat) Viruses cross the placental barrier easily
Birth: LBW, preemie, <5 in 5 minutes APGAR, birth complications Neonatal: irritability, poor feeding, lethargy (floppy baby), poor tone, jaundice (bili 24/25 (Kernicturus) pathologic jaundice Family Hx: genetics, neuro disorder |
|
|
More neuro hx
|
Current hx:
head trauma, febrile illness (1 or 2 not abnormal) Developmental delays, school performance H/A, dizziness, speech, cognition, mobility, seizures, vomiting, nausea, blurred vision, photophobia |
|
|
What is the earliest indicators of neuro changes?
|
Changes in LOC
|
|
|
What is an altered level of consciousness (ALOC)?
|
Varying state of unconsiousness, from confusion to disorientation to lethargy to coma
|
|
|
What is the definition of unconscious?
|
Depressed cerebral functioning, no subjective experiences
|
|
|
What is a coma?
|
When a person cannot be aroused even with powerful stimuli
|
|
|
What needs to occur to produce a coma?
|
Extensive, diffuse, bilateral cerebral hemispheric destruction (the brain may be intact)
A lesion in the diencephalon Destruction of the brainstem down to the level of the lower pons |
|
|
Coma assessment
|
Mental status: LOC, cry, irritability, lethargy
Note response to environ, parents, strangers Infant cry, activity, feeding, dev., reflexes Older child: alert, oriented, memory, cognition, affect, H/A |
|
|
What is the Glasgow Coma Scale, and how is it used?
|
3 part assessment; eye opening, verbal response and motor response. Max 15 score (<9 indicates coma)
Motor: spontaneous vs pain stimuli Verbal: smile, cry, coos, interaction; below 5 years... any sound Unilateral differences highly significant Evaluating cry is vital in pre-verbal pts |
|
|
What is brain death?
|
The total cessation of brainstem and cortical brain function that may result from irreversible traumatic, anoxic, or metabolic conditions.
|
|
|
What are the conditions for the pronouncement of brain death?
|
Complete cessation of clinical evidence of brain function, AEB lack of activity on flow study
Irreversibility of the condition *Brain death cannot be determined if certain CNS meds have been given ex: phenobarbital |
|
|
What is Cushing reflex?
|
Pressor response that causes a slowing of the pulse and an increase in B/P. It is uncommon in kids; when it does occur, it is a very late sign
|
|
|
What happens physiologically seconds before herniation?
|
Increased ICP to Cushing triad to decreased heart rate to increased B/P, to Apnea
NOT GOOD |
|
|
Other objective data
|
VS (inc. B/P, breathing pattern, cushing reflex)
Head (OFC, fontanel, sutures, nuchal rigidity) Skin: injuries, petechiae (menigococcal meningitis) Eyes: PERL, nystagmus, photophobia, setting sun) Motor Fx: tone, strength, gait, asymmetry, tremor, twitching, opisthotonos,paralysis, ROM, DTR,seizures, decorticate (flexion), decerebrate (extention upper extremities, pronate lower extremities)cerebrum Spinal column (dimpling, hair) Cranial nerve fx: CN 2,3:pupillary response CN 9: gag CN8: calorics, dolls eye CN 3,4, 6:nystagmus, dysconjugate eye move Sensory fx (pain, dull, vibrations, temp) Cerebellar (soft signs/balance, coord.... like DUI test) |
|
|
Diagnostics for neuro fx
|
CT scan (may need sedation)
LP for meningitis: viral: self-limiting/bacterial: VERY serious; positive gram stain MRI EEG Shunt series Infection workup |
|
|
What is cushings triad?
|
Decreased HR, apnea, positioning, inc B/P
|
|
|
What is the tx for IICP?
|
Any stimuli: crying will further increase pressure.
Maintain normothermia inc HOB, neutral head position, decrease noxious stimuli, pain control, steroids, 02 Acidotic state adds to edema |
|
|
What are the causes of IICP?
|
tumor
trauma infection CSF production problems (hydrocephally), hypoxia |
|
|
What is Spina Bifida?
|
A midline defect involving failure of the osseous spine to close. This is the most common defect of the CNS.
2 types: Occulta and cystica |
|
|
What are manifestations of SB Cystica?
|
Visible defect w/external sac-like protrusion
Sensory disturbances usually parallel to motor dysfunction Below L2: flaccid, partial paralysis of lower ex., varying degrees of sensory deficit, overflow incontinence w/ constant dribbling of urine, lack of bowel control. Below S3: No motor impairment, bladder and anal sphincter paralysis Joint deformities: Talipes valgus or varus (foot contractures) Kyphosis, lumbosacral scoliosis, hip dislocation |
|
|
What are manifestations of SB Occulta?
|
Frequently no observable manifestations (not visible externally)
May be assoc. w/ one or more cutaneous manif: skin depression or dimple, port-wine angiomatous nevi, dark tufts of hair, soft, subcutaneous lipomas May be neuromuscular disturbances: progressive disturbance of gait w/ foot weakness, bowel & bladder sphincter disturbances |
|
|
What is Myelomeningocele?
|
Develops in the first 28 days of pregnancy, when the neural tube fails to close & fuse at some point along its length
Most are found in the lumbar or lumbosacral area. Location and magnitude of defect determine extent of neurologic impairment, Common complications include: hydrocephaly, mental retardation & club foot |
|
|
What is the dose of folic acid needed daily to prevent NTD's?
|
0.4 mg (400 mcg) can be obtained from a multivitamin supplement
|
|
|
What is the anomaly most frequently associated with myelomeningocele?
|
Hydrocephalus; 80-85% of kids with SB will develop hydrocephaly. It can occur because the NTD itself disrupts the flow of CSF. In many cases, Chiari malformation (type II is resp.)
|
|
|
What is a chiari malformation?
|
A brain defect involving posterior fossa contents
Type II Chiari malformation, seen almost exclusively w/ myelomeningocele, is characterized by herniation of a small cerebellum, medulla, pons, and fourth ventricle into the cervical spinal canal through an enlarged foramen magnum. The resulting obstruction of CSF flow causes the hydrocephalus. |
|
|
What are manifestations of hydrocephalus?
|
Increased Occipital Frontal circumference, bulging font, prominent forehead, setting sun, poor feed, vomiting, irritable, dev. delay, ataxia
|
|
|
What is the tx for hydrocephaly?
|
VP Shunt (ventricular peritoneal shunt) for life
|
|
|
What is the nursing care for Myelomeningocele?
|
Initially: monitor neuro fx, infection, prone position, avoid latex
Later: bowel/bladder dysfunction; addressing orthopedic issues Need bowel program and CIC Latex precautions/silicone based catheters. From the lesion down, there are no vertebrae... if lesion is higher up, can develop scoliosis; can develop club feet |
|
|
What does a head injury involve?
|
Head injuries are pathologic processes that involve the scalp, skull, meninges, or brain as a result of mechanical force.
|
|
|
what are the 3 major causes of brain damage in childhood in order of importance?
|
1. Falls
2. Motor vehicle injuries 3. bike injuries |
|
|
Can a child bleed to death from a scalp laceration?
|
Yes. The surface area of the child's scalp is large and has remarkable vascularity.
|
|
|
.What is an acceleration-deceleration injury?
|
Shearing force causes bruising and tearing
these kids demonstrate diffuse generalized cerebral swelling produced by increased blood vol. or by a redistribution of cerebral blood volume rather than by the increased water content seen in adults. |
|
|
What is a lumbar puncture, and how is it done?
|
They are done as a diagnostic measure to measure spinal fluid pressure, obtains CSF for lab analysis. Can be used to inject meds, helps rule out subdural effusions, can remove CSF to relieve pressure
A spinal needal is inserted between L3 & L4, or L4 & L5 vertebral spaces into subarachnoid space; CSF pressure is measured, and sample is collected. Contraindicated in pts. with increased ICP |
|
|
what is the nursing care of the unconsious child?
|
Observe LOC, pupillary rxn, eye opening, motor resp., verbal resp., fontanel fullness, and VS. Compare neuro status & behavior w/preillness and trauma state. Temp measured every 2-4 hours
Pain mgmt requires astute nursing obs. and mgmt. Usually, an incresed heart rate, rr, and bp & decreased 02 sats are possible indicators of pain Cerebral hypoxia at normal body temp that lasts longer than 4 minutes nearly always causes irreversible brain damage HOB elevated to 15-30 degrees, and the child is positioned so that the head is maintained in midline to facilitate venous drainage & avoid jugular compression |
|
|
What are the most effective measures to take in preventing further increased ICP?
|
Proper positioning and prevention of straining, such as during coughing, vomiting or passing stool. antiepileptic drugs such as dilantin or phenobarbital may be ordered for control of seizure activity
|
|
|
What is a subdural hematoma?
|
Bleeding between the dura and the cerebrum, usually venous in origin secondary to the rupture of the cortical veins that bridge the subdural space. these hematomas are 10X more common thatn epidural hematomas and occur most often in infancy with a peak incidence at 6 mos.(shaken baby syndrome)
|
|
|
What is an epidural hematoma?
|
On top of dural mater, usually arterial in origin (can be venous) most often a result of skull fx that penetrates the groove in the skull occupied by the middle meningeal artery. The lower incidence in childhood has been attributed to the fact that the middle meningeal artery is not embedded in the bone surface of the skull until around 2yrs. therefore a fx of the temporatl bone is less likely to lacerate the artery.
This type of hematoma is unusual <4yrs age, has rapid changes, and is most concerning... blood accumulates quickly |
|
|
What are the clinical manifestations of acute head injury
?TEST Question????? |
Minor injury:
may or may not lose consciousness Transient period of confusion Somnolence Listlessness Irritability, Pallor, vomiting (one or more episodes) Progression signs: Altered mental status (hard to wake up) mounting agitation dev. of focal lateral neuro signs marked changes in vitals Severe injury: Signs of ICP Bulging fontanel Retinal hemorrhages Extraocular palsies hemiparesis quadriplegia elevated temp unsteady gait papilledema Assoc. signs: scalp trauma other injuries (to extremities) |
|
|
Head injury assessment
|
Assess level of severity:
height of fall, LOC, vomiting >2x, <1yr, increased bleeding, seizure, slurred speech |
|
|
signs and symptoms of head injury?
|
Minor: confusion transient, irritable, 1-2x vomiting
Prog: altered mental state, arrousability, change VS, seizure, gait, speech slurred/vision blurred |
|
|
What is the nursing care for head trauma?
|
Frequent neuro checks to assess for increased IICP
|
|
|
What is a concussion?
|
A traumatically induced alteration in mental status; A transient and reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness from trauma to the head. This is the most common head injury
|
|
|
what are the hallmarks of concussion?
|
Confusion and amnesia
|
|
|
What is the goal of nursing mgmt of the child with a head injury?
|
Maintain adequate ventilation, oxygenation, and circulation; to monitor and treat increased ICP; to minimize cerebral 02 requirements; and to support the child and family during the recovery phases
|
|
|
What is the pathophysiology of near drowning?
|
Occurs when a victim of a submersion incident survives at least 24 hours after rescue, regardless of the final outcome
Injury r/t length of submersion/irreversible damage in 4-6 minutes Cardiac arrest secondary to laryngospasm and/or aspiration and asphyxia physiologic problems arise from hypoxia, aspiration and hypothermia hypoxemia causes acidosis Aspiration causes pneumonitis, pulmonary edema, bronchospasm |
|
|
What is the nursing care mgmt of a child w/ near drowning?
|
Care related to degree of cerebral insult
may need intensive respiratory care with attn. to vs, mech. vent or trach, blood gas determination, chest therapy & IV infusion. Often the child has suffered a hypoxic insult and requires the same care as an unconscious child |
|
|
What is bacterial meningitis?
|
An acute inflammation of the meninges and CSF
|
|
|
What causes b. meningitis?
|
Meningococci, H flu, Bacterial strep pneumonia, Bstrep
|
|
|
What are the s/sx?
|
Infant: poor feed, vomit, cry Anterior font full, temp instab., seizures
Child: flu-like sxs, fever, v/d, H/A, irritable, lethargy, rash, nuchal rigidity, LOC, photophobia, seizure |
|
|
What is the tx for b. meningitis?
|
LP (test for C-reactive protein), Abx (high dose to cross the BBB... 200-400 mg/kg)
fever and pain control |
|
|
what is the etiology of b. meningitis?
|
Currently H. influenzae type b, S. pneumoniae, and neisseria meningitidis (meningoccocus) are responsible in 95% of cases of children older than 2 mos.
Most often occurs in school age and teens, males affected more than females |
|
|
what is the pathophys of b. meningitis?
|
Altered permeability of the BBB can be produced by bacterial products; the release of tumor necrosis factor appears to initiate the meningeal inflammation
The brain becomes hyperemic and edematous, and the entire surface of the brain is covered in purulent exudate that varies with the type of organism. |
|
|
What are the complications of Meningitis?
|
Nursing care:
Neuro status, OFC, IV, critical to begin Abx admin. ASAP, hydration, isolate until Abx x 48hrs, SG, VS, watch for comp, IICP. Fluids at 3/4 maintenance Complications: Mental retardation, hearing loss, behavioral Seizure disorder Hydrocephalus Cognitive impairment |
|
|
What is Aseptic (Viral) Meningitis?
|
Caused by many different viruses. Onset may be abrupt or gradual.Self limiting.
Initial manifestations are: H/A, fever, malaise, and GI symptoms. Meningeal irritation symptoms develop 1-2 days after onset. Dx based on clinical features and CSF findings Tx is primarily symptomatic, such as tylenol for headache and muscle pain, maintenance of hydration, and positioning for comfort. |
|
|
What does CSF analysis look like fo b. meningitis?
|
WBC elevated (polys)
Protein content elevated Glucose content decreaed Gram stain;bacteria culture: positive Color: negative |
|
|
What does CSF analysis look like for viral meningitis?
|
WBC slightly elevated;increased lymphs
Protein normal or slightly inc. Glucose Normal Gram stain; bacteria culture:turbid or cloudy Color Clear or slightly cloudy |
|
|
Seizure Disorder: what it is, causes, types, nursing care, tx
|
Altered neuronal activity, hypermetabolic state/abnormal firing of the brain
Causes: familial, metabolic, infection, trauma Types: motor: absence Febrile: temp rise rapid and high (104) Neonatal: subtle; lip smacking, tongue thrust, blink, leg pedaling Nursing care: describe what you saw, observe muscle movement, breathing, color, eyes Keep safe, prevent aspiration (suction, 02 prn) Tx: anti-convulsant Rx Dilantin, Phenobarbital, Tegritol, Depakote All cause drowsiness, irritability, serum levels Dilantin for status epilipticus |
|
|
What is Epilepsy?
|
A condition characterized by two or more unprovoked seizures and can be caused by a variety of pathologic processes on the brain
|
|
|
What are the classification of epileptic seizures?
|
Acute symptomatic:assoc. w/an acute insult such as head trauma or meningitis
Remote symptomatic:those w/o an immediate cause but with an identifiable prior brain injury, such as major trauma, meningitis or encephalitis, etc. Cryptogenic seizures are those occuring w/ no clear cause Ideopathic seizures are genetic in origin. |
|
|
What is the most common cause of seizures in kids older than 3 years?
|
Idiopathic
|
|
|
What are partial seizures, and what are the three types?
|
Simple partial seizure w/ motor signs:
no alteration of consciousness(also called an aura) most common form of simple partial seizure.The simplest form is clonus. Complex partial seizures: complex symptoms and impairment of consciousness most difficult to dx and control Most common type of seizures/ aura part of the event & is assoc. w/ EEG changes Simple or complex seizures secondarily generalized... evolve into generalized seizures, usually a tonic-clonic event. |
|
|
What is a tonic-clonic seizure?
|
Most dramatic of all seizures in childhood
Usually occurs w/o warning, and consists of two distinct phases: tonic and clonic Tonic phase:the person rolls eyes upward and immediately loses consciousness... fall to ground. Musculature stiffens in a generalized and symmetric tonic contraction of the entire body. Mouth snaps shut and tongue may be bitten. sometimes produce a tonic "cry". Avg. tonic phase lasts 10-30 secs during which child is apneic& may become cyanotic. Clonic phase: Tonic rigidity is replaced by intense jerking movement. Child cannot control oral secretions and may lose control of bladder or bowel...lasts 30-50 secs. Postical phase 1-15 minutes. Child may remain semiconscious & difficult to arouse. No recollection of event. |
|
|
What is an absence seizure?
|
a generalized seizure, they have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and automatisms.
5-12 years age onset/often stop abruptly in teens. Abrupt onset with the child having 20 or more events daily. lasts 5-10 secs.May be confused with inattentiveness or day dreaming.Child seldom falls.Automatisms: smacking lips, twitching eyelids, fumbling w/ clothes Atypical Ab. Sei. have a less abrupt onset and there is greater loss of tone.. may last several minutes, |
|
|
What are Atonic seizures?
|
Sudden, momentary loss of muscle tone. Onset 2-5 y/o
May just exp. several sudden brief head drops/more severe suddenly fall to ground (generally face down)will lose consciousness briefly, and afer a few secs. will get up like nothing happened. These kids suffer injury to head, face and shoulder. should wear a helmet with face guard to protect head and teeth. |
|
|
What are Myoclonic seizures?
|
Characterized by sudden, brief contractions of a muscle or group of muscles. Often occur in combo w/ other seizure types.Should not be confused w/ myoclonic jerks that occur normally in falling asleep
|
|
|
What is Cerebral Palsy?
|
Impairment of motor fx resulting from hypoxic insult to the brain. It is nonprogressive and may be accompanied by perceptual problems, language deficits, and intellectual involvement.
|
|
|
What are the manifestations of CP?
|
initially hypotonia, then hypertonic, delay in gross motor, persistent infantile reflexes, posturing, irritability, poor feeding, gait uncoordinated
Associated: poor attn. span, mental retardation, seizures, dev. delays |
|
|
What are the tx and nursing care of CP?
|
Tx: maintain fx, early intervention, multidisciplinary
Nursing care: position, nutrition, comp, cope Spastic quad CP/cannot control any of their movements CP kids hard to feed due to increased metabolic rate. |
|
|
What is Dilantin (phenytoin)?
|
Used in tx & prev. of tonic-clonic seizures & complex partial seizures
Chronic tx w/ this drug may cause lymphoid hyperplasia that is most noticeable in the gums/surgical removal of excess tissue may be needed in severe cases |
|
|
What is Valproic Acid (Depakene, Depakote)?
|
Used in tx of multiple seizures
may cause liver toxicity, especially in child <2yrs |
|
|
What is Phenobarbital?
|
Used in tx of partial & tonic-clonic seizures/convultions
Pedi: po, IV... NO IM! Prophylaxis for febrile convultions, tonic-clonic;psychomotor seizures convulsions |
|
|
What is Tegratol (carbamazepine)?
|
Used in tx of partial seizures w/ complex symptoms; tonic-clonic, mixed seizures
|
|
|
What is Valium (diazepam)?
|
Used in tx of seizure disorders (e.g. status epilepticus) acute seizure activity, febrile seizure prophylaxis
|
|
|
What is a ketogenic diet?
|
high fat, low carb, low protein
Forces the body to shift from using glucose as primary energy source to using fat, and the pt develops a state of ketosis |
|
|
What are complications of drug therapy for seizures?
|
Dose related side effects: dizziness, h/a, ataxia & sleepiness disappear over time
May require monitoring of serum drug levels Knowledge of drug-to-drug interactions, including other meds such as antibiotics is critical in caring for epileptic pts |
|
|
What is status epilepticus?
|
A continuous seizure that lasts more than 30 minutes, or a series of seizures from which the child does not regain a premorbid level of consciousness
Tx: rectal diazepam |
