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Peds Exam 2
Alteration in Intracranial Regulation Neuro Disorder
| Question | Answer |
|---|---|
| brain begins to form | 3-4 weeks gestation |
| Structural risk factors for children | Cranial bones- not fused, less development and protection (sutures) Brain vascular Large head Weak neck muscles Excessive spinal mobility |
| Brain vascular | so prone to hemorrhage |
| large head so | lots of accel/decel injuries |
| excessive spinal mobility | Risk of SCIWORA - spinal cord injuries without radiographic abnormalities Cervical injuries - might not be a fracture but doesn't mean no cervical injuries |
| children have fragile capillaries so | they are at risk for IVH |
| cellular risk factors for children | Immature nervous system Nerve cells not completely myelinated - not until 2-3y Immature immune system |
| since children have immature immune system, they have | increased risk for infection, meningitis |
| developmental risk factors for children | Unsteady gait Poor judgment they just do things without thinking |
| cognitive risk factors for children | Unaware of environmental hazards |
| protective benefits of children skull | elastic skull open fontanels room inside cranium |
| elastic skull | can absorb direct energy of physical impact |
| open fontanels | allows for expansion which can signify brain bleed if large can tolerate higher ICP |
| room inside cranium for | swelling to occur |
| Cerebral Hemodynamics | Cranial compartment is incompressible Pressure-volume relationship between Intracranial pressure (ICP) Cerebral perfusion pressure (CPP) |
| Cranial compartment is incompressible which means | fixed volume and cannot expand |
| Pressure-volume relationship between | brain tissue (80%) but if tumor then increase in brain tissue % cerebrospinal fluid (CSF) (10%) blood (10%) |
| increase in CSF means | hydrocephalus |
| when there is an increase in one of the 3 areas in the brain then | there needs to be a decrease in another area to compensate doesn't matter where the increase is, the ICP will still increase |
| Intracranial pressure (ICP) | force exerted by the brain, blood and CSF within the cranial vault Normal 5-15 mm/Hg |
| if trauma, what ICP will we accept | 20mm/Hg |
| Cerebral perfusion pressure (CPP) | Affected by blood pressure and ICP MAP-ICP = CPP |
| hypotension doubles | mortality in trauma patients |
| you need compensation or | will have an increased ICP |
| compensation displaces | CSF - either shift the flow, decrease production or increase absorption |
| compensation requires | Cerebral blood vessels to vasoconstrict |
| what does vasoconstriction of cerebral blood vessels do | Reduces blood flow and cerebral perfusion pressure Decreases brain oxygenation |
| Compensation has it’s limits then Intracranial Hypertension occurs | ICP > 15mm/Hg- concerning Traumatic Brain Injury -> Severe injury: goal- keep ICP < 20mm/Hg |
| signs of increased ICP (children) | Headache Nausea/Vomiting Personality changes Visual changes Balance issues Alteration LOC Seizures Papilledema |
| headache in children | worse in AM or when laying down because that position affects venous/CSF drainage |
| visual changes in children | diplopia, blurred vision |
| papilledema in children | swelling optic disc |
| increased ICP typically means | brain tumor |
| signs of increased ICP (infants) | Irritability High pitched cry Tense, bulging fontanel Increased head circumference Dilated scalp veins Wide sutures Increased sleeping Poor feeding Sunsetting eyes |
| high pitched cry in infants | neuro cry- inconsolable |
| tense, bulging fontanel in infants is a | key finding!!! |
| dilated scalp veins in infants | can see veins in their head |
| poor feeding in infants | because they are nauseated |
| sunsetting eyes in infants | lose ability to look upward |
| signs of increased ICP (late) | Significant deterioration LOC Respiratory distress Cushing’s Triad Decreased motor response, posturing Decreased sensory response to painful stimuli Alteration in pupil size and reactivity |
| earliest indication of late increased ICP | Significant deterioration LOC |
| Respiratory distress | working hard to breathe |
| Cushing's Triad | Bradycardia Wide pulse pressure- increased SBP and low DBP Altered respirations |
| Decreased motor response, posturing | Decorticate- flexion Decerebrate- extension |
| Alteration in pupil size and reactivity | notify physician immediately Delayed response to light Anisocoria One pupil or both pupils fixed and dilated |
| Anisocoria | asymmetrical pupils |
| if one pupil is fixed and dilated, | child may survive |
| if both pupils are fixed and dilated, | brain death |
| brainstem herniation | increased ICP forces brain tissue to shift and compress the brainstem |
| structural defects | Positional plagiocephaly Craniosynostosis –potential teaching project Hydrocephalus |
| Positional/Deformational Plagiocephaly and Brachycephaly | Asymmetrical head- misshapen, uneven, or involves a flat spot Acquired skull deformity |
| Acquired skull deformity is a result of | cranial molding |
| Positional/Deformational Plagiocephaly and Brachycephaly is associated with | Positioning Muscular torticollis |
| Muscular torticollis | tightening in neck muscles, favor one side |
| Plagiocephaly | one side, back or side |
| Brachycephaly | both sides - back head |
| Positional Plagiocephaly does not | affect ICP |
| Positional Plagiocephaly is diagnosed | clinically through X-rays, CT |
| Positional Plagiocephaly signs and symptoms | Asymmetrical head Flattened spot |
| what may you also see in Positional Plagiocephaly | Misaligned ears Sloped or bulging forehead Widening back of head- Brachycephaly Asymmetrical facial features |
| Positional Plagiocephaly initial management | Repositioning Prone positioning- “tummy time” for 30-60 min, strengthen neck Treat torticollis if present - with PT to stretch muscles |
| Positional Plagiocephaly management for moderate to severe cases | Cranial remodeling helmet, if they don't respond to PT in 4-6wks |
| what can you do for Positional Plagiocephaly | change sides for feeds, change ways on back |
| Cranial remodeling helmet | plastic shell with foam lining and the flat area of the head has no shell |
| if there is no improvement of Positional Plagiocephaly | they need to be checked for Craniosynostosis |
| Craniosynostosis | Premature closure of cranial sutures |
| Craniosynostosis inhibits | brain growth |
| Craniosynostosis appearance | distorted skull |
| in Craniosynostosis, | 2 or more sutures are fused = Hydrocephalus and increased ICP |
| manifestations of Craniosynostosis | Skull deformity Prominent bony ridge |
| Craniosynostosis treatment | surgery |
| Craniosynostosis is an | urgent referral because it will increase ICP |
| Hydrocephalus | Excess accumulation of cerebrospinal fluid (CSF) Ventricular dilation and increased ICP Constant CSF production |
| Excess accumulation of cerebrospinal fluid (CSF) due to | Imbalance in production and absorption |
| CSF is known as | shock absorber |
| Hydrocephalus, if gets worse, | will be permanent and cause brain damage |
| types of Hydrocephalus | communicating and non communicating |
| communicating Hydrocephalus | Impaired CSF absorption but CSF is still flowing Blocked after exiting ventricles, communicates between ventricles |
| non communicating Hydrocephalus | Obstruction of flow between ventricles most common type, there is a blockage so CSF is not flowing normally |
| Hydrocephalus can be | Congenital or acquired |
| any sign of increased ICP can lead to | Hydrocephalus |
| Hydrocephalus- Clinical Manifestations in infants | Abnormal head growth: ventriculomegaly (large head) Bulging fontanel Inconsolable irritability High-pitched cry Sunsetting sign (eyes) Macewen’s sign (cracked-pot sound on percussion) Seizures |
| Hydrocephalus- Clinical Manifestations in older child | Headache, especially upon awakening Papilledema Nausea/ vomiting Blurred or double vision Sunsetting of eyes Problems with balance, coordinationn Changes in personality |
| diagnosis of Hydrocephalus | CT or MRI to confirm, allows you to see big ventricles and ventriculomegly |
| treatment of Hydrocephalus is | surgical intervention |
| surgeries for Hydrocephalus | Removal of underlying cause Shunt- permanent Endoscopic Third Ventriculostomy |
| removal of underlying cause as treatment for Hydrocephalus | space occupying lesion, hydrocephalus is caused by other problem |
| permanent shunt types | VentriculoPeritoneal (VP) shunt- most common VentriculoPleural shunt (VPL) VentriculoAtrial shunt (VA) |
| permanent shunts work by | diverting flow of CSF |
| VP shunt | ventricle to peritoneum Coiled in abdomen to allow for growth, grows with child |
| most common shunt | VP shunt |
| VA shunt | ventricle to atrium |
| VPL shunt | ventricle to pleural space, use this if there are issues with abdomen |
| what is flow rate of shunts | regulated by internal valve |
| Complications of VP shunt | Malfunction Infection- most common Bowel obstruction May need to externalize shunt-(EVD) external ventricular drain temporarily |
| if VP shunt is removed or doesn't work, | symptoms come back |
| when a VP shunt is infected, | it results in malfunction |
| once infection clears, VP shunt | can be reinserted |
| Endoscopic Third Ventriculostomy | Used for obstructive, non communicating Perforation made in floor of third ventricle, promoting drainage of CSF |
| advantages of Endoscopic Third Ventriculostomy | No foreign object, decreases risk for infection Decreased risk long term complications |
| disadvantages of Endoscopic Third Ventriculostomy | May fail and patient may need shunt placed Only for obstructive hydrocephalus |
| nursing management for Hydrocephalus | assessment is key!!! |
| nursing assessment for Hydrocephalus | Head circumference daily (HC or OFC) if <3y Neurological checks Respiratory status I’s and O’s Abdominal exam S/S infection |
| abdominal exam during Hydrocephalus | bowel sounds, distention done once they have shunt |
| where to look for s/s of infection in Hydrocephalus | incisions, shunt |
| Postoperative shunt insertion | Position on unoperated side, and as ordered, possibly flat never 90deg, normally 30deg |
| Hydrocephalus VP Shunt Placement Family Teaching | Signs & symptoms of increased ICP and infection Sleep with head slightly elevated - make sure head isn't hanging off side of bed! Avoid constipation Wear safety helmets Call with fever, signs of infection Regular follow up |
| infectious disorders | Bacterial meningitis Reye Syndrome |
| Meningitis | Acute inflammation of meninges from bacteria, virus or fungus in CSF |
| two types of Meningitis | viral (aseptic) or bacterial (septic) |
| viral Meningitis | Supportive care |
| bacterial Meningitis | Contagious Serious morbidity and mortality Crowded living conditions Injuries with access to CSF |
| when is meningitis seen more | late winter and spring |
| Meningitis Physical Assessment Findings | Preceding respiratory illness, sore throat May develop signs of increased ICP Infants have more subtle, atypical signs |
| Infant physical assessment findings of meningitis | Seizures, high pitched, weak cry, fever, irritability, bulging fontanels, possible nuchal rigidity, poor feeding, vomiting, lethargy, Opisthotonic position |
| Opisthotonic position | reflex muscle movement where the infant is arching their back and their neck is down |
| 2 years- adolescent physical assessment findings of meningitis | Seizures (initial sign), nuchal rigidity, positive Brudzinski’s and Kernig’s sign, fever and chills, headache, vomiting, photophobia, irritability and restlessness- can progress drowsiness, delirium, stupor and coma |
| nuchal rigidity | if can't put their chin to neck |
| what else can happen in 2 years- adolescent with meningitis | petechiae or purpuric- type rash (meningococcal) joint involvement (meningococcal and Hib) chronic ear drainage (pneumococcal) |
| kernigs sign | child lays on back and it is painful to straighten their leg when lifted like soccer stretch |
| Brudzinski’s sign | child lays on back and when their head is picked up their knees bend too |
| Meningitis Diagnostic Tests | Lumbar puncture for CSF analysis- indicative of meningitis Blood cultures Complete blood counts CT scan or MRI |
| bacterial meningitis lumbar puncture results | Cloudy Elevated WBC Elevated protein Decreased glucose Positive gram stain |
| viral meningitis lumbar puncture results | Clear Slightly elevated WBC Normal of slightly elevated protein Normal glucose Negative gram stain |
| if patient has meningitis and increased ICP, then | do CT before LP because you could cause brain herniation |
| Lumbar Puncture patient position | Position side lying - hold child securely and monitor airway and respiratory status head flexed (chin to chest), knees to abdomen/chest |
| during a lumbar puncture, a child may be | sedated, local injectable anesthetic used In addition- lidocaine and prilocaine 45min-1 hour before- routine LP |
| Lidocaine and prilocaine 45min-1 hour before- routine LP BUT | don’t delay for suspected meningitis!! |
| Prenumbered tubes for collection of specimen: collect in chronological order | Chemistry/Immunology- protein- glucose Microbiology- culture Hematology- cell count and differential Specimen control – held for 30 days |
| after a lumbar puncture, | Remain flat afterwards to prevent CSF leak and headache Band aide and dry 24 hours |
| if patients head up and there is spinal leak and then they lay down and it's better, | tell HCP! |
| Viral Meningitis Treatment | supportive |
| Bacterial Meningitis Treatment | MEDICAL EMERGENCY!! IV Antibiotics asap Corticosteroids- dexamethasone Analgesics Antipyretics |
| what should you do before IV abx in Bacterial Meningitis pts | LP and Blood cultures |
| if there is a Petechiae or purpuric- type rash, | immediate attention is needed |
| Nursing care to prevent spread of meningitis | Isolate and maintain droplet precautions Treat close contacts |
| Nursing care: diagnostic | Assist with LP Obtain blood cultures |
| Nursing care: treatment | Administer antibiotics ASAP, don't delay if can't get LP right away |
| Nursing care: reduce fever | Antipyretics- Acetaminophen, Ibuprofen Tepid bath, cooling blanket, fan Avoid shivering |
| why should you avoid shivering | because shivering increases metabolic rate which is undoing what you're trying to decrease |
| nursing care: prevention | Education early and complete treatment URI Maintain appropriate immunizations Pregnancy screening- group B streptococcus BEFORE delivery |
| Maintain appropriate immunizations for meningitis | Hib and PCV vaccines- 2, 4, 6, and between 12-15 months old Meningococcal vaccine 11-12 years- booster 16 |
| other nursing care for meningitis | NPO if decreased LOC Seizure precautions Assessment: vitals, I & O’s, pain, neurologic, ICP, electrolytes, infants need OFC and fontanels checked Decrease environmental stimuli Provide measures for comfort and to decrease ICP |
| Complications of meningitis | Increased intracranial pressure- can lead to neurologic dysfunction Obstructive hydrocephalus Sepsis can lead to death Vision or hearing loss |
| Reye syndrome | Life threatening acute encephalopathy and fatty liver changes Mitochondrial insult, induced by virus and causes cerebral edema and liver dysfunction |
| Reye syndrome follows | common viral illness |
| Reye syndrome patho | unknown! |
| Reye syndrome risk factors | Use of Aspirin (salicylates) during viral illness Influenza, gastroenteritis, varicella, upper respiratory infection |
| Reye Syndrome findings | Profuse vomiting and lethargy Progressive neurologic impairment: delirium, seizures, coma, increased ICP, herniation and death |
| Reye Syndrome diagnostic tests | Liver enzymes: ALT, AST elevated and serum ammonia elevated Electrolytes Prolonged bleeding times Liver biopsy- definitive diagnosis Lumbar puncture- CSF analysis to rule out meningitis |
| Reye Syndrome Management | !!!!!!!!Education avoid aspirin during illness!!!!!!! No cure Neurological checks Mechanical ventilation- possible HOB elevated Decrease ammonia levels Hydration and electrolytes- IVF Diuretics Vit K, FFP, and platelets |
Created by:
leh195