child w/neurological disorder 1

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child w/neurological disorder 1
2015-04-29 22:19:52

poor kiddies
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  1. Anatomy and Physiology Overview
    • brain and spinal cord developed during first trimester
    • development of CNS is complete but immature at birth- myelin sheth not fully develop- cant lift head bc nervous system is immature but..
    • Myelinization occurs in a cephalocaudal "head to toe" direction- grow develop this way
    • At birth and early childhood fontanels and sutures are not closed and not fused
    • young infants have proportionally large heavy head and lack neck strength
    • - head conts to grow to 5 yrs
    • infant brain is highly vascular- alot of blood supply. shaking head can cause some of the vessels to dislodge and cause hemmorahage
    • vertebrae not completely ossified- at risk for compression fractures
    • preterm infants are at risk for brain damage and delayed development of motor skills- risk hemmorahage and injury and devel with suck and swallow. problem with apnea
  2. Major regions of the brain
    • Cerebrum: four lobes, parietal, frontal, temporal and occipital
    • - frontal: thought personality behavior
    • - parietal: sensation in body
    • - temporal: hearing
    • - occipital: vision
    • - cortex- grooves, thin layer billions of neuron responsible for conscious behavior- communications, memory, voluntary movement
    • - white matter: communicates with the lower regions. tells lower region what to do (where myelinization occur. impulses)
    • - diencephalon: house thalmus (relay station, pain), hypothalmus (automatic control, hormones to maintain homostatis), epithalmus (pineal gland, sleep pattern, melatonin to help sleep), 3rd ventricle (where CSF is)
    • cerebellum: coordination of smooth movement, balance, maintain posture
    • brain stem:cardiac and respiratory center. vital signs for life
  3. membranes of brain (meninges)
    • Dura: outermost layer
    • arachnoid: middle CSF flows thru this
    • pia mater: closest to the brain- spongy layer
    • function is to protect the CNS, enclose all the venus CSF in place to protect the brain
  4. Cerebral Spinal Fluid CSF
    • circulates in brain to protect us
    • starts off in the middle of the brain from the carcoid plexus to the lateral ventricle and goes thru a juntion and then flows into the 3rd ventricle
    • 90-150ml (3-4oz), small amount
    • brain nutrients to the brain and takes waste away from the brain (ie glucose, electrolytes)
  5. Blood Brain Barrier (BBB)
    • protect the brain from substance that can hurt it and allows things that can do good for it.
    • good things pass thru like glucose, electrolytes
    • bad things pass thru: drugs (herion), alcohol,
    • some antibiotics can pass, viruses, bacteria can pass, o2, h2o, caffiene, nicotine, anethesia
    • BBB breakdown: brain injury due to trauma, toxins, inflammation
  6. Developemental considerations
    • infants:
    • movements by primitive reflexes
    • neurological intact infants display primitive reflexes (which go away) but neurologically intact adults
    • primitive reflexes are tested during brain injury
    • Premature infants are missing the grooves and fissure of the jira of the brain. it doesn't fully develop until term at risk for the apnea and problems with breathing, may have bradycardia
  7. Nursing Assessment
    • Hx- pregnancy history, our 1st clue as to what is going on
    • PMH birth hx, Fhx (NTD, seizures), developmental hx
    • review of systems H-T ask questions about each system
    • chief compliant
    • history of present illness
  8. PE s/s
    • If head is increase- measure, rapid brain growth
    • bulging frontals or forehead
    • crying not consiable
    • headache
    • no pupil response (not equal..problem)
    • projectile vomiting (concern)
    • systolic and diastolic are far apart
    • any home remedies
    • decre HR RR- medulla can be impacted
    • pain in neck- could be spastic and can occur with meningitis
  9. PE neurological
    • Inspect and observe for:
    • - VS for baseline
    • - LOC affect ok
    • - head face and neck symmetry
    • - cranial nerve
    • - motor funtion
    • - senses
    • - DTR
    • - increase ICP
    • Palpate: fontanel and skull
  10. LOC PE neuro
    • exhibiting age approriate behavior
    • Full conscious behavior: alert and oriented x3
    • confusion: disoriented, alert but not responding appropriately
    • lethargic: dull, sluggish, half asleep can arouse easily
    • obtunded: blunted dull, and responding less and less to what is going. have to be stimulating roughly
    • stupor: only respond to vigious stimulation
    • coma: cant be aroused with painful stimuli
    • earliest indicator of neurological status is their LOC
    • continue cry, irrititated is not normal
  11. pedi Glasgow Coma
    • tool used to asses a person level of conscious and level of brain damage
    • different from adult one- different things on it
    • for children who is too young to talk
    • eye movement, verbal response, motor
    • if brain trauma:
    • 13-15 mild brain injury
    • 9-12 moderate brain injury
    • 3-8 severe brain injury
    • <3 vegatitive state
  12. PE: neuro VS
    • VS can provide information about probable underlying cause of decre LOC
    • Changes in VS can occur with: cerebral infection, increased ICP, coma, brain stem injury, head injury
    • report changes in VS promptly
  13. PE: neuro head face and neck
    • head:
    • size and shape do this until 3. to identify anything abnormal
    • microcephaly- small brain
    • hydrocephalic- big brain

    face: symmetry, paralysis, edema

    neck: ROM of neck, stiff neck- report nuchal rigidity (because of a muscle spasm)- report this right away
  14. Cranial nerves PE neur
    Developmental consideration
    • think about techniques used for different ages
    • EOM of eye
    • Babies:
    • - dolls eye maneuver to assess Cranial nerves III, IV, VI
    • - turn head side to side to determine symmetry with eye movement
    • - flex and extend neck to assess vertical eye movement
    • observe for sunset eyes and nystagmus (
    • pupillary response is abnormal w/neurological dysfunction
    • - fixed dilated pupil (neuro emerency)
  15. PE: neuro motor and sensory function
    • Motor Funtion:
    • - observe for changes in gait muscle tone and strength- in babies u see flaccid not good
    • - observe for spontaneous activity, balance, asymmetrical movement and posture
    • normal infant slightly flexed
    • posturing abnormal posturing, decorticate and decerbrete
    • Sensory function:
    • - test: light touch, pain, vibration, hot and cold
  16. Posturing
    • you see this with severe injury. certain parts of the brain are affected. poor outcome for patient
    • Decorticate posturing: arms come to the core (abbucted), hands flexed to the chest, feet are flexed.
    • - damage to the cerebral cortex
    • Decerebrate posturing: severe, brain stem involved. this is the worst one. arms are flexed hands rotated and outward, feet are plantar flexed, legs are rigid
  17. PE: reflexes
    • infant: assess primitive and protective reflexes
    • average is 2+
    • brisk is not good
    • hypotonic not good
    • no response no good
  18. Increased Intracranial pressure
    • higher than normal pressure in the skull
    • - if persistent will destroy health brain tissue, and alter mental function
    • - fatal if not corrected
    • - severely high ICP can cause brain herniation
    • causes:
    • -trauma to brain
    • - bleeding, hemorrhage, inflammation
    • - tumor or space occupying lesion
    • - hydrocephalus- too much CSF
    • - infection
  19. incre ICP what is happening now?
    • Pathophysiology:
    • rigid skull allows for little expansion of the brain tissue, inc CSF, and blood
    • CNS can compensate only for short period of time
    • - by limiting blood flow to the head
    • - by displacing CSF in the spinal canal
    • - altering CSF production
    • complication brain death, cardiac arrest, respiratory insufficiency or arrest
  20. Incre ICP assessment
    • S/S
    • Infants: bulging/tense fontannels, suture lines widen, head circum bigger, child irritable, high pitch cry (shill cry), poor feeding, distended scalp veins
    • General: incre BP, HR RR down (compensatory measure), decre LOC and sleepiness, nausea, pupil reaction decre, headache, dizzy, vomiting, changes in vision, diplopia
    • late signs: decr LOC, fixed dilated pupils, posturing, irregular or cheynne stokes respiration (abnormal breathing like near death breathing), papiledema (swallowing in eyes), bradycardia bc medulla
    • EMERGENCY: sudden fixed dilated eyes neurosurgey emergency
  21. Incre ICP dx, therapeutic and meds
    • Dx: CT, MRI, nuclear brain scan, ICP monitoring (probe in brain)
    • Therapeutic management:
    • - provide O2
    • - hyperventilation via mechanical ventilation- helps to reduce ICP
    • - incre bp
    • - subdural tap/ventricle tap- to take some CSF only a little but to take out
    • meds:
    • - antibiotics- infection
    • - steriods- reduce swollen
    • - diurectics- to get rid of fluid
    • - pain meds
    • - sedative- calm reduce metabolic need so they are not using too much
    • - anticonvulsants- seizure
  22. ICP intervention
    • monitor neurological status closely LOC, pupils (hallmark neuro problem-change in pupils and reactivity size, LOC)
    • monitor incr ICP report deviations- sunset, irritability, fontannel,
    • monitor VS- changes in bp, rr, hr
    • measure head circumference
    • maintain patent airway, monitor mechanical ventiliation
    • maintain HOB 15-30- promote drainage, head midline
    • quiet dark enviroment
    • manage pain
    • emergency equipment- intubation kit, o2,
    • maintain seizure precautions
    • provide emotional support to fam