Neuro-peds exam 2

top heavy

thin, not developed

vascular with small subarachnoid space

immature mylineation

spinal mobility

wedge-shaped cartilaginous 

plasticity

total pressured exerted by brain, blood, CSF w/in cranial fault

• brain: 80%
• CSF: 10%
• blood: 10%

• blood
• CSF

changes in pCO2! MOST POTENTIAL MEDIATOR 

increase pCO2 will cause vasodilation and increase ICP

acidosis / hypoxemia = vasodilation and increased ICP

seizures and fever=increased CBF and increased metabolic rate

• traumatic brain injury: 
• hematoma
• cerebral edema
• cerebral ischemia
• IVH 
• intracerebral hemorrhage

• hydrocephalus
• infections: inflammatory response, cerebral edema, hydrocephalus, cerebral hyperemia (IICP following ischemia)
• brain tumor: mass effect, peritumoral edea, hydrocephalus
• intracranial hemorrhage: mass effect, cerebral edema
• intraventricular hemorrhage: hydrocephalus

• family hx 
• pregnancy hx: fetal distress, labor/delivery, apgar scores, maternal drug use, maternal diabetes

• M: metabolic (blood sugar abnormalities), electrolyte imbalances, inborn errors of metabolism 
• I: infection, menigitis, congential viral infections
• T: toxins, CO, lead, NAS
• T: trauma; subdural hemotoma, shaken baby syndrome
• E: endocrine; blood sugar abnormalitites
• N: neur/neoplasm; malformations, intracranial hemorrhage, HIE

• "just doesn't act right"
• eyes: crossed, droopy eyelids, unequal pupils, blurred or double vision
• behavior: subtle initially, irritability, restlestness, lethargy 
• motor function: movement? spontaneous?
• skin: dry vs diaphoretic?

• systolic: increases
• diastolic: decreases 
• pulse: decreases (brady) 
• *wide pulse pressure 

• maybe irregular breathing (Cheyvne-Stokes)
• elevated temp (hyperpyrexia)

• irritability 
• restlessness
• full/bulging fontanels
• poor feeding
• poor sucking
• vomiting (even projectile)
• distention of superficial scalp veins
• sunset sign
• shrill/ high pitched cry
• nuchal rigidity and seizures (LATE SIGNS)

• sudden change in mood
• HA, poor feeding
• vomiting
• difficulty waking
• weakness on one side
• nuchal rigidty
• deterioation of cogn. ability

• changes in vitals (Cushing's)
• seizures
• photophobia
• positive Kernig's and Brudzinski's sign (infection)
• opisthotonus (spasms causing backward arching of head, neck, spine)

• damange to upper brain stem 
• arms abducted and extended, wrists pronated and fingers flexed 
• legs are stiffly extended, plantar flexion of feet

• damage to one or both corticospinal tracts adducted and flexed, wrists and fingers on CHEST
• legs are stiffly extended and internally rotated with plantar flexion of feet

• CBC: increase in WBC(infection) and decrease H&H (bleeding)
• metabolic panel: blood sugar-hypo or hyperglycemia (DKA), sodium, calcium
• toxiocology screen (urine drug screen)
• UA
• blood gas: O2 and acid-base status
• blood culture
• CSF analysis and culture
• infants: ammonia, metabolic screen

• cell count: over 40 WBCs
• grain stain: presence of organism

POSITION!

• may withhold sleep
• no caffeine several hours prior
• adminster sedatives as ordered
• help attach electrodes to head
• monitor

CT scan: study of choice in child with acute neuro impairment or deteroiation 

MRI: assessment of brain tissue; precautions: metal, implants, o2 cycliners

• GCS <8! 
• signs of increased ICP
• post resusciation of acute traumatic IC hematoma or other procedure
• others who have high chance of IICP
• gold standard is intraventricular monitoring

• A: rapid sequence intubation may be neccessary 
• B: ventilation (normoventilation) or hyper for some
• C: avoid hypotension
• positioning: midline to facilitate JVdrainage (elevate for 15-30 degrees)
• osmotic therapy: mannitol bolus every 4-6 hours, hypertonic saline infusion

• maintain normal temp
• prevent shivering, fever
• sedation, anagelisc
• seizure prevention, prophylaxis in kids <1 or those with TBI
• no steriods
• surgical intervetion: only for lesions producing mass effects
• euvolemic, normoglycemic, avoid dextrose for 48 hours

paradoxical electrical discharge of neurons in the brain that result in a change in function or behavior

• 30k diagnoses / year
• 10% of pop. will have 1 in lifetime
• epilepsy: recurrence of seizures

• genetic predisposition
• acute febrile state
• head trauma
• cerebral edeam
• abrupt cessation of AED meds
• infections
• metabolic disorders
• exposure to toxins (leads)
• hypoxia
• acute drug and ETOH withdrawal

• increased physical activity
• excess stress
• overwhelming fatigue
• acute EOTH ingestion
• exposure of flashing lights
• caffeine, coacine, aersols, glue products..

• more common in preterm
• eye deviation
• repetitive blinking, fluttering of eyelids, fixed stare (preemie)
• repetitive mouth and tongue movements (drooling, sucking, tongue - thrusting, yawning)
• apnea: 'if aint breathin, they a seiz'ing"

• single limb jerking
• extension of arms/legs
• decorticate like movements
• myclonic jerks
• abnormal movements: pedaling, swimming, rowing

• eyes roll upward
• LOC
• tonic contractions
• salivation
• apnea->cyanosis
• violent jerk
• incontinence
• gradual slowing til cessation

• difficulty arousing
• confused for several hours
• impaired fine motor function
• lack of coordination
• possible vomit, HA
• sleepy
• no recollection of event

• 4-12 years common
• brief periods of altered consciouness with sublte motor activity
• appears to be day dreaming
• lasts about 10 sec
• no hisotry of motor involvemtn or resp. compromise

• sudden, jerking or stiffening of extremities
• may occur 100x a day
• each episode lasts 1-2 sec

• sudden loss of muscle tone and consciousness 
• lasts a few seconds wihtout resp. signs 
• HIGH FALL RISK

• first 8 months of life 
• sudden, brief, symmetric contraction 
• head flexed with arms and legs extended
• possible eye deviation
• possible cry, giggle
• possible flushing, pallor, cyanosis

• aversive seizure
• rolandic: tonic-clonic movements of face, most common during sleep
• tinglining, numbness may spread

• altered behavior 
• unable to respond to environment
• impaired consciousness
• confusion, amneisa
• aura*****
• last 2-3 min to up to 10 min

• responsive 
• resolves with touch-passive flexion of extrememity
• NO autonomic changes
• gaze normal
• predominant motion: tremors

• not responsive to stimuli
• abnormal gaze
• autonomic changes occur
• predominant motion: clonic jerking

• EEG
• ct 
• mri
• lumbar punct
• metabolic panel
• tox screen
• consider metabolic screenin for inborn errors of metabolism

• adminster sedatives as ordered
• assist w. position
• no caffeine for several hours prior
• wash hair before/after
• may need to take deep breaths 
• withhold sleep if instructed
• not painful!!

• AEDs: phenobarbital, valium, phenytonin, carbamazepine, depakote, cerbyx, levitracin
• monitor levels
• be aware of food/med interaction

implanted device used to abort or shorten seizures

• high-fat foods
• limited CHO
• useless in kids whose seizures cant be controlled by meds, start diet in hospital and supervise by a doctor

• kids with persistent seizures unresponsive to meds
• remove part of brain responsible for seizures (corpus callosotomy, focal resection)

major nonphyschoactive ingredient in weed

• used for unrelenting seizures
• mechanism is unkwonw
• studies underway

greater than 10 min long or cluster of seizures where child does not awake between seizures

• EMERGENCY: CALL AMBULANCE
• if prescribed: give Diazepam gel (DIASTAT) into rectum

• time begins and ends
• precipating event
• body parts involved
• description of motor involvement
• description of eye movement
• resp. status, color, desaturation
• behavioral state (LOC)
• postical state
• all nursing interventions and childs response

• RISK FOR INJURY!
• know warning signs
• use padded side rails and keep up
• move child away from furniture
• bed in lowest position
• safety helmet for repetitive seizures
• use TM themometer
• remove glasses
• do not restrain!
• reorient, obtain v/s after 
• adminster meds as ordered

• ineffective airway clearance
• avoid gum, small candy
• supine with head turned to side
• loosen restrictive clothes
• no padded tongue blades
• sunction prn
• provide O2 ,,PPV if indicated
• emergency equipment ready

• maintain sidelying
• check vitals
• assess injuries
• perform neuro check
• allow rest
• orient
• encourage child to describe before/after and if aura?
• no foods/liquids until fully awake and can swalow
• try to determien trigger
• complete documentation

• explore feelings about self and disorder
• ecournage expression 
• use play therapy
• treat child as nomrla and not vulnerable
• refer to suppor group
• routine eval for sucidie risk

• discss triggers
• promote good dental care
• what to do

• avoid biking, skating, skateboarding on streets with heavy traffic
• avoid activities at height
• supervise around water
• tell teachers
• ID bracelet
• driving restrictions by state
• counsel on effects of seziures and AEDS on sex
• avoid recreational drugs and EOTH

• most common birth defect in CNS
• results: neural tube failure to close during embyronic development in 1st 3-5 weeks of gestation 
• latin term: "spilt" or "open" spine
• elevated alpha-feto-protein in mother may indicate fetus with NTD 
• most common in girls

• insufficent folic acid intake during pregnancy
• maternal malnutrition
• medications
• exposure to radiation/chemicals
• prepregnancy conditions; diabets, obseity, hyperthermia, low b12 
• genetic predisposiiton

• 0.7 per 1000 in Us
• 4.45 per 1000 in TN

*significant decrease since folic acid supplement was made mandatory

• veretebral body fails to close
• spinal cord is intact
• no meninges are exposed
• no neuro deficient seen

• protustion involves sac-like cysts that contains CSF in the midline of the back 
• spinal cord not involved
• neuro deficient usually not present

• protrustion involves meninges, CSF, nerve roots, and spinal cord
• neuro deficients evident*

• visible spinal defect-inspect to see if intact
• flaccid paralysis of legs
• hip/joint deformtities
• altered bowel and bladder function

• prepare parents for surgery within 24-48 hours
• position prone with hips flexed and legs abducted
• cover defect with a moist, nonadhearing dressing using NS, change q 2 hours
• maintain infant in open warmer
• inspect sac closely for leaking, irritation

• monitor vitals
• assess for infection
• provide pain relief
• incisional care as prescribed
• assess for CSF leak
• maintain PRONE until okayed by neurosurgeon
• begin ROM to lower extremities 
• monitor HC daily

• teach ROM, incisional care
• allergies
• teach signs of ICP
• asses bowel/bladder function

• risk for infection:
• monitor temp
• ATB
• change dressing
• prevent soiling of wound from urine and feces 
• meticulous aspetic technique 
• monitor for UTIs

• avoid rectal temp
• keep pressure off site
• coordinate OT/PT
• monitor HC in infants
• evaluate nutritional status
• keep pressure of bony prominences
• reposition q 1-2 hours
• observe skin under splints and braces
• ROM to legs
• position in proper alignment

• intermittent self-cath
• note color and blah blah crap
• monitor for UTIs
• no rectal temps
• adminster laxative or enmeas as needed
• antispasmodics as prescribed

• nonlatex gloves, caths, equipment
• provide parents iwth list of household items
• s/s of latex allergy
• provide info on epi-pen

• assess mobilit skills
• assist devices
• passive ROM TID

• measure Hc and abd girht
• signs of IICP
• DO NOT POSITION ON SIDE OF SHUNT
• Monitor for skin breakdown
• reposition
• monitor for bleeding

• IEP
•  legal 
• created by parents

• foster it
• encourage act. with friends
• talk to professionals about sexuality
• contraception, folic acid intake
• safety important

a syndrome, sign, resluting from distrubances in the dynamics of CSF which may be caused by several diseases

• 3-4 q 1000 births
• congenital or acquired
• congential: due to maldevelopment of intraurterine infection
• acquired: due to infection, neoplasms (rare), or hemorrhage (common)

• CSF is formed by 2 mechanisms:
• secretion by choroid plexus
• lymphatic-like drainage by the ECF in brain 

CSF circulates thru ventricular system and is absorbed within subarachnoid spaces by unknown mechanisms

• hydrocelphalus results from:
• impaired absorption of CSF within the subarachnoid space (communicating hydrocephalus) or 
• obstruction to the flow of CSF: through the ventricular system (noncommunicating)

• both lead to increase accumulation of CSF in ventricles
• ventricles become dilated and compress brain---> cranial sutures are closed, skull enlarges

result from development malformations 

other: neoplasms, intrauterine infections, trauma

type 2 malformation of brain seen most exclusively with myelomeningocele, is charactered by herniation of a small cerebellum, medualla, pons, and 4th ventricle into cervical spinal canal through enlarged foramen magnum

depends on acutiy of onsent and presence of preexisitng structural lesions

• head grows at alarming rate!
• 1st signs: bulging of fontanels without head enlargement
• tense, bulging, non-pulsatile ant. fontanel
• thin skull bones with separated sutures (cracked pot head sounds on percussion)
• increasing HC: more than 0.5 cm/day
• setting sun eyes, may signify brain damage
• vomiting, lethary, irritability

• ultrasound
• easy, quick, not painful

should have ultrasound at 7 days or age (sooner if suspect significant IVH)

see dilated ventricles on ultrasound

• releive it
• treat complications
• manage problem resutling from effects of disorder on psychomotor development
• usually surgical!

• for infants with hydro from IVH: lp done to relieve pressure
• espeically if infant to small for surgery
• Allow CSF to drain freely (amount depends on MD)

• key is successful positioning!
• sitting up or lying on side

• monitor CP status
• hold infant still in proper position
• chin to chest
• bend in C shape
• send CSf to lab for cell count, glucose, protein, culture, gram stain

• therapy of choice!
• direct removal of source of obstruciton (neoplasm, cyst, and hematoma)
• most require shunt procedure to drain CSF from ventricles to extracranial area; usually peritoneum (VP shunt), or right atrium (VA shunt) for absorption

• neonates and young infants
• greater allowance for excess tubing: which minimizes number of revisions needed as child grows

• older children who have attained most of smoatic growth or children with abnromal patho
• contraindicated in children with cardiopulmnoary diseaes or with elevated CSF protein

• infection!****
• greatest risk period: 1-2 months following placement 
• staph and strep most common organisms

• mechanical difficulities; kinking, plugging, migration of tubing
• malfunction is most often by mechanical obstructin!
• look for signs of increased ICP, fever, lethargy, vomiting

• place on un-operated side to prevent pressure on shunt valve
• keep HOB flat: rapid decrease in IC fluid cause subdrual hemotoma due to small vien rupture in cerebral cortex
• DO NOT PUMP SHUNT WITHOUTH SPECIFIC DIRECTION FROM DOCTOR! too many different devices..

incision on the head, behind ear, and on the abd

• OBSERVE FOR SIGNS OF INCREASE ICP!
• may indicate obstruction of shunt
• assess pupil size; as pressure on oculomotr nerve may cause dilation on same side as pressure
• blood pressure may be variable due to hypoxia to brainstem
• abd distention: due to CSf peritonitis or post-op ileus due to cath placement

• monitor for I/O: may be on fluid restriction or NPO for 24 hours to prevent fluid overload 
• monitor VS : increased temp may indicate infection
• give good skin care to prevent tissue damage

• fear
• support: provide info
• prepare for discharge: teach signs of ICP and when to call the doctor
• teach positioning, wound care
• have PT/OT teach parents

dx based on clicnal and lab evidence of brain injury due to lack of O2 and reduced blood flow to brain

partial or complete lack of O2 in the brain or blood stream

state in which the placental or pulmonary gas exchange is compromised or cases

occurs during 1st and 2nd stages of labor when fetus is otherwise nml

occurs anytime during the perinatal period from conception through 1st month of life

abnormal neuro behavior in neonates from hypoxic-ischemic event

• 2-8 gases per 1k live births
• 23% of all neonatal deaths worldwide
• severe cases: mortality rate: 25-50%

• antepartum risk factors
• labor/delivery
• postnatal events

profound metabolic or mixed acidosis (ph less than 7)

perisistance of an Apgar score of 3 or less for longer than 5 min 

neontal neuro sequalae, such as seizures or hypotonia

multiple organ involvement

• immature: lower metabolic rate
• immature balance of neurotransmitters
• plasticity of immature CNS
• glucose: only substrate used for energy metabolism

• reduces cerebra metabolism, decreases rate of energy ultiziation
• decreases neurotrans release
• supresses free radical activity
• reduces vascular permeability and edema
• reduces secondary neurnoal death
• decreases degree of global brain damage

• infants born at 36 weeks or greater
• within 6 hours of insult
• evidence of acute injury around the time of birth
• specific criteria for cooling events

good signs: 7 days old, EEg with normal background activity, absence of seizures, adequate head growth, able to take oral feedings

poor signs: lack of spontaneous resp. effort 30 min after birth, seizures, persistent feeding difficulty, poor head growth

• 10%: generally healhty
• 10%: minor disabilites
• 30-50 may develop mod-severe disability
• 30 may have disabling CP
• 16% epilepsy
• 14-70 blindness
• 6 hearing impair
• others: ADD, ADHD, intellect challenges

• infant born to a drug affected mother-withdrawal
• withdrawal:set of symptoms as the body attempts to remove an addictive substance
• accurately assessed*
• therapetuic measures and often medication

• depends on drug
• how each individual baby metabolizes the drug
• baby's own tolerance

*no two babies will react the same. responsibility of caregiver to monitor and read the infant and signs

• common trait
• little tolerance
• swallowing, closenes, sound, can escalate baby into frantic state

babies need protection from overstimulation but should NOT be stimulus-deprieved

• muscle tone is degress of stiffness
• unusually limp of stiff
• particularly in limbs and neck 
• stiffness may come and go
• tremors, jerking, other signs of distress-sign of baby tryin to control uncomfortable sensations

• drugs attack gastric system-at 12 mon
• watery stool, explosive diarrhea, excoiatred butttocks, gas, constipation 
• need proper handling to prevent serious health concerns
• distress and high stimulation can increase
• diarrhea can irritate fragile lining of the intestines and also lead to dehydration

• chronic ear infection
• unexplained fecer(opioates and opioids)
• sleep/week irregualr
• extreme appetitie (barbitures, cocaine)
• hyperrefleia, moro

• comforting techniques ! 
• basica principeles of handling apply to all

• swaddling: contains extremties
• C position: allows infant to relax
• vertical rock
• clapping: stop if infant does not respond 
• feeding: get infant relaxes, minimize stimulation 
• controlling environment: next

• limit number of caregivers
• offer calm surroujndings
• minimize loud noise--low volume
• keep lights low
• caregiver should have calm presence
• rountine beneficial *

• determines level of therapetuic intervetion necessary
• helps to determine effectivness of intervnetions being used
• assess sjmptoms
• oringiallydevelped by Loretta Finnegan

• set of observed signs and sympotms in the infant
• obsereved at regular intervals=every 3 hours
• should refelct all symptoms obsereved sing the last scoring
• high scores are nOT lowered by therapuetic handling should assessed for medical intervention

• begun depneding on Finnegan scores
• once stable, medicated is tapered, based on Fs
• med of choice: morphine sulfate
• 2nd line: clonidine
• 3rd line: phenobarbital (use contravseral )

• ENacted 4/29/14
• expires 7/1/16
• prosecuted for illegal use of narcotic if infant is harmed
• aggravated assault (up to 15 years)
• homicide if infant dies!

• BORN DRUG FREE TN
• new to redue NAs babies
• inform, resoureces, newroom, hint for families and firneds 
• explore website

• viral: wide variety of viral agents or enterovirus
• bacterial: haemophilus influenzae (type B), streptococcus pneumonia, neisseria minigities (meningococcal)

• risk for ineffective breathing pattern
• pain
• risk for injury
• risk for ineffective thermoregulation

Iv ATB senstive to culture oragnism for 7-14 days (droplet precautions for 24 hours)

• viral: tylenol for symptomoatic treatment 
• preventive carE: HiB vaccine to prevent from hemo in B infection