neuro

• First 3-4 weeks of gestation


  • Physical defects from infection, trauma, teratogen, and malnutrition may can affect CNS development
• Birth


  • Cranial bones underdeveloped and not yet fused
  • Increase risk for fracture
  • Brain is very vascular → risk for hemorrhage
• Childhood


  • Spinal cord is mobile → high risk for cervical spine injury
• Head measurement


  Important to track brain development
• PMH findings r/t neuro diseases

  • Prematurity
  • Difficult birth
  • Infection during pregnancy
  • Falls
  • Recent trauma
  • Maternal drug or alcohol use
  • Fetal malnutrition in utero
• Common S/S r/t neuro disease

  • Altered LOC
  • Frequent headaches → usually in the early morning
  • n/v
  • Changes in how they walk/loss of motor Fx
  • Increased irritability
• Obtunded consciousness


  Limited responses to environmental stimuli, falls asleep unless stimulated
• Stupor


  Only responds to vigorous stimuli
• Common lab and Dx tests

  • Lumbar puncture (LP - do NOT do for neural tube defects)
  • CSF (cerebrospinal fluid) analysis
  • Intracranial pressure (ICP) measurements
• Increased ICP


  Increase in brain, CSF, or blood volume that is too much for cranial capacity
• Manifestations of increased ICP

  • Cushing triad → increased systolic BP, decreased pulse, decreased resps
  • High temp from inflammation, infection, or hypothalamic damage
• Early signs of ICP

  • ALOC
  • Decreased HR and RR
  • Projectile vomiting
  • Changes in pupillary reactions
  • Seizures
• Late signs of ICP

  • Increased head circ. And bulging fontanelles
  • Headache
  • Decreased LOC
  • Decreased motor function/sensory
  • Bradycardia
  • Irregular resps
  • Opisthotonic posturing
  • Fixed, dilated pupils
• Diagnostic tests


  • EEG → measures electrical activity in the brain
  • Head and neck radiograph
  • US, fluoroscopy
  • CT, MRI, PET scan, SPECT (single photon emission computed tomography)
• SPECT


  Imaging test that uses a radioactive substance to make a 3D scan, shows what internal organs look like and how well they are working
• Ventricular shunt placement


  Shunt placed in top of the brain to remove CSF in ventricles (increased ICP)
• Ketogenic diet


  HIGH FAT LOW CARBS AND PROTEIN, forces body to burn fats instead of carbs, high fat diet creates ketone bodies (energy source) that fuel cells in heart and brain, low sugar and high fat decreases excitability of brain → less seizure activity
• Seizure


  Sudden, intermittent episodes of ALOC w/ tonic and clonic movements
• Tonic


  Muscles in the body become still
• Clonic


  Periods of twitching/jerking/shaking
• Generalized seizure


  Involves both halves of the brain, has 3 phases: aura, tonic-clonic, postictal
• Partial seizure


  Located in one part of the brain, looks like an uncontrolled muscle spasms, child will be awake and alert but cannot control spasms
• Specific causes of seizure disorders

  • Epilepsy
  • Congenital anomaly
  • Birth injury
  • Infection
  • Trauma
  • Degenerative disease
  • Vascular disorder
  • Fever
  • Heart disease
  • Metabolic disorders
  • Hypocalcemia
  • Hypoglycemia
  • Dehydration
  • Malnutrition
  • Anesthetics
  • Drugs
  • Poisons (household cleaners, etc)
• Febrile seizures


  Occur w/ fever that is too high related to a viral illness, typically transient (lasts a short time), occur between 6mos-5yrs and most common in toddlers, may be a sign of underlying infection → meningitis or sepsis, fever management (acetaminophen) does not help reduce the risk, temperature threshold lowers with a Hx of seizure
• Epilepsy


  Recurrent sudden attacks of impaired or unconsciousness, may be followed by alternating contractions and relaxation of the muscles involved, may also be followed by disturbed feelings/behavior, CNS disorder where neurons fire off abnormally, can be idiopathic or symptomatic
• Idiopathic epilepsy


  Unknown cause
• Symptomatic epilepsy


  Cerebral abnormality present
• Nursing care and Tx for seizures

  1. First aid: loosen clothing around neck, turn to side to maintain airway, reassure child when they regain consciousness

  2. Seizure precautions: padding, oral airway, oxygen, oral suction

  3. Anticonvulsants

  4. Surgery is considered for uncontrolled seizures that do not respond to medication
• Drowsiness


  Common side effect of seizure meds
• Do not stop taking seizure meds suddenly → status epilepticus (prolonged seizures)
• Take seizure meds at same time every day
• Points of interest for convulsions

  • Were arms/legs/face involved?
  • Right or left side of the body?
  • Mild or severe?
  • Length of convolution
  • Condition before and after seizure
• Chiari malformations


  Categorized based on which structures are affected and displaced, Type I: milder, not associated w/ hydrocephalus, Type II: associated w/ hydrocephalus and myelomeningocele, more common
• Chiari Type I


  • Deformation comes from cerebellar tonsils (leaves) being displaced downward into the upper cervical canal (between the top 2 vertebrae), mostly seen in adolescence and adulthood, S/S: neck pain, recurrent headaches that increase w/ physical activity or valsalva mvts (laughing, coughing, sneezing), lower extremity stiffness
• Chiari Type II


  • Deformity results from the cerebellum, medulla oblongata, and 4th ventricle displace downwards into cervical canal → CSF obstruction → hydrocephalus, typically detected prenatally or at birth, S/S: weak cry, stridor, apnea, GI upset w/ chronic aspiration, choking, gagging, long feeding times, weight loss
• Hydrocephalus


  Increased CSF in the brain ventricles → vent. obstruction causing poor CSF circulation, may occur with a myelomeningocele or after infections (encephalitis, meningitis, TORCH)
• TORCH


  • Toxoplasmosis
  • Other
  • Rubella
  • Cytomegalovirus
  • Herpes
• S/S of hydrocephalus


  • Bulging anterior fontanelle
  • Cranial sutures separating
  • Shiny scalp, dilated veins
  • Eyes appear deviated downwards ("setting sun" sign)
• Dx and Tx of hydrocephalus

  1. Daily head measurements

  2. Echoencephalography, CT, MRI

  3. Ventriculoperitoneal (VP) or ventriculoatrial (VA) shunts

  4. S/S of shunt infection: elevated vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity, signs of inflammation along where the shunt is placed, infection is treated with IV abx, shunt is removed and an external ventricular drainage (EVD) system is placed until the CSF is sterile if infection does not respond to abx therapy
• Spina bifida


  Congenital embryonic disorder → imperfect closure of spinal vertebrae "Divided spine", development of a cyst in the middle of the spine (meningocele or meningomyelocele)