NCMA - FINALS

• Neurologic history and physical examination


  • Complete assessment, evaluation of mental & emotional status
  • CN function, sensory function, motor function, reflexes
• Mini assessment


  Bedside assessment: focus more on LOC, pupillary response, motor function, sensory function, reflexes, VS
• Glasgow Coma Scale


  • Assess eye opening, verbal & motor responses
  • Provides quick, standard account of neuro status
  • Pedia-version; pre-verbal child
  • Each response receives numerical value
  • <7: comatose, severe neuro damage
  • 15: normal; 3: lowest possible score (not always) – brain death
• Motor function


  • Good indicator of level of consciousness
  • Can point to CNS & PNS damage
  • Mastery of gross & fine motor skills related to myelination of NS
  • Cephalo-caudal, proximodistal development
  • To evaluate muscle strength: grip hand & squeeze, push against palm with foot, compare muscle strength on each side
• Pupillary response


  • (+) Brain damage: lack of changes in pupil size in response to light
  • Use flashlight/penlight to assess pupillary response at bedside
• Diagnostics


  1. Minimize emotional trauma: tell child what to expect in simple, age appropriate term, be honest about pain/discomfort, tell child it's ok to be afraid, allow child to see the equipment before test, encourage child to ask questions, allow parents to remain with child, give the child a "job" to do during the test, praise child after test

  2. Nurse should not expect cooperation from a young child: may require sedation
• Brain scan


  • Measures gamma rays produced by the radioisotope material
  • Identify focal brain lesions, pathologic conditions (tumor, infarction, mass, vascular lesions) involving cortex in patients with headache, epilepsy, etc.
  • Test material accumulates in areas where blood-brain barrier is defective
  • Distinguishes density of various intracranial tissues & structures
• Nursing considerations for brain scan

  1. Explain procedure to patient & family

  2. Only discomfort is IV puncture

  3. Contrast material is excreted within 6-24 hours

  4. Encourage child to drink fluid after test to aid in excretion of isotope
• CT scan


  1. D image, identify tumor, infarcts, bleeding, hematoma, & provide information about ventricular system of brain
• Nursing considerations for CT scan

  Explain procedure: cooperation is necessary, must lie still during procedure, show child picture of machine, may hear clicking noise as scanner moves around his head but machine won't touch him, child won't be able to eat/drink 4 hours before scan: contrast dye may cause nausea, assess for allergy to iodinated dye/shellfish, encourage to drink fluids after scan
• Electroencephalogram (EEG)


  • Graphic recording of electrical activity of brain
  • Identify & evaluate patients with seizure
  • Identify tumor & infarction, confirm brain death
• Nursing considerations for EEG

  Reassure he won't feel anything, child continues to eat/drink before test, child will not drink anything with caffeine on morning of test because of caffeine stimulating effect, patient needs to remain still during test, movement may cause interference
• Lumbar puncture


  • Needle placed on subarachnoid space of spinal column
  • Measure pressure of space & obtain CSF for examination & diagnosis
  • L3-L4 or L4-L5
  • Assist in diagnosis of brain metastasis or spinal cord neoplasm, meningitis, cerebral hemorrhage, encephalitis
• Nursing considerations for lumbar puncture

  Explain procedure, written informed consent, instruct child to empty bladder & bowel before, monitor VS during & after (may sedate), explain importance of remaining still, gently hold child to prevent injury, positioning: lie on bedside at edge of bed, chin tucked to chest & knees drawn up, place hand behind neck & other behind knees, hold child firmly, monitor color & respiratory status, keep child on reclining position for 12 hours, encourage to drink lots of fluid, assess for numbness, tingling, decrease movement, pain, drainage
• MRI


  • Non-invasive
  • Provides information about anatomy in greater details than CT scan
  • No exposure to ionizing radiation
  • For evaluation of headache or neurologic signs of CNS lesions
  • Assess neck & back pain, lesions of bones & joints
• Nursing considerations for MRI

  Explain procedure: no exposure to radiation, may talk/read to the child in the imaging room, inform parents: child may be sedated, need to be motionless during procedure, no food/fluid restriction
• Seizure


  • Occurs when the brain functions abnormally, resulting in a change in movement, attention, or level of awareness
  • 3% of all children have seizure <15 y/o, half of which are febrile seizures
  • 1 in 100 children has epilepsy-recurring seizures
  • Disturbance in normal brain function resulting from abnormal electrical discharge in the brain, which can cause unconsciousness, uncontrolled body movement, changes in behavior & sensation, & changes in autonomic system
  • During a seizure, the neurons in the brain may fire as many as 500 times a second
• Febrile seizure


  • Occurs when a child contracts an illness such as an ear infection, cold or chicken pox accompanied by fever
  • Most common type seen in children
• Types of partial seizures

  • Simple partial (Jacksonian) seizure: have a motor (movement) component that is located in one portion of the body, average duration 10-20 seconds, remains awake and alert, may involve face, arms, extremities
  • Complex partial seizure: similar, except that the child is not aware of what is going on, repeat an activity, with alteration of consciousness
• Types of generalized seizures

  • Convulsive (muscle jerking)
  • Nonconvulsive with several subgroups
• Absence seizure (petit mal)


  Brief loss of consciousness, minimum or no alteration in muscle tone, may go unrecognized because of little change in child's behavior, abrupt onset, suddenly develops 20 or more attacks daily, look like client is staring into space for a few seconds, doesn't lead to physical injury
• Myoclonic seizure


  Brief shock-like jerks of a muscle or group of muscles, awake and able to think clearly, don't last more than a second or two, can be mistaken for tics, tremors or clumsiness, usually involve the neck, shoulders, upper arms and often the face
• Tonic-clonic seizure (grand mal)


  Most common and most dramatic, occur without warning, tonic phase: lasts approximately 10-20 seconds, clonic phase: lasts about 30 seconds but can vary from only a few seconds to a half hour or longer, violent jerking movements as the trunk and extremities undergo rhythmic contraction and relaxation, may foam at the mouth, may be incontinent of urine and feces, rhythmic jerking and muscle spasm, difficulty breathing and rolling eyes, sleepy and confused
• Atonic seizure


  Sudden loss of muscle tone in the muscles that hold the body and head upright, occurs without warning and usually causes the person to fall down
• Epilepsy


  • Refers to a pattern of chronic seizures of any type over a long period
  • A condition characterized by recurrent 2 or > unprovoked seizure in a day
  • After a 5 to 10 years seizure free, without medications, may considered to be resolved
  • Derived from the greek word for "attack"
  • Brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormality
  • Develop because of an abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters, or some combination of these factors
• Causes of seizure


  • Vascular (Stroke, embolic stroke)
  • Infections (meningitis, encephalitis)
  • Trauma (Head trauma)
  • AV malformation
  • Metabolic (hypoglycemia, hyponatremia, hypoxia)
  • Idiopathic
  • Neoplasms (primary or secondaries)
  • Others: sleep deprivation, drug overdose, fever, eclampsia, hydrocephalus, Multiple sclerosis
• General causes of seizure

  • Genetic factors
  • Disorders (brain tumors, alcoholism, and Alzheimer's disease)
  • Head injury
  • Prenatal injury and Developmental problem
  • Poisoning
• Manifestations of seizure


  • Eyes roll upward
  • Immediate loss of consciousness
  • If standing, falls to floor or ground
  • Stiffens in generalized, symmetric tonic contraction of entire body musculature
  • Arms usually flexed, legs, head, and neck extended
  • May utter a peculiar piercing cry
  • Apneic, may become cyanotic
  • Increased salivation and loss of swallowing reflex
• Diagnostics for seizure

  • Lumbar Tap (Spinal tap)
  • CT Scan
  • EEG
  • MRI
• Drug therapy for seizure

  • Appropriate AED or combination of drugs: carbamazepines, phenytoin, valproic acids (partial &/Generalized Sz), ethosuximides/valproic acids (absence Sz)
  • Single meds preferred to minimize adverse effects
  • (+) continuous Sz: multiple anticonvulsants
  • Other drugs: phenobarbital, diazepam, lorazepam
• Nursing care management for seizure

  1. Assist client with KETOGENIC DIET (high fat, low Carbohydrates, and low protein diet). Potential side effects of the diet are constipation, weight loss, lethargy, and kidney stones

  2. Observe the seizure episode and accurately document the event

  3. Administer anti-epileptic drug

  4. Educate family
• Piercing cry


  • Apneic, may become cyanotic
  • Increased salivation and loss of swallowing reflex
• DIAGNOSTICS


  • Lumbar Tap (Spinal tap)
  • CT Scan
  • EEG
  • MRI
• Types of seizures


  • ABSENCE SEIZURE (PETIT MAL)
  • MYOCLONIC SEIZURE
  • TONIC-CLONIC SEIZURE (GRAND MAL)
  • ATONIC SEIZURE
• Epilepsy


  A condition caused by an imbalance in the production and absorption of CSF in the ventricular system
• DRUG THERAPY


  • Carbamazepines, phenytoin, valproic acids (partial &/Generalized Sz)
  • Ethosuximides/valproic acids (absence Sz)
  • Phenobarbital, diazepam, lorazepam
• Single meds preferred


  To minimize adverse effects
• Continuous Sz: multiple anticonvulsants
• NURSING CARE MANAGEMENT


  • Assist client with KETOGENIC DIET
  • Observe the seizure episode and accurately document the event
  • Administer anti-epileptic drug
  • Educate family and child
  • Monitor side effects of AEDs and therapeutic levels
  • Stress importance of adherence to medication regimen
  • Teach patient and family to identify and avoid situations that are known to precipitate a seizure
  • Initiate seizure precautions in the hospital
  • Educate family to initiate seizure precautions at home
• SELF-CARE AT HOME


  • Help the child to lie down
  • Remove glasses or other harmful objects in the area
  • Do not try to put anything in the child's mouth
  • After the seizure ends, place the child on one side and stay with the child until fully awake
  • If the child has a fever, acetaminophen (such as tylenol) may be given rectally
  • Do not try to give food, liquid, or medications by mouth to a child who has just had a seizure