Transcript Neurology

Neurology
Elisa A. Mancuso, RNC-NIC, MS, FNS
Professor of Nursing
Peripheral nerves
– Not completely myelinated @ birth.
• ↑ Myelinization = ↑ Coordination
1st Gross motor function then fine motor
Primitive reflexes disappear by 5 months.
– Moro, Fencing, Step
• Primitive reflexes evolve to meaningful
movements
• Reappearance/persistent reflexes
– Neurological disease
Assessment
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Cognitive –
– √ Appropriateness, speech
Gross and fine motor– √ Strength, coordination, gait
Sensory– √ Reflexes, pain, temperature
Cranial nerves I-XII– √ Motor & sensory
Developmental milestones– √ Delay or deviation from expected milestones.
Obtain accurate history!
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√ family/genetic
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√ any past head injuries or trauma at birth
Glasgow Coma Scale
• Eye Opening
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Spontaneous
To Verbal Stimuli
To Pain Only
No response
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Coos & babbles/Oriented
Irritable cries/Confused
Cries to pain/Inappropriate words
Moans to pain/Non specific words
No response
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• Verbal Response
• Motor Response
• Moves Purposely/Obeys commands
• Withdraws to touch/localizes painful stimuli
• Withdraws to pain
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Decorticate posturing/Flexion
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Decerebrate posturing/Extension
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No response
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Intracranial Pressure (ICP)
Etiology ↑ ICP
1. Mass
• Brain tumor, head trauma
2. Generalized brain edema
• Hypoxia, encephalopathy
3. ↑ Blood Volume
• IVH, obstruction of jugular veins
4. ↑ CSF production• Meningitis
Signs and Symptoms
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Differ according to developmental level
Infant
1. Poor feeding or vomiting
2. Irritability
3. Lethargy
4. Bulging Anterior Fontanel
5. ↑ HC
6. High pitched cry
7. Sun setting sign Eyes deviated downward
Signs and Symptoms
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Child
HA
Diplopia
Mood swings
Slurred speech
Papilledema (48 hours of ↑ICP)
Altered LOC
N/V especially in AM
1. ↑ pressure from lying flat
Therapy
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Maintain Patent Airway
Supine & ↑ HOB @ 30
Avoid Prone & head turned to side
↓ venous drainage and ICP
Avoid CO2 retention
 CO2 = Cerebral vasodilatation
blood flow and ICP
Hyperventilation = ↓ CO2
Cerebral vasoconstriction
↓ blood flow & ↓ICP
√ for cerebral hypoxia & ischemia
If Pt mechanically ventilated
only suction PRN!
Therapy
• ICP monitoring
– Catheter in ventricle
– √ pressure in brain.
– Glasgow Coma scale <7
• Manitol
– Osmotic diuretic
Unconscious Child
• Head trauma, infection, ICP, tumor
• √ LOC
– ∆ = earliest indicator of ∆ in neuro
status!
– Lethargy
• √ Pupillary response
– Fixed and dilated pupils
• MEDICAL EMERGENCY!!!
• ↑ pressure on oculomotor nerve
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√ VS =↓ HR ↓ RR ↑ BP ↑ Temp
Nursing Interventions
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↓ ICP & Maintain ABCs
Turn and position q2H
Passive ROM
Don’t leave on affected side > 30 min
Seizure precautions
Assess skin
Thermoregulation (↑ temp can ↑ICP)
Nursing Interventions
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Eye care
– Artificial tears
– Cover to prevent corneal abrasions
• Mouth care
– Tooth brushing
– Dental Care
• Incontinence
– Foley care
– May need suppositories to stimulate BM
Nursing Interventions
Nutrition
• Tube feedings
• NGT- Short term
• PEG- Gastrostomy- Long term
• TPN
– Broviac
– √ Labs, Glucose, LFTs,
Neoplasms
• High incidence in 5-10 years old
• Prognosis is best
– when tumor is completely removed
• >60% found in
– cerebellum and brain stem
Signs and Symptoms
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First cardinal sign = ↑ ICP
HA
Irritability
Projectile vomiting
Personality changes
Location/size of tumor
– Focal Affects (Behavior, Speech)
– Cerebellar tumor = Ataxia
Glioblastoma
(Astrocytoma)
• Tumor of brain or spinal cord
(astrocytes)
• Most common brain tumor in children
• 75% survival rate
Signs and symptoms
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Depends on location of tumor
Headache
Ataxia
Eyes deviating (cover/uncover test)
Hemiparesis
+ Babinski
Staring spells
↑ ICP
Diagnosis
• Complete Neuro exam & cranial nerves
• CT scan, MRI, Pet Scan
Treatment
• Chemotherapy
• Radiation
• Surgery
– Retain as much viable tissue as possible!
Nursing Interventions
• Pre-op: Prepare child and family
– Assess developmental milestones
– Shave all/part of head
– Extensive dsg with multiple drains
• Post-Op
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√ LOC & Glasgow Coma Scale
√ VS
√ Infection
Restrict fluids post-op
√ I & O
External shunts/drains/monitors (√ for  ICP)
Increase HOB slowly- No trendelenburg!
No Narcotics = ↓ cerebral functioning
Seizure Disorder
• Epilepsy is recurrent seizure activity
– Does not occur with a known cause i.e.
infection, tumor
• Seizure is excessive discharge of neurons.
• Status Epilepticus
– Prolonged or recurrent seizures
– Not regaining consciousness >30 minutes
Etiology
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Primary
Linked to genetic predisposition
Include febrile, absence and benign seizures
Early infancy from birth trauma or congenital
defects
Secondary or symptomatic seizure
A temporary or permanent structural or
metabolic abnormality.
Cerebral lesions, malformations, metabolic
disorders and hypoxia.
Late infancy and early childhood from acute
infections – meningitis.
Idiopathic
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Most common = >3 years 50% of seizures.
Diagnosis
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Family Hx & Hx of symptoms
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Behavior before, during and after seizure
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√ Infection or metabolic causes
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√ trauma, tumor, malformation
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Serum Calcium, Glucose, & Magnesium
Any predisposing illnesses/fever
LP
CT scan, MRI
√ Labs
Electroencephalogram (EEG)
– Measures voltage in brain
– Sharp waves on EEG = Epilepsy
– ↓ sensory stimulation during exam
Classification of Seizures
Generalized
• Both cerebral hemispheres and ∆ in LOC
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Tonic-Clonic
Absence
Myoclonic
Atonic
Partial
• One hemisphere c/s ∆ in LOC
• Symptoms occur on one side of body
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Partial
Simple partial
Complex partial
Generalized Seizures
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Tonic clonic
Aura
LOC
Tonic phase (10-20 secs)
Clonic phase (>30 sec)
Post-ictal State
Generalized Seizure
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Absence seizure “petit-mal”
↑ Incidence btwn 4-12 years
RT brain immaturity
Usually cease at puberty
Brief LOC may be mistaken for daydreaming
Minimal or no alteration in muscle tone
Sudden arrest of activity with no memory
of event
Lasts 5-20 seconds up to 20 times/day
Partial Seizures
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Simple partial
Localized motor symptoms
Somatosensory and autonomic symptoms
Unilateral hand or 1 side of body
No LOC!
Eyes deviate toward opposite side
Jacksonian
Sylvian/Rolandic
Partial Seizures
2. Complex
• Psychomotor seizures-most common
• Age 3-adolescence
• Period of altered behavior &
repeated purposeless activities
• Last 5-10 minutes
• Aura
• Lip, smacking, chewing, drooling
• May yell out, inappropriate behavior
Status Epilepticus
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Medical emergency
Prolonged or recurrent seizures
Not regaining consciousness >30 minutes
Most common cause
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LOC can last hours or days
Maintain airway
Will most likely be intubated
Ativan (lorazipam)
– Sudden withdrawal of anticonvulsant meds
– Quicker onset & longer acting
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Less respiratory depression than valium
Medication Therapy
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Controls symptoms
Prevent seizures or decrease # & activity
Raise the seizure threshold
Decrease responsiveness to neurons
Loading & maintenance doses
Phenobarbital (luminal)
– Therapeutic level 10-40 mcg/ml
√ respirations can cause respiratory arrest!
• Dilantin (phenytoin)
– Therapeutic level 10-20mcg/ml.
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SE hyperplasia of gums!
Medication Therapy
• Tegretol (carbamazepine)
– Therapeutic level 4-12 mcg/ml– Monitor LFT’s! Hepatotoxic.
– SE neutropenia √ WBC’s!
• Valproic Acid (depakene)
– Therapeutic level 50-110 mcg/ml– Monitor LFT’s!
Nursing Interventions
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Monitor serum drug levels
Seizure precautions
– Padded bed rails
– O2 & Suction
Teaching plan
– Parents, Pt, School, Sports, Community etc.
– Type of seizure
– Medications & SEs
Med alert bracelet
Protocol for discontinuing seizure meds:
1. Pt should be seizure free for 2 years
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Normal EEG
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Slowly taper doses
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EEG’s Q 6 months
Meningitis
• Bacterial meningitis 10-15% mortality rate
• Acute inflammation of the meninges
– Infection: URI, OM or sinusitis
– Bacteria enters CNS/brain via nasal cavity, sinuses.
– HIB, Group B strep, S.pneumoniae and Neisseria
meningitides
• N. Meningitides is most invasive disease.
– 13 serogroups
– Vaccine only covers A,B,C,Y and W-135
Incidence
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↑ Risk <1 year of age and >15 yrs
Deficiencies in terminal complement
URI
HIV
Asplenia
Crowding
Smoking or passive exposure
Clinical Signs
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Depend on age and organism
Nucchal Rigidity “stiff neck”
Brudzinski’s sign
Kernig’s sign
Abrupt onset fever and chills
Vomiting & No Nausea
HA
Seizures
Irritability
Anorexia
Petechiae and pupura = Sepsis
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disseminated disease
Diagnosis
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CBC with Diff
BC
NP/Pharyngeal cultures
Lumbar Puncture LP
– √ CSF color, consistency, pressure of
fluid.
– Sterile procedure
– √ Complications;
• Infection, bleeding, spinal fluid leak,
• Hematoma, Spinal HA
CSF Fluid Analysis
• Clear, cloudy or bloody
• Bacterial or viral meningitis
– ↑ Protein
– ↓ Glucose
–  WBC (PMN cells)
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Gram stain- +/Culture-identifies organism
√ pressure >15 = ↑ ICP
↑ Blood = ↓ skill or traumatic tap
Contraindications to LP
• ↑ ICP– Need CT scan.
– If LP done fatal herniation can occur
• Bleeding disorders
• Overlying skin infection (Staph/MRSA)
• Unstable patient
Therapy
• Respiratory isolation right away!
• Antibiotics 2-3 immediately!!!!
– Meningitic dose (2x usual dose)
– Cephalosporins and Ampicillin
• Dexamethasone
– ↓ inflammation
• Phenobarbital
– ↓ seizure activity
• Mannitol
– ↓ brain edema
Nursing Interventions
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Keep HOB >30%
Quiet environment
Frequent neurochecks & VS
Maintain Isolation
Prophylaxis medication = Rifampin
– Persons in close contact
– Urine turns orange and stains contact
lenses
Reyes Syndrome
Acute Toxic Encephalopathy
• ↑ Incidence with 6-11 years & virus infection
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(flu/varicella)
• + Relationship when treating fever with ASA
• NH4 accumulates and builds up urea →
– Brain edema, necrosis of neurons and cell death
– Fatty infiltration of liver cells, kidney and
myocardium
– Impaired hepatic, renal and cardiac function
Signs and symptoms
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A history of preceding URI or chickenpox
Nausea and vomiting x 24 hours/intractable
Mental status changes
Lethargy
Confusion
Combative behavior
Loss of consciousness or coma may develop
Seizures
Hepatomegaly
Diagnosis
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↑↑ LFT’s 2x normal
Prolonged pt/ptt
↑↑ NH4 4x normal
Palliative Support
↑↑ Mortality if pt is in coma = 40%
Cerebral Palsy
• Impaired neuromuscular control
– Abnormality in cortex, basal ganglia
and cerebellum
• Brain injured area determines type of
neuromuscular disability
• Non-progressive
Etiology
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Developmental anomalies
Infections
Toxins
Cerebral trauma
Hypoxia
Vascular occlusion RT IVH
Clinical signs
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Abnormal muscle tone: hyper or hypotonicity
Impaired coordination and motor function
Delayed gross motor development
Abnormal postures
Persistent primitive reflexes
Spasticity or uncontrolled movements
Seizures
Sensory impairments
Classifications
Spastic
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Most common with cortex involvement.
Muscles very tense with any stimulus
Sudden jerking movements
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Injury at basal ganglia.
Slow, writhing, uncontrolled, involuntary
movements involving all extremities
Dyskinetic
Classifications
Ataxic
• Cerebellum affected.
• “Clumsy” characterized by loss of
coordination, equilibrium and kinesthetic
sense
Rigid
• Rare form with poor prognosis.
• Rigidity of flexor and extensor muscles.
• Tremors at rest and with movement
Mixed
Therapy
• Early recognition and intervention is goal
• Maximize child physical abilities
– (Child intellectually intact)
• Multidisciplinary team approach-
– PT, OT, Neurologist, Orthopedic surgeon, RN,
social worker
• Family support & community via UCP
• Treat symptoms
– Baclofen pump- skeletal muscle relaxant
• Increase locomotion, communication and
self-help
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Correct defects
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Contractures or spastic deformities
Braces
Retinoblastoma
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Most common congenital intraocular tumor
60% non-hereditary and unilateral
25% genetic & bilateral
15% genetic & unilateral
Red inflamed eye.
Persistent redness, irritation & itchy
Leukokoria
Loss of red reflex
Strabismus-25% present
Glaucoma
Therapy
• Genetic counseling
• Early stage
– Radiation or cyrosurgery
• Late stage
– Radiation, Chemo
– Enucleation
– Fit with prosthesis in 3 weeks
• 90% survival rate
• Unaffected eye is fine!