Neurology

1. Neurology Elisa A. Mancuso, RNC-NIC, MS, FNS Professor of Nursing

2. 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

3. Assessment • 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! • √ family/genetic • √ any past head injuries or trauma at birth

4. Glasgow Coma Scale • Eye Opening • Spontaneous 4 • To Verbal Stimuli 3 • To Pain Only 2 • No response1 • Verbal Response • Coos & babbles/Oriented 5 • Irritable cries/Confused 4 • Cries to pain/Inappropriate words 3 • Moans to pain/Non specific words 2 • No response1 • Motor Response • Moves Purposely/Obeys commands 6 • Withdraws to touch/localizes painful stimuli 5 • Withdraws to pain 4 • Decorticate posturing/Flexion 3 • Decerebrate posturing/Extension 2 • No response 1

5. Intracranial Pressure(ICP) Etiology ↑ ICP • Mass • Brain tumor, head trauma • Generalized brain edema • Hypoxia, encephalopathy • ↑ Blood Volume • IVH, obstruction of jugular veins • ↑ CSF production- • Meningitis

6. Signs and Symptoms • Differ according to developmental level Infant • Poor feeding or vomiting • Irritability • Lethargy • Bulging Anterior Fontanel • ↑ HC • High pitched cry • Sun setting sign- √ Eyes deviated downward

7. Signs and Symptoms Child • HA • Diplopia • Mood swings • Slurred speech • Papilledema (48 hours of ↑ICP) • Altered LOC • N/V especially in AM • ↑ pressure from lying flat

8. Therapy • 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!

9. Therapy • ICP monitoring • Catheter in ventricle • √ pressure in brain. • Glasgow Coma scale <7 • Manitol • Osmotic diuretic

10. 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 • √ VS =↓ HR ↓ RR ↑ BP ↑ Temp

11. Nursing Interventions • ↓ 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)

12. Nursing Interventions • Eye care • Artificial tears • Cover to prevent corneal abrasions • Mouth care • Tooth brushing • Dental Care • Incontinence • Foley care • May need suppositories to stimulate BM

13. Nursing Interventions Nutrition • Tube feedings • NGT- Short term • PEG- Gastrostomy- Long term • TPN • Broviac • √ Labs, Glucose, LFTs,

14. Neoplasms • High incidence in 5-10 years old • Prognosis is best • when tumor is completely removed • >60% found in • cerebellum and brain stem

15. Signs and Symptoms • First cardinal sign = ↑ ICP • HA • Irritability • Projectile vomiting • Personality changes • Location/size of tumor • Focal Affects (Behavior, Speech) • Cerebellar tumor = Ataxia

16. Glioblastoma (Astrocytoma) • Tumor of brain or spinal cord (astrocytes) • Most common brain tumor in children • 75% survival rate

17. Signs and symptoms • Depends on location of tumor • Headache • Ataxia • Eyes deviating (cover/uncover test) • Hemiparesis • + Babinski • Staring spells • ↑ ICP

18. Diagnosis • Complete Neuro exam & cranial nerves • CT scan, MRI, Pet Scan Treatment • Chemotherapy • Radiation • Surgery • Retain as much viable tissue as possible!

19. Nursing Interventions • Pre-op: Prepare child and family • Assess developmental milestones • Shave all/part of head • Extensive dsg with multiple drains • Post-Op • √ 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

20. 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

21. Etiology • 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 • Most common = >3 years 50% of seizures.

22. Diagnosis • Family Hx & Hx of symptoms • Behavior before, during and after seizure • Any predisposing illnesses/fever • LP • √ Infection or metabolic causes • CT scan, MRI • √ trauma, tumor, malformation • √ Labs • Serum Calcium, Glucose, & Magnesium • Electroencephalogram (EEG) • Measures voltage in brain • Sharp waves on EEG = Epilepsy • ↓sensory stimulation during exam

23. Classification of Seizures Generalized • Both cerebral hemispheres and ∆ in LOC • Tonic-Clonic • Absence • Myoclonic • Atonic Partial • One hemisphere affected & ∆ in LOC • Symptoms occur on one side of body • Partial • Simple partial • Complex partial

24. Generalized Seizures 1. Tonic clonic • Aura • LOC • Tonic phase (10-20 secs) • Clonic phase (>30 sec) • Post-ictal State

25. GeneralizedSeizure 2. 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

26. Partial Seizures 1. 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

27. PartialSeizures 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

28. Status Epilepticus • Medical emergency • Prolonged or recurrent seizures • Not regaining consciousness >30 minutes • Most common cause • Sudden withdrawal of anticonvulsant meds • LOC can last hours or days • Maintain airway • Will most likely be intubated • Ativan (lorazipam) • Quicker onset & longer acting • Less respiratory depression than valium

29. Medication Therapy • 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. • SE hyperplasia of gums!

30. 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!

31. Nursing Interventions • 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: • Pt should be seizure free for 2 years • Normal EEG • Slowly taper doses • EEG’s Q 6 months

32. 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

33. Incidence • ↑ Risk <1 year of age and >15 yrs • Deficiencies in terminal complement • URI • HIV • Asplenia • Crowding • Smoking or passive exposure

34. Clinical Signs • 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 • disseminated disease

35. Diagnosis • CBC with Diff • BC • NP/Pharyngeal cultures • Lumbar Puncture LP • √ CSFcolor, consistency, pressure of fluid. • Sterile procedure • √ Complications; • Infection, bleeding, spinal fluid leak, • Hematoma, Spinal HA

36. CSF Fluid Analysis • Clear, cloudy or bloody • Bacterial or viral meningitis • ↑ Protein • ↓ Glucose •  WBC (PMN cells) • Gram stain- +/- • Culture-identifies organism • √ pressure >15 = ↑ ICP • ↑ Blood = ↓ skill or traumatic tap

37. Contraindications to LP • ↑ ICP- • Need CT scan. • If LP done fatal herniation can occur • Bleeding disorders • Overlying skin infection (Staph/MRSA) • Unstable patient

38. 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

39. Nursing Interventions • Keep HOB >30% • Quiet environment • Frequent neurochecks & VS • Maintain Isolation • Prophylaxis medication = Rifampin • Persons in close contact • Urine turns orange and stains contact lenses

40. Reyes Syndrome Acute Toxic Encephalopathy • ↑ Incidence with 6-11 years & virus infection • (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

41. Signs and symptoms • 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

42. Diagnosis • ↑↑ LFT’s 2x normal • Prolonged pt/ptt • ↑↑ NH4 4x normal • Palliative Support • ↑↑ Mortality if pt is in coma = 40%

43. Cerebral Palsy • Impaired neuromuscular control • Abnormality in cortex, basal ganglia and cerebellum • Brain injured area determines type of neuromuscular disability • Non-progressive

44. Etiology • Developmental anomalies • Infections • Toxins • Cerebral trauma • Hypoxia • Vascular occlusion RT IVH

45. Clinical signs • 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

46. Classifications Spastic • Most common with cortex involvement. • Muscles very tense with any stimulus • Sudden jerking movements Dyskinetic • Injury at basal ganglia. • Slow, writhing, uncontrolled, involuntary movements involving all extremities

47. 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

48. 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 • Correct defects • Contractures or spastic deformities • Braces

49. Retinoblastoma • 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

50. 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!