_Assessment of NS and Head Trauma

**Pediatric Differences in A & PSIGNIFICANCE1.

2.

3.

4.

5.

6.

7. DIFFERENCES1. Top heavy

2. Cranial bones not well developed, sutures not fused

3. Highly vascular brain

4. Excess spinal mobility; cervical muscles & ligaments immature

5. Incomplete vertebral ossification

6. Immature thermoregulation

7. Developmental, physical, cognitive factors 2010 Laurel R. Talabere, PhD, RN, AE-C

2010 Laurel R. Talabere, PhD, RN, AE-C

**Assessing the Child for Signs & Symptoms of a Neurological Alteration


**Assessment of Neurological StatusBACKGROUND INFORMATIONBrain - enclosed space

Volume: 80% brain, 10% CSF, 10% blood

If volume of one increases, then volume of another must decrease


**Assessment of Neurological StatusEARLY SIGNS of IICPsubtle, variable changes in personality & behavior slight changes in LOCchanges in vital signsseizurespupil changesvision changes such as diplopiahigh-pitched cryvomitingheadachefull anterior fontanel What is AVPU? Compare to Levels of Response used at NCH:

Verbal stimuliTouchMild painDeep painUnresponsive


**Assessment of Neurological StatusLATER SIGNS of IICPsignificant decreasing LOC

decreasing sensory & motor response

changes in pupil size, reactivity

decerebrate / decorticate posturing

Cheyne-Stokes respirations

Cushings triad: bradycardia, wide pulse pressure, increased SBP (uncommon in infant/young child; may see in adolescent)What is AVPU? Compare to Levels of Response at NCH:

Verbal stimuliTouchMild painDeep painUnresponsive


**Assessment of Neurological Status: LOCAltered LOC earliest indicator of change in neurological status

Determined by infant/child response

Ranges from full consciousness to persistent vegetable state

Differentiate among these termsconfusiondeliriumlethargyobtundedstuporcomapersistent vegetative stateSee p. 1036 for definitions


**Assessment of Neurological Status: PupilsA. Left eye with ptosis. B. Bilateral small pupils. C. Midposition D. Bilateral dilated & fixed pupils. E. Left eye abducted with ptosis. F. Pinpoint pupils. Variations in pupil size with altered states of consciousness. 2000, Mosby, Inc.

Also see Fig. 26-3


**Assessment of Neurological Status: PosturingA. Decorticate posturingLesions above brainstemB. Decerebrate posturingLesions of brainstemDecorticate & decerebrate posturing. 2000, Mosby, Inc. See Fig. 26-4

**Assessment of Neurological StatusSIGNS TO REPORT IMMEDIATELYIn a comotose child:Lack of response to painful stimuliSudden, marked change in appearance of pupil(s): asymmetric, fixed (unreactive) or dilatedPupil changes following brain surgeryIn a child with a head injury:Bleeding or watery discharge from ears or noseLoss of consciousnessVomiting > 3 timesPeriorbital ecchymosisWHY?WHY? 2010 Laurel R. Talabere, PhD, RN, AE-C



**Assessment of Neurological StatusPediatric Coma ScalePupils: size & reactivityEyes openBest motor responsenot valid < 6 months of ageBest response to auditory/visual stimulus parallel scales for children < 2 & > 2 years of agefamiliar person more likely to elicit best responseAlso grip, muscle tone, fontannel, LOC, eye movement, mood/affectSee Glasgow Coma Scale - Table 26-3


**Assessment of Neurological Status

Interpretation

15 = no alteration in LOC

8 = intubation probably needed, likely to be in a coma

4 minutes causes irreversible damageAirway obstruction leads to cardiac arrestCO2 potent vasodilator, increasing cerebral blood flow & ICPDysfunction of CNs IX & X increases what??Laryngospasm common occurrence in comotose childArtificial airway often requiredABGsO2 / mechanical ventilation


**Unconscious ChildSPECIFIC INTERVENTIONS for ICP ManagementSedationCSF drainageOsmotic diuretic (i.e. Mannitol)Position to avoid compression of neck veins. WHY?Avoid stimulation of ICP through pain, emotional stress, environmental noise, nontherapeutic touchGentle therapeutic touchSoothing soundshttp://www.nlm.nih.gov/medlineplus/ency/imagepages/9187.htm


**Unconscious ChildSPECIFIC INTERVENTIONS for Nutrition and HydrationIV for fluids, TPN / lipids for nutrition

Avoid overhydration WHY?

N-G tube for feedsIncreased calorie density but avoid overfeeding WHY?

Assess for Syndrome of inappropriate antidiuretic hormone (SIADH)Causes overhydration WHY?

ThermoregulationHyperthermia increases metabolic demands, brain damageAntipyretics & cooling blanket -- avoid shivering WHY?


**Unconscious ChildSPECIFIC INTERVENTIONS for EliminationUrinary catheterizationStool softenerLiquid stool after no bowel activity signals impaction WHY?

SPECIFIC INTERVENTIONS for Hygienic CarePressure alternating deviceSpecial monitoring of areas at risk for breakdown children with increased pigmentation at risk WHY?Skin, hair, mouth, eye careIf hair shaved for procedure, save for family

**QuestionWhich are clinical signs of increasing intracranial pressure in infants & children? (Mark all that apply)A. High-pitched cry.B. Sunken anterior fontanel.C. Tachycardia.D. Seizures.E. Projectile vomiting.

**Question

Increased levels of carbon dioxide _______________ cerebral flood flow.

This effect occurs because carbon dioxide is a potent ______________.

**Question

In caring for an unconscious child, which of the following nursing interventions are appropriate? (Mark all that apply)

Positioning the child with the head turned sideways. Assessing the eyes for early signs of irritation. Monitoring the child for constipation. Keeping the child extra warm.


**Head Trauma:EtiologyFalls - leading cause of head injury in children < 5 yearsMVA injuries - child < 2 yrs.Bicycle injuries - child 5 to 15 yrs.Pictures, counterclockwise:3-point injury, pedestrian At risk for injury. WHY? Bicycle-car collision Risk of falling


**Head Trauma: PathophysiologyDegree of injury related to force of impact

Pediatric differences:Increased vulnerability to acceleration- deceleration injuriesIncreased surface area & vascularity of scalp

Primary head injuryAt time of injurySecondary head injuryBodys response to the traumaHypoxic brain damageCerebral edema & IICP Infectionhttp://www.altham.com/html/health_cartoons.html


**Head Trauma: TypesSkull fracturesLinearDepressedCompoundBasilarwww.medepict.com/ Ball, J.W. & Bindler, R.C. (2006). Child Health Nursing: Partnering with Children & Families. Upper Saddle River, NJ: Pearson Prentice Hall.See Types of Skull Fractures - Table 26-10


**Head Trauma: Types of brain injuriesConcussion altered mental statusMost common typeResult of blunt traumaConfusion & amnesia more likely than loss of consciousness

Contusion - bruising of cerebral tissueDifficult to distinguish contusion & concussion clinicallyMay occur simultaneously

Laceration - tearing of cerebral tissueOccurs with a penetrating or depressed skull fracture


**Head Trauma: Types of brain injuriesConcussion mild traumatic brain injuryMVA & sports injuries most common causes in childrenLoss of consciousness occurs in less than 10% Easily missed if other, more pressing injuries presentS/S vary in type & timing2nd Impact Syndrome (SIS) If another concussion occurs before original one healed:50% mortality100% adverse effectshttp://www.valleyhealth.com/images/image_popup/r7_concussion.jpgSee Levels of Concussion Severity - Table 26-9


**Head Trauma: Types of brain injuriesConcussion invisible injuryManagementThorough history & evaluationNeurocognitive testing May be other reasons for cognitive, social & emotional s/sPlan forIndividualized treatmentRe-entry to school, sports, driving, etc.RecoveryMost do recover fullyMay take up to a yr or longerSlower if previous concussionsPremature return to sports by athlete significantly increases risk of severe problemshttp://www.sw.org/web/iwcontent/public/dorfam/en_us/images/dorfam_football.jpg


**Head Trauma: Types of brain injuries

Coup-contrecoupBruising at point of impact & distance points

Fig. 26-20. Ball, J.W. & Bindler, R.C. (2008).


**Head Trauma: Types of brain injuriesShearing stressesTearing of blood vessels and/or nerve fibers

Greatest impact at cerebral surface

Greatest damage in brainstem

Whiplash movement of head producing tearing of posterior draining veins resulting in subdural hemorrhage


**Head Trauma: ComplicationsHemorrhageEpidural hematoma (usually arterial bleeding), may be venous)Tends to occur rapidly

Subdural hematoma (usually venous bleeding)Most commonFrequent in infantsTends to occur slowly

Both injuries Compress the temporal lobeRisk tentorial or brainstem herniationSee Clinical Manifestations: Intracranial Hematomas p. 1090


**Head Trauma: ComplicationsInfectionPostraumatic meningitis

Cerebral edemaPeaks at 24-72 hoursCreates IICP causingCollapse of venulesVenous stasisTissue anoxiahttp://www.med.umich.edu/lrc/students/m1/patientsandpopulations/resources/Lecture6/images/16_Cerebral_Edema.jpg&imgrefurl


**Head Trauma: DiagnosisHistoryof incidentS & S: loss of consciousness, behavior changes, headache, seizures or emesisClinical presentationSkull filmsCT scanSubdural tapMRI Soft tissue detailFor stable or recovering child


**Head Trauma: ManagementFocus on secondary problems (primary injury has already occurred)Close observation at home if:No loss of consciousnessNo evidence of severe brain injuryHospitalized if: Loss of consciousness, seizures, or neuro signsIV fluids with close attention to fluid balanceMeds for headache, seizures, risk of infectionScalp lacerations suturedDepressed fractures reducedSurgical evacuation of hematomasPrognosis - Varies but more favorable for children than adultshttp://services.epnet.com/getimage.aspx?imageiid=6863

**BLUE LACE SOCKS by Jeanne BrynerThree nurses work on the childin the center of the bed. A little girl.She is not yet dead. When we ask her to move,only her chest rises. It is unbearable to watch.My flashlight shows her pupils spreadinglike pools of oil in her iris. Her curls are yellow.Without thinking, I smoothher bangs across her forehead.Her tiny bodys silent. I want to putmy arms around her,Tell her we are all terribly sorry for this,and the farmer who hit her will be caught and punished,But I dont. The doctor says, Shell have to goby helicopter. I walk her glazed mother to the desk;she signs forms. I try to buy timewith only coffee moneyin my pocket. I am aware of hanging bags of clear fluidand listening for the whisper of her blood pressure.The copters blades: Thump, Thump, Thump, Thump,Thump, Thump, Thump, Thump.This noise should wake the dead,but it doesnt. The flight nursewaves through her window.I bite my lip and pull the sheets.The childs blue lace socks hit the floor, like petals,and their echo drowns the copters blades.This poem describes a nurses experience with a young girl hit by a car on a country road. 2010 Laurel R. Talabere, PhD, RN, AE-C


**QuestionA 3-month old infant has been admitted with a diagnosis of a head injury from a motor vehicle accident. The first nursing priority would be to assess:A. Pupillary reaction.B. Level of consciousness.C. Airway patency.D. Fontanels.

**Question

Bleeding between the dura and the cerebral surface of the brain is called a _____________________.

**Question Which of the following signs following a head injury should be reported immediately? (Mark all that apply)

A. Difficulty speaking.B. Clear fluid leaking from the ears.C. Vomiting 3 or more times. D. Unsteady gait.

**QuestionThe nurse is assessing a 3-month-old infant following a car accident. Moro & tonic neck reflexes are present. This suggests:

A. Neurologic health.B. Decerebrate posturing.C. Cerebral cortex trauma.D. Severe brain damage.

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_Assessment of NS and Head Trauma