Pediatric Neuro assessment – Flashcards
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Assessing child's mental status
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- Watch infant interact with mom or dad - Ask older child to follow directions or answer questions. - Assess speech in the older child
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Assessing child's motor function and balance
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- Have child push and pull against the doctors hands with arms or legs - squeeze fingers, hop, skip, jump - Assess balance with one side - Passive and active motion
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Assessing child's sensory perception
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Dull needles, tuning forks, alcohol swabs.....etc. and have child identify sensation upon touch.
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Cranial nerve 1
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Olfactory (smell)
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Cranial nerve 2
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Optic (vision)
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Cranial nerve 3
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Oculomotor (pupil size and adjustment)
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Cranial nerve 4 (goes with 2, 4, and 6)
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Trochlear (movement of eye, pupillary reaction, ability to follow an object)
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Cranial nerve 5
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Trigeminal (chewing, rooting, sucking)
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Cranial nerve 6
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Abducens (following object with they eyes)
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Cranial nerve 7
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Facial nerve (taste, smiling)
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Cranial nerve 8
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Acoustic (hearing)
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Cranial nerve 9
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Glossopharyngeal (swallowing, taste)
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Cranial nerve 10
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Vagus (swallow and gag)
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Cranial nerve 11
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Accessory (movement of shoulders and neck
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Cranial nerve 12
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Hypoglossal (stick tongue out)
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What is your dirty pnemonic?
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Oh, Oh, Oh, To Touch And Feel A Girls' Vagina And Hymen.
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Blinking reflex
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infant closes eyes to bright lights (permanent)
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Babinski reflex
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toes fan out upon stroke up and out of foot (8-12 months)
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Crawling reflex
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infant placed on abdomen will make crawling motions
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Morrow reflex
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sudden change in position will cause infant to throw back head, thrust out the arms, and open the palms (6 months)
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Palmar and plantar grasp reflex
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put something in the baby's hand and they will grasp it (3-4 months)
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Reflex hammer
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test reflexes at knee or elbow of the older child
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What to ask the parent
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- Is what you are seeing normal for the child? *you might see large changes, but mom and/or dad will notice the subtle changes for their child.
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Early warning signs of altered neuro status in the child
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Change in level of consciousness and/or behavior Persistent headache Vomiting Irritability Acute seizures
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Late warning signs of altered neuro status in the child
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- changes in vital signs - pupillary changes
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Complaints that warrant a full neuro examination include
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Headaches Blurry vision Change in behavior Fatigue Change in balance or coordination Numbness or tingling in the arms or legs Decrease in movement of the arms or legs Injury to the head, neck, or back Temperature (fever of unknown origin = FUO) Seizures Slurred speech Weakness Tremor
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Full consciousness
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awake and alert; oriented to time, place, and person; behavior appropriate for age
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Confusion
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Impaired decision making
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Disorientation
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Confusion regarding time, place; decreased LOC
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Lethargy
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Limited spontaneous movement, sluggish speech, drowsy, falling asleep quickly
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Obtundation
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arousable with stimulation
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Stupor
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remaining in a deep sleep, slow response to vigorous and repeated stimulation or moaning responses to stimuli
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Coma
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no motor or verbal response or extension posturing to noxious (painful) stimuli
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Persistent vegetative state
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Permanently lost function of the cerebral cortex; eyes follow objects only by reflex or when attracted to the direction of loud sounds; all four limbs are spastic but can withdraw from painful stimuli; hands show reflexive grasping and groping; the face can grimace, some food may be swallowed, and the child can groan or cry but utter no words.
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Things that contribute to altered level of consciousness Pnemonic = AEIOU TIPS
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Alcohol Epilepsy, encephalopathy, electrolyte abnormalities, endocrine disorders Insulin, intussusception Overdose, oxygen deficit Uremia Trauma Infection Poisoning, psychiatric conditions Shock, stroke, space-occupying lesion
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Neurologic assessment scales
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They have been adapted for age- feature the pediatric glasgow coma scale + AVPU scale
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What does AVPU scale stand for?
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alert, responds to verbal stimulation, responds to pain, unresponsive
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Pediatric glasgow coma scale
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Based off verbal response, eye opening, and
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What are some pertinent nursing diagnoses for the patient with an altered level of consciousness?
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1. high risk for injury 2. risk for altered growth and development
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Nursing interventions for the child with altered level of consciousness
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1. seizure precautions 2. maintains a safe environment based on LOC and developmental level 3. Maximizes development /independence within limitations
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Monitoring
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LOC - Glasgow Coma Scale for infants Developmentally appropriate orientation Motor response (able to follow directions) Abnormal postures Decorticate (adducted shoulders, flexed fingers, internally rotated legs, plantar flexion) Decerebrate (adducted shoulders, flexed fingers, extended arms, pronation or arms, plantar flexed) Pupillary reactivity Fontanel, N/V, HA, vision changes, poor feeding
