Brain
what is CSF
clear watery substance that helps cushion our brain and our spinal cord
Extra Info
produced into ventricles --> choroid plexus = network vessels (responsible for making CSF)
what does uncontrolled ICP result in
Cushing's Triad: decreased heart rate, irregular respiration, widened pulse pressure
hypertension, bradycardia, irregular breathing, bad sign = brain herniation will be happening soon
how is epilepsy defined
defined as two or more seizures that are separated by at least 24 hours
causes: brain damage, TBI - stroke, brain tumors
meningocele
meninges herniate into cyst
defect will be visible through vertebra
spinal will be in correct position still
occurs from prolonged seizures lasting longer than 5 minutes or recurring seizure that lasts more than 5 minutes but they have no return to normal --> lactic acidosis, altered blood brain barrier, increased ICP
EMERGENCY
status epilepticus
first line = valium, antivan or versed (benzo IV) + usual antiepilpetic
second line = 2nd dose of benzo OR fosphenytoin or phenobarbital
third line = valproate (depakote) and levetiracetam (Keppra)
what does the medulla oblongata help with
breathing, blood pressure, heart rhythm, swallowing
injury of this part of the brain results in brain death
what are some motor activity signs of increased intracranial pressure
abnormal posturing = late sign
flexion positioning (decorticate) = rigid flexion of arms and extension of legs, legs extended and rotated with plantar flexion
extension positioning (decerebrate) = rigid extension and pronation of arms and legs
difference in simple vs. complex febrile seizures
simple = not a lot of treatment, outgrow them by 5 years old, control the fever
complex = lasting longer than 5 min, treatment = rectal volume - diazepam, Tylenol to control fever
myelomeningocele
motor and sensory dysfunction will occur below that defect
increased risk of meningitis and bladder/bowel incontinence is possible - AFFECTS LOWER EXTREMITIES
The nurse is assessing a 4-month-old infant diagnosed with hydrocephalus. Which finding would require immediate notification of the healthcare provider?
A. Anterior fontanel is open and flat
B. Occasional spit-up after feeding
C. High-pitched cry and bulging fontanel
D. Head circumference within normal limits for age
C. High-pitched cry and bulging fontanel
Rationale:
C. A high-pitched cry and bulging fontanel are signs of increased intracranial pressure, a serious complication of hydrocephalus that needs immediate intervention.
A. An open, flat fontanel is normal for this age and indicates no acute ICP increase.
B. Spit-up can be normal in infants and is not directly related to hydrocephalus.
what does AVPU stand for
alert
voice
pain
unresponsive
how is ICP diagnosed
H&P
Lumbar Puncture: CT PRIOR TO LUMBAR PUNCTURE IF ICP IS SUSPECTED, allows for drainage of CSF fluid
intraventricular catheter
papilledema
Explain Focal Seizures
occurs in ONE part of the brain on ONE side
may or may not lose consciousness
motor symptoms = rhythmic jerking, rigid muscles, muscle twitching, limp, automatisms
non-motor = lack of movement, change in sensation, emotions, cognition
can develop into generalized seizures
what are the diagnostics for spina bifida
test for alpha-fetoprotein and acetylcholinesterase
A nurse is caring for a child with spastic cerebral palsy. Which of the following is an expected finding?
A. Flaccid muscle tone and poor head control
B. Involuntary, writhing movements
C. Muscle stiffness with scissoring of the legs
D. Loss of previously acquired motor skills
C. Muscle stiffness with scissoring of the legs
Rationale:
C. Spastic cerebral palsy is the most common type and is characterized by increased muscle tone (hypertonia), stiff muscles, and scissoring of the legs due to tight adductor muscles.
A. Flaccidity is more typical of early signs or other types of CP, not spastic CP.
B. Involuntary, writhing (athetoid) movements are seen in dyskinetic CP.
D. Loss of previously acquired skills is concerning for a neurodegenerative condition, not typical of CP.
what would the CSF fluid look like if a patient gets a lumbar puncture and has meningitis
cloudy, protein increased, neutrophils increased, glucose decrease (due to being used as an energy source)
treatment of ICP
reduce pressure in skull, treat underlying cause, keep head in neutral position and HOB at 30 degrees, ensure adequate respirations, increase CO2 and hypoxia leads to ICP - so make sure oxygenating well, decrease agitation, control temperature, analgesics to control pain, osmotic diuretics, catheter - reduce CSF fluid. decompressive craniotomy
Explain generalized seizures
affects BOTH sides of brain
loss of consciousness
motor = rhythmic jerking, rigid muscles, muscle twitching, limp
clonic seizures = limp eventually, bite their tongue, have incontinence
non motor = staring spells, brief twitches
what is the treatment for spina bifida
deliver via c-section to minimize any risk of the child
if they need surgery after delivery - done with 24-48 hours to reduce risk of infection
nursing care - minimize risk of heat and fluid loss from spinal defect, cover with warm sterile saline dressing, radiant warmer, prone or on side to avoid pressure to defect, IV fluids, urinary catheter placed
high risk for developing latex allergies and risk for infection
The nurse is observing a 10-month-old infant during a well-child visit. Which behavior may suggest a visual impairment?
A. The infant smiles when hearing a parent’s voice
B. The infant reaches for and grasps toys
C. The infant does not make eye contact or track objects
D. The infant responds to bright lights with eye blinking
Correct Answer:
C. The infant does not make eye contact or track objects
Rationale:
C. Lack of eye contact and failure to visually track objects are key signs of possible visual impairment and should be further assessed.
A. Responding to sound is more related to hearing, not vision.
B. Grasping toys usually requires vision and coordination, suggesting no impairment.
D. Eye blinking in response to light indicates intact visual reflexes.
what is a normal ICP level adn what are the three things that indicate a maintained ICP level
7-15 mmhg
ICP is maintained when there is a balance of volume of brain tissue, CSF, and blood
** if one increases, the other two decrease to compensate
A nurse is caring for a child with a traumatic brain injury who is at risk for increased intracranial pressure (ICP). Which of the following findings should the nurse report immediately to the healthcare provider?
A. Sleepiness after receiving pain medication
B. Temperature of 100.4°F (38°C)
C. Sudden onset of vomiting without nausea
D. Heart rate of 98 bpm
Correct Answer:
C. Sudden onset of vomiting without nausea
Rationale:
C. Sudden onset of vomiting without nausea is a classic sign of increased ICP and indicates a need for immediate intervention to prevent further neurological deterioration. This type of vomiting, often referred to as “projectile vomiting,” can occur due to pressure on the vomiting center in the brain.
A. Sleepiness after pain medication is expected, especially if opioids are given; this is not necessarily indicative of increased ICP.
B. A mild fever (100.4°F) can be common post-injury or due to other minor causes; while it should be monitored, it is not as urgent as signs of increased ICP.
D. A heart rate of 98 bpm is within normal limits for a child and does not specifically indicate increased ICP.
seizure managment
keto diet = option for epilepsy, increase recovery time
control vs. rescue meds
- benzos to STOP seizure
vagus nerve stimulation
A newborn is diagnosed with myelomeningocele, a form of spina bifida. Which of the following is the priority nursing intervention?
A. Monitor urinary output closely
B. Place the infant in a supine position
C. Cover the sac with a sterile, moist non-adherent dressing
D. Educate the parents about surgical repair options
Correct Answer:
C. Cover the sac with a sterile, moist non-adherent dressing
Rationale:
C. The priority nursing intervention for a newborn with myelomeningocele is to protect the exposed sac from infection and drying. Covering it with a sterile, moist, non-adherent dressing (usually moistened with normal saline) helps prevent rupture and reduces the risk of meningitis, which can be life-threatening.
A. Monitoring urinary output is important since many infants with spina bifida have neurogenic bladder, but it is not the priority at this moment.
B. The infant should not be placed in a supine position as this can put pressure on the sac and increase the risk of rupture. The preferred position is prone or side-lying with padding.
D. Parental education is important but not the immediate priority in the acute setting.
A school nurse is reinforcing teaching to parents of a child newly diagnosed with ADHD. Which statement by the parent indicates a need for further teaching?
A. “We will give the medication every morning before school.”
B. “I’ll make sure to give the medication with a high-fat meal.”
C. “We’ll work on setting up a consistent routine and structure at home.”
D. “We’re planning to try behavior therapy along with medication.”
B. “I’ll make sure to give the medication with a high-fat meal.”
Rationale:
B. ADHD stimulant medications (e.g., methylphenidate) are best taken on an empty stomach or with a light meal, as high-fat meals can delay absorption and reduce effectiveness.
A, C, and D all reflect appropriate management strategies: scheduled medication, structured routines, and combination therapy.