Cranial Nerve - Brainstem Function

Cranial nerve assessment is basically an assessment of brainstem function because nuclei of 10 of the 12 cranial nerves are located in the brainstem. The proximity of these nuclei to the reticular activating system (arousal center) located in the midbrain is the anatomic rationale for assessing cranial nerves in conjunction with LOC. Important neurological functions and protective reflexes are mediated by the cranial nerves and many functions are dependent on more than one nerve. Some of the cranial nerves have both motor and sensory functions.

Diagram of the base of the brain showing entrance and exits of the cranial nerves

The two cranial nerves that do not arise in the brainstem are the olfactory nerve (CN I) and the optic nerve (CN II). CN I is located in the medial frontal lobe and is responsible for the sense of smell. This can be difficult to assess in the younger child, so is often omitted unless there is specific concern that there has been damage in that area. Taste may also be affected with injuries to CN I. CN II is assessed by determining a child’s visual acuity. This may be done more formally with visual screening or more generally by noting if the child’s vision appears normal in routine activities.
Pupil size and response to direct light are mediated by CN II and the oculomotor nerve (CN III) as well as the sympathetic nervous system. Many things can affect the pupillary response in a child, including damage to the eye or the cranial nerves, pressure on the upper brainstem, local and systemic effects of certain drugs, anoxia, and seizures. Pupillary size varies with age and is determined by the amount of sympathetic input, which dilates the pupil and is balanced by the parasympathetic input on CN III, which constricts the pupil. Pupillary response in the eye that is being checked with direct light as well as the other pupil (consensual response) are significant in that they can point to where damage to nerves exists and are an objective clinical sign that can be followed over time .

Read More

Modified Glasgow Coma Scale For Infants And Children

Modified Glasgow Coma Scale for infants and children. Coma scoring system appropriate for pediatric patients.
Obtained from Marcoux (2005) [24]

Activity	Score	Infant/non-verbal child (<2 years)	Verbal child/adult (>2 years)
Eye Opening	4	Spontaneous	Spontaneous
	3	To Speech	To verbal stimuli
	2	To Pain Only	To Pain Only
	1	No Response	No Response
Motor Response	6	Normal/ spontaneous movement	Obeys commands
	5	Withdraws to touch	Localizes pain
	4	Withdraws to pain	Flexion withdrawal
	3	Abnormal flexion (decorticate)	Abnormal flexion
	2	Extension (decerebrate)	Extension (decerebrate)
	1	No response	No response
			2–5 years	> 5 years
Verbal Response	5	Cries appropriately, coos	Appropriate words	Oriented
	4	Irritable crying	Inappropriate words	Confused
	3	Inappropriate screaming / crying	Screams	Inappropriate
	2	Grunts	Grunts	Incomprehensible
	1	No Response	No Response	No Response

Read More

Developmental Screening Tools Commonly Used To Assess Child Development

Developmental screening tools commonly used to assess child development. Data from references: Behrman et al. (2004) [4] and Wong et al. (2000) [35]

Tool name	Revised Denver developmental screening test (Denver II)	Prescreening developmental questionnaire R-PDQ)	Developmental profile II	Draw a person (DAP) test
Author	Frankenburg [13]	Frankenburg et al. [14]	Alpern et al. [1]	Goodenough [15]
Items scored	Gross motor Fine motor Language Personal-social	Parent answered prescreen of items on Denver II	Physical Self-help Social Academic Communication	Score for body parts
Age range	Birth–6 years	Birth–6 years	Birth–7 years	5–17 years
Interview	Parent/child	Parent only	Parent/child	Child only
Testing time	30–40 minutes	15–20 min	20–40 min	As needed
Training/certified	Yes	Self-instruction	Self-instruction	Self-instruction
Pros/cons	Range of items Identify child’s strengths/weakness Validity tested Cultural bias Teaching tool	Parent report Can rescreen If delays administer Denver II	Range of items Low rate of sensitivity	Nonverbal Nonthreatening Cultural unbias Few items to score Gives IQ score

Read More

Age-appropriate Neuroassessment

Age-appropriate neuroassessment table. A brief guide to developmental milestones in children from infancy to age 12 years as a guide when performing a neurological assessment (Phoenix Children’s Hospital)

Age	Gross Motor	Fine Motor	Personal/social	Language
Newborn	Head down with ventral suspension Flexion Posture Knees under abdomen-pelvis high Head lag complete Head to one side prone	Hands closed Cortical Thumbing (CT)	With sounds, quiets if crying; cries if quiet; startles; blinks	Crying only monotone
4 weeks	Lifts chin briefly (prone) Rounded back sitting head up momentarily Almost complete head lag	Hands closed (CT)	Indefinite stare at surroundings Briefly regards toy only if brought in front of eyes and follows only to midline Bell sound decreases activity	Small, throaty noises
6 weeks	In ventral suspension head up momentarily in same plane as body Prone: pelvis high but knees no longer under abdomen	Hands open 25% of time	Smiles	Social smile (1st cortical input)
2 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Alert expression Smiles back Vocalizes when talked to Follows dangled toy beyond midline Follows moving person	Cooing Single vowel sounds (ah. eh, uh)
3 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Smiles spontaneously Hand regard Follows dangled toy 180° Promptly looks at object in midline Glances at toy put in hand	Chuckles “Talk back” if examiner nods head and talks Vocalizes with two different syllables (a-a. oo-oo)
4 months	Head to 90° on extended forearms Only slightly head lag at beginning of movement Bears weight some of time on extended legs if held standing Rolls prone to supine Downward parachute	Active play with rattles Crude extended reach and grasp Hands together Plays with fingers Toys to mouth when supine	Body activity increased at sight of toy Recognizes bottle and opens mouth For nipple (anticipates feeding with excitement)	Laughs out loud increasing inflection No tongue thrust
6 months	Bears full weight on legs if held standing Sits alone with minimal support Pivots in prone Rolls easily both ways Anterior proppers	Reaches for toy Palmar grasp of cube Lifts cup by handle Plays with toes	Displeasure at removal of toy Puts toy in mouth if sitting	Shy with strangers Imitates cough and protrusion of tongue Smiles at mirror image
7 months	Bears weight on one hand prone Held standing, bounces Sit on hard surface leaning on hands		Stretches arms to be taken Keeps mouth closed if offered more food than wants Smiles and pats at mirror	Murmurs “mom” especially if crying Babbles easily (M’s, D’s, B’s, L’s) Lateralizes sound
9 months	Sits steadily for 15 min on hard surface Reciprocally crawls Forward parachute	Picks up small objects with index finger and thumb (Pincer grasp)	Feeds cracker neatly Drinks from cup with help	Listens to conversation Shouts for attention Reacts to “strangers”
10 months	Pulls to stand Sits erect and steadily (indefinitely) Sitting to prone Standing: collapses and creeps on hands knees easily Prone to sitting easily Cruises – laterally Squats and stoops – does not recover to standing position	Pokes with index finger, prefers small to large objects	Nursery games (i.e., pat-a-cake), picks up dropped bottle, waves bye-bye	Will play peek-a-boo and pat-a-cake to verbal command Says Mama, Dada appropriately, finds the hidden toy (onset visual memory)
12 months	Sitting; pivots to pick up object Walks, hands at shoulder height Bears weight alone easily momentarily	Easy pinch grasp with arm off table Independent release (ex: cube into cup) Shows preference for one hand	Finds hidden toy under cup Cooperated with dressing Drinks from cup with two hands Marks with crayon on paper Insists on feeding self	One other word (noun) besides Mama, Dada (e.g., hi, bye, cookie)
13 months	Walks with one hand	Mouthing very little Explores objects with fingers Unwraps small cube Imitates pellet bottle	Helps with dressing Offers toy to mirror image Gives toy to examiner Holds cup to drink, tilting head Affectionate Points with index finger Plays with washcloth, bathing Finger-feeds well, but throws dishes on floor Appetite decreases	Three words besides Mama, Dada Larger receptive language than expressive
14 months	Few steps without support	Deliberately picks up two small blocks in one hand Peg out and in Opens small square box	Should be off bottle Puts toy in container if asked Throws and plays ball	Three to four words expressively minimum
15 months	Creeps up stairs Kneels without support Gets to standing without support Stoop and recover Cannot stop on round corners suddenly Collapses and catches self	Tower of two cubes “Helps” turn pages of book Scribbles in imitation Completes round peg board with urging	Feeds self fully leaving dishes on tray Uses spoon turning upside down, spills much Tilts cup to drink, spilling some Helps pull clothes off Pats at picture in book	Four to six words Jargoning Points consistently to indicate wants
18 months	Runs stiffly Rarely falls when walking Walks upstairs (one hand held-one step at a time) Climbs easily Walks, pulling toy or carrying doll Throws ball without falling Knee flexion seen in gait	Tower of three to four cubes Turns pages two to three at a time Scribbles spontaneously Completes round peg board easily	Uses spoon without rotation but still spills May indicate wet pants Mugs doll Likes to take off shoes and socks Knows one body part Very negative oppositions	One-step commands 10-15 words Knows “hello” and “thank you” More complex ‘jargon’ rag Attention span 1 min Points to one picture
21 months	Runs well, falling some tires Walks downstairs with one hand held, one step at a time Kicks large ball with demonstration Squats in play Walks upstairs alternating feet with rail held	Tower of five to six cubes Opens and closes small square box Completes square peg board	May briefly resist bathing Pulls person to show something Handles cup will Removes some clothing purposefully Asks for food and drink Communicates toilet needs helps wit h simple household tasks 3 body parts	Knows 15–20 words and combines 2–3 words Echoes 2 or more Knows own name Follows associate commands
24 months	Rarely falls when running Walks up and down stairs alone one-step-at-a time Kicks large ball without demonstration Claps hands Overthrow hand	Tower of six to seven cubes Turns book pages singly Turns door knob Unscrews lid Replaces all cubes in small box Holds glass securely with one hand	Uses spoon, spilling little Dry at night Puts on simple garment Parallel play Assists bathing Likes to wash 6 dry hands Plays with food + body parts Tower of 8. Helps put things away	Attention span 2 min Jargon discarded Sentences of two to three words Knows 50 words Can follow two-step commands (ain’t) Refers to self by name Understands and asks for “more” Asks for food by name Inappropriately uses personal pronouns (e.g., me want) Identifies three pictures
3–5 years	Pedals tricycle Walks up stairs alternating feet Tip toe Jump with both feet	Copies circles Uses overhand throw	Group play Can take turns	Uses three-word sentences
5–12 years	Activities of daily living	Printing and cursive writing	Group Sports	Reads and understands content Spells words

Read More

Surgical Risk Factors And Preventive Strategies : Perioperative Nursing

Obesity

Danger

• Increases the difficulty involved in the technical aspects of performing surgery; risk for wound dehiscence is greater
• Increases the likelihood of infection because of compromised tissue perfusion
• Increases the potential for postoperative pneumonia and other pulmonary complications because obese patients chronically hypoventilate
• Increases demands on the heart, leading to cardiovascular compromise
• Increases the risk for airway complications
• Alters the response to many drugs and anesthetics
• Decreases the likelihood of early ambulation

Therapeutic Approach

• Encourage weight reduction if time permits.
• Anticipate postoperative obesity-related complications.
• Be extremely vigilant for respiratory complications.
• Carefully splint abdominal incisions when moving or coughing.
• Be aware that some drugs should be dosed according to ideal body weight versus actual weight (owing to fat content); otherwise, an overdose may occur (digoxin [Lanoxin], lidocaine [Xylocaine], aminoglycosides, and theophylline [Theo-Dur]).
• Avoid intramuscular injections in morbidly obese individuals (I.V. or subcutaneous routes preferred).
• Never attempt to move an impaired patient without assistance or without using proper body mechanics.
• Obtain a dietary consultation early in the patient's postoperative course.

Poor Nutrition

Danger

• Greatly impairs wound healing (especially protein and calorie deficits and a negative nitrogen balance)
• Increases the risk of infection

Therapeutic Approach

• Any recent (within 4 to 6 weeks) weight loss of 10% of the patient's normal body weight or decreased serum albumin should alert the health care staff to poor nutritional status and the need to investigate as to the cause of the weight loss.
• Attempt to improve nutritional status before and after surgery. Unless contraindicated, provide a diet high in proteins, calories, and vitamins (especially vitamins C and A); this may require enteral and parenteral feeding.
• Review a serum prealbumin level to determine recent nutritional status.
• Recommend repair of dental caries and proper mouth hygiene to prevent infection.

Fluid and Electrolyte Imbalance

Danger

Can have adverse effects in terms of general anesthesia and the anticipated volume losses associated with surgery, causing shock and cardiac dysrhythmias

Patients undergoing major abdominal operations (such as colectomies and aortic repairs) often experience a massive fluid shift into tissues around the operative site in the form of edema (as much as 1 L or more may be lost from circulation). Watch for the fluid shift to reverse (from tissue to circulation) around the third postoperative day. Patients with heart disease may develop failure due to the excess fluid “load.”

Therapeutic Approach

• Assess the patient's fluid and electrolyte status.
• Rehydrate the patient parenterally and orally as prescribed.
• Monitor for evidence of electrolyte imbalance, especially Na⁺, K⁺, Mg⁺⁺, Ca⁺⁺.
• Be aware of expected drainage amounts and composition; report excess and abnormalities.
• Monitor the patient's intake and output; be sure to include all body fluid losses.

Aging

Danger

• Potential for injury is greater in older people
• Be aware that the cumulative effect of medications is greater in the older patient
• Medications in the usual dosages, such as morphine, may cause confusion, disorientation, and respiratory depression

Therapeutic Approach

• Consider using lesser doses for desired effect.
• Anticipate problems from chronic disorders such as anemia, obesity, diabetes, hypoproteinemia.
• Adjust nutritional intake to conform to higher protein and vitamin needs.
• When possible, cater to set patterns in older patients, such as sleeping and eating.

Presence of Cardiovascular Disease

Danger

• May compound the stress of anesthesia and the operative procedure
• May result in impaired oxygenation, cardiac rhythm, cardiac output, and circulation
• May also produce cardiac decompensation, sudden arrhythmia, thromboembolism, acute myocardial infarction (MI), or cardiac arrest

Therapeutic Approach

• Frequently assess heart rate and blood pressure (BP) and hemodynamic status and cardiac rhythm if indicated.
• Avoid fluid overload (oral, parenteral, blood products) because of possible MI, angina, heart failure, and pulmonary edema.
• Prevent prolonged immobilization, which results in venous stasis. Monitor for potential deep vein thrombosis (DVT) or pulmonary embolus.
• Encourage position changes but avoid sudden exertion.
• Use antiembolism stockings and/or sequential compression device intraoperatively and postoperatively.
• Note evidence of hypoxia and initiate therapy.

Presence of Diabetes Mellitus

Danger

• Hypoglycemia may result from food and fluid restrictions and anesthesia.
• Hyperglycemia and ketoacidosis may be potentiated by increased catecholamines and glucocorticoids due to surgical stress.
• Chronic hyperglycemia results in poor wound healing and susceptibility to infection.

Therapeutic Approach

• Recognize the signs and symptoms of ketoacidosis and hypoglycemia, which can threaten an otherwise uneventful surgical experience. Dehydration also threatens renal function.
• Monitor blood glucose and be prepared to administer insulin, as directed, or treat hypoglycemia.
• Confirm what medications the patient has taken and what has been held. Facility protocol and provider preference varies, but the goal is to prevent hypoglycemia. If the patient is NPO, oral agents are usually withheld and insulin may be ordered at 75% of the usual dose.
• Reassure the diabetic patient that when the disease is controlled, the surgical risk is no greater than it is for the nondiabetic patient.

Presence of Alcoholism

Danger

The additional problem of malnutrition may be present in the presurgical patient with alcoholism. The patient may also have an increased tolerance to anesthetics.

 

Therapeutic Approach

• Note that the risk of surgery is greater for the patient who has chronic alcoholism.
• Anticipate the acute withdrawal syndrome within 72 hours of the last alcoholic drink.

Presence of Pulmonary and Upper Respiratory Disease

Danger

Chronic pulmonary illness may contribute to hypoventilation, leading to pneumonia and atelectasis. Surgery may be contraindicated in the patient who has an upper respiratory infection because of the possible advance of infection to pneumonia and sepsis.

 

Therapeutic Approach

• Patients with chronic pulmonary problems, such as emphysema or bronchiectasis, should be evaluated and treated prior to surgery to optimize pulmonary function with bronchodilators, corticosteroids, and conscientious mouth care, along with a reduction in weight and smoking and methods to control secretions.
• Opioids should be used cautiously to prevent hypoventilation. Patient-controlled analgesia is preferred.
• Oxygen should be administered to prevent hypoxemia (low liter flow in chronic obstructive pulmonary disease).

Concurrent or Prior Pharmacotherapy

Danger

Hazards exist when certain medications are given concomitantly with others (eg, interaction of some drugs with anesthetics can lead to hypotension and circulatory collapse). This also includes the use of many herbal substances. Although herbs are natural products, they can interact with other medications used in surgery.

 

Therapeutic Approach

• An awareness of drug therapy is essential.
• Notify the health care provider and anesthesiologist if the patient is taking any of the following drugs:
  • Certain antibiotics
  • Antidepressants, particularly monoamine oxidase inhibitors, and St. John's wort, an herbal product
  • Phenothiazines
  • Diuretics, particularly thiazides
  • Steroids
  • Anticoagulants, such as warfarin or heparin; or medications or herbals that may affect coagulation, such as aspirin, feverfew, ginkgo biloba, nonsteroidal anti-inflammatory drugs, ticlopidine (Ticlid), and clopidogrel (Plavix)

 

Read More

Diagnostic Imaging and Testing in Neurological Assessment - Pediatric Neurosurgery Patient

Diagnostic imaging and other diagnostic tests play an important role in understanding the nature of neurological disorders. Advances in medicine, technology, and pharmacology have contributed to safer outcomes for children who may need sedation for diagnostic tests. Imaging or other tests may be performed to obtain a baseline for future studies.

In general, radiographic or digital imaging is looking at brain structure, while other diagnostic tests like electroencephalogram (EEG), single photon emission computed tomography scanning (SPECT),
nuclear medicine scans, and Wada tests are evaluating specific functions of the brain. Positron emission tomography (PET) scans look at metabolic function and utilization of glucose by the brain. Newer technologies allow for the evaluation of cerebral blood flow and brain perfusion. Some tests serve both diagnostic and therapeutic outcomes are:

1. X-rays of the skull and vertebral column; X-rays to look at boney structures of the skull and spine, fractures, integrity of the spinal column, presence of calcium intra-cranially. Patient should be immobilized in a collar for transport if there is a question of spinal fracture.
2. Cranial ultrasound; Doppler sound waves to image through soft tissue. In infants can only be used if fontanel is open. No sedation or intravenous access needed. Used to follow ventricle size/bleeding in neonates/infants.
3. Computerized tomography with/without contrast; Differentiates tissues by density relative to water with computer averaging and mathematical reconstruction of absorption coefficient measurements. Non-invasive unless contrast is used or sedation needed. Complications include reaction to contrast material or extravasation at injection site.
4. Computerized tomography - bone windows and/or threedimensional reconstruction; Same as above with software capabilities to subtract intracranial contents to look specifically at bone and reconstruct the skull or vertebral column in a three-dimensional model. No changes in study for patient. Used for complex skull and vertebral anomalies to guide surgical decision-making.
5. Cerebral angiography; Intra-arterial injection of contrast medium to visualize blood vessels; transfemoral approach most common; occasionally brachial or direct carotid is used. Done under deep sedation or anesthesia; local reaction or hematoma may occur; systemic reactions to contrast or dysrhythmias; transient ischemia or vasospasm; patient needs to lie flat after and CMS checks of extremity where injection was done are required.
6. MRI with or without contrast (gadolinium); Differentiates tissues by their response to radio frequency pulses in a magnetic field; used to visualize structures near bone, infarction, demyelination and cortical dysplasias. No radiation exposure; screened prior to study for indwelling metal, pacemakers, braces, electronic implants; sedation required for young children because of sounds and claustrophobia; contrast risks include allergic reaction and injection site extravasation.
7. MRA MRV; Same technology as above used to study flow in vessels; radiofrequency signals emitted by moving protons can be manipulated to create the image of vascular contrast. In some cases can replace the need for cerebral angiography; new technologies are making this less invasive study more useful in children with vascular abnormalities.
8. Functional MRI; Technique for imaging activity of the brain using rapid scanning to detect changes in oxygen consumption of the brain; changes can reflect increased activity in certain cells. Used in patients who are potential candidates for epilepsy surgery to determine areas of cortical abnormality and their relationship to important cortex responsible for motor and speech functions.
9. SPECT; Nuclear medicine study utilizing injection of isotopes and imaging of brain to determine if there is increased activity in an area of abnormality; three-dimensional measurements of regional blood flow. Often used in epilepsy patients to diagnoses areas of cerebral uptake during a seizure (ictal SPECT) or between seizures (intraictal SPECT).
10. SISCOM; Utilizing the technology of SPECT with MRI to look at areas of increased uptake in conjunction with MRI images of the cortex and cortical surface. No significant difference for patient; software as well as expertise of radiologist is used to evaluate study.
11. PET; Nuclear medicine study that assesses perfusion and level of metabolic activity of both glucose and oxygen in the brain; radiopharmaceuticals are injected for the study. Patient should avoid chemicals that depress or stimulate the CNS and alter glucose metabolism (e.g., caffeine); patient may be asked to perform certain tasks during study.
12. EEG Routine Ambulatory Video; Records gross electrical activity across surface of brain; ambulatory EEG used may be used for 24–48 h with data downloaded after study; video combines EEG recording with simultaneous videotaping. Success of study dependent on placement and stability of electrodes and ability to keep them on in children; routine studies often miss actual seizures but background activity can be useful information.
13. Evoked responses;SSER;VER;BAER ; Measure electrical activity in specific sensorypathways in response to external stimuli; signal average produces waveforms that have anatomic correlates according to the latency of wave peaks. Results can vary depending on body size, age and characteristics of stimuli; sensation for each test will be different for patient – auditory clicks (BAER), strobe light (VER), or electrical current on skin – somatosensory (SSER).

Read More

Maternal and Neonatal Care

Because of its profound emotional implications for mother and child, maternal-neonatal care requires expertise that goes beyond clinical skills. Such care must combine clinical competence, sensitivity, and good judgment. It must consider the patient's sexuality and self-image and recognize changing social attitudes and values—especially those concerning conventional and alternative methods of conception and childbirth.

More than 4 million infants are born in the United States each year. Many are born with considerably less medical intervention than was customary in previous decades, and many were conceived with considerably more intervention. As a result, nurses today must be prepared to implement or assist with a wide range of procedures.

If you're working with a pregnant patient, you'll need to use your teaching skills. For instance, you may be called on to organize and direct natural childbirth classes or to teach the mother-to-be how to breathe and control pain during childbirth. You may teach fathers and other support persons to participate in childbirth by providing comfort and direction.

You may also be asked to give information about childbirth options. Although most births still occur in a hospital, many parents inquire about delivery in a birth center. Usually located on the maternity unit of a hospital or sponsored by a childbirth association, a birth center combines the advantages of a homelike setting with the emergency medical and nursing interventions available in a hospital. Today's nurse may staff or direct the birth center.

Historically, the midwife has been a fixture in remote or poor communities. Today's professional nurse-midwife, however, brings advanced technical skills and certification to diverse communities—urban center to country town alike. She may work in collaboration with—or be supervised by—a physician or a group. In some areas, she may even practice independently. In fact, several states permit insurers to make direct payment to the nurse-midwife for her services.

Accompanying the changes in maternity care are changes in neonatal care—thanks to advanced knowledge and techniques for improving fetal monitoring and promoting neonatal survival. New clinical evaluation methods, combined with new electronic and biochemical monitoring techniques, allow improved neonatal care. To make use of these advances, you must be familiar with neonatal physiology, procedures, and equipment.

Read More