PEDIATRIC FINAL EXAM BLUEPRINT
Neuro
Biological Variance in Children
Nervous system grows faster before birth
Reflexes present at birth tend to disappear at one year
Neurological assessment of the child is dependent on developmental level
Birth - brain is 25% of adult size
Age 5 - 90% of the adult size
Spinal cord terminates at L3 in the infant
Neurologic Assessment
Children under 2 require special evaluation because they can not respond to directions to elicit
specific neurologic responses. - NEED TO OBSERVE
Assess using observation, reflex response delay, deviation from expected milestones
Need baseline neuro status to know what might be different
Level of Consciousness - implies awareness
What stimuli is needed?
o Light touch, virgous?
o Lack of response to painful stimuli is abnormal and must be reported immediately
What is quality of the response?
o Short, quick, none
What is length of response?
Difference Levels of Consciousness*
Full conscious - awake, alert, behavior is appropriate, ANO X 4
Confusion - disoriented to time place or person, impaired decision making
Lethargy - marked by limited spontaneous movement, sluggish speech, drowsiness and falling asleep
quickly
Obtundation - arousable with stimulation
Delirium - confusion, fear, agitation, hyperactive, anxious
Stupor - deep sleep, responsive only to vigorous stimuli, moaning to stimuli
Coma - no response to stimuli
ALWAYS NEED BASELINE NEURO STATUS
Glasgow Designed as a standardized assessment 8 or less = severe injury
Coma scale of the patient with disturbed 9 - 12 - moderate injury
consciousness 13 - 15 - mild injury
The lower the score at time of
admission the poorer the outcomes
Motor and verbal responses must be
related to the child’s age
,Pupil Fixed and dilated pupil (s) is neuro
Changes emergency
Pinpoint pupils - suggest a narcotic
overdose, poisoning
Midpoint fixed pupils - structural
damage in the midbrain
Dilated or large pupils - severe anoxia
(absence of oxygen) or overdose
One pupil fixed and dilated - potential
herniation of the temporal lobe
Widely dilated and reactive - often seen
after a seizure, may only affect one side
Unilateral fix - suggest lesion on one
side
Bilateral fix - brainstem damage if
present for more than 5 minutes
CT SCAN Special procedure to assess cerebral function
Noninvasive; gives three dimensional look at normal and abnormal structures
Scan soft tissue and solid matter
Childs head needs to be placed in special immobilizing devices
Young children may require sedation to remain still
Lumbar Purpose - Measure spinal fluid pressure
Puncture Drawn from between two vertebrae
Insert spinal needle into subarachnoid
space L3 - L4 and L4 -L5
CSF is measured and a sample is
collected
Pre-Lumbar Puncture
Have child empty bladder first.
Contraindicated - ↑ ICP or infection
near puncture site
During the Procedure
Side lying position for lumbar puncture
After the procedure
Keep them flat for an hour
CAUTION - spinal headache if they get
up early
Analysis of CSF
CSF is analyzed for number of white
and red blood cells
Cerebrospi Normal CSF Abnormal CSF
nal Fluid Clear odorless Turbid, cloudy
WBC’s O - 5 WBC’s 1,000-2,000
Protein 15 - 45 Protein 100 - 500
Glucose 50 - 80 Glucose lower than blood sugar
, Pressure - 50 - 189 Pressure 180 or greater
Volume of Brain volume can increase with
Brain o Edema
o Blood flow
o Bleed within the brain
o Tumor
Vital Signs Pulse rate decreases as ICP increases
Respirations: rate, quality, and
characteristic change
Blood pressure rises slowly
Initially as ICP rises respiratory rate can
become rapid and noisy, leading to
apnea
Cushing Triad (reflex)
o Bradycardia
o Increase blood pressure (late
sign)
o Irregular respirations
ICP children - diplopia and blurred
vision, high pitched cry, bulging
fontanel
A high shrill cry in an infant can be a
sign of increased ICP
, Seizures
A paroxysmal, uncontrolled episode of behavior that results from an abnormal electrical discharge
from the brain
Manifestation of seizures depends on the area of the brain they originate from:
Altered responsiveness, Altered sensation or perception, altered movements, mobility or muscle tone
Classification of Seizures - Partial, generalized, unclassified
Partial Partial seizures are categorized as simple (meaning without associated
impairment of consciousness) or complex (with impaired consciousness);
both types may become generalized.
Simple Partial Seizures
result from one hemisphere from the brain
Last 30 seconds or less, no loss of consciousness
Symptoms depend on what area of the brain is involved
Often presents as a staring episode or slight twitching of eyes and
drooling
Neuro
Biological Variance in Children
Nervous system grows faster before birth
Reflexes present at birth tend to disappear at one year
Neurological assessment of the child is dependent on developmental level
Birth - brain is 25% of adult size
Age 5 - 90% of the adult size
Spinal cord terminates at L3 in the infant
Neurologic Assessment
Children under 2 require special evaluation because they can not respond to directions to elicit
specific neurologic responses. - NEED TO OBSERVE
Assess using observation, reflex response delay, deviation from expected milestones
Need baseline neuro status to know what might be different
Level of Consciousness - implies awareness
What stimuli is needed?
o Light touch, virgous?
o Lack of response to painful stimuli is abnormal and must be reported immediately
What is quality of the response?
o Short, quick, none
What is length of response?
Difference Levels of Consciousness*
Full conscious - awake, alert, behavior is appropriate, ANO X 4
Confusion - disoriented to time place or person, impaired decision making
Lethargy - marked by limited spontaneous movement, sluggish speech, drowsiness and falling asleep
quickly
Obtundation - arousable with stimulation
Delirium - confusion, fear, agitation, hyperactive, anxious
Stupor - deep sleep, responsive only to vigorous stimuli, moaning to stimuli
Coma - no response to stimuli
ALWAYS NEED BASELINE NEURO STATUS
Glasgow Designed as a standardized assessment 8 or less = severe injury
Coma scale of the patient with disturbed 9 - 12 - moderate injury
consciousness 13 - 15 - mild injury
The lower the score at time of
admission the poorer the outcomes
Motor and verbal responses must be
related to the child’s age
,Pupil Fixed and dilated pupil (s) is neuro
Changes emergency
Pinpoint pupils - suggest a narcotic
overdose, poisoning
Midpoint fixed pupils - structural
damage in the midbrain
Dilated or large pupils - severe anoxia
(absence of oxygen) or overdose
One pupil fixed and dilated - potential
herniation of the temporal lobe
Widely dilated and reactive - often seen
after a seizure, may only affect one side
Unilateral fix - suggest lesion on one
side
Bilateral fix - brainstem damage if
present for more than 5 minutes
CT SCAN Special procedure to assess cerebral function
Noninvasive; gives three dimensional look at normal and abnormal structures
Scan soft tissue and solid matter
Childs head needs to be placed in special immobilizing devices
Young children may require sedation to remain still
Lumbar Purpose - Measure spinal fluid pressure
Puncture Drawn from between two vertebrae
Insert spinal needle into subarachnoid
space L3 - L4 and L4 -L5
CSF is measured and a sample is
collected
Pre-Lumbar Puncture
Have child empty bladder first.
Contraindicated - ↑ ICP or infection
near puncture site
During the Procedure
Side lying position for lumbar puncture
After the procedure
Keep them flat for an hour
CAUTION - spinal headache if they get
up early
Analysis of CSF
CSF is analyzed for number of white
and red blood cells
Cerebrospi Normal CSF Abnormal CSF
nal Fluid Clear odorless Turbid, cloudy
WBC’s O - 5 WBC’s 1,000-2,000
Protein 15 - 45 Protein 100 - 500
Glucose 50 - 80 Glucose lower than blood sugar
, Pressure - 50 - 189 Pressure 180 or greater
Volume of Brain volume can increase with
Brain o Edema
o Blood flow
o Bleed within the brain
o Tumor
Vital Signs Pulse rate decreases as ICP increases
Respirations: rate, quality, and
characteristic change
Blood pressure rises slowly
Initially as ICP rises respiratory rate can
become rapid and noisy, leading to
apnea
Cushing Triad (reflex)
o Bradycardia
o Increase blood pressure (late
sign)
o Irregular respirations
ICP children - diplopia and blurred
vision, high pitched cry, bulging
fontanel
A high shrill cry in an infant can be a
sign of increased ICP
, Seizures
A paroxysmal, uncontrolled episode of behavior that results from an abnormal electrical discharge
from the brain
Manifestation of seizures depends on the area of the brain they originate from:
Altered responsiveness, Altered sensation or perception, altered movements, mobility or muscle tone
Classification of Seizures - Partial, generalized, unclassified
Partial Partial seizures are categorized as simple (meaning without associated
impairment of consciousness) or complex (with impaired consciousness);
both types may become generalized.
Simple Partial Seizures
result from one hemisphere from the brain
Last 30 seconds or less, no loss of consciousness
Symptoms depend on what area of the brain is involved
Often presents as a staring episode or slight twitching of eyes and
drooling
