©THEBRIGHTSTARS 2024
Nur4467 Exam 3 Study Guide.
Intracranial Pressure (ICP) - answer✔pressure that may accumulate inside the brain, LOC
decreases
can be due to
- submersion injury/ near drowning
- infection
- cerebral trauma
- hemorrhage
- tumor
- congenital or acquired obstruction to CSF flow
- swelling
- fluid and electrolyte imbalances
clinical manifestations
*infants*
o Irritability, poor feeding
o High-pitched cry, difficult to soothe
o Fontanels: tense bulging
o Cranial sutures: separated
o Eyes: setting-sun sign
o Scalp veins: distended
*children*
o Headache
, ©THEBRIGHTSTARS 2024
o Forceful vomiting, blurry vision
o Seizures
o Drowsiness, lethargy, decreased activity
o Inability to follow simple commands
*late signs*
o Bradycardia
o Decreased motor response to command and sensory response to painful stimuli
o Alterations in pupil size/reactivity
o Extension or flexion posturing
o Decreased consciousness and then coma
submersion injury/ near drowning - answer✔a major cause of accidental death in children that
can occur with even small quantity of water (even as small as a pail of water)
- survival for at least 24 hours after submersion
- cerebral hypoxia: brain cells die within 4-6 minutes
- aspiration: occurs with most injuries and can lead to pulmonary edema, atelectasis, airway
spasm, and acute pneumonitis
- hypothermia
- prognosis is based on length of submersion
- TEACH PREVENTION
lumbar puncture - answer✔cerebrospinal fluid culture to identify organism; appearance and cell
count of CSF can help with diagnosis and intervention
- if fluid is clouded, turbid, has elevated WBC count, and protein is present—BACTERIAL
- if fluid is clear or slightly cloudy, negative gram stain, normal or slightly elevated WBC count
and protein—ASEPTIC
meningitis - answer✔inflammation of the meninges (EMERGENCY)
clinical manifestations
§ More acute than viral/aseptic, with sudden onset
, ©THEBRIGHTSTARS 2024
§ Patient looks ill—toxic appearance with fever
§ Headaches
§ Chills
§ Changes in sensorium
§ Photophobia
§ Nuchal rigidity
§ Infants—high-pitched cry, bulging fontanels, other s/s of increased ICP
§ Kernig and Brudzinski sign—may not be elicited in infants and younger children
nursing management
o Manage hydration, ventilation, ICP reduction, treat shock
o Quiet with minimal stimuli
o Monitor pain
o HOB elevated, side-lying position
o Isolation precautions
o Prophylactic antibiotics for individuals who were in contact
o Family support—education, consider possible long-term effect
Acute Flaccid Myelitis (AFM) - answer✔- rare but serious polio-like disease in children
- sudden onset of arm or leg weakness
- affects the nervous system and causes muscles and reflexes to become weak
encephalitis - answer✔inflammation of the CNS with altered function of brain and spinal cord
primarily viral cause
- herpes simplex
- mosquitoes and ticks
cerebral trauma (head injury, TBI) - answer✔major causes in childhood
- falls
, ©THEBRIGHTSTARS 2024
- motor vehicle injuries
- bicycle or sports-related injuries
types
- *concussion*: alteration in neurologic or cognitive function with or without loss of
consciousness
- *contusion/laceration*: visible bruising and tearing of tissue
- *skull fractures*: results from direct blow or injury to the skull
Glasgow Coma Scale (GCS) - answer✔a scale used to assess the consciousness of a patient
upon physical examination, typically in patients with neurological concerns or complaints
- pupillary reaction
- vitals
- motor function
- posturing (decorticate and decerebrate)
- reflexes
decorticate - answer✔flexion into body, cerebral cortex
decerebrate - answer✔extended away from body, more severe due to midbrain or brainstem
involvement
Reye's syndrome - answer✔potentially serious or deadly disorder in children that is
characterized by vomiting and confusion
metabolic encephalopathy associated with other organ involvement and may be caused by aspirin
therapy
characterized by
- fever
- profound impaired consciousness
- disordered hepatic function
Nur4467 Exam 3 Study Guide.
Intracranial Pressure (ICP) - answer✔pressure that may accumulate inside the brain, LOC
decreases
can be due to
- submersion injury/ near drowning
- infection
- cerebral trauma
- hemorrhage
- tumor
- congenital or acquired obstruction to CSF flow
- swelling
- fluid and electrolyte imbalances
clinical manifestations
*infants*
o Irritability, poor feeding
o High-pitched cry, difficult to soothe
o Fontanels: tense bulging
o Cranial sutures: separated
o Eyes: setting-sun sign
o Scalp veins: distended
*children*
o Headache
, ©THEBRIGHTSTARS 2024
o Forceful vomiting, blurry vision
o Seizures
o Drowsiness, lethargy, decreased activity
o Inability to follow simple commands
*late signs*
o Bradycardia
o Decreased motor response to command and sensory response to painful stimuli
o Alterations in pupil size/reactivity
o Extension or flexion posturing
o Decreased consciousness and then coma
submersion injury/ near drowning - answer✔a major cause of accidental death in children that
can occur with even small quantity of water (even as small as a pail of water)
- survival for at least 24 hours after submersion
- cerebral hypoxia: brain cells die within 4-6 minutes
- aspiration: occurs with most injuries and can lead to pulmonary edema, atelectasis, airway
spasm, and acute pneumonitis
- hypothermia
- prognosis is based on length of submersion
- TEACH PREVENTION
lumbar puncture - answer✔cerebrospinal fluid culture to identify organism; appearance and cell
count of CSF can help with diagnosis and intervention
- if fluid is clouded, turbid, has elevated WBC count, and protein is present—BACTERIAL
- if fluid is clear or slightly cloudy, negative gram stain, normal or slightly elevated WBC count
and protein—ASEPTIC
meningitis - answer✔inflammation of the meninges (EMERGENCY)
clinical manifestations
§ More acute than viral/aseptic, with sudden onset
, ©THEBRIGHTSTARS 2024
§ Patient looks ill—toxic appearance with fever
§ Headaches
§ Chills
§ Changes in sensorium
§ Photophobia
§ Nuchal rigidity
§ Infants—high-pitched cry, bulging fontanels, other s/s of increased ICP
§ Kernig and Brudzinski sign—may not be elicited in infants and younger children
nursing management
o Manage hydration, ventilation, ICP reduction, treat shock
o Quiet with minimal stimuli
o Monitor pain
o HOB elevated, side-lying position
o Isolation precautions
o Prophylactic antibiotics for individuals who were in contact
o Family support—education, consider possible long-term effect
Acute Flaccid Myelitis (AFM) - answer✔- rare but serious polio-like disease in children
- sudden onset of arm or leg weakness
- affects the nervous system and causes muscles and reflexes to become weak
encephalitis - answer✔inflammation of the CNS with altered function of brain and spinal cord
primarily viral cause
- herpes simplex
- mosquitoes and ticks
cerebral trauma (head injury, TBI) - answer✔major causes in childhood
- falls
, ©THEBRIGHTSTARS 2024
- motor vehicle injuries
- bicycle or sports-related injuries
types
- *concussion*: alteration in neurologic or cognitive function with or without loss of
consciousness
- *contusion/laceration*: visible bruising and tearing of tissue
- *skull fractures*: results from direct blow or injury to the skull
Glasgow Coma Scale (GCS) - answer✔a scale used to assess the consciousness of a patient
upon physical examination, typically in patients with neurological concerns or complaints
- pupillary reaction
- vitals
- motor function
- posturing (decorticate and decerebrate)
- reflexes
decorticate - answer✔flexion into body, cerebral cortex
decerebrate - answer✔extended away from body, more severe due to midbrain or brainstem
involvement
Reye's syndrome - answer✔potentially serious or deadly disorder in children that is
characterized by vomiting and confusion
metabolic encephalopathy associated with other organ involvement and may be caused by aspirin
therapy
characterized by
- fever
- profound impaired consciousness
- disordered hepatic function
