1/27/2017. Nursing Care of the Pediatric Neurosurgical Patient. Assessment is the key...

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1 Nursing Care of the Pediatric Neurosurgical Patient Julie Deibel, APN, NP-C, CNE Pediatric Neurosurgery Illinois Neurological Institute Assessment is the key..... Overview Consideration of development is the major distinction between pediatric medicine and adult medicine. Very true in the neurological assessment. Knowledge of milestones and normal Growth/Development is key. Essential Neurological Pediatric Nursing Skills Knowledge of Growth and Development Development of a Therapeutic Relationship Communication with Children and Parents Understanding of Family Dynamics and key relationships Knowledge of Health Promotion and Disease Prevention Patient Education and Anticipatory Guidance Therapeutic and Atraumatic Care Patient and Family Advocacy Care Coordination Critical Thinking History A detailed history is the cornerstone of any neurological assessment---a true statement in pediatrics as well as the adult population. Children over the age of three can contribute to the history and should be questioned directly as much as possible Historian Consider the source Start with the chief complaint Consider the chief complaint in the context of development Other Elements of the History HPI Utilizing the OLDCART format Review of Systems (Very important) 1

2 Birth History Consider the context of the situation when determining the need for birth history information. What aged patient requires this history to be included?? Elements of Birth History: Length of pregnancy (# weeks gestation at time of birth), General Health of pregnancy, Complications of pregnancy or birth, Quantify cigarette, alcohol, and drug consumption, Discuss any abnormal results from prenatal testing. Discuss type of birth, complications of birth, complications during neonatal period. Historical Markers for Neurological Dysfunction Full term infants who are unable to breathe spontaneously Infants who have poor and uncoordinated suck/swallow Infants who take long periods of time to feed Infants requiring gavage feedings Developmental context should be considered as these issues might be expected in a premature infant Developmental History is Most Important Consider the domains social, cognitive, language, fine motor, and gross motor. Isolated vs Global Developmental Delay Abnormalities since birth vs Regression Generally, parents are aware of developmental delays Age (months) Gross Motor Fine Motor Social Skills Language 3 Supports weight on forearms Opens hands spontaneously 6 Sits momentarily Transfers Objects Smiles appropriately Shows likes and dislikes 9 Pulls to stand Pincer Grasp Plays pat-a cake and peek-aboo 12 Walks with one hand held 18 Walks upstairs with assistance Releases an object on command Feeds from a spoon Comes when called Mimics actions of others Coos, laughs Babbles Imitates sounds 1-2 meaningful words At least 6 words 24 Runs Builds a tower of blocks Plays with others 2-3 word sentences Family History Social History First Degree Relatives Age and neurological history of any first degree relative Include developmental delay Consider the importance of siblings in pediatric population Social history is of great importance in pediatrics Include current living environment, stressors, hardships, academic and social performance, any abrupt changes in academic or social performance 2

3 Pediatric Neurological Physical Exam Begins when you enter the room Conduct the exam in a non-threatening child friendly setting Mental Status Evaluation, level of arousal and interaction with environment Alert and oriented at an age appropriate level with an example should be documented Informal evaluation of memory though recall of personal events or telling a story can be helpful Head Circumference measured at each well care visit until 36 months of age Fontanelle assessment Anterior-juncture of the metopic, sagittal, and coronal suture with a normal measurement of 3-6 cm, through months of age Posterior-juncture of the sagittal and lambdoid sutures, cm, closes at 2 months Feel fontanelle should be soft/flat. Tense fontanelle is a sign of increased ICP. Early Fontanelle Closure Delayed Fontanelle Closure Craniosynostosis Hyperthyroidism Hyperparathyroidism Consider ridging of sutures and decreasing head circumference when concerned for early fontanelle closure Normal Variation Congenital Hypothyroidism Primary Megalencephaly Increased Intracranial Pressure Down syndrome Rickets Other examination techniques Auscultation for bruit, diagnostic of arteriovenous malformation Transillumination hydranencephaly and hydrocephalus Evaluation of overall head shape, consider plagiocephaly Palpation of the newborn/infant skull, looking for bony ridges or overriding sutures Evaluate hair patterns and cutaneous malformations Cranial Nerve Evaluation CN 1 Not routinely evaluated unless a cc CN 2, Optic Nerve Recall what is normal. A 37 week infant is able to turn the head and eyes toward a soft light and fix/follow a target like the examiner s face Visual Acuity is 20/150 in term infants at birth and rapidly improves to 20/20 by six months of age 3

4 Cranial Nerve 2-Optic Nerve Visual Fields Testing Moving an object from behind and noting when the child first looks toward the object Evaluate pupil size, symmetry and reactivity Ophthalmoscopic exam Evaluate the disc and evaluate papilledema Extra Ocular Eye Movement EOM, CN III, IV, VI Dysconjugate gaze is often the result of extraocular muscle weakness Evaluated by having the child/infant or older child follow an object, toy, or finger through the 6 cardinal fields of gaze Consider adventitious movements like nystagmus Craniosynostosis Craniosynostosis results from the premature fusion of one or more cranial sutures Impacts 1 in every 2000 births worldwide Many hypothesis on the causes: Genetic mutation Abnormal dural attachments in utero Intrinsic abnormalities in the cranial base Endocrine abnormalities, warfarin, or Depakote use during pregnancy Craniosynostosis Incidence 1 in 2000 live births Age of onset Most cases evident at birth Risk factors Familial Autosomal dominant and recessive Chromosome: 7p21.3-p21.2 Male=female Except sagittal type where M>F (4:1) Craniosynostosis Management Physical Exam Rule-out secondary causes Imaging Endocrine - Hyperthyroidism, hypophosphatemia, vitamin D deficiency, renal osteodystrophy, hypercalcemia, and rickets Hematologic disorders that cause bone marrow hyperplasia (ex: sickle cell disease, thalassemia) Skull x-rays CT 3D reconstruction? Otologic hearing and airway Ophthalmologic vision and strabismus 4

5 Types of Craniosynostosis Stereotyped head shape by suture involved Sagittal (50%): scaphocephaly Coronal (30%) uni: plagiocephaly, bi: brachycephaly Metopic (10%): trigonocephaly Lambdoid (3%): posterior plagiocephaly Sagittal 5

6 Sagittal Surgical Repair Sagittal Before and After Asymmetry Plagiocephaly 6

7 Pediatric Headache OSF Heart & Vascular 7

8 SNOOPPPY S: Systemic Symptoms N: Neurologic Signs O: Onset O: Occipital P: Precipitated by Valsalva P: Positional P: Progressive P: Parents lack of family history Y: Years ( <6) Pediatric Head Injury and Concussion Pediatric Statistics More commonly diagnosed in pediatric patients than in previous decades Why? CDC reports 1.7 million children and adults each year are diagnosed with a TBI or concussion. Some sources as high as 3.8 million. 250,000 ED visits children 20% of these injuries are sports related Dramatic increase in concussed kids being seen in the ED and PCP s office, 485% increase at the PCP in the Boston 2015 study Trends in Care Point of contact is changing... From ED to PCP PCP visits increased 485% Most pediatricians reported some discomfort treating concussion in the Boston Children s Study. Specialist visits are increasing in response to the need up 919% in the study Taylor et al., Journal of Pediatrics, (2015). Head Injuries Why Scan? Pediatric Red Flags Abnormal neurological exam, abnormal mental status, and suspected skull fracture S/S of skull fracture large boggy scalp hematoma, hemotympanum, raccoon eyes, battle sign and otorhinorrhea (basal skull fracture) GCS score < 14 two hours post injury Known coagulation disorder Worsening symptoms following an observation period of several hours Treatment Plan for Concussion in Kids Individualized Requires clinician judgment and knowledge Mainstay is cognitive and physical rest Total rest is no longer recommended, possibly first Most children recover in 2 weeks, some require months Stepwise plan to normal activity should be developed and supervised by a provider trained to manage concussion 8

9 Patient Stories Teratoma of The Spine Repair of Craniosynostosis A Family Affair 9

10 Juvenile Pylocitic Astrocytoma Neuroblastoma Pediatric Neurosurgery Patients Need More than just a Pediatric Neurosurgeon Thank you -- OSF Heart & Vascular 10