Pediatric Neurologic Assessment: Assessing Level of Consciousness (Nursing)

by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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    00:00 Hi. Welcome to the Pediatric Neuro Assessment lecture. We're going to go over some basic terms and concepts. We'll review a pediatric neuro assessment and then we'll talk about some signs and symptoms you might see if there's a problem. Let's start with terms and concepts. The Glasgow Coma Scale, Pediatric Glasgow Coma Scale, and the AVPU Scale are all 3 different ways you can assess level of consciousness in a child. The way you use depends on their age and their sedation level or level of alertness. The Glasgow Coma Scale is the most common one used for level of consciousness assessment. It's also used to help grade the severity of traumatic brain injuries. It's very useful and consistent when you use in adults, in general. But in kids, it can be a little unpredictable. Well, I guess I should say kids can be unpredictable. So, do you think a toddler is going to answer your questions when you ask them in a hospital and they have no idea who you are. Probably not.

    01:00 In fact, many anxious toddlers will just not talk to you at all, they may not even look at you. So that's going to kind of mess up your Glasgow Coma Scale. For this reason, the Pediatric Glasgow Coma Scale was created to make it a little more realistic for children. You can see, you could actually probably accurately assess an infant. Again, a toddler might be a little challenging but they pretty much challenges at any point. So, this is just another option you can use if you can properly assess each of the 3 types of response. The 3rd one is my favorite and there may be more but this is one that's been validated for both first aid and emergency response. Some emergency departments also use this scale for pediatric patients and adults actually. I love this scale because it basically looks at the major responses, the need to knows. Are they alert to the point they should be based on their age and development? Or if they don't seem alert, do they wake up or become somewhat alert when you talk to them? And if not, do they wake up and become somewhat alert if you pinch them or if you prick them with something slightly sharp or maybe do a sternal rub, something uncomfortable doesn't make them rouse. One way we test this in pediatric sometimes without necessarily meaning to test it is by starting an IV on a child who's not very responsive. If they don't respond to an IV stick, it's very concerning. Lastly, the worst case is if they're unresponsive. So that's the child that does not respond to an IV stick, that does not cry, and doesn’t even move. You can probably understand how the AVPU Scale might produce more consistent results than the GCS scales and that's just because there are fewer choices and because it's going to be easier for you and I if we both assess the same child to agree on the score that's given to them. Alright, now let's go through the rest of the pediatric neuro assessment. First of all, if you're assessing an infant, you should always include a fontanelle assessment as part of the neuro assessment. So, the reason why is because the fontanelles of the infant are the junctions of some of the major regions of the skull. They're there for a reason until the infant is about 18 months when they're both close. They actually offer kind of like a window into the brain, not a real window. There is material there but it's not completely solid like bone. It's kind of fibrous. We talked about that more in another lecture that we have called the Newborn Head, if you want to hear more about it. So, this here is the posterior fontanelle. It's basically the fontanelle that will close the first before, usually by about 1-2 months old. These fontanelles are there basically just to allow for general expansion and growth of the brain. After the posterior fontanelle closes, the anterior fontanelle stays open for a few more months. It closes by about 12-18 months. It can be a little bit different in each child. Again, it just keeps allowing for brain expansion and growth, which is normal. These fontanelles should not close early and if they do, if they close too early, it can actually cause the brain to get kind of squish, it can cause pressure to build up. And that's one of the reasons why you should include a fontanelle assessment in any neuro assessment of an infant to check for both fontanelles. But in addition to doing that, check for how they feel. A fontanelle should feel pretty flat. Fairly, you might feel fluid in it, you might feel what feels like fluid in it, but it should feel pretty flat. If it's bulging or if you see it kind of being, if it's really tensed like if it's very full, that can indicate increased intracranial pressure and so that is definitely a red flag that you need to report to a provider immediately. On the other hand, if it's sunken, that's basically kind of like a window into the infant's general fluid status. It could indicate dehydration. Also, bulging fontanelles can also indicate just too much volume so either way bulging fontanelles are bad, sunken fontanelles are bad but sunken fontanelles are more likely to be like hydration directly related. Alright, now let's talk about the pupillary assessment in a pediatric patient and what that looks like. It can be pretty interesting. So, pupils should be equal, round, reactive to light and accommodation. And what this means is they should be the same size, they should be round, they should react to light.

    05:53 So if you are in dim light or your patient is in dim light, your pupils should naturally dilate. If you have light shown into them from a pen light or just from light in the room, they should get smaller or constrict more. They should also change if you're pointing something at them and moving in and out. That's called accommodation if they're able to kind of change to accommodate to where an object is. Checking them in children can be challenging as was everything else that you check in children. Sometimes, not everybody measures the pupils when they do the PERRLA exam, but regardless of whether you measure them you should be able to tell if the pupils are equal or not and that is a very important part of the assessment.

    06:40 PERRLA is often used to refer to the assessment, but it's actually just an acronym for normal findings. Alright, now let's talk about what normal pupillary findings should be during a pupillary exam that's part of the neuro exam. When you're going to look at the pupils, you should have the patient look straight ahead at some kind of object in the room, have them fixate on it so that their eyes don't inadvertently move as you're trying to examine them. You're going to take the light source whether it's a pen light and otoscope or some other type of light source and either move it from below their face up to each eye separately or from the side to each eye separately and watch what the pupils do, what size they are, how their shape changes, and whether they change together or in different ways. This is what pupils should do when a light is shown in them. They should constrict when light is shown in them. This is a natural response that basically limits the amount of light that goes in the eye. It's abnormal to have no reaction to light. There are many things that can cause this. You won't always know the reason, but in general any kind of abnormal response to light could mean there's some sort of damage in the brain. There could be some kind of disease or infection. There could be optic nerve damage or just eye damage or it could be a reaction just from a drug either prescription drug or even a recreational drug. Let's look at some examples of abnormal pupils. Pinpoint pupils are not normal. This term is also called myosis, which you may hear in nursing school as well as when you're taking care of patients. Pinpoint pupils can indicate that a person has some kind of substance abuse, some prescription drug use especially narcotics. They're pretty well known for causing pinpoint pupils. And also some diseases can cause them. Abnormal pupils may also be widely dilated. This is called mydriasis, and this is done intentionally if you go get an eye exam because it helps the eye doctor look inside your eye and see the nerves and the retina and all the different parts. It can also happen as an abnormal reaction to something such as drugs, recreational drugs, or prescription drugs. And it can happen sometimes after a seizure temporarily but it should resolve once the patient is out of the postictal period.

    09:19 Abnormal pupils may react the same or one may be normally reactive and one may be abnormally reactive. Fixed basically means bad whether it's in one or both.

    09:32 Some people will call fixed pupils, blown pupils, so you may hear that in practice.

    09:38 Paralysis or increased intracranial pressure that causes brain damage basically can Paralysis or increased intracranial pressure that causes brain damage basically can cause this reaction whether it's one-sided or two-sided, it's always alarming and it's cause this reaction whether it's one-sided or two-sided, it's always alarming and it's definitely a red flag that needs to be reported immediately to a provider. This is bilateral fixed and the prior slide was unilateral fixed. Strabismus is an abnormal finding but is more benign, so it doesn't necessarily indicate any kind of brain damage or trauma or disease. Basically, the eyes look crossed. You may notice that's quite bad in infants and young children. They usually grow out of it, but if they don't grow out of it they can have special therapy such as an eye patch or special glasses and then if that doesn't help they can even have surgery to correct this. Some of the most concerning pupillary findings are dilated and fixed or unequal and one side fixed. These findings, if new, need to be very urgently evaluated. They can definitely indicate brain damage, paralysis, increased ICP. They're all bad things.

    About the Lecture

    The lecture Pediatric Neurologic Assessment: Assessing Level of Consciousness (Nursing) by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN is from the course Neurologic Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. AVPU
    2. Pediatric Glasgow Coma Scale
    3. Adult Glasgow Coma Scale
    4. Apgar score
    1. Assessing fontanelles
    2. Assessing motor response
    3. Assessing pupils
    4. Assessing verbal response
    1. Increased intracranial pressure
    2. Dehydration
    3. Malnutrition
    4. Acute infection
    1. Bilateral fixed and dilated pupils
    2. Bilateral miosis
    3. Strabismus
    4. Bilateral mydriasis
    1. Miosis
    2. Mydriasis
    3. Strabismus
    4. Aniscoria

    Author of lecture Pediatric Neurologic Assessment: Assessing Level of Consciousness (Nursing)

     Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

    Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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