Pediatric Neurologic Assessment: Increased Intracranial Pressure (Nursing)

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

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    00:01 Alright, let's just review the signs and symptoms that are concerning for brain damage or some other neuro problem. First thing I'll say about assessing infants is that nothing is easy. They often are very subtle in their signs and symptoms of really serious illness. That's one of the biggest challenges of taking care of pediatric patients especially if they're sick pediatric patients. Even when they have increased intracranial pressure, their symptoms may not be obvious and if you think about it it kind of makes sense because they can't talk to you, they can do very few things especially when they're really really little and it's just hard for them to communicate when they're hurt, when they have some other problem or if they're just not feeling quite right. So, some of the major signs can be the bulging fontanelle that you may feel during a neuro exam. Increased head circumference. Same idea behind it basically if there's excessive fluid on the brain causing excessive pressure. It might also expand the brain a bit and cause the head circumference to expand. An infant often shows the first signs of illness by just refusing to feed or from crying a whole lot like high-pitched crying. It's more of an irritable cry versus a fussy cry. They often cannot be consoled when they're feeling this bad and when they have that increased intracranial pressure. Their eyes may do something special called a setting sun sign, which basically means the brain pressure pushes down on the eyes like a setting sun and pushes the eye balls down so you see more of the white over the iris. Another thing that is sometimes noticed in these infants is just basically tensed muscles and if they get really bad, if they have a lot of increased intracranial pressure and if not identified early, they may end up having vital signs changes such as bradycardia, increased blood pressure, and decreased respirations. Older children are a little easier to assess for anything including increased intracranial pressure. They can still be fairly subtle in how they present especially if they're not fully verbal. Again, they may have lethargy, pupillary changes, mental status changes. Those are always concerning. If they're old enough to report, they may report not being able to see well, they may report that their head hurts, and they may have vomiting and nausea. They also might present with a seizure. This is something an infant can present with as well, but infants are really tough. Sometimes they're really tough to tell if an infant is having a seizure versus a child because infant seizures are so subtle they're often very limited to their face, their lips, or their eyes. Older child that has a seizure should be a little more obvious if they're seizing. And again, if the increased intracranial pressure goes on for a bit, is not identified early, they can also develop the vital signs abnormalities that indicate increased intracranial pressure such as bradycardia and increased blood pressure. The early versus late signs of increased intracranial pressure, sometimes important to know and you may need to know that's an NCLEX question so let's go over them real quick. Early signs in an infant or young child may include more subtle changes of mental status such as fussiness, inability to be consoled, not wanting to wake up to feed, that sort of thing. The caregivers may report if they're crying in a way that they haven't cried before. It's a very high-pitched cry or very irritable cry. And you may notice some pupillary changes, but they shouldn't be blown or fixed at this early stage. If increased intracranial pressure keeps going and gets worse, then you see more prominent signs of variations of level of consciousness. They may become what we call obtunded. That term is used a lot in infants and young children that are truly lethargic and won't react to much at all, if anything. They may not react, for instance, to an IV stick. And eventually, a late sign of increased intracranial pressure are those vital signs changes such as decreased pulse, increased blood pressure, and abnormal respirations. The NCSBN Clinical Judgment Measurement Model is a framework being used for NCLEX questions and case studies. The first 2 steps or steps we're going to go over right now and make connections to the content you just heard, recognizing cues and analyzing cues. In order to recognize cues and analyze cues in a child may be suspected of having a neurological problem, you have to be able to do a pediatric neuro assessment. You have to know how to assess their level of consciousness based on whatever system is used in your institution. You may need to use a Glasgow Coma Scale, a Pediatric Glasgow Coma Scale, or an AVPU Scale. Or some institutions just allow a general assessment of neuro status based on how alert or reactive they are, how playful they are, how they interact with their family. So know it's expected on your unit and in your institution. The most important thing, in my opinion, to assessing pediatric neuro status is really understanding typical pediatric growth and development and how that affects their brain and their communication skills and how they may act and what things they might be afraid of because that will help you assess as to whether their reaction to you and to the questions you may ask them are appropriate. In addition to that, it's also important to be able to assess their pupils. In some way you may or may not be measuring them, but you will be assessing them, assessing their reactivity, assessing their accommodation, and assessing how equal they are to each other. And lastly, you're going to be able to monitor, you need to be able to monitor for signs of increased intracranial pressure because those are things that need to be reported immediately because they can really indicate major problems that sometimes needs surgical correction.

    About the Lecture

    The lecture Pediatric Neurologic Assessment: Increased Intracranial Pressure (Nursing) by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN is from the course Neurologic Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. Bulging fontanelles
    2. Increased head circumference
    3. High-pitched cry
    4. Hypotension
    5. Setting-sun sign
    1. Decreased pulse
    2. Abnormal respirations
    3. Decreased blood pressure
    4. Pupillary changes
    5. High-pitched cry
    1. Blurred vision
    2. Headache
    3. Projectile vomiting
    4. Tachycardia with hypotension
    5. Increased activity level

    Author of lecture Pediatric Neurologic Assessment: Increased Intracranial Pressure (Nursing)

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

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

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