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.