Transcript Pediatric Nursing

Pediatric Nursing
Module 6
Caring for Children
with Alterations in
Neurosensory
Functions
Neurological Assessment
 Assessment
 indirect measurements
 children under 2 years
 normal growth and development
parameters
 parents evaluation of their child
 developmental milestones
 history
 prenatal
 birth history
 post natal
Neurological Assessment
 Behavior
 personality, affect, level of activity, social
interaction, attention span
 Motor function
 muscle - size, tone, strength
 abnormal movements
 Sensory function
 discrimination of touch with eyes closed
Neurological Assessment

Cranial Nerves
 Olfactory - smell
 Optic - light perception
visual acuity

peripheral vision
 Ocular motor - 6 cardinal
positions of gaze PERRLA
 Trochlear - have child look
down and in
 Trigeminal nerves - bite
down and try to
 open jaw, sensation to face
Neurological Assessment
 Abducens- look toward
temporal side
 Facial - make a funny face or
smile
 Acoustic - hearing and
balance
 Glossopharyngeal - gag
reflex, taste
 Vagus - uvula is midline,
swallow
 Accessory - shrug shoulders
against
mild applied
pressure
 Hypoglossal - move tongue
in all directions
Video - Neurological exam in
children

http://video.google.com/googleplayer.swf?docid=3314499774483652601&hl=en&fs=true
http://video.google.com/googleplayer.swf?docid=7363212422012619904&hl=en&fs=true
http://video.google.com/googleplayer.swf?docid=-728577715202828264&hl=en&fs=true
Increased Intracranial Pressure
 Causes
 tumors
 accumulation of fluid
within the ventricular
system
 bleeding
 edema in cerebral
tissues
 early signs and symptoms
are often subtle and
assume many patterns
Assess for signs of Increased
Intracranial Pressure
 Level of consciousness (LOC)
 earliest indicator of changes in
neurological status
1. Alertness
 arousal-waking state
 ability to respond to stimuli
2. Cognitive abilities
 process stimuli
 produce verbal and motor
responses
Increased Intracranial Pressure
Signs/symptoms
 Lack of painful stimuli is abnormal and is
reported immediately
 as ICP increases LOC decreases
 3. Vital Signs
 pulse
 variable, may be rapid or slow, bounding or
feeble
 B/P
 normal or elevated with a widening pulse
pressure, at shock level
 Respiration's
 varies
Increased Intracranial Pressure
Signs/symptoms
 Temperature
 elevated especially with infections and
intracranial bleeding
 subnormal in a coma of toxic origin
 Pupils
 size and reactivity
 bilateral vs unilateral
 sudden fixed and dilated pupils is a
neurosurgical emergency
 pressure from herniation of the brain
through the tentorium
Neuromuscular - Signs/symptoms
 Neuromuscular Movement
 strength, spontaneous movements
 asymmetric or absent movements
 tone
 may be increased or decreased
 tremors, twitching, spasms
 purposeless flapping
 hyperactive or flaccid
Increased Intracranial Pressure
Signs/symptoms
 Posturing
 decorticate
 adduction and
flexion
 decerebrate
 rigid extension and
pronation
Diagnosis Procedures
 Lumbar puncture
 measure pressure and sample
for analysis
 Subdural tap
 r/o subdural effusions,
relieves ICP
 EEG
 measures electoral activity
 detects abnormalities
Diagnosis Procedures
 Computer Tomography (CT)
 visualizes horizontal and vertical
cross section of the brain
 distinguishes density
 MRI
 permits tissue discrimination
unavailable with other techniques
 Transillumination
 localized glowing seen in abnormal
fluid
Diagnosis Procedures
 Labs
 CSF
 blood glucose
 electrolytes
 Ca, Mg, Na




clotting studies
liver function tests
blood cultures
drug titre
Cerebral Trauma
Head Injury
 Etiology




falls, MVA, bicycle injuries
head is larger, heavier
children curious
incomplete motor development
 Concussion
 Contusion/laceration
 Fracture
Shaken Baby Syndrome
coup
countrecoup
 Fatal bacterial
meningitis
Meningitis
 Inflammation of the
meninges
 Spread
 vascular dissemination
 OM or URTI
 exudate covers the
brain
 brain becomes
hyperemic and
edematous
Meningitis
 Causative Organism
 H. Influenza, type B
 S. Pneumoniea
 N. Meningitis
 Meningococcus
 Signs and Symptoms
 FUO
 lethargy
Meningitis
Signs/symptoms




irritable
vomiting and/or diarrhea
signs of meningeal irritation
guarding of the neck
 nuchal rigidity
 cries when moved
 poor feeding
Meningitis
Diagnosis

Labs
 CSF
 culture, glucose, protein, cell count, gram
stain
 Blood Culture
 r/o sepsis
 Urine Culture
 r/o UTI
 Chemistry panel
 electrolytes, glucose, BUN, creatinine
Meningitis
Treatment
 Antibiotics
 administer within 1 hour of diagnosis
 type is based on age and causative
organism
 neonate - ampicillin / claforan
 3 months to 3 years - ampicillin /
ceftriaxone
 older children - penicillin / chloramphemicol
Meningitis
Treatment
 Fluid Management
 fine balance between dehydration and
cerebral edema
 child may be dehydrated due to v/d, poor
po, fever
 2/3 maintenance of IV replacement
 fluid restriction
Meningitis
Nursing Care
 PC: Neurological dysfunction
 cerebral hypoxia
 seizures
 increased ICP
 PC: Seizure
 High Risk for spread of infection
 needs resp. isolation for first 24 hrs of
antibiotic therapy
Meningitis
Nursing Care
 Fluid Volume Deficit: less than body
requirements r/t dehydration




NPO/fluid restriction
I&O
daily weights
Labs
 specific gravity and electrolytes
 IV fluid - careful, conservative
replacement
Meningitis
Nursing Care
 PC: Neurological damage
 seizures
 sequelae to meningitis
 seizures
 hydrocephalus
 visual/hearing deficits
Reye Syndrome
 Toxic encephalopathy with additional organ
involvement
 Etiology
 follows viral illness, ASA
 Signs and Symptoms
 fever
 decrease LOC
 hepatic dysfunction
 Prognosis
 good
Febrile Convulsions
 Age
 most common between 6 months and 3
years
 Occurrence
 Seizure accompanied by fever without
CNS infection
 Occurs during the temperature rise
 Treatment
 fever - tylenol
 seizure - ativan, valium
 Tonic clonic seizure
 Tonic – stiff
 Clonic - jerking
 Rescue position
 Assessment
 seizure precautions
 emergency
treatment
 rescue position
 Nursing Care
 protect from injury
 open airway
 accurately observe
and record
happenings
Hydrocephalus
Hydrocephaly

Abnormal condition characterized by an increase volume of
normal cerebrospinal fluid under increased pressure with in
the intracranial cavity
 Communicating
 obstruction is located in the subaranoid
cistern or within the subarachnoid space
 Non-communicating
 blockage is within the ventricles
Hydrocephaly - Pathology
 3 possible mechanisms
leading to hydocephalus
 1. Over production of
CSF
 2. Defective absorption
of CSF
 3. Obstruction of CSF
 3 major causes
 inflammation
 congenital malformations
 tumors
Hydrocephalus
Signs/symptoms
 Signs of increased fluid pressure
 tense or bulging anterior
fontanel
 scalp becomes thin and shiny
 vein dilate
 cranial suture lines begin to
separate
 Other clinical symptoms
 vomiting
 wide bridge between eyes
 bulging eyes - sunset eyes
Hydrocephalus
Signs/symptoms
 Severe Form
 head size increases rapidly
 infant’s cry is shrill, high pitched
 hyperirritability, restlessness
 Older Children




no head enlargement
papilledema
spasticity
H/A
ataxia
Alter mental status
strabismus
Hydrocephalus
Treatment
 Surgical
 VP (ventriculo-peritoneal)
Shunt
 Nursing Care
 Pre-op
 assessments
 daily head circumference
 size and fullness of anterior
fontanel
 behavior
 nutrition - vomiting
Hydrocephalus - Nursing Care
 fluid and electrolyte needs
 positioning
 prevent pressure ulcers
 support the neck
 good skin care
 neuro assessments
 LOC
 irritable child/infant
 vital signs
 observe for seizures
Hydrocephalus
 Nursing Care
 Post-op
 monitor feeding and behavior patterns
 assess for increasing ICP and cerebral
irritability
 HOB flat or set elevation
 Shunt observation
 infection - along the line or cerebral
 abdominal girth
 valve function, blockage, separation
 emotional needs - hold and cuddle
 teaching
Cerebral Palsy
 Non-specific disorder
characterized by early onset of
movement and posture
impairments
 abnormal muscle tone and
coordination
 Spastic
 hypertonicity, stiff
 Dyskinectic
 slow, worm-like movement
Spina bifia - myelomeningocele
 Failure of the neural tube to
close during early development
 Treatment
 early surgical closure
 Associated Problems
 hydrocephalus
 paralysis
 bone deformity
 Andrew, age 10 was a passenger in a MVA 3
weeks ago, he sustained a closed head injury
from the impact. He is unconscious in the E.R.
 What are is needs in the Emergency Room?
 What are his priority nursing interventions?
 He was admitted to the PICU, now transferred
to your Pediatric Unit. He tracks his parents
movement, he is receiving 02 via trach collar,
has G-tube with enteral feedings, is incontinent
of urine and stool, is able to nod his head
appropriately.

Why do you think Andrew has a trach?

Why do you think Andrew has a G-tube?
 What risk factors predispose Andrew to
infection?
 Why is he on these medications?
 ranitidine 70mg bid - zantac
 metoclopramide 3.5 mg qid - reglan
 phenytoin sodium 70mg bid - dilantin
 How can you intervene to help met Andrew’s
growth and development needs?