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53 Cards in this Set
- Front
- Back
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Developmental Differences
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Incomplete development of the nervous system
- fetal development at 3-4 weeks gestation -early closure of the fontanels -myelinization of nerves (full fat diet until the age of 2 is needed) -cephalocaudal, proximodistal -prematurity -proportion of head to body size (typically 1:8 at age 12 compared to 1:5 as an adult) |
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Pediatric Glascow Coma Scale
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Three part assessment tool
◦ Eye opening ◦ Motor response ◦ Response to auditory or visual stimulus < and > 2 years Score of 3 to 15 Best to involve parents to get most accurate assessment |
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Epilepsy
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No apparent cause, febrile type always comes with a fever
Predisposing associations acute head trauma, meningitis remote stroke, cerebral palsy Multiple types partial, generalized Outgrow 5-80% (Epilepsy Assn) |
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Febrile Seizure
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Association with a fever
Predisposing associations 3-8% children 6-36 months, boys>girls family tendency Generalized tonic clonic Outgrow Rare after age 7 |
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Febrile Seizures
Health History-Current |
Where occurred?
Sleeping, eating, playing, waking? Child’s behavior/movement patterns Length of seizure is directly related to respiratory problems (timing is very important) Act after seizure post ictal period of altered consciousness Recurrent? Frequency Precipitating factors fever, fall, flashing lights, loud sounds |
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Febrile seizures - risks and recurrences
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Risk factors for developing epilepsy
simple (<15 minutes) risk is 1% multiple simple, < 12 months, and FH – 2.4% Cognitive capabilities no significant differences in learning Reoccurrence rate < 12 months 50% second seizure >12 months 30% second seizure Second – 50% chance of a third seizure Morbidity – theoretical only, no record of child dying from febrile seizure |
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Febrile Seizures
Diagnostic evaluation |
Laboratory tests
WBC, glucose, electrolytes Lumbar puncture Imaging Skull x-rays, CT and MRI EEG abnormal electrical discharges Depending on history and examination may have no testing! |
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Febrile seizures
medication management |
Antipyretics
Prophylactic antipyretics not recommended : -safety of antipyretics overdose, risk factors -tepid sponge baths cooling causes discomfort shivering metabolic activity Anticonvulsants Not recommended due to adverse and side effects 20-40% cognitive, lethargy, sleep and behavioral problems, allergic response |
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Febrile seizures
medical management for status epilepticus |
Prolonged seizure activity >5 minutes (status epilepticus)
Call 911 Rectal diazepam (Valium) Intranasal midazolam (Versed) One seizure > 30 minutes series of seizures does not regain typical state ABC of life support administering oxygen IV access Administration of IV anticonvulsants monitor for respiratory depression Diagnostics blood sugar level, electrolytes |
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home education of febrile seizure
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Home Care
Reassurance Safety Teaching prolonged seizure activity call 911 >5 minutes position child medication |
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Nursing management of febrile seizure in the hospital
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Hospital Care
Status epilepticus ABC of life support IV access IV medication (Ativan) lorazepam is preferred due to decreased risk of respiratory depression> (Valium) diazepam fosphenytoin high risk of apnea |
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Developmental issues of neurological dysfunction
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◦ Mobility and height
◦ Natural curiosity ◦ Incomplete motor coordination ◦ Young have a disproportionately larger head ◦ Immature neck muscles Shaken baby syndrome |
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Accidents
Head Injury |
Stationary brain sustains a blow
◦ Injury can be on opposite side of blow or at site of blow acceleration or deceleration ◦ Shearing forces tearing of small arteries causes brain hemorrhage |
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Head Injury
Concussion |
Most common head injury
older children from sports younger from falls Brain injury from a direct blow to the head. This can result in changes in brain function. Lasts minutes to hours, followed by: ◦ Amnesia and confusion about the injury and time after it ◦ Parents must monitor through the night ◦ Bleeding complications occur up to 48 hrs later |
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Concussion
Athletes |
Three times more likely to sustain a 2nd concussion in same season
‘Second Impact Syndrome’ ◦ Second concussion before complete recovery from first Acute brain swelling Cognitive impairment Death |
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Drowning
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◦ Death from asphyxia while submerged within 24 hours
35% of immersion accidents result in death in children 2nd leading cause of death from accidents aged 1-14-years Swimming, ability over-estimated, lack of supervision, life jacket, alcohol use Infants bathtubs and buckets, Ages 1-4 swimming pools Older >5 rivers and lakes (AAP.org) |
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Near Drowning
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◦ Survival for at least 24 hours after submersion
◦ 33% have neurological damage, 11% is severe Assessment Priority nursing intervention – resuscitation History of what happened, time submerged Fresh or salt water, cleanliness (infection) Warm or cold water Physical injuries ◦ Spinal cord (from diving in shallow water) ◦ Bruises |
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Near Drowning
Outcomes |
Complete recovery
Variable deficits Severe brain injury ◦ Abnormal brain function at 24 hrs poor prognosis Eventual death due to complications Best outcomes ◦ Under water < 5 minutes ◦ Resuscitated for < 10 minutes |
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National Drowning Statistics
2004 |
◦ 430 deaths unintentional drowning age 1-4 years
◦ 2nd leading cause of death ages 1-4 years after MVA Leading cause of death in Florida ages 1-4 years ◦ For every one drowning, ED cares for 4-6 near drown ◦ Miami-Dade ME Chart Review 2000-2006 Data, Age 0-4 Drowning ◦ 3/4 occurred in a swimming pool ◦ 2/3 occurred in their own home, with a parent supervising 1/3 occurred with non-parents supervising 2/3 were ages 1-2 years ◦ 20% reportedly out of sight less than 10 minutes ◦ Only 4% had adequate barriers ◦ CPR done for most, 40% done by EMS |
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Reye Syndrome
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Rare metabolic disorder (from acute VIRAL illness) causes encephalopathy
Elevated liver testing, elevated ammonia levels Associated with aspirin during viral illness ◦ Avoid aspirin in children!! ◦ Varicella vaccine to avoid chicken pox fever ◦ Yearly influenza vaccine to avoid fever from the flu |
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Spina Bifida
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Myelomeningocele
Neural tube defect associated with maternal vitamin B12 deficiency (folic acid) ◦ Also associated with maternal anti-epileptic drugs (AED) Malformation of the spinal cord and canal due to the vertebrae not developing and closing around the cord Spina bifida occulta bony defect only Meningocele -Only meninges protruding ◦ No paralysis, at risk for hydrocephalus, bladder dysfunction Myelomenigocele-Meninges and spinal cord protruding ◦ Paralysis, bladder, bowel dysfunction (Figure 43.3, p.;1429) ◦ Spina Bifida |
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Spina Bifida
Co-morbidities |
◦ Hydrocephalus
◦ Spinal curvatures ◦ Skin breakdown ◦ Latex allergy! (so many interventions at such a young age) ◦ Bladder and bowel dysfunction ◦ Renal involvement from urinary retention ◦ Sexual dysfunction |
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Spina Bifida
Diagnostic Tests |
Prenatal
◦ Maternal alpha-fetoprotein, U/S ◦ Amniocentesis Post natal ◦ U/S, MRI, CT of spinal column ◦ Bladder and bowel function evaluation ◦ Neurologic and motor function |
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◦ Spina Bifida
Pre-Operative Nursing Care |
Prevent infection
Prevent comorbidities In warmer, prone position without diaper Legs abducted, hips flexed to ¯ tension on sac Vaseline or sterile, wet gauze dressing on lesion Feed with head turned to side, prone or side lying Assess infection Daily head circumference No rectal temps, risk of rectal prolapse No latex |
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Spina Bifida
Post-Operative Nursing Care |
◦ Prone until wound heals, then sleep supine
◦ Gentle range of motion exercises ◦ Assess for infection or meningitis ◦ Daily head circumference Hydrocephalus, increased ICP risk Shunt care if one was placed ◦ Bowel and bladder program needed Catheterize q 3-4-hours ◦ Mobility assistance devices as child ages |
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Spina Bifida
Education |
Bladder/Bowel Issues
◦ Catheterization Self catheterization ◦ Signs and symptoms of urinary tract infection or pyelonephritis, kidney stones ◦ Prophylactic medications Bladder antispasmodics oxybutynin (Ditropan®) Stool softeners Hydrocephalus risk ◦ Signs of intracranial pressure Learning normal intelligence, hydrocephalus Psychological issues (J of Ped Psychology, 1997) Latex allergy medical equipment, personal use equipment (Spina Bifida Assn) Family planning ◦ Increased risk of another child with NTD ◦ Folic acid 400 mg/day |
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Hydrocephalus
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Imbalance in production and absorption of CSF which leads to increased CSF volume
◦ Congenital or acquired spina bifida, intraventricular hemorrhage in prematurity meningitis, brain tumors, and trauma |
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Hydrocephalus - communicating vs non-communicating
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◦ Communicating
Normal flow within ventricles but impaired absorption in the subarachnoid space and arachnoid villi Causes: Hemorrhage and intrauterine infection ◦ Non-communicating Obstruction impedes flow within ventricles Causes: Meningitis, spina bifida, Chiari malformation |
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Hydrocephalus - manifestations
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Increased in intracranial pressure Infants
Rapid in head circumference Bulging fontanel Frontal bossing Sunsetting of eyes Hyperreflexia Hypertonicity Shrill cry, poor feeding, emesis Sunset eyes Increased intra cranial pressure older children Headache and vomiting on arising (especially in the morning) Mental status or personality changes ◦ Poor judgment, apathy, memory loss, irritability Ataxia, motor changes, dizziness Blurred, double vision (diplopia) |
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Hydrocephalus
Clinical Therapy |
◦ Diuretics
◦ External ventricular Device temporary situation, infection, trauma, monitoring of intracranial pressure ◦ Ventricular peritoneal shunt permanent placement of catheter in ventricle to pass CSF to peritoneum or heart (VP or VA shunt) |
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VP Shunt
Post Operative Care |
HOB gradually after initially flat, to 30°
◦ To decrease too rapid CSF drainage Align body with towels, don’t stretch neck Passive ROM, turn frequently, every 2 hours position on non operative side |
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Hydrocephalus Family Education
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Signs of shunt malfunction
◦ ICP and infection (usually 1-2 months after surgery) Specialized car seats Rear facing car seat if poor head, even if older Avoid contact sports that present a head injury risk Appropriate, diligent helmet use Emergency plan of care for malfunction |
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Muscular Dystrophy
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Inherited disorder
x linked recessive or dominant 9 types-most in childhood, some in adulthood, Jerry’s Kids *Duchenne Muscular Dystrophy ALL marked with progressive muscular weakness - voluntary muscle - protein decrease or absence |
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Duchenne Muscular Dystrophy (DMD)
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Incidence 1/3,500
X linked recessive (mother passes to son) Specific protein is absence of dystrophin Proximal muscles, Fatal by twenties |
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Duchenne Muscular Dystrophy (DMD)
Testing |
Electromyography (EMG)
Muscle biopsy- definitive testing DNA testing |
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Duchenne Muscular Dystrophy (DMD)
medical management |
Corticosteroids
protective against specific protein deficiency Side effects of steroids Positioning devices, braces orthoses Complications cardiopulmonary system learning or behavioral concerns urinary concerns |
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Nursing assessment
Duchenne Muscular Dystrophy (DMD) |
Health History
family history pregnancy, birth and developmental history functional status, ADL/feeding need for ambulatory/mobility aids Review of systems psychosocial needs |
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Inspection
Duchenne Muscular Dystrophy (DMD) |
Motor delay/disturbance Gowers Sign (illustrated in book, lift up from the floor)
gait abnormalities; balance concerns -lordosis, wide balance, waddling -stair climbing -wheelchair between age 7-12 scoliosis Auscultation heart and lungs tachycardia, breath sounds Palpation muscle strength against resistance, muscle atrophy Gower’s Sign |
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Duchenne Muscular Dystrophy (DMD)
Nursing management |
Promote mobility
Calcium supplements, weight bearing hand and foot bracing scheduling activities parental education Maintain cardiopulmonary function assessment, positioning, deep breathing, cough progress to positive pressure ventilation Altered family processes Parental depression, self esteem (J of Pediatric Neurology July, 2004) developmentally appropriate activities school, diversional activities, camps, Special Olympics, Camp Boggy Creek |
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Cerebral Palsy
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Abnormal development of or damage to motor areas of the brain (Kyle and Ricci, 2009)
Brains inability to control movement and posture. Results in coordination problems Non progressive |
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Causes of Cerebral Palsy
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No one known cause, multiple associated factors
malformation of the brain, strokes, hemorrhages, anoxia Intrauterine infections premature birth low birth weight babies congenital or genetic malformations shaken baby syndrome anoxia during birth process 70% occur before child is even born |
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Health History
Cerebral Palsy |
Prenatal History
Mothers health during pregnancy Labor and delivery Condition immediately after birth intraventricular hemorrhage |
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Developmental History
Cerebral Palsy |
Delayed gross motor development
History of feeding problems Abnormal motor performance early hand preference persistence in primitive reflexes asymmetric crawl ‘bunny hopping’ head lag difficulty with diapering |
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Physical Evaluation
Cerebral Palsy |
Hypertonicity
Reflexes p. 772-774 Moro Scissoring Deep tendon reflexes (Asymmetric)Tonic neck |
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Cerebral Palsy diagnostics
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MRI
hearing/vision testing EEG Growth Weight gain patterns Birth to 6 months - 5-7 oz wk; double (normal) 6-12 months (normal) -3-5 oz wk; triples (normal) Typically shorter in height, lighter in weight Asymmetric Tonic Neck Reflex Moro reflex Typically symmetric reflex Disappears by 4 months |
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Cerebral Palsy Types
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Cerebral Palsy Types
Spastic 75% cerebral cortex one or both sides; hemi, di, quadriplegia Dyskinetic/Athetoid 15% basal ganglia purposeless, involuntary movement Ataxic 5% cerebellum coordination, equilibrium Mixed 5% spastic and athetosis Spastic type cerebral palsy Diplegia lower extremities involved, upper body normal Quadriplegia all extremities involved equally Hemiplegia one side involved, upper>lower Other manifestations |
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other manifestations of Cerebral Palsy
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Visual and hearing deficits
strabismus = muscle weakness of one or both homonymous hemianopsia (look up) Oral motor, feeding Developmental delay Mental retardation >quadriplegia <hemiplegia 60% normal intelligence Seizures 16-94% >spastic quadriplegia, hemiplegia <dyskinesia, ataxia |
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Nursing Care Plans for Cerebral Palsy
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Impaired physical mobility
Risk for infection Imbalanced nutrition Risk for injury Impaired physical mobility Provide incentives to move Assist reciprocal leg motion Inspect orthopedic equipment Inspection for scoliosis 5-65% |
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Interventions for impaired physical mobility in Cerebral Palsy
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Antispasmotics
Baclofen intrathecal or oral -pain -maintenance of ambulation |
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Cerebral Palsy
increased risk for: |
Complications of pump
-infection of pump , dislodgement blockage of catheter Risk for infection Urinary tract infections related to incomplete bladder emptying, fluid restriction and infrequent voiding -assist child to void frequently (q2h) -encourage fluid intake -encourage developmental toilet training -assist with specialized devices to be able to use toilet, restraint on chair Pneumonia -respiratory assessment RR, HR, temp, work of breathing, cough - ensure all vaccines given HIB PCV-7 annual flu, risk vaccines PPSV-23, meningococcal Imbalanced nutrition Implement specialized feeding techniques -manual jaw control anterior and side -spoon placement Use of specialized growth charts segmental measurements and body fat analysis High calorie, high quality food and snacks Supplemental or solely enteral feedings Risk for injury Padded furniture, no sharp edges Side rails on bed to prevent falls Sturdy furniture that does not slip to prevent falls Avoid throw rugs Safety restraints when sitting Encourage head helmet use for high fall risk Encourage use of ambulatory aids ie, crutches, walkers |
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Mental retardation
page 1703-04 text |
Impairment
-intellectual reasoning standardized tests ie IQ -functional strengths and weaknesses -skills necessary to mature to independent status -communication, self care, home living, health and safety, academics and work life -before age 18, begins in childhood |
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Classification of Mental Retardation
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Above 75 Normal
50-75 Mild, mental age of 8-12 years as an adult 35-50 Moderate, mental age of 3-7 years as an adult 20-35 Severe, mental age of toddler as an adult Below 20 Profound, mental age of young infant as an adult |
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Mental Retardation - Nursing assessment
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Identify with developmental screening
Health history, emphasis on pregnancy, birth history mental and adaptive abilities of child and parents sequence and age of developmental milestones associated orthopedic or sensory problems Self care deficits Early intervention programs for children with disabilities -Public Law 101-476 Birth to 21 years includes therapy and nursing services in Central Fl 0-3 services Orlando Health 3-21 public school system Task analysis breaking down a skill into multiple smaller steps Motivation use of technology as a reward Signs of readiness Interrupted family processes Individualized Family Service Plan Demonstrate acceptance of child through own behavior child first Encourage family support groups Encourage family to express thoughts and concerns Care for the child with mental retardation during hospitalization Recognize insecurity Plan for child’s care together with parents Detailed history of strengths and needs Procedures explained through appropriate cognitive level Assist in expanding the child’s self care skills |
