Exam 3 Flashcards
Mannitol
Preferred diuretic for increased ICP
Mannitol What it does
Osmotic diuretic for ICP, decreased ICP
Works quickly, lasts longer,
*Does NOT affect sodium levels compared to other diuretic
Mannitol Nursing considerations
Administered intravenously is the drug most frequently used for rapid reduction.
The infusion is generally given slowly but may be pushed rapidly in cases of herniation or impending herniation
Digoxin
Improves cardiac function in heart failure patients
Digoxin What it does
Improves contractility Increases CO Decreased heart size Decreased venous pressure Relief of edema Rapid onset
Digoxin Side effects
Dysrhythmias
Toxicity: narrow therapeutic range
Note: a ↓ serum K+ increases the risk for Digoxin toxicity
Dig toxicity signs: N/V Anorexia Bradycardia Dysrhythmias Blurred vision Weakness Yellow halos
Digoxin Nursing considerations
Check K+ levels **Check apical pulse!!!!** Hold if < 90-110 for infants Hold if <70 for children Check dig levels!
Infants rarely receive > 1 mL in one dose
Lasix
Common diuretic used in heart failure pediatric patients
Lasix What it does
Removes accumulated fluid and sodium associated with heart failure.
Works in loop of henle
Lasik Side effects
Hypokalemia (not potassium sparing!)
Lasik Nursing Considerations
Check K+ levels. Be careful because Digoxin and Lasix are commonly used together in HF.
Low K+ can cause Dig toxicity.
Baclofen
Muscle relaxant for cerebral palsy patients
Baclofen What it does
Centrally acting skeletal muscle relaxant
Decreased hypertonia; decreases spasm and spasticit
Baclofen Side effects
Drowsiness and confusion
““The most common side effects of these agents include drowsiness, fatigue, and muscle weakness; less commonly, central nervous system (CNS) depression, hypotension, diaphoresis, and constipation may be seen with baclofen”
Midazolam
Treatment for febrile seizure
Midazolam Side effects
More than 2 doses can cause resp. depression
Midazolam Nursing Consideration
Commonly administered buccally or intranasally
VSD Pathophysiology
- abnormal opening between right and left ventricles
- membranous (80%) or muscular
- left to right shunt
- increased blood volume to lungs
VSD Clinical Presentation (Manifestations):
- HF Common
- loud holosystolic murmur LSB
- increased risk for pulmonary vascular obstructive disease
VSD Management/Surgical Treatment:
palliative: PA band
- complete repair:
- small: closed with suture
- large: Dacron patch
Prognosis Depends on:
- location of defect - number of defects - other associated defects
PDA (Patent Ductus Arteriosus) Pathophysiology:
- Failure of fetal Ductus Arteriosus to close
- Blood flows from high pressure aorta to lower pressure pulmonary artery
- Left to right shunt
- Increase workload on Left side of heart
- Increase pulmonary congestion
- May cause increase in right ventricle pressure and hypertrophy
PDA Clinical Presentation:
- HF
- Machine like murmur
- Widening pulse pressure
- Bounding Pulses
- Crackles, SOB
PDA Treatment:
- Medical: Administer Indomethacin
- Surgical: Ligation of patent vessel
- Coils used to occlude PDA
- Low risk: increased in preterm infants
Role of Prostaglandin E
- Patent ductus arteriosus, give indomethacin which blocks Prostaglandin E, which is how PDA closes.
- Prostaglandin E keeps the duct open! Defect that keeps producing Prostaglandin E.
Increased pulmonary blood flow:
VSD
PDA
Decreased Pulmonary blood flow:
Tetralogy of fallot
Obstruction of blood flow from the heart:
COA (Coarctation of the Aorta)
Ventricular Septal Defects (VSD) Patho
Abnormal opening between R & L ventricles
L → R shunt
Blood flows from higher pressure L. vent to lower pressure R. vent
Increased blood to lungs
increased blood flow to lungs
Ventricular Septal Defects (VSD) Manifestations
HF
Loud holosystolic murmur (blood is flowing through hole that should not be there)
↑ risk pulmonary vascular disease
Ventricular Septal Defects (VSD) Treatment
Medical management initially
Surgical closure if past one year of age
Palliative: PA band (↓ pulmonary blood flow)
Complete repair: if small close w/ suture, if large dacron patch
Patent Ductus Arteriosus (PDA) Patho
Failure of fetal Ductus Arteriosus to close
L → R shunt
Blood flows from high pressure aorta to lower pressure pulmonary artery
*causes HIGH pulmonary blood flow, LOW systemic blood flow
Patent Ductus Arteriosus (PDA) Manifestations
HF
Machine like murmur
Bounding pulses
Widened pulse pressure
Patent Ductus Arteriosus (PDA) Nursing Management/Treatment
Nursing Management:
Administer Indomethacin for PDA repair (blocks prostaglandin E)
Treatment:
Surgical -Ligation of patent vessel (thoracotomy/through thorascope)
Nonsurgical- Coils used to occlude PDA
Coarctation of the Aorta (COA) Patho
Localized narrowing near insertion of the Ductus Arteriosus
↑ Pressure proximal to defect (Head & Upper extremities)
↓ Pressure distal to obstruction (Lower extremities)
Coarctation of the Aorta (COA) Manifestations
HF in infants → deteriorate fast (acidosis & hypotension)
↑ BP & weak pulses in legs/feet
↓ BP & bounding pulses in arms
Older Children:
Dizziness, headaches, fainting spells, epistaxis
Coarctation of the Aorta (COA) Treatment
Treatment:
Surgical for < 6 month old:
-End to end anastomosis
-Graft prosthetic
Nonsurgical:
- Balloon angioplasty
- Post-op HTN is treated with Nipride esmolol or Milirinone
- Oral: ACE inhibitors or Beta blockers
Tetralogy of Fallot Patho
4 Defects:
- Pulmonary Stenosis
- Right Ventricular Hypertrophy
- Overriding Aorta
- Ventricular Septal Defect
Normal O2 sat is ~80%
Tetralogy of Fallot Manifestations
Mild - severe cyanosis
Systolic murmur
Hypercyanotic Tet Spells (acute episodes of cyanosis & hypoxia) - KNEES TO CHEST POSITION
*happens usually during crying or after feeding
Polycythemia: due to deoxygenated blood being in the systemic circulation resulting in a need for increased RBCs (thick blood)
Tetralogy of Fallot Nursing Management/Treatment
Nursing Management of Tet Spells: Knee-chest position O2 Morphine IV fluid bolus
Treatment for TOF:
Palliative shunt (Modified Blalock-Taussig Shunt)
Complete repair
Prenatal risk factors of CHD
Maternal: chronic illness, ETOH consumption, exposure to environmental toxins, infections, family hx of CHD
Child Risk Factors:
Chromosomal abnormalities
Down Syndrome: Trisomy 21 (AV Canal)
Trisomy 13 & Trisomy 18
DiGeorge Syndrome: 22q11 deletion (interrupted Aortic Arch, Truncus Arteriosus, Tetralogy of Fallot, VSD)
Noonan Syndrome: Pulmonic valve anomalies, cardiomyopathy
Williams Syndrome: Aortic & pulmonic stenosis
Extracardiac defects
Renal abnormalities: TE fistula, diaphragmatic hernia
intrauterine to postnatal circulation
- The right and left side of the heart have equal pressure until the transition to postnatal, when the Left side has more pressure.
- Ductus Venosus and Ductus Arteriosus go away
- Foramen Ovale closes
- Pulmonary Vascular resistance goes down and Systemic Vascular resistance goes up
Tet spell Interventions
-R vent is spasmism. Not pushing out blood. Push blood to it
- knee to chest. Increases blood flow to heart and lungs.
- Admin O2
- Admin Morphine (vasodilator; helps relieve the spasm)
- Fluid bolus. To increase vascular volume. Give slowly to avoid overwhelming heart.
Bacterial Meningitis S/S Children & Adolescents
- Abrupt onset
- Fever
- Chills
- Headache
- Seizures
- Irritability
- Nuchal rigidity (can’t extend neck to chest)
- Kernig (inability to straighten leg/ hamstring tightness causes spinal cord stretching)
- Brudzinski signs (neck stiffness w/ lower knee movement to stretch spine)
- Petechial or purpuric rashes (non-blanching)
- Agitatio
Bacterial Meningitis S/S Infants & Young Children
- Classic presentation rarely occurs in children 3-2 years
- Fever - if baby shows up in hospital with fever will get sepsis workup → lumbar puncture, blood, urine, stool cultures, CBC, CMP → start on broad spectrum ABX (Gent & Amp) and usually more than one
- Poor feeding
- Marked irritability
- Seizures
- High pitched cry
- Bulging fontanel
Bacterial Meningitis S/S Neonates
- at greater risk due to not having their vaccines yet
- Look well at birth and then begin to look & act poorly
- Refuses feedings
- Poor sucking
- Vomiting or diarrhea
- Poor tone
- Lack of movement
- Weak cry
- Full, tense, bulging, fontanel
Viral Meningitis S/S & Treatment
- May be preceded with viral infection, rash
- Diagnostics: LP, CSF eval (mildly elevated WBC, negative gram stain, normal glucose)
Treatment: self-limiting, resolves in 7-14 days, monitor in hospital until ABC’s are stable
Medications: antivirals (Acyclovir)
Not contagious
Bacterial Meningitis plan of care
- Protect self
- Place on C/D precautions for both until it is known what type
- Assess V/S and behavior
- Antibiotics
- Monitor lab values
- Strict I&O’s
- Monitor fontanels and head circumference as applicable (up to 3 years of age)
- Bedrest: do not flex neck
- Comforting: they are very irritable
Bacterial Meningitis Nursing interventions
*Protect self first
Diagnostics: LP, CSF eval (increase WBCs, gram stain +, increase protein, decrease in glucose)
Treatment: ABCDs, cerebral edema, seizure control, antibiotics, steroids
Contagious – contact droplet isolation at least 24 hrs after initiation of ABX
Prevention: Vaccination (HiB & Pneumococcal at 2, 4, 6, and 12 mos)
Infants/Neonates at GREATEST risk
lumbar puncture plan of care
Pain/ Fear: Sedate with fentanyl/ versed
Know your ICP: Brain could herniate in skull if LP is done with high ICP (ask for CT scan first)
Advocate for your patient
*if ICP suspected than a lumbar puncture is contraindicated
prolonged seizures medications
Benzodiazepines:
IV lorazepam
Diazepam
Midazolam
Haemophilus influenzae type B (HIB)
(2,4,6,12 months)
-H influenzae causes meningitis in kids
Pneumococcal conjugate vaccine- PCV13
(2,4,6,12 months)
-Protects against pneumococcal meningitis
Meningococcal polysaccharide vaccine - Menactra
(for older kids)
11-13 and 16 y/o
Increased ICP S/S Infants:
- Tense bulging fontanel
- Wide sutures
- MacEwen sign (palpation of skull, feels like cracked pot)
- Dilated scalp veins (blood trying to go places)
- High pitched cry
- Irritability or restlessness
- Poor feeding (obtunded, don’t wanna eat)
- Increase in head circumference
Increased ICP S/S Children:
- Headache (holding head may be a cue)
- Nausea and forceful vomiting
- Blurred vision (watch for them walking funny)
- Seizures
- Lethargy
- Inability to follow simple commands
- Increased sleeping, altered LOC
Late Signs of Increased ICP:
-Bradycardia
-Decreased motor response to commands
-Decreased sensory response to painful stimuli
-Alterations in pupil size and reactivity
-Change in resp pattern (Cheyne-Stokes respirations)
(irregular apneic episodes; fast, shallow, ineffective breathing that blows off Co2, following by apnea or extremely slow, heavy breathing) -D/t dysregulated breathing center d/t high ICP.
-Papilledema
-Sunset eyes (setting sun sign)
-Decreased or change in LOC
-Extension or flexion posturing
-Decorticate: flexed, holding onto cord
-Decerebrate, extending
Cushing’s Triad
Increased BP
Decreased HR
Decreased RR
*Treat with mannitol
Hydrocephalus S/S
- Enlargement of skull
- Dilation of ventricles
- Separation of sagittal sutures in < 12 years of age
- Developmental defects
- Chiari malformation
- Aqueduct stenosis (clog in the drain that drains the ventricles)
- Dandy-Walker syndrome
- Myelomeningocele
- Intrauterine infection
- Intraventricular hemorrhage
- Intracranial masses or infections in older children
Hydrocephalus Treatment:
Ventriculoperitoneal Shunt Ventricular catheter Flush pump Unidirectional flow valve Distal catheter
Hydrocephalus Infections
- Highest risk within the first 6 months after placement
- Sepsis
- Bacterial endocarditis
- Shunt nephritis
- Meningitis
- Ventriculitis
- Wound infection
*Treat with antibiotics for 7-10 days IV or intrathecally. May need removal and placement of an EVD until CSF is stable
Meningitis Bacterial Manifestations
WBC count: ↑ with ↑ polys Protein Count: increased Glucose Content: ↓ Decreased Gram Stain: Culture Positive Color: Cloudy/ Purulent
Meningitis Viral Manifestations
WBC count: Slightly ↑ with ↑ lymphs Protein Count: Normal or slightly elevated Glucose Content: Normal Gram Stain: Culture Negative Color: Clear
Febrile Seizures
- Seizure activity related to fever (above 38.8’C or 101.8’F) - due to rapid temperature elevation
- Uniquely pediatrics - between 6months and 5 years. 6 or 7 y/o cannot develop febrile seizures.
- Usually not chronic condition
- ⅓ will have another seizure associated w/ fever
- 1% will develop epilepsy
- Associated infections: otitis media, pharyngitis, adenitis, UTI
- No negative outcome from these seizures related to intelligence, behavior, academic performance → NO long lasting effects
- If febrile seizure lasts > 5 minutes, call 911
- Give acetaminophen PRN
- Antiepileptic medications are NOT indicated
- Antipyretic therapies will not prevent a seizure → treats fever as a symptom (what infections could cause a fever? UTI, ear, pneumonia, strep)
- Tepid sponge baths are NOT recommended
Head Trauma Subsequent complications
Hypoxia from brain damage
Increased ICP
Infection
Cerebral edema
Linear Skull Fracture
- Single fracture line
- Does not cross suture line
Depressed Skull Fracture
- Several irregular fragments
- Pushed inward
Comminuted Skull Fracture
- Multiple linear fractures
- May suggest child abuse
Basilar Skull Fracture
- Bones at base of skull
- posterior and anterior region
- Serious do to proximity to brainstem
Open Skull Fracture
-Communication between skull and scalp
Growing Skull Fracture
Associated with underlying dura tear that does not heal properly
Statistic CP:
Pyramidal (hypertonicity, posture, balance)
Most common form of CP (77%)
Damage to cortical motor areas of the brain
Spastic Hemiplegia: affecting only one side of the body
Spastic Monoplegia: affecting only 1 limb
Spastic Diplegia: affecting all extremities
Spastic Quadriplegia or Tetraplegia: affecting all extremities as well as torso and face
Hypertonia
Contractures
Dyskinetic CP:
Extrapyramidal (movement disorder) Two subtypes: Athetoid/ Dystonic Injury to basal ganglia Affects 11-15% Slow, involuntary movements of extremities Speech and language disorders Can have increased and decreased muscle tone
Ataxic CP:
Injury to cerebellum 5-10% of cases Weakness Lack of coordination Decreased muscle tone Difficulty with fine motor skills Wide-based gait
Mixed Type CP:
Combination of spastic and dyskinetic types
Often have ataxia
Spastic Ataxic Diplegia is a common mixed type/ Often associated with hydrocephalus
Developmental Milestones
Delayed gross motor development Abnormal motor performance Alterations in muscle tone Abnormal postures Reflex abnormalities
Baclofen CP
- centrally acting skeletal muscle relaxant
- Decreases spasms and spasticity
- Can cause diaphoresis and/or constipation
Diazepam: CP
- skeletal muscle relaxant
- Decreases muscle spasms and spasticity
Botulinum toxin A: CP
- blocks nerve activity in muscles
- Causes a temporary reduction in muscle activity and reduces spasticity for specific muscle groups
