Exam 3 Flashcards
Physical Cues of Cerebral Palsy
Nonprogressive impairment of motor function, especially muscle control, coordination and posture
Can cause abnormal perception and sensation, visual, hearing and speech impairments; Seizures and Cognitive disabilities
Exact cause is unknown; associated with several prenatal, perinatal and postnatal factors with the majority of causes (80%) occurring before delivery
6 Cerebral Palsy Priority Care
Oxygenation/Ventilation – positioning, suctioning, incentive spirometry, aspiration prevention
Pain management – management of muscle spasms
Adequate nutrition – oral & enteral (tailored to ability), monitor ht & wt. Can use Baclofen, botulinum toxin A (botox), and carbidopa
Skin care – repositioning, monitoring skin under splints/braces
Communication – electronic devices, picture boards, touch screen computers
Psychosocial – promote independence & positive self-image; support family
Developmental – monitor developmental milestones, interact based on developmental level rather than chronological age
5 Complication of Cerebral Palsy
Complications:
Seizures
Delayed G&D
Hydrocephalus
Aspiration
Injury r/t limited mobility
Cues of Muscular Dystrophy
Absence of dystrophin that causes progressive weakness of voluntary muscle of hips, thighs, pelvis, and shoulders initially
+ Gower’s sign
3 Lab/Diagnostics of Muscular Dystrophy
Electromyography (EMG): reveals nerve/muscle dysfunction
Muscle BX: Definitive DX showing absence of dystrophin
DNA Testing: Positive for dystrophin gene mutation
Nursing Priorities of Muscular Dystrophy
Primary goal is to promote mobility, maintain cardiopulmonary function, prevent complications, and maximize quality of life
Optimize physical function – ROM, strength & muscle training
Oxygenation/Ventilation – breathing exercises, suctioning, O2, cough devices, Assess WOB
Adequate Nutrition – low calorie, high protein & fiber
Skin Care – repositioning, monitoring
Psychosocial – support groups, respite care/palliative, End-of-life care
Cues of Dysplasia of the Hip
Incomplete dislocation of the hip with intact femoral head
Asymmetry of gluteal folds in prone position
Unequal number of skin folds on posterior thigh
Shorter affected limb, walk with limp (older child)
Priority Care/assessment of Dysplasia of Hip
Neurovascular assessment
Skin care
Parent teaching
Parent teaching of Pavlik Harness
Do not take off and adjustment by provider only 24/7 for a week or longer
Skin care
Cues of Scoliosis
Lateral curvature of the spine exceeding 10° and spinal rotation that causes rib asymmetry, idiopathic being the most common cause
Asymmetry in shoulder height, prominence of one scapula, uneven curve of waistline, or rib hump on one side
Management of Scoliosis
Moderate curves (25-45°) usually treated with thoracolumbosacral (TLSO) bracing and exercise
Surgical Intervention if curve >45° or progresses despite bracing or if cardiac/respiratory compromise
Scoliosis Post-Op Care
Frequent NV assessment of extremities with VS; TC&DB; Hemovac; Foley care; PRBCs (severe blood loss anticipated)
Log-rolling only to prevent damage to hardware
Pre-medicate for pain prior to moving, and slow ambulation to avoid orthostasis; PCA pump
Operative site assessment
What is Meningocele?
Less serious form of spina bifida cystica (only has CSF in sac)
Visible defect with saclike protrusion of meninges through defect in vertebrae
Usually minor or no neurological deficits
Requires surgical correction
Priority care of Meningocele (Sac Care)
Surgery can be delayed if normal neurological function and sac intact
Report any leakage -> infection
Prone positioning
Monitor head circumference(↑ICP)
What is Myelomeningocele?
Most serious form of spina bifida cystica (sac contains CSF, nerves leading to degrees of neuromuscular, limb, and sensory deficits)
Nursing Action for Myelomeningocele
NS moistened dressings to keep sac moist
Report leaking of sac
Prone position
Avoid swaddling and blankets (keep in isolette/warmer)
Atraumatic care
Avoid Latex and post-op contamination from pee and poo
Result most frequently from accidental trauma and are the
2nd most common injury in child physical abuse
Fractures
What are the neural assessment for fractures?
Sensation
Skin temperature
Skin color
Spontaneous movement
Capillary refill
Pulses
***It is similar to the 5 Ps (pain, paresthesia, pulselessness, pallor, and paralysis)
What are the complications of fractures?
Compartment syndrome (5Ps) and osteomyelitis (irritability, fever, tachy, edema, constant pain, and tenderness )
What are the nursing priorities of care for fractures?
Promote & monitor tissue perfusion – NV assessment on a regular schedule; skin assessment
Pain management – use age-appropriate pain tool; provide both pharmacological & nonpharmacological interventions
Infection prevention & monitoring
Promote mobility – proper alignment; ROM of fingers, toes & unaffected extremities
Pt/family support & education – activity restrictions; cast application & care; proper crutch use; signs to report
What is hydrocephalus?
Not a specific brain disorder but caused by an underlying condition
Accumulation of excessive CSF within the cerebral ventricles and/or subarachnoid spaces = ventricular dilation & IICP
Prognosis depends on cause and whether brain damage has occurred
Increased risk for developmental disabilities, visual problems, abnormalities in memory, and reduced intelligence
What are physical Cues of hydrocephalus?
They are the same as increased ICP
S/S vary by age
◘Baby: bulging fontanelles, sunken eyes, prominent sutures
◘Older children: HA (headache)
Common Signs: irritability, lethargy, poor feeding, vomiting, complaint of HA (older children), altered, diminished, or change in LOC
Physical: Wide, open, bulging fontanels; Large head or recent change in HC; Thin, shiny scalp w/ prominent, visible scalp veins; Sun-set eyes; Seizures
What is the most common complication of VP shunts?
Most common complication of blockage/obstruction and infection
What is VP shunt used for?
Therapeutic management of hydrocephalus
What are the s/s cues of VP blockage/obstruction?
Increased ICP
Vomiting, drowsiness, and HA typically r/t shunt malfunction
What to do for a Shunt infection?
Shunt infection treated with IV antibiotics; if persistent, shunt is removed and external ventricular drain (EVD) placed until CSF is sterile
When do most shunt infection happen?
Shunt infection most common 1-2 months after placement (can occur any time as well)
Early Sign of Increased ICP
HA
Vomiting, possibly projectile
Blurred vision, double vision (diplopia)
Dizziness
Decreased pulse and respiration
Late signs of increase ICP
Lowered LOC
Decreased motor and sensory response
Bradycardia
Irregular respiration (cheyne-strokes respiration)
Decerebrate or decorticate posturing
Fixed and dilated pupils
What characterizes Cushing Triad
Irregular breathing
HTN
Bradycardia
Intervention to decrease ICP
Head midline with 30° on bed
Decrease stimuli
Avoid suctioning/blowing nose/coughing
Use stool softeners
Fever management
ICP monitoring
Careful fluid regulation (I/Os)
Sedation and analgesia
Mannitol or hypertonic saline
Seizure treatment/prophylaxis
Labs for Bacterial Meningitis
Increased WBCs and Protein
Decrease Glucose
Cloudy in color
Sudden s/s onset of meningitis
HX of URI or sore throat
Fever, chills, HA, vomiting
Photophobia
Stiff neck
Rash
Irritability, drowsiness, lethargy
Muscle rigidity or SZ
Bacterial Meningitis Management
PICU admission with strict droplet precaution until 24H of antibiotics
IV broad-spectrum antibiotic after all CXs
Measures to reduce ICP
What are S/S of Reye syndrome
Severe and persistent vomiting, lethargy, positive Babinski, sluggish pupils, and hepatomegaly
Priorities of Care for Reye syndrome
Measures decrease ICP
Supportive care for the sequalae r/t to liver failure
Reye Syndrome Management
Hyperammonemia may be treated with Lactulose (osmotic laxative) but may require hemodialysis if level greater than 500mcg/dl.
Coagulopathy may be treated (especially before invasive procedures or with clinically significant bleeding) using fresh frozen plasma (FFP) or Vit.K.
Hypoglycemia may be treated with dextrose-containing fluids (D50, D10, D5) with a serum glucose goal of 100-120mg/dl.
What to do during a seizure?
Protection from injurie, do not attempt to restrain; loosen restrictive clothing
Patent airway - position, oral suction, O2 and side-lying
Do not attempt to open jaw or insert airway
Stay with the patient
What to do after a Seizure
Maintain side-lying position
Monitor breathing/VS/ head position, tongue
Assess for injuries (head, tongue, body)
Neuro checks
Swallow reflex before food/fluid
Seizure precations
Padding of side rails and other hard objects
Side rails raised on bed at all times when child is in bed
Oxygen and suction at bedside
Supervision, especially during bathing, ambulation, or other potentially hazardous activities
Bracelet
Febrile Seizures
Most common type of seizure in children <5 and peak incidence between 12-18 months
SZ lasting 15-20 seconds once in a 24 hr period
Brief postictal period
Tonic-clonic seizure
Most common of all seizure types
Starts with phase where body & limbs stiffen; piercing cry & loss of swallowing reflex to phase with violent jerking of body; incontinence
Long postictal period
Absence seizures
Motionless, blank stare with minimal change in behavior; resembles daydreaming
SZ lasting 5-10 seconds; may lip smack or twitch eyelids/face
Immediately resumes previous activities/no postictal period
Seizure Management
Phenytoin (IV and PO; IM is contraindicated)
Fosphenytoin (IM or IV only)
Phenytoin Vs Fosphenytoin
Phenytoin can be administered PO/IV and Fos can be administed IV/IM
Phenytoin has more adverse effect (gingival hyperplasia, etc), you also need to monitor for adequate intake of Vit D, mg, calcium, folate, and vitamin B levels
Phenytoin HAS TO BE GIVEN WITH NORMAL SALINE
Fosphenytoin does not cause local irritation, but is more expensive drug. faster and easire administration and does not precipitate
Lab/diagnostics for Seizures
Glucose, Electrolytes, Ca+: Rule out ↓ BS and ↓ Ca+
LP: Rule out meningitis or encephalitis
Skull XR: Rule out FX or trauma
CT/MRI: Identify abnormality, bleeds, tumors
EEG: Evaluate SZ type; “normal” does not rule out epilepsy
Video EEG: Evaluate behavior and “catch a SZ” (Requires admission to hospital)
Decerebrate
Rigid Extension
Damage to brainstem and extrapyramidal tracts = rigid extension and pronation of arms/legs, flexed wrists and fingers, clenched jaw, extended neck, and possibly arched back
Decorticate
Rigid Flexion
Damage to cerebral cortex or lesion to corticospinal tracts above brainstem = rigid flexion of arms held tightly to body, flexed elbows/wrists/fingers, plantar flexed feet, legs extended and internally rotated, and possibly fine tremors or intense stiffness
Opisthotonos
Abnormal posturing caused by muscle spasms due to immature nervous
Pupils Indication
Pinpoint: poison, brainstem dysfunction, and opiate use
Dilated (reactive): after seizures
Dilated (fixed): brain stem herniation increased ICP
Anisocoria: naturally different sized pupils
Sunset eyes: increased ICP/hydrocephalus
Unilateral sudden dilation: intracranial mass
Level of Consciousness
Full consciousness (AxOx4, playful)
Confusion: disorientation, may not respond appropriately to questions
Obtunded: limited responses and fall asleep unless stimulated
Stupor: response to vigorous stimulation
Coma: cannot be aroused, even with painful stimuli
What are physical cues of a child with Growth Hormone Deficiency?
Large/prominent forehead; under-developed jaw
High-pitched voice
Delayed sexual maturation
Delayed dentition/skeletal maturation
Decreased muscle mass
How is Growth Hormone Deficiency Diagnosed?
Skeletal Survey: 2+ SD < normal in bone age
CT/MRI: Rule out tumors/other abnormalities
Pituitary Function Test to confirm
Growth Chart deviations
How is it treated?
SOMATROPIN
SUBQUTANEOUS
GIVEN DAILY
0.18-0.30 mEQL/Kg/Wk
Physical Cues of Congenital Hypothyroidism
Poor sucking, hypothermia, constipation, lethargy, hypotonia, periorbital puffiness, cool/dry/scaly skiing, bradycardia, RR distress, large fontanelles and delayed closures
Macroglossia and coarse facial features
Medication for Hypothyroidism? Medication management and teaching?
Thyroid hormone replacement (Levothyroxine)
Mush be crushed
Never use in whole bottle of feeding
Give in a small amount of formula
Medication absorption is affected by soy-based formulas, fiver, calcium, iron preparation, and antacids
Reduce L-thyroxine effects
Missed doses may lead to developmental delay/poor growth
Diagnosis/Labs for Congenital Hypothyroidism
Thyroid function test done at 2 nd day of life
Free T4: 0.8-2.4 ng/dL
TSH: 0-10 mu/L
T4 low and TSH high
Teaching for Levothyroxine
If untreated can cause intellectual disability, delayed physical maturation, short stature, and growth failure
Medication education
What is Diabetic Ketoacidosis?
An acute life-threatening condition characterized by glucosuria & breakdown of body fat for energy.
What are expected Lab findings for DKA?
Main ones: Hyperkalemia, Metabolic Acidosis, Glucosuria, Ketonuria
Blood glucose > 300
Decrease serum bicarb
Acidic pH
Increased creatine
decrease sodium
increased potassium
increase hemo-A1c
increased WBC
Urinalysis (+ketones)
KDA management
PICU admission
Hourly blood glucose monitoring to prevent BS falling more than 100 mg/dL/hr (can cause cerebral edema)
IVFs to treat dehydration, correct Na+ and K+, and improve peripheral perfusion
IV regular insulin via titrated infusion based on protocol sliding scale
DM diagnostics
BS >200 mg/dL
Fasting Glucose (>126 mg/dL)
Oral GTT (>200 mg/dL at 2 hrs)
HgbA1C: >6.5%
DM Labs
Chem Panel: Evaluate BUN/Creatinine, Ca+, Mg+, PO4-, Na+, K
CBC; UA
C-Peptide: After glucose challenge to verify endogenous insulin secretion
Hypoglycemia management
If child coherent: feels S/S of hypoglycemia and glucose monitor shows low BS:
-Give glucose paste/tablets or 10-15 g of simple carbohydrate (OJ or milk); Followed with complex carbohydrates (peanut butter and crackers) to maintain glucose level
If incoherent: Glucagon Sub-Q or IM:
Under 20kg - give 0.5mg
Over 20kg - give 1mg
D50: IV PRN
Down Syndrome (Trisomy 21) Complications
1 PREVENTING COMPLICATIONS
Aspiration: (Due to small mouth, large tongue, poor suck/tone, increased nasal stuffiness
-Use of bulb syringe & humidification
-Chin/neck support
Hypothyroidism: Thyroid testing at 6 months, 12 months, then annually
Atlantoaxial instability: Cervical XR at age 3-5 yr to screen: Report changes in gait or continence or weakness in head, neck
Cardiopulmonary issues
Hearing/Vision Impairments: screen regularly (cataract, OM)
How to promote nutrition for trisomy 21 patients
Plot length, weight, head circumference on Down Syndrome growth charts only; grow more slowly
FTT: Poor suck/tone, nasal stuffiness, cardiac issues
-Altered feeding positions
Monitor GI conditions (celiac disease, constipation, Hirschsprung disease, imperforate anus)
Routine dental care every six months and daily teeth brushing
Regular diet and exercise
Name insulins and their generic names
Rapid acting
