neurosensory & neuromuscular Flashcards
What are the general manifestations of meningitis?
photophobia
nausea
headache
What are the manifestations of meningitis in a newborn?
No illness present at birth; progresses w/in a few days
poor muscle tone
weak cry
supple neck
What are the manifestations of meningitis from 3 months to 2 years?
seizures w/ a high pitched cry
fever
bulging fontanels
poor feeding
What are the manifestations of meningitis from 2 years through adolescence?
seizures (initial sign)
nuchal rigidity
positive brudzinski’s sign & Kernig’s sign (not reliable until 2 years old)
What should be monitored with meningitis in newborns & infants?
head circumference & fontanels
What requires immediate medical attention with meningitis?
presence of petechiae or a purpuric-type rash
What are the priority nursing interventions for meningitis?
ISOLATE!
Correct fluid volume deficits, then restrict fluids until no inc. ICP
keep room cool
slightly elevate HOB or side-lying
NPO if decreased LOC
seizure precautions
decrease stimuli
What medications are indicated for meningitis?
Antibiotics
Corticosteroids (dexamethasone)
-not indicated for viral
-most effective for decreasing neuro complications
Analgesics
What will the CSF test look like if the infection is bacterial?
cloudy
inc WBC
inc protein
dec glucose
+ gram stain
What will the CSF test look like if the infection is viral?
clear
slightly inc WBC
normal or slightly inc protein
normal glucose
- gram stain
What are the precautions for meningitis?
droplet
wear a mask
isolation for 24 hrs after antibiotics
What position is the patient in during a lumbar puncture for meningitis?
side-lying
head flexed
knees drawn up
assist in holding the child still
4-8 hrs after remain flat in bed
What are the manifestations of inc ICP in newborns & infants?
bulging fontanels
separation of cranial sutures
inc head circumference
high-pitched cry
distended scalp veins
bradycardia
resp changes
What are the manifestations of inc ICP in children?
headache
N/V
diplopia (double vision)
blurred vision
seizures
Bradycardia
resp changes
What are the late manifestations of inc ICP?
alt. pupil response
posturing
dec motor response
Cheyenne-stokes
dec LOC
coma
flexion/extension
What is flexion caused by?
dysfunction of cerebral cortex
What is extension caused by?
dysfunction at the level of the midbrain
What are the priority assessments for inc ICP?
LOC/GCS
pupils
motor activity
sensory perception
verbal response
What are the priority interventions for inc ICP?
stabilize spine
airway
o2 sat >95%
insert foley
seizure precautions
calm restful environment
What are the interventions to decrease ICP?
keep head midline
HOB >30
avoid hip flexion/extension
minimize oral suction (NO nasal suction)
avoid coughing, blowing nose, straining (stool softener)
What findings should you report if inc ICP?
clear fluid (CSF) from ears & nose
bleeding from ears & nose (indicates skull fx)
epidural hematoma
subdural hematoma
cerebral edema
brain herniation
Signs of epidural hematoma?
a short period of unconsciousness, then normal for a few hours & then lethargy, and coma
Signs of a subdural hematoma?
vomiting
inc head circumference
lethargy
seizures
coma
signs of brain herniation?
loss of blinking
loss of gag reflex
pupils don’t react to light
systemic HTN
bradycardia
coma
resp arrest
What is a VP shunt used for?
provides primary drainage of CSF to the peritoneum
What are the complications of a VP shunt?
shunt malfunction/failure
- signs of inc ICP
shunt infection (serious)
- change in LOC, low-grade fever, dec appetite, sleep disturbances, signs of inc ICP
What happens in the tonic phase of a tonic-clonic seizure?
10-30 sec
eyes roll upward
loss of consciousness
contraction of the entire body (flexed arms, extended legs, head & neck)
mouth snaps & tongue can be bitten
increased salivation
BP & HR increase
What happens in the clonic phase of a tonic-clonic seizure?
30-50 sec
violent jerking movements
trunk & extremities have rhythmic contraction & relaxation
foaming at the mouth
incontinent
movements slow down gradually then stop
What is the postictal phase in a tonic-clonic seizure?
30 min
arouses w/ difficulty
confused
impaired fine motor movements
possible vomiting
HA
vision/speech difficulties
excessive sleeping
sore muscles
no recollection
What are the priority interventions during a seizure?
prevent injury
side position
loosen tight clothing
DO NOT restrain, open their jaw or put anything in their mouth
note onset, time, & characteristics of seizure
allow seizure to end naturally
reorient after, check for injuries
What are the priority interventions after a seizure?
side position
check VS
neuro checks
NPO until completely awake
reorient and calm the child
maintain seizure precautions
check if tongue or lips were bitten
When should you call EMS during a seizure?
child stops breathing
seizures last more than 5 min
status epilepticus occurs (seizure >30 min)
pupils unequal post-seizure
vomiting for 30 min following the seizure
the child is unresponsive to pain or cannot be awakened
Seizure occurs in water
child’s first seizure
What visual impairments are expected with cognitive & sensory impairments?
myopia
hyperopia
Astigmatism
anisometropia
amblyopia
strabismus
-esotropia
-exotropia
cataracts
glaucoma
What hearing impairments are expected with cognitive & sensory impairments in infants?
lack of startle reflex
failure to respond to noise
absence of vocalization by 7 months
lack of response to a spoken word
What hearing impairments are expected with cognitive & sensory impairments in older children?
using gestures rather than talking after 15 months
failure to develop understood speech by 24 months
yelling
irritability due to inability to gain attention
shy or withdrawn
inattentive
speaking in monotone
What are the nursing interventions for visual impairments?
provide normal to bright light for activities that require close vision
assist w/ independence (braille, audiotapes, special computers)
corrective lenses or laser surgery
What are the nursing interventions for hearing impairments?
promote speech development, lip-reading & use of cued speech (hand gestures w/ verbal Communication)
encourage socialization & use aids to promote independence
-flashing light when the doorbell or phone rings, telecommunication devices, closed captioning
sign language or interpreter
help w/ the use of hearing aids
How is preschool visual acuity tested?
Snellen chart, tumbling E or picture chart
stand 10 feet away with heels on 10 foot mark
How is preschool visual acuity tested?
Snellen chart, tumbling E or picture chart
stand 10 feet away with heels on 10 foot mark
wear glasses
keep both eyes open
cover 1 eye and read bottom line first
must identify 4 out of 6 in the line to pass then start at top and move down
What is partial visual impairment?
visual acuity of 20/70 to 20/200
What is legal blindness?
visual acuity of 20/200 or worse OR a visual field of 20 degrees or less in the child’s better eye
