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Critical Care > Peds Neuro > Flashcards

Peds Neuro Flashcards

1
Q

Near Drowning
What happens?

A

Near Drowning = Submersion injury
- Inhalation of water can damage alveoli in lungs, damage lung surfactant
- Aspirated water damages lung surfactant (due to chemicals/bacteria/algae) and impairs alveolar gas exchange
- Present with HYPOXIA (risk for respiratory distress)

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2
Q

Drowning
What happens?
Associated Symptoms?

A

Drowning = where there is enough water to cover the nose and mouth. (can take 20-60 seconds)
- Sequence of Drowning: Panic -> Sporadic motions -> Aspiration -> Laryngospasms -> Hypoxia
- Laryngospasms = bronchoconstriction of the child’s airway. This limits and/or eliminates breathing causing further aspiration of water into the lungs.
- Hypoxia -> Anoxia -> Cerebral Edema -> ICP concern
- Anoxia = cerebral edema and increased ICP
- When the brain is not getting O2, there is swelling
- Concerns for increased ICP
Associated Symptoms:
- LOC changes,
- Irregular breathing and/or Apnea
- Gastric Distention due to swallowing water (NG/OG to decompress stomach)
- Vomiting
- Seizures due to cerebral edema and increased ICP

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3
Q

Clinical considerations of a drowning victim: hypothermia
What to do if you find a drowning victim

A

-Hypothermia: occurs quicker in water than in air
Symptoms & recovery depend on
- Temperature of water
- Length of time submerged
- 5-10 min or less: better likelihood of surviving with a full recovery (fewer symptoms)
Initial scene treatment
- What was EMT able to do?
- Did parents bring them straight to hospital after drowning?
- Type of water can play a role as well.
- Decreased systemic perfusion (vasoconstriction -> cardiac muscle impairment -> heart stops)
- What would you do if you found a drowning victim? ABC -> secure an airway, initiate CPR
- Immediate CPR**
- BLS (30:2 1 provider / 15:2 2 provider for pediatrics)
- Before you shock, DRY the victim

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4
Q

Hospital care of a drowning victim

A

What to focus on for recovery
*Airway & Hyperoxygenation
*Rewarming
- Passive External: remove wet clothing, blankets, increase room temp
- Active External: warm blankets, heating pads, radiant heat, warm bath, forced warm air (putting something on)
- Active Internal: endovascular rewarming, peritoneal and pleural irrigation; for drowning: warmed IV fluids, blood

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5
Q

Drowning Prevention:

A

Family Education
- Swim Lessons
- Life jackets
- TWO EYES on child while around water
- Flags at the beaches
- No Alcohol and drugs around water
- Don’t to the beach/pool while sleepy with a child
Environmental Changes
- Alarms/Fencing around water

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6
Q

Normal Intracranial Pressure
Causes of increased ICP
Increased ICP often leads to …

A

Normal pressure in the cranial vault (Brain, CSF, Blood): < 20 mmHg
Causes
Traumatic Injury
- MVA (never alter car seats)
- Gunshot wounds (GSW)
- Anoxia (drowning)
- Falls (if a child falls 2x their height and hits their head we are concerned for head injury)
Abuse/Non-Accidental trauma (Shaken Baby Syndrome)
- Causing bleeding and swelling
Autonomic
- Hydrocephalus
- Tumors
- Infection
- Seizures
- Hypoxia
Increased ICP often leads to decreased cerebral perfusion pressure (decreases oxygen and nutrient delivery to brain tissue)

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7
Q

Early signs of increased ICP in children

A

Subtle and typically reported by parents as poor feeding, vomiting, irritability, lethargy, and if old enough they can report a headache.
- Headache
- Visual Disturbances
- Nausea/Vomiting
- Dizziness or Vertigo
- Slight changes in vital signs
- Slight changes in LOC
- Sunsetting eyes: cranial nerve IV palsy; the iris of the eye appears to be setting into the lower eyelid leaving sclera visible above the iris.

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8
Q

Signs of Increased ICP in infants specifically

A

Early signs of increased ICP along with…
- Irritability
- Bulging fontanelle (anterior)
- Wide sutures, increased head circumference (growth chart)
- Dilated scalp veins
- High-pitched, catlike, cry

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9
Q

Late signs of Increased ICP in children

A

*Significant decrease in LOC
*Seizures
*Fixed & dilated pupils
*Papilledema (disc swelling)
*Cushing Triad (can lead to brain herniation)
- Increased systolic BP and wide pulse pressure
- Bradycardia
- Irregular respirations

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10
Q

Hydrocephalus
Causes
Patho

A
  • Typically idiopathic in nature
  • Dilation of the ventricles due to an increase in CSF production
  • Too much CSF = increased ICP
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11
Q

Nursing Interventions for Hydrocephalus/IICP

A

HOB Elevated!!!
- Drains CSF
- Decreases Intrathoracic Pressure (also reduces intra-abdominal pressure)
- Head in neutral alignment
- May stay in C collar
Low Stimulation
- Cluster care
- Low lights, low volume
Avoid lumbar punctures with patients who have an increased ICP, as it may lead to brain herniation, typically into the brain stem

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12
Q

Surgical Treatment for Hydrocephalus/IICP and post-op nursing interventions/teaching

A

*External Ventricular Drain (for traumatic injuries)
*VP Shunt (ventriculoperitoneal shunt)
*Drains excess fluid into the peritoneal cavity
*Post-Surgical Care Considerations
- Assess ICP
- Assess surgical incision for infection
- Vital Signs
- Pain
Family Home Care Teaching:
- Do not press on the shunt. (this includes do not lay the child on the shunt side until follow up with surgeon ~ 2 weeks after surgery)
- Located typically behind the ear. Will eventually be a small quarter sized raised area.
- Sutures/ Staples come out in 1-2 weeks
- Assess for Complications

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13
Q

Complications of a VP shunt

A

*Infection
- Infection of a new shunt typically happens within the first 2 months. Staph Aureus most common.
- Signs of Shunt failure/infection include rapid onset of vomiting, severe headache, irritability, lethargy, and fever. *Malfunction: Look for signs of malfunction
*Overshunting
- Over - draining the CSF too quickly
- Depleting the ventricles of CSF leads to collapse of ventricles
- Can lead to bleeding and blood clots
- Cues: Severe HA, N/V, Seizures, Abdominal Swelling due to catheter tip location
- Will need CT scan of brain and surgery (revision)
*Shunt Revisions happen with growth (sides are swapped)
- Also needed if there is infection or overdraining
- Typically once they hit 80% of their adult height, the revisions will cease

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14
Q

Spinal Cord Injuries
Complete vs. Incomplete
Causes

A
  • Complete = irreversible loss of all sensory, motor, and autonomic function below the level of the injury
  • Incomplete = varying degree of sensory, motor, and autonomic function below the level of the injury
    *Common Pediatric Causes
  • # 1 MVC Accident (car seats, seatbelts, 8 yo and 80 lbs)
  • Bike accidents
  • ATV Rollovers
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15
Q

Complications of Spinal Cord Injuries

A
  • Impaired respirations may be secondary to diaphragm paralysis OR decreased capacity
  • Autonomic dysreflexia is a condition associated with injuries above the T6 level
  • Overactivity of the autonomic system can lead to HTN, arrhythmias, pupillary constriction, and H/A.
  • Scoliosis
  • Hip Instability
  • Pressure sores
  • DVT
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16
Q

Spinal Cord Injury
Diagnostics
Nursing Care

A

*Diagnostics
- X-ray
- CT/MRI
- Myelography
*Airway
- Nasal cannula/Face mask
- Intubation
- Tracheostomy
- What are their needs long term regarding airway?
Nutrition
- TPN/Lipids
- NG tube
- G tube
- Short term vs. long term goals
- Won’t do a G tube right away (NG first)
- Look at weight
*Bowel and Bladder program
- Stool softeners
- Timing/routine,
- Enema/straight or indwelling catheter
- Diaper
- Initial plan won’t necessarily be the long-term plan.
- With spinal healing, depending on the type of injury, plans can progress and/or return to normal
- Autonomic dysreflexia
*Prevent Skin breakdown
- Frequent repositioning vs. Air mattress vs. Rotating beds vs. Early ambulation
- What are their limitations?
- Is it due to complete injury or are they on strict restrictions due to having surgery?
*Promote independence – what capabilities does the patient maintain?
- Keep in mind their caregivers with this.
- What are their goals for the client.
- Body image (adolescents)

17
Q

Cerebral Palsy
Congenital vs. Acquired
Types

A
  • Congenital: brain damage BEFORE birth; most common form
  • Acquired: brain damage AFTER birth
    Spastic
  • Difficulty moving one side, just legs, or all limbs; Most common
  • 70% of CP cases.
  • Spastic di/hem/quadriplegia or riparesis
    Athetoid
  • Difficulty controlling movements/ can have sudden changes in muscle tone.
    Ataxic
  • Problems with balance and coordination issues; especially with purposeful movements, such as writing.
    Mixed
  • Any or all of the above most common mix is spastic/dystonic CP.
18
Q

Risk factors of Cerebral Palsy (congenital and acquired)

A

Congenital Risk Factors
- Maternal Infections
- Placental Abnormalities
- Multiple Births
- Low Birth Weight
- Asphyxia at Birth
- Meconium Aspiration
Acquired Risk Factors
- Bacterial Meningitis
- Severe Jaundice
- Anoxic Injury after Birth

19
Q

Cerebral Palsy
Patho/Clinical Manifestations

A
  • Muscle growth is limited due to spasticity which affects bone growth. This leads to the client having varying degrees of contractures as well as developmental abnormalities.
  • The scope or range of ailments associated with CP vary widely from one patient to another.
  • Where some patients may be treated for physical deformities alone, others are diagnosed with related conditions such as seizures, vision or hearing impairments, scoliosis, and/or intellectual disabilities
  • High risk for respiratory infection
20
Q

Cerebral Palsy Clinical Screenings

A

Infants and young children
- Not meeting developmental milestones
- Patients may be delayed in physical development (rolling, sitting, crawling, walking) and/or motor development (language skills)
- Hypertonia (stiff) or hypotonia (floppy)
- Accidental or Nonaccidental Trauma victims
- CNS infection (meningitis)

21
Q

Cerebral Palsy
Nursing Care

A

1) Airway Support
Ventilation needs
2) High risk for infection
3) Nutrition (high risk for malnutrition)
Nurses intersect with patients who are diagnosed with CP in a variety of settings from school nursing or clinical based care, to post-procedural in-patient care.
Supportive Therapies
- Physical, Occupational, and Speech

22
Q

Duchenne Muscular Dystrophy
Etiology
S/S

A

Most rapid form
DX before age 6
From mother -> male
S/S
- Dystrophin mutation (on X chromosome)
- Learning Difficulties
- Muscle wasting and weakness (progressing)
- Fatigue
- Calf pseudohypertrophy
- Falls and waddling gait
- Scoliosis
- Gower’s Sign = using hands to push on legs to stand “walking up legs”
- Respiratory problems (late)
- Cardiac involvement (late)
Death in the 20s due to cardiac or respiratory failure.

23
Q

Duchenne MD
Patho

A

Lack of Dystrophin
Dystrophin helps with integrity of muscle membranes … When we don’t have enough, destruction of muscle begins.
Where can we find this protein in the body? Heart & smooth muscle tissue.
Without dystrophin, there is a rapid decline and destruction of these tissues, leading to respiratory and cardiac arrest

24
Q

Osteogenesis Imperfecta
Patho
Diagnostics

A

Connective tissue disease that primarily affects the bones.
- Defect in the production of collagen (autosomal dominant)
Diagnostics
- Ultrasound (in utero): Collagen analysis +/- ultrasound in utero
- Genetic Screenings
- Delayed walking
- Frequent Fractures
- DEXA Scan: bone density scan
- Radiological Imaging for fracture frequency (often mis-diagnosed with child abuse!)
Diagnosed with genetic screening, delay in walking, and frequent fractures

25
Q

Osteogenesis Imperfecta
Signs and Symptoms:
Care Goals:

A

Signs and Symptoms:
- Multiple frequent fractures
- Blue sclera
- Short stature
- Thin, soft skin
- Weak muscles
- Altered joint flexibility
Care Goals:
- Maximize Independence
- Maximize mobility
- Minimize risk of fractures

26
Q

Osteogenesis Imperfecta
Nursing Care

A

*Fracture prevention
- Do not do BP as often (look at cap refill instead)
- Manual BP instead of automatic because you can control the amount of pressure
- No tourniquet for IVs
Prevention of further deformities
- Fall prevention
- Side rails up
- Close to nurse’s station
- Bed in lowest position
- Bed alarms
*Nutritional Support
- Well balanced diet with vitamins C, D and calcium
*Physical Therapy
- Casting, bracing, and/or splinting
*Surgical stabilization for some cases.
*{{Researching impact of stem cell transplant in severe cases}}

27
Q

Juvenile Arthritis:
Etiology:
Clinical Indicators:
Diagnostics:

A

*Begins as early as age 2 with presenting inflammation or pain in multiple joints.
*Genetic in nature; most common rheumatic illness among peds population
*Commonly Affected Joints
- Ankle
- Knee
- Hips
Clinical Indicators
- Joint Pain & Inflammation
- Typically, bilateral joint pain, but can present gradual over months and be unilateral**
- Reported by families to happen for months, off and on.
Diagnostics:
- CBC, ANA titer, Epstein-Barr Virus Titer, CRP are the most common
- Rheumatoid panels
- Physical Exam by HCP

28
Q

Juvenile Arthritis
Nursing Care

A

Pain Control
- Aleve, Naproxen, Methotrexate are anti-inflammatory of choice.
Promote normal growth
Preserve function
- Physical and Occupational Therapy with every hospital admission.
Monitor this patient population for:
- Nutritional deficits
- Uveitis (inflammation of the iris)
- Delayed puberty

29
Q

Child Abuse & Maltreatment:
Risk Factors & At-Risk Populations

A
  • Young Parents
  • Domestic Violence
  • Parental Mental Health Concerns (Bipolar, Schizophrenia)
  • Substance Abuse
  • Families caring for premature or chronically ill children
  • Parents of kids with ODD or ADHD
  • Sexual Abuse from paternal figure
30
Q

Physical Abuse
Example
Signs

A

Ex: Spiral fracture of femur, burn to face (coffee)
- “Accident prone”
- Inconsistency with story vs. injury
- Redirecting blame on siblings/visitors
- Delays in seeking medical treatment
- Uncommon injury sites
- Hypervigilant parents

31
Q

Sexual Abuse
Example
Signs

A

Unfortunately these are typically found out about when abuse has been happening for a period. Examples: At mom’s boyfriends house & comes back to dad asking questions; teenager skips school to come to ER for UTI complaints and doesn’t want to call her parent
- Genital complaints
- Difficulty walking/sitting
- Stained clothing (blood)
- Inappropriate sexual behaviors to others
- Excessive/Public Masturbation (due to altered mentation)
- Drawings of Sexual Actions

32
Q

Non-specific behaviors
Examples/signs

A

Doesn’t mean there is a problem
Changes in child appetite, demeanor, mood, and sleep are commonly seen with maltreatment AND stress. Stress can mimic a lot of the same behaviors as maltreatment.
Examples: best friend is being mean to them, break up, mom and dad divorcing

33
Q

Neglect
Examples/signs

A
  • Poor hygiene
  • Clothes do not match weather needs/concerns
  • Developmental lags
  • Constant hunger and fatigue
  • Unattended medical needs.
    Examples: Parents not there, not enough money, etc.
34
Q

What to do with suspected child abuse or neglect

A

Call CPS for ALL situations

Critical Care (12 decks)

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