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Pediatric care > T3: Neuro/Trauma/Informed Consents/MSK/Hematological Disorders > Flashcards

T3: Neuro/Trauma/Informed Consents/MSK/Hematological Disorders Flashcards

1
Q

If a parent’s decision is considered neglect, what might happen?

A

The state may overrule their choice.

Start with ethics committee then move to legal action.

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2
Q

What healthcare is given without parental consent?

A
  • Pregnancy counseling, prenatal care, contraception.
  • STI testing and/or treatment
  • Substance abuse
  • Mental health treatment
  • Injury treatment related to a crime.
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3
Q

How are we able to obtain consent over the phone?

A

Having 2 witnesses, if the situation is of the essence.

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4
Q

When are we able to give emergency care if a parent/guardian is not present to consent?

A

Consent is implied and care is given.

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5
Q

In the state of CO, how is a 16 year old able to consent for him/herself?

A

If they are legally emancipated.

If they are pregnant, they have consent for themselves up to 6 weeks postpartum.

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6
Q

Why is consent so important?

A

It ensures that the patient or family is informed of:

a) Risks
b) Benefits
c) Alternatives
d) Details of the procedure.

Nurse should NOT sign as witness unless they are CERTAIN that everything is understood.

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7
Q

What are some considerations to take in to account when informing?

A
  • Teach to the level of the decision-maker
  • NO pressure on them for one way or the other
  • Be certain that they are old enough AND COMPETENT
  • You want to include the child in the teaching

Rules depend on the state.

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8
Q

What do you do if a child vomits more than 2 times?

A

Get medical help.

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9
Q

SandS of ICP in child:

A

Fussy

Restless

Irritable

Vomiting

HA: head rubbing/banging

  • Cushing reflex (bradycardia, HTN) is a LATE sign.
  • Actual changes in pulse and BP are MORE important than the direction of the change.
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10
Q

Modified Glasgow Coma Scale for Pediatric patients, be very familiar with what is used for scoring.

A

look in your book

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11
Q

What monitoring is essential to management of CNS disorders?

A

Continual observation of LOC

Pupillary reaction

VS’s

Temperature must be monitored as hyperthermia may occur in children with CNS dysfunction.

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12
Q

A group of non-progressive disorders characterized by impaired movement and posture, and may include perceptual problems, language deficits, and intellectul impairment:

A

Cerebral Palsy

MAY appear to worsen as child ages but only bc they’re not able to reach milestones. Severity varieties tremendously, mild you may not even be aware of it.

Etiology is unknown. Possible: birth trauma, infection, LBW infant, hyperbilirubinemia.

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13
Q

Spastic and athetosis are the most common types of what disorder?

A

Cerebral Palsy

Spastic = muscle tension with jerky, uncoordinated movements with attempted voluntary movement.

Athetosis = involuntary, purposeless, writhing type movements.

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14
Q

FTT, persistence of reflexes, feeding problems, seizures, ataxia, MR (30-50%, more with milder problems), dental decay, vision problems, hearing problems, and scoliosis are all signs and symptoms of what neurological disorder?

What would be our nursing care for these pts?

A

CP

Goal: promote independence, maximize capabilities, and prevent complications (pressure sores, constipation, bone issues r/t lack of muscle tone, infections). Ask the parent “what is your child able to do?”

  • Skin care (spasticity, incontinence, bones, decreased mobility).
  • Contractures (splints, braces, ROM)
  • Nutrition: High protein, vit. and minerals, feed slowly, tube)
  • Communication aids
  • Rest (cluster care)
  • Emotional support
  • Stimulation: need a lot for sensory input
  • Set limits
  • Meds: Baclofen or Botox may be helpful for spasticity but often lose effectiveness over time (develop tolerance?); fewer choices.
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15
Q

This infection is often caused by Haemophilus influenzae (Hib vaccine!), Strep pneumoniae, Neisseria meningitidis (meningococcal), or E. coli:

A

Bacterial Meningitis

Brain becomes edematous, inflammed, exudation.

S and S:
Varies from age to age…
– Irritable, restless to drowsiness, coma (from increased ICP)
– HA, NV
– Bulging fontanels
– Seizures
– Fever
– Nuchal rigidity, opisthonic positioning (arching, can’t bend neck to chest)
– High pitched cry (often indicative of ICP)
– Petechial or purpuric rash (meningococcal) = ER!!!
– Vision changes, diplopia (double vision)

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16
Q

What is opisthonic positioning/posturing?

A

A state of severe hyperextension and spasticity in which an individual’s head, neck and spinal column enter into a complete “bridging” or “arching” position.

Greek:
opisthen meaning “behind”
tonos meaning “tension”

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17
Q

What is the treatment for bacterial meningitis?

A

IV antibiotics immediately after LP and cultures.

Always MAINTAIN IV access (which is difficult in kids bc they may be scratching/fidgeting/pulling). The antibiotics kill the bacteria but not the endotoxins which can cause the child to decline and go into DIC (15-24 yr olds have higher mortality rate).

Droplet isolation

Hydration maintenance, with care to not OVERhydrate… strict I’s and O’s, daily weights.

Monitoring VS and neuro checks

Supportive care: fever, seizures, pain

Dexamethasone to reduce inflammation (esp H. Flu)

Skin care, ROM

Decrease stimuli (during this time we will not be doing ROM)

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18
Q

What are the complications seen in bacterial meningitis?

A

(Meningococcal is worst)

  • Hearing and vision problems
  • Seizures
  • Mental retardation
  • Motor problems
  • SIADH: Syndrome of Inappropriate Diuretic Hormone (A condition in which high levels of a hormone cause the body to retain water.)
  • Gangrene = amputation(s)
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19
Q

What are the vaccines available to prevent meningitis?

A
  1. Hib vaccine (for Haemophilus influenzae)
  2. Menactra decreased the risk for meningococcal infection by 99%. Approved for 9 months to 55 yrs.
  3. MCV4 is like menactra… they both protect against 4 types of meningococcal diseases… this one is approved for 2 yrs and up.
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20
Q

What drug do we give to help with the meningitis inflammation, esp in H. flu strain?

A

Dexamethasone.

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21
Q

This type of meningitis is usually viral and is milder than the bacterial with fewer complications, it is also the most common type of meningitis:

A

Aseptic Meningitis

S and S:

  • HA
  • Fever
  • GI symptoms
  • Meningeal signs… resolves in 1-2 weeks

Treatment is symptomatic once the aseptic Dx is confirmed.

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22
Q

This condition is due to the inflammation of the CNS and its severity can range from mild (like viral meningitis) to severe, fulminating:

A

Encephalitis.

Fulminating means develop suddenly and severely.

S and S:
- similar to meningitis (says look at pg 1044)

Dx:
Clinical findings
Detection of organism in blood
CSF (may be normal though)

Tx:
Supportive care
Similar to meningitis but no antibiotics… unless it’s bacterial.

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23
Q

This syndrome is due to mitochondrial damage causing acute inflammatory encephalopathy and hepatopathy:

A

Reye’s Syndrome.

** This is a condition that has a RAPID progression with CEREBRAL edema and increased ICP.

Etiology is unknown but trigger may be aspirin or non-aspirin SALICYLATES.

Hepatopathy: an abnormal or diseased state of the liver.

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24
Q

What is the etiology of encephalitis?

A

Usually viral (herpes simplex, measles)

Can also be bacterial, fungi, etc.

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25
Q

How is Reye’s Syndrome diagnosed and treated?

A

Dx:
Liver biopsy is DEFINITIVE

Elevated ammonia levels

Tx:
Focus is on preventing ICP, fluid status, maintaining cerebral perfusion… STRICT I’s and O’s
- IV
- Foley, NG, ET tube possible

  • Accurate, Frequent monitoring of fluid status
  • WATCH for bleeding: petechiae, stool, anywhere (r/t liver dysfunction)
  • decrease stimuli (dim lights, cluster care)
  • Possible induced coma
  • Family support
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26
Q

What are the signs and symptoms of Reye’s Syndrome?

A

Early signs:

    • V/D
    • Rapid breathing
    • Severe fatigue

Later signs:

    • Confusion/Disorientation/Delirium
    • Seizures, Respiratory arrest
    • Coma
    • Hyperventilation
    • Posturing
    • Liver dysfunction
    • Hyperreflexia or Loss of reflexes
    • Fixed pupils
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27
Q

All epilepsy cases have had seizures but less than 1/3 of seizures are epilepsy.

A

Epilepsy is considered if 2 unprovoked seizures in 24 hours.

It’s a disorder of the CNS with abnormal cortical discharge.

May be accompanied by unconsciousness or muscle involvement or by disturbed feelings or behavior. Varied levels of LOC.

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28
Q

Etiology of epilepsy:

A

Most are unknown but with a trigger that alters the seizure threshold.

Can be congenital or acquired.

Possible connection between migraines with auras and epilepsy.

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29
Q

Name some possible epileptic triggers:

A
  • Hormonal (women)
  • Lights/ Noises/ Fatigue/ Dehydration/ Emotional
  • Electrolyte imbalance/ Hypoglycemia
  • Medications
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30
Q

These seizures are caused by high or rapidly rising temperature:

A

Febrile seizures.

None-epileptic = no need for anti-epileptic drugs

Usually between 6 months and 3 years. Rare after 7 years.

Usually short in duration, no complications

  • Treat fevers, not the seizure.
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31
Q

This type of seizure has an abrupt onset, with a possible aura, and afterward the pt is disoriented, has a HA, may be sleepy, sore and doesn’t remember it:

A

Tonic-Clonic

Tonic phase: 30 seconds of rigidity, loss of consciousness, cyanosis.

Clonic phase: seconds to minutes, rapid jerking, incontinence.

Post-ictal: disoriented, amnesia, HA, sleepy, sore

32
Q

This type of seizure usually occurs in those who are 5-12 years in age and is often mistaken for daydreaming:

A

Absence.

It is a brief interrupted consciousness.

Abrupt onset, lasts only seconds

33
Q

This type of seizure has a sudden loss of muscle tone, and is often called “drop seizures”:

A

Atonic/ Akinetic

Momentary loss of consciousness.
The sudden loss of muscle tone causes child to fall (drop).

34
Q

This type of seizure is described as having localized motor symptoms such as having a Jacksonian march:

A

Simple Partial Motor

35
Q

This seizure is described as visual or sensory signs, numbness, pain, tingling that spreads…

A

Simple Partial Sensory

May hear, see, smell things that are not there.

36
Q

What type of seizure is described as: Impaired consciousness, altered behavior, confusion with amnesia afterward?

A

Complex partial.

May have aura.
May vary from staring into space to posturing, stiffness, limpness

May perform automatisms.

37
Q

How are seizures diagnosed?

What teaching needs to be included?

A 
Dx By:
EEG
CT
xrays
bloodwork
LP
etc.

Teaching:

    • What side effects to expect but still need to take
    • Seizure care
    • Driving
    • Getting off meds: gradual attempts if no seizures for 2 yrs on meds (and clear EEG?)
38
Q

What are the treatments involved with seizures?

A

Seizure precautions:

  • Safe environment (nothing in mouth/no restraints)
  • Maintain airway, O2 if cyanotic
  • Roll to side
  • 911 if lasts longer than 5 minutes, or is seizing for the first time
  • Medications: Valium to stop it by relaxing muscles and decreasing neural activity… other meds to remain seizure free. (only 50-75% remain seizure-free)
  • After 2 years with no seizures AND a normal EEG, can wean off of meds slowly (side effects).

*Document:
Onset, duration, behavior

39
Q

This can occur if pt is not taking anti-seizure medication correctly and is very dangerous:

A

Status epilepticus

A continuous seizure for 30 minutes.
Monitor airway, O2, blood glucose (bc body is using stores during seizure), electrolytes

Have to give valium rectally or IV
Cerebyx IV or IM

May die from:
Hyperthermia
CV dysfunction
Respiratory arrest
Metabolic problems
40
Q

This condition is caused by an imbalance of production and absorption of CSF in ventricular system, causing increased pressure and dilating the ventricles:

A

Hydrocephalus

Under normal circumstances, the CSF is constantly being made and absorbed, if there’s a problem then the CSF builds up.

Etiology: Congenital or acquired (trauma/ tumor/ infection)

The most common type is non-communicating: an obstruction in the system.

The other type of hydrocephalus is communicating: an absorption problem.

41
Q

What are the signs and symptoms of hydrocephalus?

A

** Decreasing LOC (early sign)

  • N/V
  • Vision changes
  • Irritability to lethargy to coma
  • Enlarged head, increased OFC occipital frontal circumference. (later sign)
  • Bulging fontanels, separated sutures, bossing (a really prominent forehead), dilated scalp veins.
  • Sunset eyes (see most of white of eyes with the pupil at the bottom like a setting sun). (late sign)
  • High-pitched cry
  • Transillumination: putting a flashlight up to the head and seeing it glow.
42
Q

How do we diagnose and treat hydrocephalus?

A

Dx:
CT, MRI, US, OFC measurements

Tx:
Needs early intervention; once the damage is done, it’s done.
– Shunts to bypass obstruction:
Drains in the peritoneal cavity on infants.
Drains to the RA of heart in older children.
The valve automatically opens at a certain pressure.

43
Q

What are the top three complications of shunts for hydrocephaly?

A
  1. Infections
  2. Obstruction (laser has been used to unblock)
  3. Outgrow it

TEACH:
The family to watch for changes in LOC (sleepy/irritable)

44
Q

Post-op shunt considerations:

A
  • Lie flat (if HOB up may decompress) and OFF of operative site (possible to compress and open valve = CSF drains)
  • Skin care
  • Protect shunt
  • Monitor VS, neuros, OFC
  • WATCH for abdominal distention (ileus)
  • Strict I’s and O’s

TEACH:
Shunt care
S an S of complications
WATCH LOC

45
Q

What is the most common diagnostic tool for hematological disorders?

A

CBC

“Left shift” usually indicates bacterial infection with increased production of immature neutrophils (bands).
This saying came from years ago when the graph they’d use showed the immature neutrophils on the left side of the graph.

46
Q

What is a normal hemoglobin range?

A

Hgb:

11.5 - 15.5

47
Q

Normal hematocrit range?

A

Hct:

35 - 45 (it’s approximately 3 times that of Hgb.

48
Q

Normal WBC range?

A

4,500 to 13,500

The total number is LESS important than differential count.

49
Q

Normal range for platelets?

A

150,000 - 400,000 are necessary for clotting.

50
Q

What is iron necessary for?

A

It’s necessary for proliferation and maturation of RBC and Hgb synthesis.

If you don’t have enough iron, your body can’t make enough healthy oxygen-carrying red blood cells.

51
Q

What is EMLA?

A

It’s a topical numbing cream.

Active ingrediants are lidocaine and prilocaine.

52
Q

Why do check for occult blood and parasites regarding hematological disorders?

A

Occult blood:
Refers to blood in the feces that is not visibly apparent

Parasites:
One of the most common causes of lower GI bleeding is colitis. This occurs when your colon becomes inflamed. This could be caused by an infection, food poisoning, PARASITES, Crohn’s disease, or reduced blood flow in the colon.

53
Q

This type of anemia is especially common in preemie babies, children 12-36 months, and teens:

A

Iron Deficiency Anemia.
Most common nutrition disorder in the U.S. Caused by inadequate dietary iron, not enough iron to make Hgb.

Preemie:
Due to low fetal iron supply since iron is stored in the last trimester.

12-36 months:
Drink a lot of cows’ milk (low AVAILABLE iron)
Seen especially in the hispanic population (3x) bc they tend to continue to bottle-feed well past 12 months where the child should be eating meat/fruits/vegetables to get their iron.

Teen:
Periods
Poor diet

54
Q

Signs and symptoms of Iron Def. Anemia:

A
  • May be subtle and may not show until advanced
  • Often overweight (milk babies) or underweight
  • Pallor (pale)
  • DOE (dyspnia on exertion)
  • low H and H
  • low RBC
  • High iron binding (measures open receptor sites)
55
Q

Common treatments for Iron Def. Anemia:

A
  1. Iron Supplements (Ferrous is best). Diet will not be enough right now. TEACH parents about tarry green/black stools, PO may stain teeth (#2).

If N/V, decrease the dose and give with food and gradually increase dose and then not with food.

If IM give deep Z-track and don’t massage.

  1. Take the iron with a glass of orange juice because vitamin C helps iron absorption. Give between meals (unless N/V). Sip with a straw to decrease chance of staining teeth.
  2. AVOID giving with milk because the Ca in the milk will bind with the iron and then the iron will not be available. Entirely avoid cows’ milk until 12 months old, and avoid too much milk 1 - 3 years. Wean from bottle by 12 - 15 months.
  3. After 4 - 6 months, give iron-fortified formulas or cereals or iron supplementation after 4 - 6 months.
  4. Encourage breastfeeding moms to increase their iron intake.
56
Q

What are some examples of heme iron-rich foods?

A 
Excellent:
- Clams
- Liver (pregnant women should avoid bc of it's high Vit. A content which can be harmful to the baby)
- Oysters
Mussels

Good:

  • Beef
  • Shrimp
  • Sardines
  • Turkey

Heme iron is more “available” and easier to digest.

57
Q

What are some examples of non-heme iron-rich foods?

A

Excellent:

  • Enriched breakfast cereals
  • Cooked beans and lentils
  • Pumpkin seeds
  • Blackstrap Molasses

Good:

  • Canned beans
  • Baked potato with skin
  • Enriched pasta
  • Canned asparagus
58
Q

What are some Iron Absorption Enhancers?

A

Meat/Fish/Poultry

Fruits: Orange, Cantaloupe, Strawberries, Grapefruit, etc.

Vegetables: Broccoli, Brussels sprouts, Tomato, Potato, Green and Red peppers

White wine

59
Q

What are some Iron absorption INHIBITors?

A

Red Wine/ Coffee/ Tea

Vegetables: Spinach, Chard, Beet greens, Rhubarb and Sweet potato.

Whole grains/ Bran

Soy

60
Q

What is the most common genetic blood disorder that is found primarily in the African American and Hispanic populations?

A

Sickle Cell Anemia.

It is inherited, where normal adult Hgb is partially or totally replaced by abnormal sickle Hgb (HgS). The sickling may not show up until later infancy bc of the presence of fetal Hgb (HgF).

Sickle Cell DISEASE (SCD) is the term used to include all hereditary disorders related to the presence of HbS.

Sickle Cell TRAIT describes people who are heterozygous for the gene.

Sickle Cell ANEMIA describes people who are homozygous for the gene.

61
Q

Signs and Symptoms for Sickle Cell Anemia:

A
  • RBC destruction
  • Vaso-occlusion: pain: (caused by sickled RBCs). Presents as hypoxia/ tissue eschemia.
  • A period of exacerbation called “Sickle Cell Crisis,” set off by illnesses or dehydration.
62
Q

Sickle Cell Crisis manifestations…

A

Vaso-occlusive = Painful

Sequestration = Shock from blood pooling in the liver/ spleen

Aplastic = Severe anemia from low RBC production

Hyperhemolytic = RBC destruction with anemia, jaundice, reticulocytosis (increase in reticulocytes, immature red blood cells. It is commonly seen in anemia.)

Acute chest syndrome = chest pain, cough, tachypnea, wheezing, hypoxia… similar to pneumonia and causes 25% of sickle cell deaths!!!

CVA = from clot in brain. 70% recurrence rate if untreated.

63
Q

How do we treat Sickle Cell Anemia?

A

– Chronic transfusions to correct low oxygen-carrying capacity caused by anemia and to improve microvascular perfusion by decreasing the proportion of sickled RBCs in circulation. Transfusions may cause excessive iron, so family may do chelation therapy at home (injection of chelating agent, a synthetic amino acid).

– PREVENT crisis: preventing illnesses (hand washing, prophylactic antibiotics, vaccinations), prevent dehydration (no long distant sports) also over hydration can cause enuresis (spontaneous void esp at night) so address this expected complication of Tx with family and child.

    • Analgesia (opioids - no Demerol bc of seizure)
    • Hydroxyurea (cancer drug) = increases fetal Hgb… is showing good results to decrease episodes of crisis and prevent hospitalization.
    • Encourage circulation with positioning
    • Rest to decrease oxygen use
    • Oxygen during crisis only if hypoxemia.
    • WATCH lytes… hypoxia causes metabolic acidosis… hydrate and the acidosis will usually correct itself.
    • Possible splenectomy to prevent sequestration crisis.
    • Mandatory newborn screenings in US
64
Q

This type of sickle cell crisis is very painful:

A

Vaso-occlusive.

65
Q

This type of sickle cell crisis is when the patient goes into shock from the blood pooling in the liver or spleen:

A

Sequestration.

66
Q

This type of sickle cell crisis is a severe anemia from low RBC production:

A

Aplastic.

67
Q

This type of sickle cell crisis is from RBC destruction with anemia, jaundice, reticulocytosis:

A

Hyperhemolytic.

Reticulocytosis is a condition where there is an increase in reticulocytes, immature red blood cells. It is commonly seen in anemia.

68
Q

This type of sickle cell crisis presents with signs similar to pneumonia - chest pain, cough, tachypnea, wheezing, and hypoxia:

A

Acute chest syndrome.

This crisis accounts for 25% of sickle cell DEATHS.

69
Q

This type of sickle cell crisis is from a clot in the brain:

A

CVA.

There is a 70% recurrence rate if untreated.

70
Q

This type of anemia is due to defective Hgb which damages RBCs when it disintegrates:

A

Thalassemia.

D/T deficiency in production of specific globin chains in Hgb. D/T the damaged RBCs from the defective Hgb, the body tries to compensate with excessive RBCs formed and excess iron is stored in organs (hemosiderosis).

71
Q

Who is at most risk for Thalassemia?

A

Greeks

Italians

Syrians (Mediterranean)

Heterozygous form:
Minor, asymptomatic. Trait: mild anemia.
Intermediate form, splenomegaly and severe anemia.

Homozygous form: major (severe) anemia. This is Cooley’s Anemia.

72
Q

What do we call the form of iron overload disorder resulting in the accumulation of iron in the organs?

A

Hemosiderosis.

The iron within deposits of hemosiderin is very poorly available to supply iron when needed.

Occurs in Thalassemia.

73
Q

What is the treatment for Thalassemia?

A

Maintain Hgb levels to prevent bone marrow expansion and bone deformities and to provide sufficient RBCs for G and D (growth and development) by:

  • Transfusions every 3-5 weeks (but causes iron overload = can cause heart disease, diabetes)
  • Desferal (chelating agent). This is given for hemosiderosis (SQ or IV over 8 - 24 hours, 5 - 7 days a week or over 4 hours with blood transfusions). This helps the body eliminate the excess iron but is OTOTOXIC.
  • Possible Vit C to help body excrete iron while Desferal is given.
  • Possible splenectomy. If this is done then watch temps for possible infection.
  • Stem cell transplant
74
Q

This type of anemia is characterized by the failure of bone marrow to produce all the formed elements of blood:

What is its treatment?

A

Aplastic Anemia.

Pancytopenia, anemia, leucopenia, thrombocytopenia.

Can be congenital (Fanconi) or acquired (often idiopathic).

Tx:
Bone marrow transplant

Immunosuppressive therapy

Watch temps CAREFULLY (infection)

**Teach safety as bleeding from injury can be fatal.

75
Q

Hemophilia

A

and Idiopathic Thrombocytopenia Purpura are the last two.

76
Q

Neural tube defects are diagnosed by either ultra sound or alpha fetal protein. What are the three involving the head?

A
  1. Anencephaly - no brain development = no life
  2. Microcephalic - brain growth is 3 deviations from norm.
  3. Encephalocele - sac-like protrusions of the brain and the membranes that cover it through openings in the skull.
77
Q

What are the neural tube defects that affect the spinal cord?

A
  1. Spina bifida occulta - 1:4 births, may never know except by tuft of hair or dimple on sacrum.
  2. Meningocele - spinal cord intact but protruding. Will need surgical correction.
  3. Myelomeningocele - deficit will vary depending on where the spinal cord nerves protrude. Will need to be delivered by C-sec and intrauterine surgery has greater outcome.

Pediatric care (4 decks)

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