MS 2 (exam 5) Flashcards
(78 cards)
1
Q
Obtundation
A
Arousable with stimulation
2
Q
Stupor
A
Remaining in a deep sleep, responsive only to vigorous and repeated stimulation
3
Q
Persistent Vegetative State (PVS)
A
Permanently lost function of the cerebral cortex
4
Q
Earliest indicator of improvement or deterioration in neurologic status is
A
LOC
5
Q
GCS
A
- determines consciousness
- Assesses: eye opening, verbal response, and motor response
6
Q
GCS scoring
A
Lower the score = the further alteration of consciousness
Highest: 15
8 or below: coma
3: deep coma or death
7
Q
In general what should you watch for in increased ICP in children?
A
- Monitor the swollen fontanelle
- Watch for an increased circumference of the head. Be sure to measure
- Watch for Setting-sun sign
- Vomiting
8
Q
S/S ICP in infants
A
- tense bulging fontanel
- separated cranial sutures
- high pitched cry
- irritability and restlessness
- drowsiness
- increased sleeping
- poor feeding
- crying when disturbed
- setting sun sign
9
Q
S/S ICP in children
A
- h/a
- n/v
- diplopia, blurred vision
- sz
- drowsiness
- decline in school performance
- increased sleeping
Inability to follow simple commands - lethargy
10
Q
LATE S/S ICP in children and infants
A
- bradycardia
- decreased motor response to command
- decreased sensory response to painful stimuli
- Alterations in pupil size and reactivity
- extension or flexion posturing
- cheyne strokes respirations
- papilledema
- decreased consciousness
- coma
11
Q
Increased ICP treated with?
A
sedation, CSF drainage, osmotic diuretics
12
Q
What is done for increased ICP
A
- Mannitol
- Usually given slow but can be pushed rapidly
- Indwelling catheter
- Maintain PaCO2 at 30 mmHg to produce vasoconstriction –> reduces blood flow –> decreased ICP
13
Q
NI for increased ICP
A
- Watch positioning - avoid neck vein compression
- Elevate the HOB to 15-30 degrees
- Maintain head at midline
- Watch pressure points
- Cluster nursing activities
- Minimize stimuli
- Gentle ROM
- Suctioning and percussion - contraindicated unless respiratory problems are present
- Monitor for s/s of increased intracranial pressure
14
Q
Make a latex free environment for kids who have ?
A
spina bifida, cerebral palsy, and are handicapped
15
Q
Whats hydrocephalus
A
- imbalance in the production and absorption of CSF in ventricular system
16
Q
causes of hydrocephalus
A
- congenital or acquired
- trauma, infection, neoplasms, developmental malformations*
17
Q
What does hydrocephalus result in
A
impaired absorption of CSF within the subarachnoid space
OR
obstruction to the flow of the CSF through the ventricular system
18
Q
3 factors that influence the clinical picture of hydrocephalus
A
acuity of onset
timing of onset
associated structural malformations
19
Q
S/S of hydrocephalus
A
- Head grows at an abnormal rate
- 1st sign may be bulging fontanels with or without head enlargement !!
- Anterior fontanel is tense, often bulging & non pulsatile
- Scalp veins are dilated
- Bones of the skull become thin and sutures are palpably separated to produce the cracked pot sound (Macewen sign) on percussion of the skull
- Frontal protrusion (frontal bossing) with depressed eyes, eyes may be rotated downward, producing a setting-sun sign (sclera is visible above the iris)
- Pupils are sluggish with unequal response to light
- Irritable, lethargic, poor feeder, changes in LOC, and lower extremity spasticity
- Reflexes may persist and new, expected reflexes may be absent
20
Q
If hydrocephalus is not treated what can occur?
A
development of lower brainstem function is disrupted = difficulty sucking, feeding, and a shrill, brief, high-pitched cry
21
Q
S/S of hydrocephalus in childhood
A
- Headache upon awakening, improvement after emesis
- Papilledema
- Strabismus
- Extrapyramidal tract signs
- Irritable
- Lethargic
- Apathetic
- Confused or Incoherent
22
Q
How is hydrocephalus dx in antenatal
A
Fetal ultrasound between 14-15 weeks gestation
Fetal MRI
23
Q
How is hydrocephalus dx in infancy
A
head circumference that crosses 1 or more percentile lines within a period of 2-4 weeks
Daily head circumferences for those with myelomeningocele, hemorrhage, intrauterine viral or CNS infections
Older infants and Children:
CT and MRI
24
Q
What is a VP shunt
A
cerebral shunt that drains excess cerebrospinal fluid (CSF) when there is an obstruction in the normal outflow or there is a decreased absorption of the fluid
25
Major complications of VP shunt
- infection and malfunction (kinking, plugging, separation, migration of tubing)
If obstructed- EMERGENCY
Signs of increased ICP
Sepsis, bacterial endocarditis, wound infection, shunt nephritis, meningitis, ventriculitis
26
Nursing care for hydrocephalus
Monitor for s/s of increased ICP
Measure head circumference daily
Palpate fontanelles and suture lines for signs of bulging, separation
Neuro status, LOC, behaviors
27
VP shunt pre op NI
- Assessment including head circumference
- Small frequent feedings
- Support head-prevent pressure sores
- Support parents
28
Nursing care for VP shunt post op
- NPO 24-48hrs
- Position on unoperated side, position the ot off of the shunt (never pump shunt)
- keep child flat
- monitor for s/s increased ICP, pupils, blood pressure
- Monitor for abdominal distention- CSF may cause peritonitis or ileus
- Monitor for fever, poor feeding, vomiting, seizures
- Administer abx as ordered (infx major complication)
- Monitor incision site
- Teach to avoid contact sports, s/s of shunt failure, enroll in early childhood dev program
29
What is an EVD (External Ventricular Drainage) used for
- Allows removal of CSF from a tube placed in the child’s ventricle that flows by gravity into a collection device
- Placed at the level of the child’s external auditory meatus with the head at a 20-30 degree elevation
- Ambulation or sitting up usually requires the tubing be clamped to prevent imbalance in CSF drainage
- Aseptic technique when handling device
30
what is MYELOMENINGOCELE
- spina bifida
- Neural tube defect
- Hernial protrusion of a saclike cyst containing meninges, spinal fluid, and a portion of the spinal cord with its nerves
- Develops in the 1st 28 days
- Neural tube fails to close and fuse
31
S/S of MYELOMENINGOCELE
- Visible outpouching
- Sensory disturbances usually parallel motor dysfunction
- Hydrocephalus very common
- Constant dribbling of urine or produces overflow incontinence
- Poor anal sphincter tone and poor anal skin reflex (no rectal temps!)
- Joint deformities in utero
- Flaccid paralysis of the lower extremities with absent deep tendon reflexes
32
How is myelomeningocele dx prenatally
- Ultrasound
- Elevated maternal concentrations of alpha-fetoprotein
- Chorionic villus sampling
33
Tx for myelomeningocele
- Prevent with folic acid supplementation pre conceptually
- Place in warmer to maintain temp without clothing or covers
- Sterile, moist, nonadherent dressing-moisten with sterile normal saline
- Change dressing frequently every 2-4 hrs
- Inspect for leaks, abrasions, irritation, and signs of infection, monitor skin pre and post-surgery
- Keep prone
- Consider a possible Latex allergy
34
Age r/t injuries for infants and early children
assess for s/s of abuse: recurrent fractures, spiral fractures, inconsistent history
35
Are fractures common for >3y/o children?
yes
36
Age r/t injuries for children 4-7y/o
increased incidence of being hit by car
37
Age r/t injuries for older children/teen
- Increase incidence of sports injuries
- Teens have increased incidence of knee injuries
38
Fracture Management
Reduction – realign fragments (closed, open)
Fixation – maintain alignment thru immobilization (internal, external)
Traction – keep weights off floor by moving child
Casts
39
S/S of fractures
Generalized swelling
Pain or tenderness
Deformity
Diminished functional use of affected limb or digit
Bruising
Muscular rigidity
Crepitus
40
NI for fractures
- Determine how the injury occurred
- Assess 6 P’s
- Keep injured extremity as still as possible
- Immobilize, elevate if possible
- Soft splint
- Reassess neurovascular status (pulses, cap refill)
- Apply cold to the injured area
- Call 911
41
What is a buckle fracture
- Incomplete fracture
- Compression of one side of the bone causes the other side to bulge
- Common in young kids because their bones are soft and healthy
42
What is a contusion
damage to the soft tissue, subcutaneous structure, and muscle (bruise)
43
What is a dislocation
force of stress on the ligament is so great as to displace the normal position of the opposing bone ends or the bone end to its socket
44
What is a sprain
trauma to a joint is so severe that a ligament is partially or completely torn or stretched by the force created as a joint is twisted or wretched
45
Whats a strain
microscopic tear to the musculotendinous unit and had features in common with sprains
46
What is the therapeutic mgmt for soft tissue injury
Rest, Ice, Compression, Elevation
Ice, Compression, Elevation, Support
47
What is muscular dystrophy
Group of hereditary, genetic disorders that cause progressive degeneration of muscle fibers leading to weakness, disability, and death
48
Duchenne Muscular Dystrophy
Most common, most severe
X-linked recessive, occurs in boys
Mother carries the trait
Causes fat to replace atrophied muscle
49
Clinical manifestations for muscular dystrophy
- Mild to moderate mental impairment
- Most reach early developmental milestones (Some subtle delays - walking)
- Muscle weakness appears between 3-7 years of age
- Difficulty in running, riding a bike, climbing stairs progressing to abnormal gait (waddling) on level surfaces
- Gower sign-rising from squatting or sitting position on the floor
- Affects the pelvic girdle area and the arms
- Promote mobility and safety
50
Physical signs of muscular dystrophy
- enlarged calves: fatty infiltration, unusually firm
lordosis; weakened pelvis
- profound muscular atrophy - later stages
contractures and deformities as the disease progresses
- ambulation impossible by 9- 12 years of age
- Relentless progression until death from respiratory or cardiac failure
51
How is the cardio system affected in muscular dystrophy
Cardiomegaly may occur
52
How is the respiratory system affected in muscular dystrophy
- Respiratory muscles not involved until advanced stage
- respiratory compromise is a major cause of death due to decreased muscular function
53
What is gower's sign
Climbing up leg using the hand when rising from the floor
OR
Get on all fours to try to get up and get up eventually
54
Diagnostics MD
Muscle Biopsy
Gene testing/Genetic analysis
EMG
Creatinine Kinase-elevated
55
Complications of MD
- Contractures, scoliosis, disuse atrophy, infections, obesity, and respiratory and cardiopulmonary problems
- Pulmonary infections
- Obesity
- Cardiac involvement
56
Mgmt of MD
- bracing, wedge placement, surgery
- atrophy should be aimed at prevention with therapy
- maintain strength with ambulation for at 3 hours per day
- treatment with digoxin and diuretics - beneficial in the early stages
- Management aims towards prevention of complications & maintaining ambulatory & vital organ function as long as possible
57
what are MD patients usually on
- Corticosteroids - prednisone
- increases muscle tone
- regularly scheduled basis
58
NI for MD
- Maintain Strength, function, *respiratory function*
- Encourage fluid and nutritional intake
- Low calorie, high protein & fiber
- Physical exams, immunizations, end of life decisions
59
What is bacterial meningitis
Acute inflammation of the meninges and CSF
Brain becomes hyperemic & edematous & entire surface of the brain is covered by a layer of purulent exudate
60
Haemophilus influenza type b has been almost eradicated with the?
Hib vaccine
61
Leading cause of neonatal meningitis
GBS and E.Coli
62
S/S of bacterial meningitis in children and adolescents
Fever, chills
Headache
Vomiting
Seizures
photophobia
Irritability, agitation
Nuchal rigidity
+Kernig and Brudzinski signs
Petechial or purpuric rash
may progress to stupor or coma
63
S/S of bacterial meningitis in infants and young children
Fever!
Poor feeding!
hypothermia
Vomiting
Irritability
restlessness
Seizures
High-pitched cry
Bulging fontanel! (high pitched cry)
Nuchal rigidity possible
64
S/S bacterial meningitis in neonates
- Refuses feeding
- Poor suck ability
- Vomiting or diarrhea
- Poor tone, lack of movement
- Weak cry
- Full, bulging fontanel (late sign)
- non-specific signs: hypothermia, drowsiness, cyanosis, weight loss, jaundice, irritability
65
Priority nursing care of a child suspected of having meningitis
- LP, BCULTURE, UA BEFORE abx!!!
- Abx (rifampin)
- respiratory isolation (contact/droplet) for at least 24hrs after initiation of abx
66
Nursing care mgmt for Meningitis
- Place inisolation.
- Keep room as quiet as possible and environmental stimuli at a minimum.
- Help families limit the number of visitors until the child is and feels better.
- Seizure precautions
67
Dx for B.meningitis
Lumbar puncture (LP)
Blood cultures
CBC-elevated WBC
68
Tx for b. meningitis
EMERGENCY
Isolation (contact, droplet)
Hydration
Antibiotics
Control seizures (antiepileptic drugs)
Monitor: ICP, temperature, vital signs, seizures
Keep room quiet, decrease stimuli
I&0
Treat fever
69
Prevention edu for meningitis
- Administration of Haemophilus influenzae type b (HIB) and pneumococcal conjugate vaccine to infants at two months of age.
- Be sure to ask parents about the HIB vaccine.
70
Two types of brain tumors
- Astrocytoma: Star shaped. Highly inoperable
- Neuroblastoma: Solid mass tumor in a child usually located near the adrenal gland.
Can vary all over. Silent tumor
71
S/S of brain tumors
Headaches
Vomiting
Neuromuscular changes
Behavioral changes
Cranial nerve neuropathy
Vital sign disturbances
Seizures, Bulging fontanel, Nuchal rigidity
72
Pre-op for brain tumors
- Prepare the Family for surgery and diagnostics
- Shaving of hair, post-op dressings, positioning after, explain possible behaviors post-op
73
Post op assessment for brain tumor
Vital signs, positioning, regulation of fluids, medications
74
How often should you preform VS checks
q 15-30 mins until stable
temperature important-hyper or hypothermia
75
What infection risk is there with brain tumors
meningitis or pneumonia
76
What will neuro assessment will consist of with brain tumor
- Ocular signs assessed q1 hour
- Reflexes, grips and cranial nerves
- LOC, pupillary reaction to light, sleep patterns, response to stimuli
- sluggish, dilated or unequal pupils=increased ICP or brainstem herniation!
- regression is a reg flag!
77
How should a pt with a brain tumor be positioned
- Place on the nonoperative side
- HOB flat or slightly elevated
- Head & neck midline
78
What fluids
