Week 5 TUES Flashcards
peds neuro
6 y.o. has hx of febrile seizures and is admitted w/ a temperature of 102.2 degrees F. What is the highest priority?
institute safety (seizure) precautions
What statement indicates child most likely had an absence seizure?
“He was just staring into space and was totally unaware”
What finding is consistent w/ increasing ICP in an infant
bulging fontanels
The nurse suspects the child may have hydrocephalus. Which s/s was observed?
Dramatic increase in head circumference
What is a first change noted in the presence of increasing ICP?
change in LOC
The nurse observes for what reponse for the child’s eye reflex exam that would indicate potential increase ICP?
- pupils will not change in diameter in response to light
Glasgow coma scale assesses what?
- eye opening, verbal response, and motor response
What information will the nurse address when teaching the child and parent about living with this condition (chronic epilepsy)?
- support for maintaining self-esteem because of the child’s altered lifestyle
place the folling orders in the order they should be completed?
- conduct neuro assess q2hr
- complete pre-op checklist
- consult social work
- administer IV phenytoin
- Implement seizure precautions
- obtain IV access
- implement seizure precautions
- obtain IV access
- administer IV phenytoin
- neuro assess q2hr
- complete pre-op checklist
- consult social work
What assessment findings are effective, ineffective, or unrelated after a VP shunt placement
- HR 108 bpm
- resp 36 breaths per min
- increased head circumference
- temp 99.1
- alert
- bulging fontanels
Effective: resp 36 bpm, Alert
Ineffective: increased head circumference, bulging fontanels
unrelated: HR 108bpm, temp 99.1
What VS’s are most concerning for ICP?
- temp 991.
- pulse 76
- resp 24
- BP 97/66
- O2 sats 95%
- Pulse 76 (100-120)
- resp 24 (30-60)
The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply.
A. increased head circumference
B. Pulse rate of 60 beats/min and regular
C. vomiting
D. Blood pressure decreased from baseline
E. Parent states ‘my infant is not acting right’
A, B, C, E
A nurse is caring for a patient who is on ICP monitoring. At the previous assessment the ICP level was 13 mm/Hg. The nurse checks on the patient who is sleeping lying flat in bed and find the most current ICP level is 18 mm/Hg. Which of the following is the first thing the nurse will do?
A. Notify the provider
B. Reassess in 1 hour
C. Consult the charge nurse
D. Elevate the head of the bed to 30 degrees
D.
- try elevation first to drain fluid!
Which of the following is/are a part of seizure precautions? Select all the apply.
A. Padded side rails
B. Side rails raised on the bed at all times
C. Oxygen and suction at bedside
D. Medic alert bracelet
E. Lay patient flat on their back
F. Supervision during bathing and ambulating
A, B, C, D, F
- always lay the person to the side!
You are taking care of a 6-month-old who has a VP shunt that was placed shortly after birth to manage hydrocephalus. Your assessment includes to the following findings:
HR: 72 RR: 22 BP: 88/52 Temp: 36.9C
Pupils are sluggish
Head circumference 18.2cm (previous 17.5cm)
Shunt incision site is clean, dry, and intact. When you leave the room patient starts vomiting.
Which of the following are you most likely cause of the symptoms?
A. Shunt infection
B. Shunt malfunction
C. Shunt replacement due to growth
D. Head injury
Shunt malfunction
- infection occurs 1-2 months after placement> too late for infection
You just received a patient in the emergency department with possible non-accidental head trauma. Place the following items in order of priority for the nurse to complete:
A. Consulting social work
B. Assess airway
C. Conduct a neuro assessment
D. Stabilize the patient’s head
E. Obtain a head CT
D, B, C, E, A
- always stabilize the neck first!
- stabilizing the neck protects airway
The 3-year-old child is admitted to the hospital with headaches, irritability, and dizziness. The child has a history of hydrocephalus and a ventriculoperitoneal shunt that was placed when the child was 8 months old. Which of the following is the most likely cause of the symptoms?
A. Head Injury
B. Shunt infection
C. Shunt malfunction
D. Need for shunt revision
C. Shunt malfunction
- Most shunt malfunctions occur within the first 2-3 years of life when a baby has them placed when they are little because of the head growth and dependent on the age of shunt placement
What concept refers to compensatory mechanisms in the brain that operate to maintain pressure w/in the cranial cavity in a safe range
intracranial regulation
Definition: The process that impacts the brain’s state of equilibrium to ensure overall neurological function
intracranial regulation
Cheyenne Stokes respirations
- also called neuro breathing
- periods of apnea
- late stage of IICP
Why is increased ICP/ IR significant or concerning?
disruption/ alteration IR in children can lead to severe complications which may have long term impacts
When does CNS development occur?
- 4 weeks in gestation
Cranial nerve development
- cranial nerves are not fully developed and not fused at birth
- myelin not fully formed
- large head size and shape, center is gravity is off
T or F: Children are top heavy and fall a lot which increases the risk of ICP/ IR impairment
True!
- more likely for head trauma
