Neuro Peds

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Neuro Peds
2013-03-25 15:16:50
Neuro nursing peds

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  1. What is sac of SB covered with?
    non adherent dressing with sterile saline, antiseptic, or antibiotic
  2. Dressing care for sac of SB?
    Don't remove.  cont to add sterile solution to the dressing
  3. What should the nurse do if dressing on SB sac becomes soiled?
    remove it, cover with new non-adhesive dressing with sterile solution ordered, continue to moisturize it with sterile solution but do not remove it
  4. 2 things to document about SB sac?
    appearance of the sac and the fluid/content withing it
  5. Positioning of a newborn with SB sac?
    side-lying position with small blanket or diaper roll under between the knees and ankles OR if sac is very large may have to be in prone position
  6. Diapering of a baby with a SB sac?
    do not fasten a diaper around the baby

    use sterile absorbent pad underneath
  7. Why are absorbent pads used instead of diapers with SB sac?
    facilitate frequent cleaning, prevent skin B/D, and prevent contamination of sac
  8. How often should temperature and V/S be assessed in a newborn with a SB sac?

    Site of temp assessment?
    temp q 1-2 h and V/S q 2-4 h depending on condition

  9. Why is it essential to monitor temp of SB sac pt?
    at risk for infection
  10. Why should the head circumference of pt with a SB sac be measured?

    How often should it be measured?
    at risk for infection / IICP

    qd to bid
  11. The nurse of pt with SB sac should perform neuro checks and palpate _____ ______ q ______ h.
    anterior fontanel

    1-2 h
  12. 5 components of neuro check in pt with SB sac?
    1. LOC:  spontaneous eye opening & response to noise/moro reflex

    2. pupil-size and reactivity

    3. mvmt of face and extremities - esp noting symmetry

    4. response to stimuli - soft and sharp

    5. primitive reflexes - moro, grasp, and rooting
  13. Special consideration when performing any procedure/assessment on a newborn with SB sac?
    use non-latex materials to decrease chance of dev latex allergy due to repeated exposure
  14. Linen for SB sac pt?
    sterile linen
  15. 2 most important nursing assessment/priorities in pt with SB sac?
    monitor temp and maintain sterility

    huge risk for infection
  16. When is surgical repair of SB sac performed?
    ASAP, not later than 48 h after birth
  17. How is urination dealt with in a pt with SB sac?
    intermittent cath q 4 h while awake
  18. Home intermittent cath for SB pt?

    When may child do this himself?
    clean procedure, use water soluble lubricant, cleanse cath with soap and water & rinse with clean water, store cleansed cath in plastic bag

    5 years old
  19. Bowel emptying in SB pt?
    suppostitory or micro-enema before breakfast then sit on toilet after breakfast

    may do anal sphincter stimulation
  20. 3 ways to do anal sphincter stimulation?
    1. wipe anus firmly with soft toilet paper

    2. apply slight pressure to each side of anus

    3. insert gloved finger into anal canal past internal sphincter and massage mucosal wall
  21. 3 interventions for musculoskeletal probs with SB?
    1. passive ROM to prevent atrophy and contractures

    2. orthopedic devices:  braces, splints, casts, and wheelchairs

    3. orthopedic surgery to max mobility
  22. Hydrocephalus?
    CSF build-up due to malabsorption or over-production that causes enlargement and dialtion of the ventricles of the brain and IICP
  23. 3 etiologies of hydrocephalus?
    congenital, acquired, and unknown

    acquired:  infection, meningitis, IC bleed, or hemorrhage
  24. 4 DX for hydrocephalus?
    • 1. serial measurement of head circumference
    • 2. CT
    • 3. MRI
    • 4. lumbar puncture
  25. Increase in head circumference that may indicate hydrocephalus?
    increase of 1 inch per month
  26. Early clinical manifestations of hydrocephalus?
    • 1. increased head circumference
    • 2. bulging/full anterior fontanel
    • 3. distended scalp veins
    • 4. widely seperated cranial sutures
  27. Late clinical manifestations of hydrocephalus?
    1. sunset eyes

    2. vomiting without reports of nausea

    3. HA that is relieved by sitting up
  28. Sunset eyes?
    sclera of the eyes is visible above the iris due to retraction of the lid
  29. 3 goals for the management of hydrocephalus?
    1. correction of hydrocephalus

    2. management of complications

    3. management of psychomotor dev affected
  30. 3 nursing interventions for a baby with hydrocephalus?
    1. hold head with palm of hand NOT fingertips

    2. use a synthetic sheepskin pad, air/water mattress

    3.  turn head q 2 h
  31. Priority nursing consideration in a baby with severe hydrocephalus?
    be careful with the head b/c the sutures are seperated and skin is stretched thin and can damage brain
  32. Tx for hydrocephalus?
    surgical placement of a shunt in the brain that will drain CSF into the peritoneal area or the R atrium of the heart
  33. 2 surgeries for hydrocephalus and where do they drain the CSF to?
    ventriculoperitoneal - peritoneum

    ventriculoatrial - R atrium of heart
  34. Where is the valve that controls shunt for hydrocephalus located and what does it do?
    behind the ear - controls flow of CSF out of ventricle
  35. Most serious complication of surgeries for hydrocephalus?
  36. When is pt most at risk for infections from ventriculoperitoneal and ventriculoatrial surgeries?
    1 to 2 months after placement
  37. Appearance of infected ventriculoperitoneal or atrial shunt?
    will be very swelled up
  38. 7 S/S that ventriculoperitoneal or ventriculoatrial shunt has become infected?
    • 1. increased temp
    • 2. poor feeding
    • 3. vomiting
    • 4. decreased responsiveness
    • 5. seizure activity
    • 6. change in child's behavior
    • 7. swelled shunt area
  39. 2 complications of shunt surgeries for hydrocephalus?>
    infection & shunt malfunction due to kinking, plugging, or separtion & migration r/t growth
  40. Nursing interventions post-op shunt replacement for hydrocephalus?
    • 1. Keep flat or no more than 30 degrees
    • 2. position on side opposite shunt for 2 days
    • 3. check VS q 15 min for 1 hour, q 30 min for 4  h, q 2 h for 24 hours, then q 4 h
    • 4. temp q 1 to 2 h
    • 5. do not feel/palpate shunt or put any pressure on it
    • 6. test any drainage for glucose with reagent strips - will show halo sign if it is CSF
  41. 6 instructions to give parents when D/C child with shunt surgery for hydrocephalus?
    • 1. Observe pump for S/S of infection: red, heat, swelling
    • 2. do not allow child to mess with pump - may need to put on a head covering
    • 3. HOB slightly elevated
    • 4. prevent constipation - can cause bowel to obstruct drainage of peritoneal tubing
    • 5. ride bike with a helmut
    • 6. call MD if have fever
  42. Why does a pt with shunt surgery for hydrocephalus need to be flat - 30 degrees?
    to prevent sudden drop in ICP r/t drainage of CSF that can cause decompression and tearing of the cerebral artery
  43. What could occur if pressure is placed on valve of shunt placed for hydrocephalus?
    valve could open and rapidly decompress CSF
  44. Cerebral palsy?
    neuromuscular disorder of posture and mvmt with permanent damage that is nonprogressive
  45. Cog disability in cerebral palsy?
    most ppl cog is not affected
  46. 3 comorbidities that may occur with cerebral palsy?
    • cognitive defecits
    • hearing and visual impairments
    • seizures
  47. Etiologies for cerebral palsy may be ____, _____, or ______.

    9 examples?
    prenatal, perinatal, or postnatal

    anoxia before, during, or after birth, maternal malnutrition/drug use/infection, birth injury, kernicterus, infection, trauma, stroke, poisoning, premature/low birth weight
  48. Most common etiology of cerebral palsy?
    premature/ low birth weight
  49. Cerebral palsy AKA?
    static encephalopathy
  50. kernicterus
    bilirubin-induced brain dysfunction
  51. What are clinical manifestations of CP dependent upon?
    area of brain injured
  52. 10 S/S of CP?
    • 1. inability to maintain posture/balance
    • 2. ataxic gait
    • 3. toe walking
    • 4. chorea
    • 5. athetoid
    • 6. difficulty holding and controlling a spoon
    • 7. hyperextended head
    • 8. hypersensitive gag reflex
    • 9. tongue thrusting
    • 10. uncoordinated mvmt of tongue, lips, and jaw
  53. Children with CP are at increased risk for ____ & ______.
    aspiration and altered nutrition r/t hyperextended head, hypersensitive gag reflex, tongue thrusting, and uncoordinated eating movements
  54. 7 complications of CP?
    • 1. contractures
    • 2. increased suseptibility to infections
    • 3. skin B/D
    • 4. compromised self - image as they grow
    • 5. caregiver role strain
    • 6. aspiration
    • 7. altered nutrition
  55. 3 reasons CP pt is at risk for aspiration?
    • 1. hyperextended neck
    • 2. hypersensitive gag reflex can cause vomiting
    • 3. increased incidence of GERD
  56. Therapeutic management of CP includes ____ &  ______.

    What types of meds are used?
    meds & multidisciplinary team

    meds are mus relaxants, seizure meds, and meds for GERD
  57. Interventions to help prevent tongue thrusting when feeding pt with CP?
    apply firm pressure to tongue with spoon and manually manipulate the jaw
  58. Dx evaluation of seizure disorders includes ____ & _____.
    electroencephalogram (EEG) & MRI
  59. EEG?
    electroencephalogram - measures electrical potential of the brain
  60. 3 things to consider pre-EEG?
    1. needs to be sleep deprived

    2. no sugar or caffeine but may eat

    3. hair should be clean and dry with no hair care products
  61. 2 considerations for during EEG?
    1. Tell the child small cups/disks will be put on their head and don't call them electrodes

    2. Tell parent/child that they will not have to cut thier hair
  62. 3 considerations post - EEG?
    1. may resume normal activities

    2. may use acetone to remove glue

    3. may wash hair
  63. Sleep deprivation pre-EEG by age?
    > 8 years old = no more than 4 hours

    <8 years old - 1/2 of normal sleep

    infants - no alterations in sleep
  64. 3 considerations for MRI?
    1. may need to sedate r/t loud sounds and claustrophobia

    2. inform about loud clicking noises

    3. head will be restrained
  65. What determines clinical manifestations with seizure disorders?
    area of electrical disturbance
  66. 3 groups of seizures?
    partial, generalized, and unclassified
  67. 4 types of generalized seizures?
    • 1. tonic, clonic, or tonic-clonic
    • 2. atonic
    • 3. myoclonic
    • 4. absence seizure
  68. 2 types of partial seizures?
    • 1. simple partial
    • 2. complex partial
  69. Unclassified seizures?
    seizures that do not fit into generalizied or partial seizures?
  70. 4 stages of a tonic-clonic seizure?
    • 1. prodromal
    • 2. aural
    • 3. tonic-clonic/ictal
    • 4. postictal
  71. Prodromal stage of tonic-clonic seizure?

    5 S/S?
    precedes seizure by hours to days

    drowsy, dizzy, malaise, lack of coordination, "not themselves"
  72. Aural stage of tonic-clonic seizure?

    6 S/S?
    peculiar sensation that precedes onset of seizure

    • 1. smelling unpleasant odors
    • 2. seeing flashing lights
    • 3. repeated hallucinations
    • 4. numbness of extremity
    • 5. cheshire cat grin
    • 6. automatisms
  73. automatisms that may be associated with aura of seizures?
    lip smacking, picking at clothing, counting out change in air, walking aimlessly
  74. 10 S/S of tonic stage of tonic-clonic seizure?

    How long does it last?
    muscles contract, fall to ground, extremities stiffen, face distorts, resp muscles contract, contraction of throat, inability to swallow, collection of saliva in mouth, biting of tongue, guttural cry

    lasts app. 20 seconds
  75. 2 results of respiratory muscles contracting during a seizure are _____ & ______.
    hypoxia and cyanosis
  76. What is the main priority during a seizure?

    preventing aspiration

    put on side and/or raise HOB, Yaunker's suction should be set up at bedside and suction things that come out of mouth but don't put inside mouth
  77. How long does the clonic stage of tonic-clonic seizure last?

    6 S/S?
    up to 5 minutes

    • 1. muscles rapidly contract & relax
    • 2. quick, jerky motions
    • 3. blow bubbles
    • 4. foamy saliva
    • 5. blood in mouth from biting tongue
    • 6. incontinent of stool and urine
  78. How long does the postictal phase of tonic-clonic seizure last?

    4 S/S?
    1 - 4 h

    • 1. falls to sound sleep
    • 2. rouse only to painful stimuli
    • 3. upon awakening will have HA
    • 4. no memory of seizure
  79. Seizure precautions?
    • CAESAR:
    • calm - dont panic
    • airway - nothing in mouth & turn on side/HOB
    • evaluate but don't restrain
    • safety - protect from injury - move stuff
    • activity - record time and describe seizure
    • remain with pt & reorient when over
  80. 3 antiseizure meds?
    dilantin/phenytoin, phenobarbital, tegretol/carbamazepine
  81. 3 instructions to parents regarding seizure pt?
    • 1. may participate in PE and sports
    • 2. avoid scuba diving, sky diving, and rock climbing
    • 3. may drive if seizures have been absent for 1 year
  82. 5 S/S of absent seizures?  AKA?
    petit mal

    • 1. staring spells over 10 sec
    • 2. unaware time has passed
    • 3. occurs 20-100 X per day
    • 4. may be accused of daydreaming
    • 5. grades may suffer
  83. Febrile seizure?
    Seizure ass. with fever but in absence of CNS infection
  84. Who is febrile seizures seen in?
    children 3 years and younger
  85. When do febrile seizures occur and what usually causes them?
    occur while temp is climbing and is usually due to height and rapidity of change in temp
  86. Temp above _____ ass. with febrile seizures.
    38.8 C and 102 F
  87. 3 infections processes that cause increased risk for febrile seizures?
    otitis media, pharyngitis, and adenitis
  88. 3 clinical manifestations of febrile seizure?
    • 1. tonic, or tonic-clonic
    • 2. last less than 5 minutes
    • 3. don't reoccur
  89. 2 things that are not effective in preventing febrile seizures?  Why?
    attempts to lower temp and tepid baths

    tepid baths do not lower temp well due to shivering increasing it and they are uncomfortable for the child
  90. Status epilepticus?
    medical emergency where have continuous seizure for longer than 30 minutes or chain of seizures and doesn't return to previous LOC
  91. 3 complications of status epilepticus?
    respiratory failure, permenant brain damage, and death
  92. 3 interventions for status epilepticus?
    • 1. Yaunkers
    • 2. O2
    • 3. drug therapy
  93. Drug therapy for status epilepticus and how is it admin?
    valium IV or rectally

    IV:  do not dilute or  mix with any drug or IV fluid except NS and admin into a large vein

    rectal:  instill via rectal catheter connected to a syringe or use a 1mL syringe and insert into rectum 1-2 cm or 1/2 to 1 inch
  94. Most common infectious process affecting CNS?
  95. Clinical manifestations of meningitis depend on what?
    age and duration of the preceding illness
  96. 3 posture related S/S of meningitis?
    opisthotonos, Kernig's sign, and Brudzinski's sign
  97. Opisthotonos?
    head and heels are bent backward and body is bowed forward

    body makes a u shape
  98. Kernig's sign?
    hip is flexed, then MD tries to extend the leg at the knee

    if pain or contraction of the hamstring occurs then positive sign for meningitis
  99. Brudzinski's sign?
    head is flexed - if hips automatically flex is a positive sign of meningitis
  100. Dx evaluation of meningitis?
    lumbar puncture
  101. CSF findings indicative of meningitis if done a lumbar puncture?
    • 1. cloudy CSF
    • 2. elevated WBC
    • 3. increased protein
    • 4. decreased glucose
    • 5. bacterial organism cultured from CSF
  102. Therapeutic management/considerations for bacterial meningitis? (5)
    • 1. is a medical emergency
    • 2. private room with droplet precautions
    • 3. will have droplet precautions for 24 h after start antibiotics
    • 4. start antibiotics before causative organisms is identified
    • 5. IV antibiotics X 10 days
  103. 3 interventions/considerations for viral meningitis?
    • 1. self-limiting in 3 to 10 days
    • 2. symptomatic treatment
    • 3. no lasting effects
  104. Prevention of bacterial meningitis?
    meningococcal vaccine
  105. Reye's syndrome 2 causes?
    viral infection varicella or flu and salicylates
  106. 7 examples of products containing salicylates?
    BC, pamprin, pepto bismol, make up, clearacil, perfume, keopectate
  107. 3 complications of Reye's syndrome?
    liver dysfunction, severe hypoglycemia, coagulation defects
  108. 3 interventions/Tx of Reye's syndrome?
    support respiratory function, control hypoglycemia, and reduce brain edema
  109. 5 S/S of atonic seizure?
    • 1. abrupt loss of postural tone- fall down
    • 2. impairment of consciusness
    • 3. confusion
    • 4. lethargy
    • 5. sleep
  110. 6 S/S of myoclonic seizure?
    • 1. brief and random
    • 2. contraction of muscle group
    • 3. loss of muscle tone
    • 4. forward falling
    • 5. occur on one side of both
    • 6. impairment of consciousness