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What is sac of SB covered with?
non adherent dressing with sterile saline, antiseptic, or antibiotic
Dressing care for sac of SB?
Don't remove. cont to add sterile solution to the dressing
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
2 things to document about SB sac?
appearance of the sac and the fluid/content withing it
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
Diapering of a baby with a SB sac?
do not fasten a diaper around the baby
use sterile absorbent pad underneath
Why are absorbent pads used instead of diapers with SB sac?
facilitate frequent cleaning, prevent skin B/D, and prevent contamination of sac
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
Why is it essential to monitor temp of SB sac pt?
at risk for infection
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
The nurse of pt with SB sac should perform neuro checks and palpate _____ ______ q ______ h.
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
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
Linen for SB sac pt?
2 most important nursing assessment/priorities in pt with SB sac?
monitor temp and maintain sterility
huge risk for infection
When is surgical repair of SB sac performed?
ASAP, not later than 48 h after birth
How is urination dealt with in a pt with SB sac?
intermittent cath q 4 h while awake
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
Bowel emptying in SB pt?
suppostitory or micro-enema before breakfast then sit on toilet after breakfast
may do anal sphincter stimulation
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
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
CSF build-up due to malabsorption or over-production that causes enlargement and dialtion of the ventricles of the brain and IICP
3 etiologies of hydrocephalus?
congenital, acquired, and unknown
acquired: infection, meningitis, IC bleed, or hemorrhage
4 DX for hydrocephalus?
- 1. serial measurement of head circumference
- 2. CT
- 3. MRI
- 4. lumbar puncture
Increase in head circumference that may indicate hydrocephalus?
increase of 1 inch per month
Early clinical manifestations of hydrocephalus?
- 1. increased head circumference
- 2. bulging/full anterior fontanel
- 3. distended scalp veins
- 4. widely seperated cranial sutures
Late clinical manifestations of hydrocephalus?
1. sunset eyes
2. vomiting without reports of nausea
3. HA that is relieved by sitting up
sclera of the eyes is visible above the iris due to retraction of the lid
3 goals for the management of hydrocephalus?
1. correction of hydrocephalus
2. management of complications
3. management of psychomotor dev affected
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
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
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
2 surgeries for hydrocephalus and where do they drain the CSF to?
ventriculoperitoneal - peritoneum
ventriculoatrial - R atrium of heart
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
Most serious complication of surgeries for hydrocephalus?
When is pt most at risk for infections from ventriculoperitoneal and ventriculoatrial surgeries?
1 to 2 months after placement
Appearance of infected ventriculoperitoneal or atrial shunt?
will be very swelled up
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
2 complications of shunt surgeries for hydrocephalus?>
infection & shunt malfunction due to kinking, plugging, or separtion & migration r/t growth
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
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
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
What could occur if pressure is placed on valve of shunt placed for hydrocephalus?
valve could open and rapidly decompress CSF
neuromuscular disorder of posture and mvmt with permanent damage that is nonprogressive
Cog disability in cerebral palsy?
most ppl cog is not affected
3 comorbidities that may occur with cerebral palsy?
- cognitive defecits
- hearing and visual impairments
Etiologies for cerebral palsy may be ____, _____, or ______.
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
Most common etiology of cerebral palsy?
premature/ low birth weight
Cerebral palsy AKA?
bilirubin-induced brain dysfunction
What are clinical manifestations of CP dependent upon?
area of brain injured
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
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
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
3 reasons CP pt is at risk for aspiration?
- 1. hyperextended neck
- 2. hypersensitive gag reflex can cause vomiting
- 3. increased incidence of GERD
Therapeutic management of CP includes ____ & ______.
What types of meds are used?
meds & multidisciplinary team
meds are mus relaxants, seizure meds, and meds for GERD
Interventions to help prevent tongue thrusting when feeding pt with CP?
apply firm pressure to tongue with spoon and manually manipulate the jaw
Dx evaluation of seizure disorders includes ____ & _____.
electroencephalogram (EEG) & MRI
electroencephalogram - measures electrical potential of the brain
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
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
3 considerations post - EEG?
1. may resume normal activities
2. may use acetone to remove glue
3. may wash hair
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
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
What determines clinical manifestations with seizure disorders?
area of electrical disturbance
3 groups of seizures?
partial, generalized, and unclassified
4 types of generalized seizures?
- 1. tonic, clonic, or tonic-clonic
- 2. atonic
- 3. myoclonic
- 4. absence seizure
2 types of partial seizures?
- 1. simple partial
- 2. complex partial
seizures that do not fit into generalizied or partial seizures?
4 stages of a tonic-clonic seizure?
- 1. prodromal
- 2. aural
- 3. tonic-clonic/ictal
- 4. postictal
Prodromal stage of tonic-clonic seizure?
precedes seizure by hours to days
drowsy, dizzy, malaise, lack of coordination, "not themselves"
Aural stage of tonic-clonic seizure?
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
automatisms that may be associated with aura of seizures?
lip smacking, picking at clothing, counting out change in air, walking aimlessly
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
2 results of respiratory muscles contracting during a seizure are _____ & ______.
hypoxia and cyanosis
What is the main priority during a seizure?
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
How long does the clonic stage of tonic-clonic seizure last?
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
How long does the postictal phase of tonic-clonic seizure last?
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
- 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
3 antiseizure meds?
dilantin/phenytoin, phenobarbital, tegretol/carbamazepine
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
5 S/S of absent seizures? AKA?
- 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
Seizure ass. with fever but in absence of CNS infection
Who is febrile seizures seen in?
children 3 years and younger
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
Temp above _____ ass. with febrile seizures.
38.8 C and 102 F
3 infections processes that cause increased risk for febrile seizures?
otitis media, pharyngitis, and adenitis
3 clinical manifestations of febrile seizure?
- 1. tonic, or tonic-clonic
- 2. last less than 5 minutes
- 3. don't reoccur
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
medical emergency where have continuous seizure for longer than 30 minutes or chain of seizures and doesn't return to previous LOC
3 complications of status epilepticus?
respiratory failure, permenant brain damage, and death
3 interventions for status epilepticus?
- 1. Yaunkers
- 2. O2
- 3. drug therapy
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
Most common infectious process affecting CNS?
Clinical manifestations of meningitis depend on what?
age and duration of the preceding illness
3 posture related S/S of meningitis?
opisthotonos, Kernig's sign, and Brudzinski's sign
head and heels are bent backward and body is bowed forward
body makes a u shape
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
head is flexed - if hips automatically flex is a positive sign of meningitis
Dx evaluation of meningitis?
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
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
3 interventions/considerations for viral meningitis?
- 1. self-limiting in 3 to 10 days
- 2. symptomatic treatment
- 3. no lasting effects
Prevention of bacterial meningitis?
Reye's syndrome 2 causes?
viral infection varicella or flu and salicylates
7 examples of products containing salicylates?
BC, pamprin, pepto bismol, make up, clearacil, perfume, keopectate
3 complications of Reye's syndrome?
liver dysfunction, severe hypoglycemia, coagulation defects
3 interventions/Tx of Reye's syndrome?
support respiratory function, control hypoglycemia, and reduce brain edema
5 S/S of atonic seizure?
- 1. abrupt loss of postural tone- fall down
- 2. impairment of consciusness
- 3. confusion
- 4. lethargy
- 5. sleep
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