N301: OB/Peds

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  1. Primary Brain Injury (accel.-decal.)
    • Injury that occurs at time of insult
    • Coup - direct initial impact
    • Contrecoup - secondary impact as brain moves forward and backward w/in skull
  2. Secondary Brain Injury
    • Biochemical and cellular response to initial insult
    • can occur over hours, days, weeks
    • cerebral edema and increased ICP
  3. Clinical Manifestations of TBI
    • Posttraumatic seizures
    • Change in resp. efforts
    • Periods of apnea
    • tachycardia
    • cushing's triad - increased systolic BP, bradycardia, irreg. resps
    • Hypo/Hyper/nonexistent reflexes
  4. Indicator of Severe TBI
    • Decorticate - rigid flexion; lesions above brainstem
    • Decerabrate - rigid extension; lesions on brainstem
  5. Diagnosing TBI
    • hx
    • assessment
    • labs - CBC, CMP, tox screen, UA
    • xray
    • CT
    • MRI
    • PET - measure blood flow in brain
  6. Tx of TBI
    • mild - supportive; allow rest for brain to heal to prevent second impact syndrome (7days of no symptoms and rest and w/activity)
    • moderate - assessments, O2 sats (>95%), cluster care, proper body alignment (good circulation)
  7. Tx of increased ICP
    • airway - oxygen; intubation
    • hypothermia
    • Mannitol or hypertonic IV solution
    • treat hypovolemic shock
    • HOB 30 degrees (if not contraindicated)
    • head midline
    • quiet environment
  8. Physical Changes with TBI
    • sleep patterns
    • seizures
    • HA
    • hearing and vision
    • ability to control body temp, BP, RR
    • uni/bi lateral body weakness
  9. Behavioral Changes with TBI
    • disinhibition
    • temper outburst
    • low frustration tolerance
    • lack of interest
    • lack of motivation
    • mood swings/depression/irritability
  10. Microcephaly
    • small head and brain
    • chromosomal abnormality
    • caused by maternal infection, anoxia
    • relationship b/t microcephaly and cognitive impairments
  11. Cause of Hydrocephalus
    body's response to imbalance between production and absorption of CSF
  12. Types of hydrocephalus
    • Communicating - CSF flows freely through brain ventricles but absorption is impaired; can be cause by meningitis and IVH
    • Noncommunicating - structural defect that doesn't allow CSF to flow; can be caused by infection, hemorrhage, tumor, chiari II malformation)
  13. Chiari II malformation (noncommunicating)
    downward placement of medulla and lower cerebellum through the foramen magnum
  14. Clinical Manifestations of Hydrocephalus (infants)
    • rapid increasing head circumference
    • bulging fontanel
    • irritable & lethargy
    • poor feeding
    • distended scalp veins
    • shrill, high pitched cry
    • N/V
    • decline LOC
  15. Clinical Manifestations of Hydrocephalus (child)
    • HA
    • irritable
    • personality changes
    • vision changes
    • N/V
  16. Diagnosing of Hydrocephalus
    infants - fontanels still open; head US; daily head circumference measurement

    child - CT and MRI
  17. Tx of Hydrocephalus
    • Ventriculoperitoneal Shunt
    • infection and blockage are biggest complications
    • look for S&S of infection - fever, malaise, redness along shunt, abd discomfort
  18. Nursing Care for Hydrocephalus
    • lie flat post-op and gradually elevate HOB over a few days
    • measure HC at each visit
    • infants with enlarged heads should not be placed in forward facing car seat regardless of age
  19. Types of Neural Tube Defects
    • Spina bifida occulta - spinal cord and meninges in vertebral canal; NO OPENING BUT DIMPLE/HAIR PRESENT
    • Meningocele - protrusion of meningeal sac with CSF and meninges through vertebral defect; no abnormalities of spinal cord; BULGING PRESENT
    • Meningomyelocele - protrusion of meningeal sac with CSF, spinal cord and nerves; increased risk for rupture
  20. Causes of neural tube defect
    • low folic acid
    • alcohol
    • certain meds
    • genetics
    • increased risk in Hispanic infants
  21. clinical manifestations of neural tube defects
    • depends on where defect occurs
    • effects are more severe as the defect goes up the spinal column
    • will usually have issues with bowel and bladder above the sacral level
  22. Diagnosing Neural tube defect
    • increased alphafetoprotein
    • US
  23. Tx for Neural tube defect
    • goal is to maximize child's independence
    • surgery within first 24-48 hrs
    • braces, walkers
    • neurogenic bladder interventions d/t lack of nerve signals (intermittent caths/ stoma in belly button to self cath)
    • bowel program (increase fiber)
  24. Nursing Care with neural tube defects
    • Pre-Op
    • place sterile soaked gauze on top of defect
    • measure head circumference
    • prone position
    • hips slightly flexed and legs abducted to minimize pressure

    • Post-Op
    • prone or side lying position to allow healing
    • always use non late gloves
  25. Causes of Cerebral Palsy
    • brain insult - prematurity (injury to periventricular white matter), infection
    • severe birth asphyxia
  26. Cerebral Palsy
    group of permanent disorders of movement and posture development caused by a nonprogressive disturbance in the fetal or infant brain
  27. types of cerebral palsy
    • Spastic - increased muscle tone (stiffness), movement can be awkward (difficult)
    • Dyskinetic - uncontrollable movements (difficult to sit and walk), muscle tone can change rapidly
    • Ataxic - poor balance & coordination, unsteady when walking, difficulty with quick movements and reaching for items (writing)
    • mixed - show characteristic from multiple categories
  28. diagnosing cerebral palsy
    • delays in meeting developmental milestones
    • prolonged reflexes present (they don't disappear when they are supposed to)
    • increased or decreased muscle tone
    • history
    • CT and MRI
  29. Tx of Cerebral Palsy
    • achieve maximum independence
    • PT, OT, speech
    • nutrition - increased calories through Gtube
    • braces, splints, promote ROM
    • scooters, wheelchairs
    • medications to decrease spasms (Baclofen)
  30. Bacterial Meningitis
    • Neisseria Meningitis
    • Group B strep
    • infection spreads to brain and WBC cover brain with thick, white, purulent exudate
  31. Viral Meningitis
    • Enterovirus
    • inflammation of meninges
  32. Clinical Manifestations of  Meningitis
    • don't appear ill with viral
    • nuchal rigidity
    • stiff neck
    • fever (high with bacterial)
    • poor sucking
    • lethargy
    • photophobia
    • irritable
    • opisthotonic position
    • bulging fontanel
    • petechiae progressing to purpura
    • positive kernig - raise leg with knee flexed and extend - will have pain or resistance if positive
    • positive brudzinski - flex head in supine position - knee or hip will flex if positive
  33. Diagnosing Meningitis
    • history
    • CBC, blood cx, CMP, clotting factors
    • Lumbar puncture (don't do if increased ICP) - will show low glucose, high WBC, high protein, and will be cloudy
  34. tx of meningitis
    • IV abx (bacterial)- up to 21 days
    • steroids to decrease edema in brain
    • supportive (viral) - IV fluids, room dim and quiet, frequent assessments, pain meds)
  35. nursing care with meningitis
    • tx as if bacterial until it is ruled out
    • if caused by herpes, treat with acyclovir
    • contact and droplet precautions
    • monitor for SIADH
  36. Lead Poisoning
    • interferes with normal cell function of nervous system, blood cells, and kidneys
    • adversely affects metabolism of vitamin D and calcium
    • accumulates in blood, soft tissues, bones and teeth and is released slowly
    • CDC recommends screening kids in Medicaid and those at risk 12-24months
    • tx with chelation therapy - agent binds to lead, decreasing its effects and increasing its rate of excretion
    • tx is considered for levels >45 and is needed for levels >70
    • home must be lead free before discharge
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N301: OB/Peds
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