Leishmaniasis

1
Altered Neurological Functions

2
Assessment of cerebral functions

• Young children lt 2 years require special
  evaluation because they are unable to responds
  directions
• Early neurologic responses are primarily
  reflexive, replaced by meaningful movement. This
  evidence of progressive maturation reflects more
  extensive myelinization changes in
  neurochemical electrophysiological properties

3

• Most information about infants small children
  is gained through observation of elicited reflex
  responses, development of increasingly complex
  locomotors fine motor skill, eliciting
  progressively communicative adaptive behaviors,
  delay or deviation from expected milestones
• Obtain history of the pregnancy, delivery,
  respiratory status at birth, neonatal health to
  determine the effect of intra uterine extra
  uterine environmental influences that affect the
  maturation of the CNS

4
History

• The history should carefully document in
  chronological order the onset of symptoms a
  thorough description of their frequency,
  duration, associated characteristics.
• Most children beyond the age of 34 yr are
  capable of contributing to their history,
  particularly about facts relating to the present
  illness.

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• It is essential to obtain a comprehensive review
  of the function interaction of all organ
  systems, because abnormalities of the CNS may
  initially present with clinical manifestations
  (e.g., vomiting, pain, constipation, or UT
  disorders).
• A detailed history might suggest that the child's
  vomiting is due to increased (ICP), that the pain
  behind the eye may be caused by migraine
  headaches or multiple sclerosis, that the
  constipation urinary dribbling may be due to a
  spinal cord tumor.

6
Physical Examination

• Size shape of the head
• Activity, postural reflex activity, sensory
  responses
• Extremities movements
• Facial features high pitch cry
• Hyperventilation, abnormal respiratory cycle,
  prolonged apnea
• Level of development, neurologic functions
• Muscular activity coordination including ocular
  movements gait, facial movement mouth
  functions

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• Assess LOC by using motor cues
• Test attention span concentration by asking the
  child to repeat a series of numbers after you
• Test the child's recent memory by showing him a
  familiar objects, waiting 5 minutes, the asking
  him to recall the object

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• Developmental delay the nurse' role is to
  establish a baseline measure, support the child
  family to assist in the provision of services
• Often children with developmental delays have
  scattered performance, exhibiting one age of
  development in the physical domain, another in
  the language domain another in the
  personal-social or self-help domain
• This assessment includes a thorough history,
  which focus on risks factors, description of gait
  achievement of developmental milestones.

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Cerebral Palsy

• CP is a non-progressive disorder accompanied by
  perceptual problems, language deficits
  intellectual involvement

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Spastic
Dyskinetic/athetoid
Ataxic
dystonic
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Clinical classification

• Spastic may involve one/both sides
  hemiparesis/quadriparesis
• Hypertonicty with poor control of posture,
  balance
• Impairment in fine gross motor
• It represents an upper motor neuron type of
  muscular weakness increased stretch reflexes,
  increased muscle tone, hypotonia or decreased
  tone

• Dyskinetic/athetoid
• Abnormal involuntary movement, slow wormlike,
  writhing movement involve the extremities, trunk,
  neck, facial muscle tongue
• Affect pharyngeal, laryngeal oral muscles ?
  drooling dysarthria imperfect speech
  articulation
• Jerky movement, dystonic in muscle tone

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• Ataxic
• Wide-based gait
• Rapid, repetitive poorly performed movement
• Disintegration of movement of upper extremities
  when the child reaches for objects

• Mixed type/ dystonic combination of spasticity
  athetoid

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Causes

• Prenatal
• Genetic syndrome
• Chromosomal abnormalities
• Brain malformations
• Intrauterine infection

• Perinatal
• Sepsis, CN infection
• Asphyxia
• Prematurity

• Childhood
• Meningitis
• Traumatic brain injury
• Toxins
• Vascular accidents.
• Anoxia.
• Neoplastic late neuro-developmental defects.

• Labor delivery
• Preclampsia
• Complicated labor
• Hyperbilirubinemia. Hemolytic disorders.
• Respiratory distress. Infections.
• Electrolyte disturbances (hypoglycemia,
  hypocalcemia).
• SGA
• Cerebral trauma during delivery.

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Pathophysiology

• No pathogenic picture, but there are gross
  malformations of the brain vascular occlusion,
  atrophy, loss of neurons
• Anoxia plays the most significant role in the
  pathologic state of brain damage
• CP associated with prematurity is usually spastic
  diplegia caused by hypoxic infarction or
  hemorrhage in the lateral ventricle
• In athetoid type of CP caused by kernicterus
  hemolytic disease of the newborn, pigment
  deposits in the basal ganglia some cranial
  nerves nuclei.
• Cerebral hypoplasia, neonatal hypoglycemia are
  related to ataxic
• CP generalized cortical cerebral atrophy ?
  severe quadriparesis with mental retardation
  microcephaly.

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Complications

• Impaired physical mobility
• Self-care deficits
• Physical injury
• Impaired communication
• Mental impairment
• Contracture

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Clinical manifestations

• All types
• Delayed gross motor development
• Abnormal motor performance coordination can
  manifest early in life as poor sucking feeding
  difficulty
• Posture abnormality occurring at rest or when
  changing position
• Altered muscle tone
• Increased or decreased resistance to passive ROM
• Opisthotonic postures "exaggerated arching of the
  back"
• Spasticity of hip muscle lower extremities,
  making diapering difficult

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• Abnormal reflexes
• Persistent primitive reflexes
• Other disabilities
• Mental retardation of varying degrees in 18 -
  50 of patients "most children have at least a
  normal IQ but can't demonstrate it on
  standardization tests"
• Seizures
• ADHD distractibility, deficit of integration
• Sensory deficits vision-hearing- speech

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1. Drooling Contribute to wet clothing skin
   irritation, abnormal posture motor performance,
   alteration in muscle tone, affect chewing,
   swallowing talking
2. Aspiration Coughing chocking especially while
   eating
3. Inadequate gas exchange uncoordinated weak
   respiratory efforts
4. Orthopedic complications Unilateral or bilateral
   hip dislocation, scoliosis, joint contracture due
   to unbalanced muscle tone
5. Constipation Due to decreased mobility
   difficulty in toileting, difficulty in eating
   bulky foods because of uncoordinated chewing
   swallowing

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• Dental caries It results from
• Improper dental hygiene
• Congenital enamel defects hypoplasia of primary
  teeth
• High carbohydrate intake retention
• Dietary imbalance with proper nutritional intake
• Inadequate fluoride
• Difficulty in mouth closure drooling
• Oral hypersensitivity ? resists dental hygiene

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Therapeutic Management

• Goal of therapy
• Early recognition promotion of an optimum
  development course
• Therapy is symptomatic preventive only disease
  is permanent
• Early recognition diagnosis provide the
  sensorimotor experiences for cognitive
  development
• Establish locomotion, communication self help
• Gain optimum appearance integration of motor
  function
• Correct associated defects
• Provide educational opportunities adapted to the
  needs capabilities of the individual child
• Promote socialization experiences with other
  affected unaffected child

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• Delivers baclofen, a skeletal muscle relaxant,
  directly to the intrathecal space around the
  spinal cord
• Use to treat spasticity
• Pump last for 3-5 years, after that time, a new
  pump must be implemented
• Muscle relaxant or neurosurgery to decrease
  spasticity
• Anticonvulsant phenytoin luminal to control
  seizures
• An artificial urinary sphincter may be indicated
  for the incontinent child who an use the hand
  control
• Orthopedic surgery to correct contractures
• Braces or splints special appliance such as
  adapted eating utensils a low toilet seats with
  arms, to help the child perform activity
  independently

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Nursing Diagnoses

• Impaired physical mobility related to altered
  neuromuscular functioning
• Delayed GD related to the nature extent of the
  disorder
• Interrupted family processes related to the
  nature of the defect, the demands of daily
  management, and resultant changes in family life
• Risk for Injury related to deficit in motor
  activity and coordination

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Nursing Interventions

• Institute a high- calorie diet for the child with
  increased motor function to help him up with
  increased metabolic demands
• Perform ROM exercises to minimize contracture
• Assist with locomotion, communication
  educational opportunities
• Promote age appropriate mental activities
  incentives for motor development to promote GD
• Make food easy to manage to decrease stress
  during meal time

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1. Provide rest period to promote rest reduce
   metabolic needs
2. Provide a safe environment for example, have the
   child use protective headgear or bed pads to
   prevent injury
3. Provide tasks into small steps to promote self
   care activity increase self esteem
4. Refer the child for speech, nutrition physical
   therapy to maintain or improve functioning
5. If the child cant speech, use assistive
   communication devices to promote a positive self
   concept
6. Assist family members in setting realistic goals
   managing stress

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• Mental retardation significant sub-average
  general intellectual functioning existing
  concurrently with deficits in adaptive behaviour
  manifested during the developmental period
• Adaptive behaviours maturation, learning skill
  social adaptation of the person.

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Causes of mental retardation

1. Prenatal factors genetic defects, chromosomal
   abnormalities, complex malformation syndrome,
   toxic exposure, congenital defects, Rh, ABO
   incompatibility, toxemia, placental insufficiency
   or Antepartum hemorrhage, infections
2. Perinatal factors complications with
   prematurity, hypoxic-ischemic episode,
   infection, maternal overdose of medication during
   labor
3. Post natal factors childhood diseases,
   accidents, anoxia infection e.g. meningitis,,
   poisoning, Hyperbilirubinemia, influences in the
   childs environment, metabolic disorder, trauma,
   severe deprivation

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Diagnosis Delay in language, cognitive skills,
gross motor skills

• Classification of mental retardation
• Mild retarded (educable IQ range 55-69)
• Individuals may be able to learn academic skills
  to sixth grade level are able to master simple
  occupational skills if given opportunities
  instructions
• Social communication skills are good, they may
  be able to help support themselves as adults
• Moderately retarded (treatable IQ range 40-54)
• Persons can learn the basics of self care in
  childhood functional academically at the low
  grade level
• They may be able to accomplish simple work with
  very close supervision

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• Severely retarded (IQ range 25-35)
• People need to a controlled environment in which
  by adulthood, they are able to learn the skills
  of communication, self-protection, hygienic
  sheltered/workshop vocation
• They may learn a few wards have basic
  communication skills
• Profound retarded (IQ range lt 25)
• People usually need complete care supervision
  during all their lives, but may show some motor
  speech development
• They have very limited self-care skills

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Down Syndrome DS

• Etiology
• Unknown
• Genetic predisposition 3-6 of the cases
  translocation of chromosome 21
• Radiation prior to conception
• Infection
• Advanced maternal age age of 35 risk is 1/385
• Age of 40
  risk is 1/106
• Age
  of 45 risk is 1/30

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• Abnormal physiological functioning affects
  thyroid metabolism hypothyroidism intestinal
  malabsorption, frequent infection due to impaired
  response,
• Decreased buffering of metabolic processes
  results in predisposition to hyperuricemia
  increased insulin resistance, DM develops
  cataract, Alzheimer disease, bone marrow
  dysfunction is indicated by leukemia.

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Clinical manifestations

• Intelligence
• Severely retarded low average intelligence
• Social development
• 2-3 years beyond the mental age especially during
  early childhood
• Sensory problems
• Ocular problems strabismus, nystagmus, myopia,
  cataract
• Up slanting palpebral fissures

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• Premature aging, early graying or loss of hair,
  ?skin tone
• Mouth teeth, tongue protrusion, fissured
  furrowed tongue, mouth breathing, drooling,
  malformed teeth
• Nose, Hypoplastic nasal bone, flat nasal bridge
• Chest internipple distance is decreased, short
  rib cage
• Abdomen umbilical hernia, protruding
• GI duodenal atresia, Hirschsprung disease,
  imperforated anus
• Skeleton short broad hands, muscle weakness,
  hyper-extensible finger joints, hypotonic

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• Growth
• short stature obesity
• Ht, Whg is reduced ?? whg
• Behaviour warmth, cheerful, gentleness, patience
• Psychiatric disorders autism, ADHD, obsessive
  compulsive disorders

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Complications

1. Seizures disorders, 5-10 tonic-clonic seizures
2. Delayed Growth
3. Physical injury
4. Aspiration
5. Death
6. Hearing loss, conductive or mixed or
   sensorineural losses, OM, narrow canal, impacted
   cerumen

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• Sexual development
• Delayed incomplete or both
• Women with DS are fertile
• Men with DS are infertile
• Congenital anomalies
• Congenital heart disease 40-50 endocardial
  cushion defect, VSD, ASD, TOF, PDA
• Renal agencies
• Duodenal atresia, Hirschsprung disease, TEF
• Skeletal defect
• Microcephaly

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Therapeutic Management

• No cure for DS
• Surgery to correct serious congenital anomalies
• The presence of DS alone doesnt adversely affect
  the outcome of surgery in the absence of
  pulmonary hypertension
• Adeno-tonsillectomies for obstructed sleep apnea
• Prevent dental caries through appropriate dental
  hygiene, fluoride treatment, good dietary habits

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• Early intervention program
• Feeding, fine gross motor development. Early
  gavage feeding if necessary because the infants
  sucking reflex may be poor
• Language personal social development
• Evaluation of sight hearing
• Treatment of OM
• Special growth chart

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• Atlantaxial instability symptoms include neck
  pain, weakness, however most affected children
  are asymptomatic.
• Screening done on the 2nd birthday before
  engage in physically active exercise or sports
• If children become symptomatic, they should
  receive prompt attention because risk of spinal
  cord compression

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• Genetic counseling recurrence risk 1
• Immunization medications
• Usual immunization
• Test for thyroid hormones to prevent intellectual
  deterioration
• Sub acute bacterial endocarditis prophylaxis
• Digital diuretics for cardiac mgt
• Treat skin disorders with whg reduction, frequent
  bath

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Nursing Considerations

• Provide activities toys appropriate for the
  child to support optimal development
• Support family at time of diagnosis
• Promote childs developmental progress
• The hypotonicity affects muscular development,
  supporting skills may be delayed
• Stimulation programs is encouraged
• Developmental screening tests to evaluate
  indications of progress e.g. strength, balance,
  coordination or muscle tone
• Investigate appropriate day care programs

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• Assist family in preventing physical problems
• The extended body position promotes heat loss,
  because more surface area is exposed to the
  environment
• Parents are encouraged to swaddle or wrap the
  infant tightly in a blanket to provide security
  warmth
• Discuss with parents about feeling concerns of
  attachment

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• Decreased muscle tone compromises respiratory
  expansion under developed nasal bone ? chronic
  problem of inadequate drainage of mucus ? URTI,
  ear infections, so clearing the nose, increased
  fluid intake, change the childs position,
  performing postural drainage
• Feeding, large protruding tongue hypotonic
  interferes with feeding, tongue thrust is a
  physiologic response not a cause for feeding
  refusal
• Dietary intake needs supervision, ? muscle tone
  affects gastric motility ? constipation
• Careful monitoring to prevent obesity

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• Assist in prenatal diagnosis genetic counseling
• Provide activities toys appropriate for the
  child to support optimal development
• Set realistic reachable goal break tasks into
  small steps to make them easier to accomplish
• Use behavior modification, if applicable to
  promote safety prevent injury to the child
  others
• Provide stimulation communicate at a level
  appropriate to the child's mental age rather than
  chronological age to promote a healthy emotional
  environment

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• Provide a safe environment to prevent injury
• Mainstream daily routines to promote normalcy
• Encourage parents to care for, bond with hold
  their child
• Teach parents to perform all of the above
  interventions because care will mostly be
  provided at home by the parents

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Head Injury

• Causes
• Motor vehicle related accidents
• Child abuse
• Vigorous shaking
• Bicycle accidents especially in those without
  helmets
• Sports accidents especially in those without
  helmets
• Falls

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Pathophysiology

• The intracranial components are damaged because
  of a force too great to be absorbed by the skull,
  muscles, ligaments that support the heads
• The skulls of infants children are pliable
  can absorb much of the physical impact, providing
  some level of protection to the intracranial
  components, but they have a larger head size
  less support from muscle ligaments making them
  more prone to acceleration deceleration
  injuries

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Types of head injury

1. Scalp laceration- can cause a child to bleed to
   death because of the vascularity of the surface
   area
2. Epidural, intracranial hemorrhage- bleeding into
   the space between the dura mater the skull
3. Subdural hemorrhage- bleeding between the dura
   mater the archnoid layer of the meninges
4. Concussion- a transient state of neurologic
   dysfunction caused by a jarring of the brain

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• Contusion- sign of petechial hemorrhage on the
  superficial aspects of the brain at the site of
  the impact
• Skull fracture
• Linear simple
• Depressed- depression of a bone towards the brain
• Basilar- "at the skull base"

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Complications

1. Hemorrhage
2. Infection
3. Edema
4. Herniation

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Assessment findings

• Change in LOC or mental status
• Confusion
• Restlessness
• Irritability
• Pale skin
• Vomiting
• Increased head circumferences
• Bulging fontanels
• Hemiparesis, quadriplegia
• Headache
• Decreased memory
• Diminished pupillary responses

51
Medical Management

1. Medications Benadryl used to decrease
   restlessness
2. Acetaminophen may be used to treat headache
3. Anticonvulsant are used to control seizures
4. Antibiotics the child sustain a laceration or
   leaks CSF
5. Lacerations of the scalp dura are sutured
6. Fractures require surgery to remove scattered
   bone fragments

52
Nursing Interventions

• Prepare for surgical evaluation of the injury
• Promote bed rest limit unnecessary body
  movements, slightly elevate the head of the beds
• Initiate seizure precautions
• Provide a quiet environment
• Awaken the child Q 2 hours to check his LOC

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• Monitor fluid status carefully, restrict fluids a
  needed to decrease ICP
• Prevent injury through family community
  teaching programs to stress child safety
• Check ear or nose drainage for glucose "CSF tests
  positive for glucose
• Note behavioral changes such as aggression,
  withdrawal, irritability" watch for alterations
  in sleep pattern, gait or school performance"

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Hearing Loss

• The inability to perceive the normal range of
  sounds that's audible to a person with normal
  hearing
• Sudden hearing loss in a person with a previous
  hearing impairment is considered an emergency
  because prompt treatment may restore full hearing

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Causes

• Congenital may be transmitted as a dominant,
  autosomal recessive or sex linked recessive trait
• Certain conditions during pregnancy or delivery
  may cause hearing loss in neonates
• Trauma- prolonged fetal anoxia, ICH causing
  damage to the cochlea or acoustic nerve
• Toxicity- ototoxic drugs, SB gt 20mg\dl
• Infection- rubella, syphilis
• Prematurity or LBW neonates- most likely to have
  structural or functional hearing impairment

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• Causes specific to sudden hearing loss
• Metabolic disorders- DM
• Vascular disorders- hypertension
• Head trauma or brain tumors
• Ototoxic disorders
• Blood dyscrasias- multiple sclerosis
• Prolonged exposure to loud noise or brief
  exposure to extremely loud noise causes noise-
  induced hearing loss
• Repeated otitis media
• Foreign objects
• Cerumen accumulation

57
Pathophysiology

• Conductive- interrupted passage of sounds from
  the external ear to the junction of the stapes
  oval window
• Sensorineural - impaired cochlea or acoustic
  8th CN" dysfunction, causing failure of
  transmission of sounds impulses within the inner
  ear or brain
• Mixed- combined dysfunction of conduction
  sensorineural transmission

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Complications

• Physical injury
• Altered perception

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Assessment findings

• A deficient response to auditory stimuli- this
  generally becomes apparent within 2-3 days of
  life
• No reaction or turning to locate a sound or
  doesn't respond to being repeatedly called by
  name unless the speaker's lip are visible
• Lack of response to simple verbal commands or
  questions
• Not soothed by music or by being read to

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• As the child grows older, impaired speech
  development
• Doesn't develop recognizable speech
• Fails to vocalize, remains at the babbling stage,
  or shows decreased babbling
• Poor academic performance
• Tendency to listen to radio TV at high volumes
• Straining to hear
• History to premature birth, meningitis, maternal
  prenatal history of rubella or use of toxic
  medications such as gentamycin

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Medical Management

• Aggressive immunization against rubella in
  children positive titers in pregnant women to
  prevent congenital hearing loss
• Hyperbilirubinemia can be controlled by
  phototherapy exchange transfusions
• Judicious use of toxic medications in children
• Overnight rest for children with noise-induced
  hearing loss
• Alterations in the location or shape of the ears
  warrant an evaluation of kidney function because
  these organs develop simultaneously in utero

62
Nursing Interventions

• Refer a child with suspected hearing loss to an
  audiologist or otolaryngologist for further
  valuation
• Develop the patient's ability to communicate
  through sign language, lip reading, or other
  effective means
• Educate pregnant women about the danger of
  exposure to drugs, chemicals, or infection
  carefully monitor during labor delivery to
  prevent fetal anoxia
• Educate parents children about the dangers of
  noise exposure encourage the use of protective
  devices in a noisy environment

63

1. Stand directly in front of the patient with
   hearing loss when communicating him
2. Make sure the light is on your face, speak
   slowly distinctly
3. If possible, speak to him at eye level
4. Approach the patient within his visual range,
   elicit attention by raising your arm or waving,
   touching him may be unsuccessful starting
5. Wait for the child's attention before speaking
6. Decrease additional noise in the room
7. Use demonstration to explain procedures
   treatments before initiating them

64
Hydrocephalus

• Hydrocephalus a condition of altered production,
  flow, or absorption of (CSF). It is characterized
  by an abnormal increase in CSF volume within the
  intracranial cavity and by enlargement of the
  head in infancy.
• When production is greater than absorption, CSF
  accumulates within the ventricular system,
  usually under increased pressure, producing
  passive dilation of the ventricles.

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Causes

• Noncommunicating
• Congenital anomalies
• Infection- syphilis, meningitis
• Tumor
• Cerebral aneurysm
• Blood clot after intracranial hemorrhage
• Communicating
• Failure in the absorption system cause unknown.
• Excessive production of CSF tumor or unknown
  causes (rare).
• Surgery to repair a myelomeingocele
• Adhesions between meninges at the base of the
  brain or meningeal hemorrhage
• Rarely a tumor in the archnoid plexus that causes
  an overproduction of CSF

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Pathophysiology

• The two mechanisms by which CSF is formed include
  secretion by the choroids plexuses lymphatic
  like drainage by the ECF of the brain.
• CSF circulates throughout the ventricular system,
  then absorbed within the subarchnoid spaces by a
  mechanism that isnt entirely clear

67

• Hydrocephalus is a symptom of an underlying brain
  disorder resulting in either
• Impaired absorption of CSF within the subarchnoid
  space communicating hydrocephalus
• Obstruction to the flow of CSF within the
  ventricles non-communicating hydrocephalus
• Any imbalance of secretion absorption causes an
  increased accumulation of CSF in the ventricles,
  which become dilated compress the brain
  substance against the surrounding rigid bony
  cranium
• It produces enlargement of the skull, as well as
  dilation of the ventricles

68
Complications

• Physical injury
• Delayed GD
• Decreased intracranial adaptive capacity
• Seizures.
• Herniation of the brain.
• Spontaneous arrest due to natural compensatory
  mechanisms, persistent increased ICP, and brain
  herniation.
• Developmental delays.
• Depression in adolescents is common.

69
Assessment Findings

• Early infancy
• Abnormally rapid head growth (may be seen up to
  age 3).
• Bulging fontanel tense
• Dilated scalp veins
• Separated sutures
• Thinning of skull bones
• Delayed closure of the anterior fontanelle.
• Signs of increased intracranial pressure.
• Alteration of muscle tone of the extremities,
  including clonus or spasticity.
• Later physical signs
• Forehead becomes prominent bossing.
• Scalp appears shiny with prominent scalp veins.
• Eyebrows and eyelids may be drawn upward,
  exposing the sclera above the iris.
• Infant cannot gaze upward, causing sunset eyes.
• Strabismus, nystagmus, and optic atrophy may
  occur.
• Infant has difficulty holding head up.
• Child may experience physical or mental
  developmental lag.

70

• Later infancy
• Frontal enlargement or bossing
• Depressed eyes
• Setting sun sign sclera visible above the iris
• Unequal response to light
• Irritability
• Lethargy
• Change level of consciousness
• Lower extremity spasticity
• Vomiting
• Advanced cases difficulty in sucking feeding,
  high pitch cry

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• Childhood
• Headache on awakening improvement followed emesis
  or upright position
• Papilledema
• Strabismus
• Irritability
• Lethargy
• Apathy
• Confusion
• Incoherence
• Vomiting

72
Medical Management

• The treatment of hydrocephalus is directed
  toward
• Relief of the hydrocephalus
• Treatment of complications
• Management of problems related to the effect of
  the disorder on psychomotor development
• The treatment is surgical by direct removal of an
  obstruction or shunt procedure that provides
  primary drainage of the CSF from the ventricles
  to the extra cranial compartment usually the
  peritoneum VP shunt
• Anticonvulsants drugs for seizures Tegretol,
  Luminal, Valium
• Removal of tumor if present

73
Shunt Complications

• Need for shunt revision frequently occurs because
  of occlusion, infection, or malfunction,
  especially in the first year of life.
• Shunt revision may be necessary because of growth
  of the child. Newer models, however, include
  coiled tubing to allow the shunt to grow with the
  child.
• Shunt dependency frequently occurs. The child
  rapidly manifests symptoms of increased ICP if
  the shunt does not function optimally. Onset may
  be sudden or insidious.
• Children with VA shunts may experience
  endocardial contusions and clotting, leading to
  bacterial endocarditis, bacteremia, and
  ventriculitis or thromboembolism and cor
  pulmonale.
• Children with VA shunts require biannual or
  annual chest X-ray to check length of tubing.
  Chest X-ray is also done during growth spurts,
  especially during puberty. When tubing is short
  or close to being out of the right atrium, shunt
  replacement needs to be scheduled.

74
Nursing Interventions

• Head circumferences is measured daily at the
  point of largest measurement- the occipitofrontal
  circumference
• Palpate fontanels for bulging, tenseness,
  separation
• Monitor vital signs IO
• Assess neurologic status
• Support the child's head circumference when the
  child's is upright
• Provide proper skin care to the head, turn it
  frequently
• Teach parents signs of increasing ICP

75
Post operative care

• Routine post operative care observation are
  instituted
• The child is positioned on the unoperated side to
  prevent pressure on the shunt valve pressure
  areas
• The child is kept flat to help avert
  complications resulting from too rapid reduction
  of intracranial fluid
• Elevate the head of bed or allow the child to sit
  up to enhance gravity flow through the shunt
• Pain management with acetaminophen with or
  without codeine for mild to moderate pain

76

• Observe for signs of ICP, which indicates
  obstruction of the shunt is continued
• IV infusion is monitored to prevent fluid
  overload
• Neurologic assessment includes evaluation of
  papillary dilation pressure causes compression
  or stretching of the oculomotor nerve, producing
  dilation of the same side as the pressure
  blood pressure hypoxia to the brainstem causes
  variability in these vital signs
• The child may have abdominal distention because
  CSF may cause peritonitis or a post operative
  ileus as a complication of distal catheter
  placement

77

• Fluid restriction with NPO\ 24 hrs
• Routine feeding is resumed after the prescribed
  NPO period, listen to bowel sounds is determined
  before feeding children with VP shunts
• Antibiotics by IV route in case of infection
• Meticulous care is continued postoperatively with
  extra care taken to prevent tissue damage from
  pressure

78
Impaired Vision

• The totally absent of sight even with correction
  or limitation in vision
• Legal blindness- optimal visual acuity of a
  20\200 or less in the better eye after best
  correction
• Severe visual impairment- describes visual
  impairment in someone who can't read ordinary
  newsprint even with correction
• Visually impairment- impairment vision in someone
  who has difficulty reading ordinary newsprint
• Low vision- impairment vision that can't be
  improved by conventional eyeglasses, contact
  lenses, medications

79
Causes

• Preventable- Xerophthalmia- dryness of
  conjunctiva cornea from vitamin A deficiency
• Acquired- glaucoma
• Complications
• Physical injury
• Altered perception

80
Assessment Findings

• Eyes may not be at the same level
• The juncture of the pinna not form a straight
  line from the lateral corner of the eyes
• Possible strabismus
• Possible nystagmus
• Delayed acquisition of behavior pattern
• Delayed posture control acquision of
  developmental tasks
• Disadvantaged in unfamiliar surroundings
• More dependent than usual

81

• Inhibited exploration because of frightening
  intimating experiences such as the feelings of
  falling
• Self stimulating behavior such as eye rubbing or
  body rocking
• Inability to fixate on objects, follows a moving
  light, or reaches out to objects
• Lack of initiation of eye contact with the
  parents
• Head tilting or frequent blinking or squinting
• Holding the head very close to book or work
• Walking or crawling into furniture or people

82
Medical Management

1. Dependent on specific cause
2. Laser eye surgery
3. Traditional surgery
4. Medication
5. Corrective lenses

83
Nursing Interventions

• Assist the child in learning to understand the
  world through the other senses
• Encourage the parents to treat the child normally
  to stimulate the child's senses with play
  touch
• Encourage exploration independence arrange
  furniture to promote mobility safety
• Acts as the child's safety advocate

84

• Announce yourself on entering the room, explain
  intended actions before doing them
• Explain strange sounds to the child
• Teach the parents tips for the child with partial
  sight
• Seat the child at the front of the classroom
• Use large print material
• Use contrasting wall colors

85
"ICP"

• The brain enclosed in solid bony cranium, well
  protected, highly vulnerable to pressure that
  accumulate with in the enclosure.
• Volume "brain 80, CSF 10, blood 10"
  remain the same at all times. Increased or
  decreased in intra cranial blood accompanied by a
  compensatory change in CSF "decrease in
  production of CSF, increase in CSF absorption,
  shrinkage of brain mass by displacement of ICF
  ECF"
• Children with open fontanels compensate by skull
  expansion, widened sutures

86
Causes

1. Tumors or space-occupying lesions
2. Accumulation of fluid with in the ventricular
   system
3. Bleeding or hemorrhage,
4. Edema of cerebral tissue
5. Trauma

87
Pathophysiology

• Initial increase in blood flow as a result of
  venous congestion or vascular paralysis
• In cerebral hypoxia associated with cerebral
  dysfunction, the compensatory vasodilatation
  caused by oxygen deficiency? increase the
  cerebral flow, blood flow is reduced as ICP is
  increased with diminished blood supply to brain
  tissue
• Signs "widening pulse pressure, ? BP" which
  rarely in children

88
Developmental manifestations of increased ICP

• Infant
• Poor feeding or vomiting
• Irritability or restlessness
• Lethargy
• Bulging fontanel
• High-pitch cry
• Increased head circumference
• Separation of cranial sutures
• Distended scalp veins
• Eye deviated down-ward "setting sun sight"
• Increased or decreased response to pain

89

• Child
• Headache
• Diplopia
• Mood swings
• Slurred speech
• Papilledema "after 48hrs"
• Altered level of consciousness
• Nausea vomiting especially in the morning

• Late signs
• Diminished response to noxious stimuli
• Altered pupil size reactivity- sudden fixed
  dilated pupil, unilaterally or bilaterally- is a
  neurosurgical emergency
• Posturing- decerebrate or decorticate
• Papilledema

90
Medical Management

• Subdural tap- a needle inserted into the anterior
  fontanel helps relieve ICPs to treat infections
• Ventricular tap- a needle inserted into lateral
  ventricle removes CSF relieves ICP
• Hyperventilation via mechanical ventilation, if
  possible, to decrease carbon dioxide levels in
  the blood
• Medications
• Antibiotic
• Corticosteroids to treat inflammatory conditions
  edema
• Osmotic diuretics such as mannitol to treat
  cerebral edema
• Barbiturates such as pavulon to treat decreased
  ICP
• Anticonvulsant to control seizures activity

91
Nursing interventions

• Monitor neurologic status frequently including
  LOC pupil size reactivity
• Monitor ICP, report deviations maintain patency
  calibration of ICP monitor
• Ensure patent airway
• Clear accumulated secretions, noting that
  suctioning may elevate ICP
• Monitor mechanical ventilation

92

• Minimize ICP
• Maintain the head of the bed at 15-30 degree
• Position the child with his head midline to
  promote drainage of the venous system avoid
  pressure on the jugular veins
• Avoid performing Vasalva's maneuver prevent
  painful stimuli
• Provide a quiet environment
• Provide pain management
• Monitor fluid electrolyte
• Provide a safe physical environment observe
  seizures precautions
• Provide emotional support to the child his
  family explain all procedures treatment

93
Bacterial Meningitis

• Bacterial meningitis acute inflammation of the
  meninges CSF.
• Causes
• Vascular dissemination from focus of infection
  elsewhere in the body infections may be include
  or result from
• Bacteremia
• Pneumonia
• Empyema
• Steomyelitis
• Endocarditis

94
Bacterial Meningitis

• Causes
• Sinusitis
• Otitis media
• Encephalitis
• Brain abscess
• Skull fracture
• Penetrating head wound
• Lumbar puncture
• Ventricular shunting procedures
• Aseptic meningitis- viral

95
Pathophysiology

• The proportion of cases due to a specific
  organism varies from year to year there is also
  considerable geographic difference. The organisms
  most commonly causing bacterial meningitis in
  different age-groups
• Birth to age 3 months Escherichia coli,
  Streptococcus, group B, Listeria monocytogenes.
• Ages 3 months to 6 years Streptococcus
  pneumoniae, Neisseria meningitidis (meningococcal
  meningitis), Haemophilus influenzae.
• Ages 6 to 16 S. pneumoniae, N. meningitidis,
  Mycobacterium tuberculosis.

96

• 2. Bacterial meningitis is frequently preceded by
  an upper respiratory infection, which is
  complicated by bacteremia. Bacteria in the
  circulating blood then invade the CSF.
• Less commonly, bacterial meningitis may occur as
  an extension of a local bacterial infection, such
  as otitis media, mastoiditis, or sinusitis.
• Bacteria may also gain direct entry through a
  penetrating wound, spinal tap, surgery, or
  anatomic abnormality.
• 3. The infective process results in inflammation,
  exudation, and varying degrees of tissue damage
  in the brain

97
Complications

1. The incidence of complications decreases with
   early diagnosis vigorous antimicrobial therapy
2. If infection extends to the ventricles, thick
   pus, fibrin, adhesions may occlude the narrow
   passage ? obstructive hydrocephalus
3. Subdural effusions
4. thrombosis in meningeal veins or venous sinuses
5. Brain abscesses

98

• Extension of infection to the areas of the
  cranial nerves, necrosis ? deafness, blindness,
  weakness or paralysis of the facial or muscle of
  the head neck ? cerebral palsy, mental
  handicaps
• Meningococcal sepsis "meningococcemia"
  characterized by overwhelming septic shock, DIC,
  massive bilateral adrenal hemorrhage, Purpura,
  mortality gt 90
• "Any child who is ill develops a Purpura or
  Petechial rashes must receive medical evaluation
  immediately for the possibility of fulminant
  overwhelming meningococcemia"
• Inappropriate antidiuretic hormone
• Seizures, learning disorders
• Cerebral edema? herniation ? hydrocephalus
• Hemi paresis quaderiparesis caused by
  thrombosis or arteritis

99
Assessment findings

• Neonate
• It is difficult to diagnose
• Refuse feeding, poor sucking
• vomiting, diarrhea, weight loss
• Lack of movement, poor cry
• Hyperthermia
• Jaundice, drowsiness, seizures
• Respiratory irregularity, apnea, cyanosis
• Bulging fontanel

100
Infants young children

• Classic picture of meningitis rarely seen in
  children 3 months 2years of age
• Fever, poor feeding, vomiting
• Marked irritability, restlessness
• Seizures
• High pitch cry
• Bulging fontanel
• Nuchal rigidity tendency to keep the neck
  immobile extended
• Kerning's sign hip flexed to 90? angle, complete
  extension of the knee is restricted painful
• Brudzinskis' sign an attempt to flex the neck
  produces flexion at the knee thigh
• Opisthotonos extension rigidity of the spine
  when the legs are hyperextended forming an arch

101
Children Adolescents

• Abrupt with fever, chills, headache, vomiting
• Alteration in sensorium
• Irritable, agitated, photophobia
• Delirium, hallucination, aggressive behaviour
• Stupor, coma
• Positive Nuchal sign Kerning's sign
  Brudzinskis' sign Opisthotonos
• Petechial or purpuric rashes

102
Therapeutic Management

• The initial therapeutic management includes
• Isolation precautions
• Initiation of antimicrobial therapy
• Maintenance of ventilation
• Maintenance of optimum hydration
• Reducing of increased ICP
• Mgt of bacterial shock
• Control of seizures
• Control of extreme of temperature
• Correction of anemia
• Treatment of complications

103

1. Analgesic to treat pain of meningeal irritation
2. Corticosteroids
3. Parenteral antibiotics possibly Intraventricular
   administration of antibiotics I.V.
   administration of the appropriate antimicrobial
   agents to promote rapid destruction of the
   bacteria to suppress the emergence of resistant
   strains. The first dose of antibiotics should be
   administered as soon as possible (cultures should
   be taken before an antibiotic is given).
4. Burr holes to evacuate Subdural effusion
5. Oxygen therapy possible intubation mechanical
   ventilation to induce hyperventilation to
   decrease ICP
6. Recognition and treatment of hyponatremia caused
   by (SIADH).
7. Supportive management of the comatose child or
   the child with seizures.
8. Appropriate prophylactic treatment provided for
   contacts when indicated

104
Nursing Interventions

• Maintain droplet precautions until at least 24
  hours of effective antibiotics therapy have
  elapsed
• Provide a hypothermia blanket
• Maintain seizures precautions
• Monitor vital signs IO to assess for excess
  fluid volume
• Assess the child's neurologic status frequently
  to monitor for increased ICP
• Provide a dark quiet environment
• Keep the child flat in bed
• Move the child gently
• Administer antibiotic parenteral

105
Intraventricular Hemorrhage

• IVH "the rupture of a part of the vascular
  network of the germinal matrix, resulting in
  bleeding in the brain
• Causes
• Vascular malformation
• Tumor
• Trauma "before, during, after birth"
• Birth asphyxia
• Respiratory distress, metabolic instability or
  hypertension
• Use of drugs such as surfactant therapy

106
Pathophysiology

• Early prenatal development, there's a delicate
  but extensive network of vasculature that
  develops in the area of the ventricles that
  receives a disproportionately large quantity of
  cerebral blood flow
• A term approaches, a more blood flow to the
  periventricular region's germinal matrix
• Events that causes increased cerebral blood flow
  "hypoxic episodes" cause the vascularized region
  to rupture

107
Complications

• Hydrocephalus
• Obliterative arachnoiditis
• Cerebral hemorrhage
• Brain death
• Motor deficit
• Mental retardation

108
Assessment findings

• Increased ICP
• Sudden deterioration in condition
• Apnea
• Bradycardia
• Cyanosis
• Hypotonia
• Decreased hematocrit

• Bulging anterior fontanel
• Increased head circumference
• Separated sutures
• Twitching
• Stupor
• Seizures

109
Medical management

• Ventilatory support as indicated
• Spinal ventricular taps
• Diuretics
• Seizure suppression

110
Nursing intervention

• Measure HC daily, note any increase of gt 0.5cm
• Assess fontanels Q 8 hours for fullness or
  bulging, check widening of sutures
• Assess for increased incidence of apnea,
  Bradycardia, change in muscle tone or activity,
  unexplained drop in HCT Hb
• Anticipate CT or MRI scans to confirm extent of
  hemorrhage

111

• Prevent fluctuations in cerebral pressure
• Decrease noxious environmental stimuli, decrease
  noise, light, handling
• Maintain head in midline position to prevent
  venous congestion that results in hydrostatic
  pressure changes increases ICP
• Monitor treat pain
• Support the family by teaching developmentally
  supportive interventions that prevent IVH or
  prevent it from worsening

112
Spina Bifida "SB" Myelomeingocele

• Myelodysplasia broadly to any malformation of
  the spinal cord canal to close during embryonic
  development at approximately 28 days after
  conception
• Spina Bifida Occulta The defect is only in the
  vertebrae. The spinal cord and meninges are
  normal.
• Meningocele The meninges protrude through the
  opening in the spinal canal. This forms a cyst
  filled with CSF and covered with skin.
• Myelomeningocele (or Meningomyelocele) The
  spinal cord and cord membranes protrude through
  the defect in the laminae of the vertebral
  column. Myelomeningoceles are covered by a thin
  membrane.
• Causes
• Exposure to a teratogen
• Isolated birth defects
• Multiple malformation syndrome- chromosomal
  abnormalities such as trisomy 18 or 13 syndrome
• Lack of folic acid in the maternal diet around
  the time of conception

113
Pathophysiology

• During the fourth week of gestation "days 24-28"
  ventral induction of the neural tube fails to
  occur.
• The degree of impairment is related to the level
  of the defect on the spinal cord and on the size
  of the defect.
• 90 of spinal cord lesions are at L2 and below,
  or varying sensory defects
• Club feet , scoliosis, contracture, dislocation
  of the hips may also be associated with the
  defect
• Associated malformations may include
  hydrocephalus Arnold-Chiari malformation a
  congenital anomaly in which the cerebellum
  medulla oblongata extend down through the foramen
  magnum

114

• Spina bifida cystica
• Visible defect with an external saclike
  protrusion.
• The two major forms of SB cystica are meningocele
  which encases meninges and spinal fluid but no
  neural elements myelomeingocele which contains
  meninges, spinal fluid nerves

• Spina bifida occulta
• Defect that is not visible externally, it occurs
  frequently in the lumbaosacral are "L5 S1"
• Incomplete closure of one or more vertebrae
  without protrusion the spinal cord or meninges
• In several forms, a protrusion of the spinal
  contents in a n external sac or cystic lesions
  occurs because of the incomplete closure

115
Encephalocele

• Saclike portion of the meninges brain protrudes
  through a defective opening in the skull
• Usually in the occipital are but may occur end of
  the neuroaxis as a result, part or entire top
  of the skull is missing, severely damaging the
  brain
• Portions of the brain stem spinal cord may also
  be missing
• Invariably fatal

116
Complications

• Death
• Multiple handicaps
• Decreased motor activity below the sac or
  paralysis
• Neurologic bladder bowel
• CNS infections
• Hydrocephalus
• Scoliosis, contractures, and joint dislocation.

117
Assessment Findings

• Spina bifida occulta
• Skin abnormalities over the spinal defect, may
  appear alone or in combination with each other
• Depression or dimple
• Tuft of hair
• Soft fatty deposits
• Port wine nevi
• Occasionally foot weakness
• Occasionally bowel bladder disturbances

118

• Spina bifida cystica
• A saclike structure protruding over the spine
• Trophic skin disturbances
• Ulcerations
• Cyanosis
• Clubfoot
• Knee contractures
• Hydrocephalus
• Possible mental retardation
• Possible Arnold-Chiari formation
• Curvature of the spine
• Permanent neurologic dysfunction
  "myelomeingocele"
• Flaccid or spastic paralysis
• Bowel or bladder incontinence

119

• Encephalocele
• Vary with the degree of tissue involvement
  location of the defect
• Paralysis
• Hydrocephalus
• Mental retardation
• Anencephaly
• Exposed neural tissue
• Skull has a froglike appearance when viewed from
  the front

120
Medical Management

• Surgical correction closure a protruding sac
  usually occurs within 48 hours of a birth,
  surgery doesn't reverse neurologic deficits
• A shunt may be needed to relieve related
  hydrocephalus
• A surgery to correct associated craniofacial
  abnormalities in encephalocele

121
Surgical Intervention

• Procedure laminectomy and closure of the open
  lesion or removal of the sac usually can be done
  soon after birth.
• Purpose
• To prevent further deterioration of neural
  function.
• To minimize the danger of rupture and infection,
  especially meningitis.
• To improve cosmetic effect.
• To facilitate handling of the infant.

122
Nursing Diagnoses

• Neonates (Preoperative)
• Risk for Impaired Skin Integrity related to
  impaired motor and sensory function
• Risk for Infection related to contamination of
  the myelomeningocele site
• Impaired Urinary Elimination related to
  neurologic deficits
• Ineffective Tissue Perfusion Cerebral related to
  potential hydrocephalus
• Fear (parents) related to neonate with neurologic
  disorder and to surgery
• Infants and Children (Postoperative)
• Ineffective Thermoregulation following surgery
• Impaired Urinary Elimination related to sacral
  denervation
• Bowel Incontinence or Constipation related to
  impaired innervation of anal sphincter and bowel
  musculature
• Disturbed Body Image related to the child's
  appearance, difficulties with locomotion, and
  lack of control over excretory functions

123
Nursing Interventions

• Prenatal
• Refer to a genetic counselor, who can provide
  information support the couples decision on
  how to manage the pregnancy
• Urge all women of childbearing age to take a
  folic acid supplement until menopause or end of
  childbearing potential
• Provide psychological support to the parents to
  help them accept the diagnosis preoperative
  post operative care

124

• Preoperative
• Check for leakage from the sac
• Check for infection around the sac
• Assess for signs symptoms of CNS infection
• Assess for motor activity below the sac
• Measure the HC to establish baseline data
• Assess bowel bladder functions patterns
  monitor intake output
• Provide emotional support to the parents be
  aware that surgery usually occurs 24 -48 hours
  after birth

125

• Teach parents family measures to prevent
  contractures, pressure ulcers, UTI, other
  complications
• Prevent trauma by keeping pressure off the sac
  keep the child on one side with the knee flexed,
  or the abdomen
• Institute measures to keep the sac from
  infection, avoid contamination from urine stool
• Prevent the sac from drying, cover it with
  saline-soaked sterile dressing
• Institute latex precaution

126

• Post operative
• Provide routine postoperative care
• Provide thorough skin care if paralysis occurs
  place the child on sheepskin
• Provide orthopedic appliances
• Prevent constipation
• Promote ROM
• Teach clean intermittent catheterization
• Assess motor ability sensation below the level
  of the lesion paralysis if possible

127
Otitis Media Middle Ear Infections

• Otitis Media- an inflammation of the middle ear
  without reference to etiology or pathogenesis
• Acute Otitis media- a rapid and short onset of
  signs and symptoms lasting approximately 3 weeks
• Otitis media with effusion- an inflammation of
  the middle ear in which a collection of fluids is
  present in the middle ear space.
• Chronic Otitis media with effusion- middle ear
  effusion that persists beyond 3 months

128

• Causes of Otitis Media
• Disruption of Eustachian tube patency
• Bacteria
• S. pneumonia
• H.influenza
• Staphylococci
• Gram negative bacteria

129

• Pathophysiology
• Supportive Otitis media occurs when
  nasopharyngeal floras reflux through the
  Eustachian tube colonize the middle ear
• Risk factors
• Respiratory tract infection
• Allergic reaction
• Nasotracheal intubation

130

• Factors predisposing to development of OM in
  children
• The Eustachian tubes are short, wide, and
  straight and l