Pediatric Nursing

1
Pediatric Nursing

• Module 6
• Caring for Children with Alterations in
  Neurosensory Functions

2
Neurological Assessment

• Assessment
• indirect measurements
• children under 2 years
• normal growth and development parameters
• parents evaluation of their child
• developmental milestones
• history
• prenatal
• birth history
• post natal

3
Neurological Assessment

• Behavior
• personality, affect, level of activity, social
  interaction, attention span
• Motor function
• muscle - size, tone, strength
• abnormal movements
• Sensory function
• discrimination of touch with eyes closed

4
Neurological Assessment

• Cranial Nerves
• Olfactory - smell
• Optic - light perception visual acuity
• peripheral vision
• Ocular motor - 6 cardinal positions of gaze
  PERRLA
• Trochlear - have child look down and in
• Trigeminal nerves - bite down and try to
• open jaw, sensation to face

5
Neurological Assessment

• Abducens- look toward temporal side
• Facial - make a funny face or smile
• Acoustic - hearing and balance
• Glossopharyngeal - gag reflex, taste
• Vagus - uvula is midline, swallow
• Accessory - shrug shoulders against mild applied
  pressure
• Hypoglossal - move tongue in all directions

6
Video - Neurological exam in children

• http//video.google.com/googleplayer.swf?docid331
  4499774483652601hlenfstrue

http//video.google.com/googleplayer.swf?docid7
363212422012619904hlenfstrue
http//video.google.com/googleplayer.swf?docid-72
8577715202828264hlenfstrue
7
(No Transcript)
8
Increased Intracranial Pressure

• Causes
• tumors
• accumulation of fluid within the ventricular
  system
• bleeding
• edema in cerebral tissues
• early signs and symptoms are often subtle and
  assume many patterns

9
Assess for signs of Increased Intracranial
Pressure

• Level of consciousness (LOC)
• earliest indicator of changes in neurological
  status
• 1. Alertness
• arousal-waking state
• ability to respond to stimuli
• 2. Cognitive abilities
• process stimuli
• produce verbal and motor responses

10
Increased Intracranial PressureSigns/symptoms

• Lack of painful stimuli is abnormal and is
  reported immediately
• as ICP increases LOC decreases
• 3. Vital Signs
• pulse
• variable, may be rapid or slow, bounding or
  feeble
• B/P
• normal or elevated with a widening pulse
  pressure, at shock level
• Respiration's
• varies

11
Increased Intracranial PressureSigns/symptoms

• Temperature
• elevated especially with infections and
  intracranial bleeding
• subnormal in a coma of toxic origin
• Pupils
• size and reactivity
• bilateral vs unilateral
• sudden fixed and dilated pupils is a
  neurosurgical emergency
• pressure from herniation of the brain through the
  tentorium

12
Neuromuscular - Signs/symptoms

• Neuromuscular Movement
• strength, spontaneous movements
• asymmetric or absent movements
• tone
• may be increased or decreased
• tremors, twitching, spasms
• purposeless flapping
• hyperactive or flaccid

13
Increased Intracranial Pressure Signs/symptoms

• Posturing
• decorticate
• adduction and flexion
• decerebrate
• rigid extension and pronation

14
Diagnosis Procedures

• Lumbar puncture
• measure pressure and sample for analysis
• Subdural tap
• r/o subdural effusions, relieves ICP
• EEG
• measures electoral activity
• detects abnormalities

15
Diagnosis Procedures

• Computer Tomography (CT)
• visualizes horizontal and vertical cross section
  of the brain
• distinguishes density
• MRI
• permits tissue discrimination unavailable with
  other techniques
• Transillumination
• localized glowing seen in abnormal fluid

16
Diagnosis Procedures

• Labs
• CSF
• blood glucose
• electrolytes
• Ca, Mg, Na
• clotting studies
• liver function tests
• blood cultures
• drug titre

17
Cerebral TraumaHead Injury

• Etiology
• falls, MVA, bicycle injuries
• head is larger, heavier
• children curious
• incomplete motor development
• Concussion
• Contusion/laceration
• Fracture

18
Shaken Baby Syndrome
coup
countrecoup
19

• Fatal bacterial
• meningitis

20
Meningitis

• Inflammation of the meninges
• Spread
• vascular dissemination
• OM or URTI
• exudate covers the brain
• brain becomes hyperemic and edematous

21
(No Transcript)
22
Meningitis

• Causative Organism
• H. Influenza, type B
• S. Pneumoniea
• N. Meningitis
• Meningococcus
• Signs and Symptoms
• FUO
• lethargy

23
MeningitisSigns/symptoms

• irritable
• vomiting and/or diarrhea
• signs of meningeal irritation
• guarding of the neck
• nuchal rigidity
• cries when moved
• poor feeding

24
MeningitisDiagnosis

• Labs
• CSF
• culture, glucose, protein, cell count, gram stain
• Blood Culture
• r/o sepsis
• Urine Culture
• r/o UTI
• Chemistry panel
• electrolytes, glucose, BUN, creatinine

25
MeningitisTreatment

• Antibiotics
• administer within 1 hour of diagnosis
• type is based on age and causative organism
• neonate - ampicillin / claforan
• 3 months to 3 years - ampicillin / ceftriaxone
• older children - penicillin / chloramphemicol

26
MeningitisTreatment

• Fluid Management
• fine balance between dehydration and cerebral
  edema
• child may be dehydrated due to v/d, poor po,
  fever
• 2/3 maintenance of IV replacement
• fluid restriction

27
MeningitisNursing Care

• PC Neurological dysfunction
• cerebral hypoxia
• seizures
• increased ICP
• PC Seizure
• High Risk for spread of infection
• needs resp. isolation for first 24 hrs of
  antibiotic therapy

28
MeningitisNursing Care

• Fluid Volume Deficit less than body
  requirements r/t dehydration
• NPO/fluid restriction
• I O
• daily weights
• Labs
• specific gravity and electrolytes
• IV fluid - careful, conservative replacement

29
MeningitisNursing Care

• PC Neurological damage
• seizures
• sequelae to meningitis
• seizures
• hydrocephalus
• visual/hearing deficits

30
Reye Syndrome

• Toxic encephalopathy with additional organ
  involvement
• Etiology
• follows viral illness, ASA
• Signs and Symptoms
• fever
• decrease LOC
• hepatic dysfunction
• Prognosis
• good

31
Febrile Convulsions

• Age
• most common between 6 months and 3 years
• Occurrence
• Seizure accompanied by fever without CNS
  infection
• Occurs during the temperature rise
• Treatment
• fever - tylenol
• seizure - ativan, valium

32

• Tonic clonic seizure
• Tonic stiff
• Clonic - jerking
• Rescue position

33

• Assessment
• seizure precautions
• emergency treatment
• rescue position
• Nursing Care
• protect from injury
• open airway
• accurately observe and record happenings

34
Hydrocephalus
35
Hydrocephaly

• Abnormal condition characterized by an increase
  volume of normal cerebrospinal fluid under
  increased pressure with in the intracranial
  cavity
• Communicating
• obstruction is located in the subaranoid cistern
  or within the subarachnoid space
• Non-communicating
• blockage is within the ventricles

36
Hydrocephaly - Pathology

• 3 possible mechanisms leading to hydocephalus
• 1. Over production of CSF
• 2. Defective absorption of CSF
• 3. Obstruction of CSF
• 3 major causes
• inflammation
• congenital malformations
• tumors

37
HydrocephalusSigns/symptoms

• Signs of increased fluid pressure
• tense or bulging anterior fontanel
• scalp becomes thin and shiny
• vein dilate
• cranial suture lines begin to separate
• Other clinical symptoms
• vomiting
• wide bridge between eyes
• bulging eyes - sunset eyes

38
HydrocephalusSigns/symptoms

• Severe Form
• head size increases rapidly
• infants cry is shrill, high pitched
• hyperirritability, restlessness
• Older Children
• no head enlargement ataxia
• papilledema Alter mental status
• spasticity strabismus
• H/A

39
HydrocephalusTreatment

• Surgical
• VP (ventriculo-peritoneal) Shunt
• Nursing Care
• Pre-op
• assessments
• daily head circumference
• size and fullness of anterior fontanel
• behavior
• nutrition - vomiting

40
Hydrocephalus - Nursing Care

• fluid and electrolyte needs
• positioning
• prevent pressure ulcers
• support the neck
• good skin care
• neuro assessments
• LOC
• irritable child/infant
• vital signs
• observe for seizures

41
Hydrocephalus

• Nursing Care
• Post-op
• monitor feeding and behavior patterns
• assess for increasing ICP and cerebral
  irritability
• HOB flat or set elevation
• Shunt observation
• infection - along the line or cerebral
• abdominal girth
• valve function, blockage, separation
• emotional needs - hold and cuddle
• teaching

42
Cerebral Palsy

• Non-specific disorder characterized by early
  onset of movement and posture impairments
• abnormal muscle tone and coordination
• Spastic
• hypertonicity, stiff
• Dyskinectic
• slow, worm-like movement

43
Spina bifia - myelomeningocele

• Failure of the neural tube to close during early
  development
• Treatment
• early surgical closure
• Associated Problems
• hydrocephalus
• paralysis
• bone deformity

44

• Andrew, age 10 was a passenger in a MVA 3 weeks
  ago, he sustained a closed head injury from the
  impact. He is unconscious in the E.R.
• What are is needs in the Emergency Room?
• What are his priority nursing interventions?

45

• He was admitted to the PICU, now transferred to
  your Pediatric Unit. He tracks his parents
  movement, he is receiving 02 via trach collar,
  has G-tube with enteral feedings, is incontinent
  of urine and stool, is able to nod his head
  appropriately.
• Why do you think Andrew has a trach?
• Why do you think Andrew has a G-tube?

46

• What risk factors predispose Andrew to infection?
• Why is he on these medications?
• ranitidine 70mg bid - zantac
• metoclopramide 3.5 mg qid - reglan
• phenytoin sodium 70mg bid - dilantin
• How can you intervene to help met Andrews growth
  and development needs?