presented by marlene meador rn, msn, cne. head to torso ratio cranial bones- thin, pliable, suture...
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Presented by Marlene Meador RN, MSN, CNE
Head to torso ratio Cranial bones- thin, pliable, suture lines not
fused Brain vascularity and small subarachnoid
space Excessive spinal mobility Wedge shaped cartilaginous vertebral
bodies
LOC & behaviorVital Signs and respiratory statusEyesReflexes and motor functionCranial nerve function
Modified Glasgow Coma Scale for ages 3 and younger
Infants Irritability &
restlessness Fontanelles / FOC Poor
feeding/sucking Skull & scalp veins Nucal rigidity,
seizures (late signs)
Children Headache Vomiting Irritable, lethargic,
mood swings Ataxia, spasticity Nucal rigidity Deterioration in
cognitive ability Vital sign changes
What assessment findings should the nurse monitor?
What emergency equipment should the nurse have on hand at all times for a child with IICP?
What diagnostic procedures would the nurse anticipate for this child?
What priority interventions must the nurse include with respect to these diagnostic procedures?◦What specific teaching is required?◦What additional lab/serum tests would you anticipate?
Corticosteroids Anti-inflammatory Contraindications-
acute infections Monitor I&O Protect from
infection Add K+ foods Discontinue
gradually
Osmotic diuretic Reduce fluid Contraindications-
intracranial bleeding Monitor I&O carefully Monitor electrolytes Teaching
What equipment is essential? Vital signs & neuro signs Additional assessment findings Activity level Hydration status Positioning Parent teaching
Febrile- rapid temp rise above 39°C (102°F) Generalized- loss of consciousness, involves
both cerebral hemispheres onset at any age Tonic/Clonic- impaired consciousness,
abnormal motor activity, posturing, automatisms
Absence- may confuse with daydreaming or inattentiveness
EEGCT, MRILumbar punctureCBCMetabolic screen for glucose, phosphorus and lead levels
Assessment findingsPriority interventions◦Prevention ◦During seizure◦Following seizure
McKinney has detailed Nursing Care Plan
Phenobarbital- CNS depressant- assess for sedation, VS, serum levels, ◦ Teach- S&S of toxicity, no ETOH, adhere to
regime
Carbamazepine- sedative/anticonvulsant ◦ hold med if lab values =◦ Teach- S&S of toxicity
Phenytoin- anticonvulsant◦ Safety measures- on-hand equipment◦ Teach- oral care, sun exposure
What is most important nursing intervention when a child is experiencing a seizure?
What is most important teaching regarding seizure medication?
Bacterial Potentially fatal; abx
given prophylactically if
bacterial suspected. May kill within 24 hrs
C/S take 72 hrs to process
Infants at greatest risk
Nuchal rigidity Severe headaches Contagious
Viral Same s/s but milder and
shorter duration May follow a viral
infection May be accompanied by
rash Nuchal rigidity Ataxia Not contagious
Why does bacterial meningitis present more of a risk than viral meningitis?
How do the manifestations of meningitis differ between infants and young children
Infant Child/Adolescent
Fever (not always present)
Poor feeding Vomiting Irritability Seizures High-pitched cry
Fever Headache Photophobia Nuchal rigidity Altered LOC Anorexia/ vomiting Diarrhea Drowsiness
What findings differentiate between bacterial and viral meningitis?
What specific interventions does the nurse include for this procedure?◦Monitor VS & neuro VS◦LOC◦Teaching
Ceftriaxone Sodium (Rocephin®)- who must receive this medication?
Cefatoxime Sodium (Claforan ®)- Dexamethasone- special nursing care
Antipyretics
What intervention must the nurse initiate to protect the patients and staff when a diagnosis of bacterial meningitis is suspected?
Hydro= Water Cephaly= of the head/brain
What priority nursing assessment of a newborn monitors for this condition?
What assessment findings occur in the older child?
What diagnostic measures confirm this diagnosis?
LP-dangerous MRI; CT scan Skull X-ray Measure FOC Provide for safety, informed consent, support for child and family, accurate H&P
Shunt placement- surgical procedure to place a tube that drains CSF into the atrioventricular or peritoneal cavity.
Atrioventricular- drains into atrium (not used as frequently)
Ventricular peritoneal- drains into the peritoneal cavity
Pre Operatively:◦Baseline VS, monitor for IICP, ◦What teaching/interventions for parents?
Post-op:◦Monitor shunt function (how?)◦Positioning and activity◦VS, neuro VS & I&O◦Teaching
Home care needs S&S of IICP S&S of infection S&S of seizures Emergency numbers of Pediatrician &
neurosurgeon Refer to home care, social services and
support groups
Most common defect of the CNS Occurs when there is a failure of the osseous spine to close around the spinal column.
What common nutritional supplement is encouraged for all women of childbearing age?
What common nutritional supplement is encouraged for all women of childbearing age?
Discuss the 3 types of neural tube defects:◦Spina bifida occult◦Meningocele◦Meningomyelocele
Visualization of the defect Motor sensory, reflex and sphincter abnormalities
Flaccid paralysis of legs- absent sensation and reflexes, or spasticity
Malformation Abnormalities in bladder and bowel function
Immediate surgical closure
Prior to closure keep sac moist & sterile
Maintain NB in prone position with legs in abduction preoperatively
Pre-Operative:Meticulous skin careProtect from feces or urineKeep in isolette
Assess surgical site Monitor VS and neuro VS Institute latex precautions Encourage contact with parents/care givers
Positioning Skin Care
Antibiotic therapy Prevent UTIEducationEmphasize the normal, positive abilities of the child
At risk for infection-◦Protect◦Position
At risk for injury- ◦Protect◦Position
Static Encephalopathy- spastic CP most common type (80%)◦Nonspecific term give to disorders characterized by impaired movement and posture
◦Non-progressive◦Abnormal muscle tone and coordination
Jittery (easily startled) Weak cry (difficult to comfort) Experience difficulty with eating (muscle control of tongue and swallow reflex)
Uncoordinated or involuntary movements (twitching and spasticity)
Alterations in muscle tone◦Abnormal resistance◦Keeps legs extended or crossed◦Rigid and unbending
Abnormal posture◦Scissoring and extension (legs feet in plantar flexion)
◦Persistent fetal position (>5 months)
EEG, CT, or MRIElectrolyte levels and metabolic workup
Neurologic examinationDevelopmental assessment
Increased incidence of respiratory infection
Muscle contracturesSkin breakdown Injury
Anatomy predisposes infant/young to injury
Pathophysiology of “Shaken Baby Syndrome”
Assessment findings- Immediate nursing interventions- Legal implications Why is it not prudent for the nurse to
discuss suspicions of abuse with the parents or primary caregiver?
Not clearly understoodCharacterized by impaired social, communicative, and behavioral development
Usually noted in the first year of life
Home Setting Reduce environmental
stimuli Communicate via age-
appropriate touch & verbalization
Keep toys or other items out of reach if child uses them for harmful self-stimuli
Ritualistic ADLs Encourage therapists &
support groups
Acute Care Setting Keep at least 1 constant
caregiver. Encourage parents to stay with,keep room quiet & limit number of staff
Anxiety/aggression when touched by strangers
Constant monitoring by nurse or parents
Allow to maintain rituals of ADLs
Encourage therapists & support groups
Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation
Failure of chromosomes to separate
Advanced maternal age No other socio-economic or geographic factors have been identified
Primary concern with cardiac and GI anomalies
What are the most obvious indications of Down’s Syndrome in a newborn
How does the nurse promote health of the child with Down’s syndrome?
Primary focus on the parents and care givers to provide support and achieve a realistic view of the child’s capabilities
Support siblings Refer to family counseling services Support parents in feelings of guilt and
chronic sorrow
