Families exam 4

Meningitis: bacterial vs viral

Viral (aseptic): usually requires supportive care for recovery

Bacterial (septic): contagious infection. prognosis depends on how quickly care is initiated

The 12 cranial nerves

Olfactory – Oh

Optic – Oh

Oculomotor – Oh

Trochlear – To

Trigeminal – Taste

Abducens – And

Facial – Feel

Vestibulocochlear – Vodka

Glossopharyngeal – Good

Vagus – Vibes

Accessory – Aha

Hypoglossal – Heaven

The 12 nerve class:

Some

Say

Marry

Money,

But

My

Brother

Says

Big

Boobs

Matter

More

S= sensory

M= motor

B= both

Meningitis clinical manifestations: General/ Newborn

- Photophobia, vomiting, irritability, HA

- Sunset eyes: eyes wide open, looking down

Newborn: no illness is present at birth, neck is supple w/o nuchal rigidy

- Poor muscle tone, weak cry, poor suck, refuses feeding, vomiting, diarrhea

- Bulging fontanels: LATE FINDING

What can you NEVER EVER give a child

ASPIRIN = REYES SYNDROME

Meningitis clinical manifestations: 3 months & 2 yrs

3 months to 2 years

- Seizures with a high-pitched cry

- Fever & irritability

- Bulging fontanels & possible Nuchal rigidy

- Poor feeding, vomiting

- Kernig's & Brudzinski's are not reliable until age 2

2 years through adolescence

- Seizures: often initial finding

- Positive Kernig's: resistance to extension of leg from a flexed position

- Positive Brudzinski's: flexion of extremities occurs with flexion of neck

- Fever, chills, HA, vomiting

- Irritability & restlessness than can lead to LOC changes (drowsiness, delirium, stupor, coma)

Meningitis priority nursing interventions

1. Droplet precautions: for 24 hrs after initiation of ABX

- Visitors -> wear a mask entering and leaving room

- Nurse -> mask, gown, gloves, facie shield

2. Dexamethasone (bacterial only): reduces neuro complications if caused by Hib & reduces inflammation

3. Seizure precautions - give anticonvulsants

4. Newborn/infant: monitor head circumference & fontanels for presence/changes in bulging

- restrict fluids until evidence of ICP and blood sodium levels within range

5. Decrease environmental stimuli & provide comfort measures:

- Keep room cool

- Slightly elevate HOB or side-lying position to reduce neck pain

6. NPO if decreased LOC, then advance to clear liquid as tolerated

Meningitis lab tests (CSF)

Viral

- Clear

- Normal glucose, normal or slightly increased WBC & protein

- Negative gram stain

Bacterial

- Cloudy

- Decreased glucose, increased WBC & protein

- Positive gram stain

Meningitis infection control procedures

VACCINES: HiB & PCV

- 2,4, & 6 months of age, then again between 12 - 15 months of age

Lumbar puncture positioning

· Side-lying, head flexed, knees drawn up towards chest & assist in maintaining that position (fetal position)

· Remain flat to prevent spinal leak & HA

· Age-appropriate care: swaddle baby, give pacifier while laying on back

Increased ICP clinical manifestations

Cushing's Triad:

- severe HTN with wide pulse pressure

- bradycardia

- cheyne-stokes (alternating respirations)

Newborns & infants

- Bulging or tense fontanels

- Increased FOC

- Respiratory changes

- Distended/seprated cranial sutures

- High pitch cry

- Irritability

- Bradycardia

Children

- Diplopia: double vision

- Increased irritability

- Bradycardia

- Seizures

- HA, N/V

- Respiratory changes

Increased ICP priority nursing interventions/plan of care

- Head midline, elevate HOB 30 degrees but no more than 30

- Avoid coughing/straining and suctioning (nasal suctioning is contraindicated)

- Decrease stimuli, dim lights

- Admin oxygen to maintain > 95%

- Seizure precautions: side rails up & padded

- Frequent neuro checks

Increased ICP findings to report

Clear fluid drainage from ears or nose = indicates CSF leakage

Increased ICP education

Educate family on effective ways to communicate with the child
- Touching, cuddling, assisting with care as appropriate

What is a ventriculoperitoneal (VP) shunt?

- treatment for hydrocephalus (obstruction in CSF flow)
- cerebral shunt that drains CSF and removes obstruction

Hydrocephalus/ventriculoperitoneal (VP) shunt priority assessment

- Increased ICP: ↑ BP & ↓ HR

- Bulging fontanels

- Widening suture lines

- Increasing head circumference

- Unequal pupil size

- Sunset eyes: eyes wide open, looking down

- Irritability (high pitch cry), change in LOC, lethargy

Hydrocephalus/ventriculoperitoneal (VP) shunt priority interventions

Monitor for
- Increased ICP & FOC (head circumference)
- Shunt malfunction
- Signs of infection
- Neuro checks

Hydrocephalus/ventriculoperitoneal (VP) shunt patient education

- Monitor for increased ICP & infection
- Need for shunt revision
- Potential growth & development problems

Cranial nerve functions: I

olfactory

Infants: Difficult to test

Children & adolescents: Identifies smell through each nostril individually

Cranial nerve functions: II

optic -

Infants: Looks at face & tracks with eyes

Children & adolescents: Has intact visual acuity, peripheral vision, & color vision

Cranial nerve functions: III

oculomotor -

Infants: Blinks in response to light & pupils are reactive to light

Children & adolescents: Has no nystagmus & PERRLA is intact

Cranial nerve functions: IV

trochlear -

Infants: Looks at face & tracks with eyes

Children & adolescents: Has the ability to look down & up with eyes

Cranial nerve functions: V

trigeminal

Infants: Has rooting & sucking reflexes

Children & adolescents

- able to clench teeth together

- detects touch on face with eyes closed

Cranial nerve functions: VI

abducens

Infants: Looks at face & tracks with eyes

Children & adolescents: Is able to move eyes laterally toward temples; side to side

Cranial nerve functions: VII

Facial

Infants: Has symmetrical facial movements

Children & adolescents

- has the ability to differentiate between salty & sweet on tongue

- has symmetric facial movements

Cranial nerve functions: VIII

acoustic

Infants

- Tracks a sound and blinks in response to a loud noise

Children & adolescents

- Does not experience vertigo

- Has intact hearing

Cranial nerve functions: IX

glossopharyngeal

Infants: Has an intact gag reflex

Children & adolescents

- Has intact gag reflex

- Is able to taste sour sensations on back of tongue

Cranial nerve functions: X

vagus

Infants: Has no difficulties swallowing

Children & adolescents

- Speech clear, no difficulties swallowing

- Uvula is midline

Cranial nerve functions: XI

accessory (spinal)

Infants: Moves shoulders symmetrically

Children & adolescents: Has equal strength of shoulder shrug against examiner’s hands

Cranial nerve functions: XII

hypoglossal

Infants

· Has no difficulties swallowing & opens mouth when nares are occluded

Children & adolescents

- Has a tongue that is midline

- Is able to move tongue in all directions with equal strength against tongue blade resistance

Infant reflexes: sucking & rooting reflex

- Elicit by stroking the cheek or edge of mouth
- Newborn turns head to toward side that is touched & starts to suck
- Disappears by 3-4 months

Infant reflexes: palmar grasp

- Place examiner finger in newborn's hand
- Newborn's fingers curl around finger
- Lessens by 3-4 months

Infant reflexes: plantar grasp

- Place examiner finger at base of newborn's toes
- Newborn curls toes downward
- Disappears by 8 months

Infant reflexes: moro/startle reflex

- Allowing head & trunk of abdomen of newborn in semi-sitting position to fall backward to an angle of at least 30 degrees
- Newborn will symmetrically extend & then abduct arms at the elbows & fingers spread to form a "C"
- Disappears by 6 months

Infant reflexes: tonic neck reflex (fencer position)

- Newborn supine, examiner turns newborn's head quickly to one side
- Newborn's arm & leg on that side extend & opposing arm & leg flex
- Disappears by 3-4 months

Infant reflexes: Babinski reflex

- Stroking outer edge of sole of foot, moving up toward toes
- Toes will fan upward & out
- Disappears by 12 months

Seizures clinical manifestations: tonic phases

Tonic-clonic

- Onset without warning, most prevalent

Tonic phase (10-20 sec) - stiffening of muscles and loss of consciousness

- Eyes roll upward

- Tonic contraction of entire body, with arms flexed & legs, head & neck extended

- Mouth snaps shut & tongue can be bitten

- Possible piercing cry, loss of swallowing reflex & increased salivation

- Apnea leading to cyanosis

Seizures clinical manifestations: clonic

Clonic phase (30-50 sec; can last 30 min or longer)

- Violent jerking movements of body

- Trunk & extremities experience rhythmic contraction & relaxation

- Foaming in mouth, incontinent of urine & feces

- Gradual slowing of movements until cessation

Seizures clinical manifestations: postictal state

Postictal state (30 min to several hours) - confusion/SLEEPY/possible agitation

- Remains semiconscious but arouses with difficulty, confused for several hours

- Impairment of fine motor movements & lack of coordination

- Possible vomiting, HA, visual or speech difficulties

- No recollection of seizure

Seizures risk factors

- Anoxia

- Brain tumors/cysts

- Cerebral edema

- Infection or hemorrhage

- Toxins or drugs

- some have no known etiology

Seizures priority nursing interventions: during

- Side-lying, maintain airway, loosen restrictive clothing, do not restrain or put anything in mouth, apply O2, note onset/time/characteristics, remain w child

Seizures priority nursing interventions: post

- Assess for injuries: inside of mouth

- VS & neuro checks

- Note time of postictal period, and determine if they experienced an aura (can indicate origin in brain)

- Document onset, duration, findings prior to, during, & following seizure (LOC, apnea, cyanosis, motor activity, incontinence)

Visual impairment clinical manifestations

Amblyopia (lazy eye): reduced visual acuity in one eye

- treatment: cover strong eye & force the brain to use the weaker eye & strengthen it but also tx with glasses if needed, might need laser surgery

Myopia (near sightedness)

- Can see close objects but not objects far away

- HA, vertigo, eye rubbing, difficulty reading

- Clumsiness, poor school performance

Hyperopia (far sightedness)

- Can see distant objects but not objects close

- Not usually detected until age 7

Visual impairment nursing care

- Maintain normal to bright lighting when reading, writing

- Identify safety hazards & prevent injury to eyes (helmet, safety glasses)

- Provide information regarding laser surgery for pts with myopia, hyperopia, or astigmatism

- Partial Impairment - 20/70 to 20/200

- Legal blindness - 20/200 or worse

Visual impairment education

- Referral services: Braille, audio tapes, special computers
- School-age: school nurse does vision & hearing tests (vision checked yearly)
- E Snellen: stand 10-20 ft away with heels on mark, depends on age
· Start at top & work way down until they cannot pass a full line (need 4 out of 6 to pass); can wear glasses

Testing pre-school visual acuity

- Allen's picture cards
- Snellen alphabet for older children

Hearing impairment clinical manifestations: infant

· Might not respond to loud noises

· Lack of startle reflex

· Failure to localize sound by 6 months

· No vocalization by 7 months

Hearing impairment clinical manifestations: older child

- Won’t make eye contact

- Using gestures rather than talking after 15 months

- Shy/withdrawn/inattentive

- No speech by 24 months

- Speaking loudly/monotone

Hearing impairment nursing care

- Safety issues: cannot hear fire alarm (use flashing light)

- ID in house in case of emergency

- Encourage socialization and use of aids to promote independence (flashing light when door bell or phone rings, closed caption on TV)

- Assess gait/balance for instability

- Use sign language or interpreter when working with a child with hearing loss (ALWAYS talk to child NOT interpreter)

- If whistling sound present on hearing aids: turn down volume or readjust hearing aid in ear

Cognitive impairment (down syndrome) clinical manifestations

· Enlarged anterior fontanel, small round head
· Upward, outward slant to eyes
· Small ears with short pinna
· Visual & hearing problems
· Protruding tongue
· Shortened rib cage
· Cardiac abnormalities (comorbidity)
· Broad short feet & hands & neck with stubby toes & fingers

Cognitive impairment (down syndrome) nursing care

· Swaddle infant to prevent heat loss
· Assist family with feeding difficulties & monitor dietary intake
· Promote good skin care
· Assist parents in holding & bonding with infant

Cognitive impairment (down syndrome) education

· Aspirate nasal secretions (high risk for respiratory complications)

· Accommodate for protruding tongue: long-handled spoon used for feeding

· Skincare: use moisturizing creams daily & change positions frequently

· Diet: high fiber & increase fluids to prevent constipation; monitor caloric intake to prevent obesity

· Report manifestations of spinal cord decompression (neck pain, loss of motor function, bladder incontinence, impaired sensations)

· Evaluate eyesight & hearing frequently

Fractures clinical manifestations: greenstick

incomplete fracture of bone (think snapping of a tree branch)

Fractures clinical manifestations: buckle

bulge or raised area at site

Fractures clinical manifestations: plastic deformation

bone bent at no more than 45 degrees

Fractures clinical manifestations: transverse

break is straight across the bone

Fractures assessment

· Pain
· Crepitus (cracking/popping)
· Deformation
· Edema
· Warmth or redness/ecchymosis
· Pinpoint where it hurts on the bone

Fractures 9 nursing interventions/plan of care

· Pain assessment using age-appropriate scale; analgesics

· Neurovascular checks: 5 P’s

· Pain, pallor, pulses, paresthesia, paralysis

· Ensure area distal is getting perfused

· Supine position for injuries to the distal arm, pelvis, lower extremities

· Sitting position for injuries to shoulder or upper arm

· Child life specialist

· Elevate cast above heart for first 24-48 hrs, ice for first 24 hrs

· Social services: child abuse suspected?

Fractures therapeutic procedures: casting types

Plaster of paris: heavy, not water-resistant, & can take 10-72 hr to dry

Synthetic fiberglass casts: light, water-resistant, & dry quickly (5-20 min)

Fractures therapeutic procedures: 6 casting nursing actions

- Prior to casting: clean, dry skin; pad bony areas
- Show child procedure on doll or toy
- Elevate above level of heart 24-48 hrs & apply ice after casting: no heat lamps or blow dryers to dry cast
- Turn frequently - support affected extremity
- Keep affected extremity supported with sling or elevated on pillow
- Pad rough edges of cast

Fractures therapeutic procedures: 4 casting education

· When cast is applied it will feel warm, but will not burn the child

· Report pain that is extremely severe or is not relieved 1 hr after admin of pain meds

· Notify provider immediately of any soft spots on the cast, change in sensation, or increased pain, cool or pale

· Removal of cast - soak extremity in warm water and apply lotion

Fractures: casting findings to report

· Unusual odor beneath cast
· Tingling, burning, swelling, numbness/can't move toes (cold, blue, or white toes)
· Drainage through cast
· Sudden unexplained fever
· Pain not relieved by comfort measures

Fractures therapeutic procedures: traction types

Skin traction (buck, russel, Bryant): pulling with weights attached with rope to extremity – straps applied to skin with boots

Skeletal traction: pulling force applied directly to bone/skeletal structure by pin/rod – 90/90 degree easily reposition – decreased mobility complications

Fractures therapeutic procedures: traction nursing actions

· Reposition frequently

· Frequent neuro, skin assessment, VS

· Pain control, comfort measures, stool softeners

· ROM to other extremities, use trapeze to assist clients to move/ROM

· Assess pin sites for pain, redness, swelling, drainage, or odor (WATCH TEMP!!)

· Ensure that all hardware is tight & that the bed is in correct position

Fractures complications: osteomyelitis assessment

Osteomyelitis: bone infection d/t open fracture or bloodborne bacterial infection

· Fever/tachycardia

· Edema

· Pain is constant but increases with movement

· Not wanting to use the affected extremity

· Site of infection tender, swollen, & warm to touch

Fractures complications: osteomyelitis plan of care

· Skin, blood, & bone cultures

· Admin IV & oral ABX therapy

· Monitor VS, I/O

· Monitor site for drainage & for development of superinfection

· Immobilize & elevate extremity

Fractures complications: compartment syndrome assessment

Compartment syndrome: compression of nerves, blood vessels, & muscles – can lead to tissue necrosis - may need fasciotomy

5 P’s

· Pain that is unrelieved with elevation or analgesics

· Pale, cold skin, cyanotic nail bed

· Paresthesia (numbness)

· Paralysis or an inability to move digits (nerve damage)

· Pulselessness distal to fracture (late finding)

Fractures complications: compartment syndrome priority nursing interventions

· Assess extremity q hour for first 24 hr
· Space between the skin & the cast should allow for 1 finger to be placed
· Avoid elevating the affected extremity
· Loosen restrictive devices or dressings
· Prepare pt for fasciotomy

Fractures complications: compartment syndrome findings to report

· Pain that is not relieved by analgesics
· Pain that continues to increase in intensity
· Numbness or tingling
· Change in color of extremity

Scoliosis clinical manifestations

- Asymmetry in scapula, ribs, flanks, shoulders, & hips
- Improperly fitting clothing (one leg shorter than the other)

Scoliosis plan of care

Bracing: customized braces slow progression of the curve

- Assist with fitting, assess skin

- Wear for 23 hr/day, only remove for showering

Surgical interventions: used for curvatures > than 45 degrees

Developmental dysplasia of the hip (DDH) clinical manifestations: Infant

- Asymmetry & unequal # of skin folds of gluteal(buttocks) or thigh

- Limited hip abduction, shortening of femur

- Positive Ortolani maneuver: hip is reduced by abduction

- Positive Barlow maneuver: hip is dislocated by adduction

Developmental dysplasia of the hip (DDH) clinical manifestations: child

Bryant Traction for the following:

- One leg is shorter than the other

- Walking on toes on one foot/ walk with a limp

- Waddle gait

- Trendelenburg sign positive: unable to maintain the pelvis horizontal to the floor while standing first on the foot & then on the other foot

Developmental dysplasia of the hip (DDH) plan of care

Newborn – 6 mo. = Palvik harness

- (wear 23 hours a day for 6 weeks)

- Maintain harness placement for 12 weeks, adjusting every 1-2 weeks

- Check straps frequently

- Neurovascular & skin integrity checks

6 mo. – 2 yrs. = surgical closed reduction & then placed in hip spica cast

- Prepare for surgery

- Neurovascular checks

- Elevation/protection of cast

- ROM with unaffected extremities

- Hygiene – keep perineal area dry

Developmental dysplasia of the hip (DDH) patient teaching

· Note color & temperature of toes on casted extremity
· Give sponge baths
· Use waterproof barrier around genital opening of spica cast

Muscular dystrophy: prednisone teaching

- increases muscle strength

- can cause infection
- admin w food

Autism spectrum disorder 6 nursing care

· Multiple therapies: PT, OT, speech, language, early education

· Decrease stimuli

· Introduce new situations slowly

· Encourage age-appropriate play

· Brief & concrete(clear) communication

· Support groups

Autism spectrum disorder behavior modification

· Assist w behavioral modification program

· Promote positive reinforcement

· Increase social awareness

· Teach verbal communication

· Decrease unacceptable behaviors

· Set realistic goals

· Structure opportunities for small success

· Set clear rules

Attention-deficit/hyperactivity disorder (ADHD) expected findings

· Inattention, hyperactivity, & impulsivity (blurting out response before questions asked, difficulty waiting turns, interrupting often)

· Hard to play quietly & sit still

· Distracted by external stimuli

· Excessive talking

· Does not follow instructions or listen

Attention-deficit/hyperactivity disorder nursing care

· Decrease environmental stimuli

· Set limits on behavior as needed

· Calm, firm, respectful approach with the kid

· Provide a safe & comfortable environment

Medications:

- Dextroamphetamine

- Methylphenidate HCL

- Atomoxetine

Attention-deficit/hyperactivity disorder education

· Structured env., charts to assist w organization, consistent study area, modeling positive behaviors, use steps when assigning chores, using pastel colors

· Teach family to use behavioral techniques such as time out, positive reinforcement, or reward system

· Refer families to local support groups and national ADHD groups

· med. admin. - gradually increase dose to reach therapeutic results

Attention-deficit/hyperactivity disorder therapeutic action of stimulant medications

Methylphenidate & dextroamphetamine

- Psychostimulants, which increase dopamine & norepinephrine levels

- Methylphenidate: 1st line of Tx for ADHD

- give both during or after meal -> due to decreased appetite

Atomoxetine

- SNRI: block reuptake of norepinephrine at synapses in CNS

- monitor for suicidal ideation

Child abuse risk factors: caregiver

· Young age, lack of parenting knowledge

· Social isolation, low self esteem

· Low economic status

· Lack of education

· hx of abuse

Child abuse risk factors: child

· 1 year or younger is at greater risk

· Infants and children who are unwanted, hyperactive, or physical/mental disabilities

· Premature infants

Child abuse risk factors: environmental

· Chronic stress

· Other caregivers

· Poverty, Unemployment, Lack of housing
· Divorce, alcohol/substance abuse

Child abuse expected findings

Warning signs of abuse

· Other injuries discovered that are not r/t the original concern

· Inconsistency between caregiver’s report & the injuries

· Vague explanation of injury

· Inappropriate responses from parents or child

Physical neglect

· Failure to thrive, malnutrition

· Lack of hygiene

· Frequent injuries, delay in seeking care

· School absences

Physical abuse

· Bruises, welts in various stages of healing

· Burns, fractures, lacerations

· Fear of parents

· Lack of emotion or aggression

Child abuse expected findings continued

Emotional neglect & abuse

· Failure to thrive, eating disorder

· Sleep disturbances

· Withdrawal, lack of smile

· Attempts suicide

Sexual abuse

· Bruises, lacerations

· Bleeding of genitalia, anus, or mouth

· Bloody, torn, or stained underwear

· Unusual body odor

· STI, UTI

· Difficulty walking or standing

Shaken Baby Syndrome

- bruising before 6 months of age should be seen as suspicious by the nurse

Depression expected findings

· Tendency to remain alone

· Withdrawn from family, friends, & activities

· Weight loss or gain

· Alterations in sleep

· Lack of interest in school

· Hopelessness, suicidal ideation, sad facial expression

Depression priority nursing care/interventions

· Assess for actual or potential risk to self

· Assess for substance abuse

· Encourage peer group discussions & counseling

Candidiasis clinical manifestations

· Found in moist areas of the skin surface

· White exudate, peeling inflamed areas that bleed easily

· Pruritic (itching)

Candidiasis nursing interventions

- Nystatin, Miconazole: topical antifungal ointments for skin
- Nystatin: oral antifungals for oropharyngeal or intestinal - Dosage based on weight

Impetigo (school sores) clinical manifestations

- Reddish macules turn vesicular with crusting -->

erupts easily, leaving moist erosion on the skin, secretions dry forming honey-colored crusts

- Spreads peripherally & by direct contact until lesions are healed

Impetigo (school sores) nursing interventions

- Topical bactericidal or triple ABX ointment; mipirocin

- Oral or parenteral ABX if severe

- Aluminum acetate compress to remove crusted exudate

Impetigo (school sores) infection control

- HIGLY contagious
Hand washing is most important
- NO sharing towels, sheets, clothing - wash on hot w bleach

Impetigo (school sores) teaching

· Keep fingernails short & clean to prevent spreading through scratching
· Wash crusts daily with soap & water to promote healing

Pediculosis capitis (head lice) clinical manifestations

Intense itching

· Small, red bumps on the scalp

· Nits (white specks) on the hair shaft

Pediculosis capitis (head lice) nursing interventions

- 1% permethrin shampoo: repeat in 7 days

- Remove nits with fine tooth comb, repeat in 7 days after shampoo tx

- Malathion 0.5% (difficult cases)

Pediculosis capitis (head lice) teaching/infection control

· Wash clothing & bedding in HOT water

· Bag objects that cannot be washed in sealed plastic bag for 14 days - or place in hot dryer for 20 min

· DO NOT share hair products AND PERSONAL ITEMS: combs, brushes, hair holders, hair clips

Diaper rash clinical manifestations

· Bright red rash that extends gradually
· Fiery red & scaly areas on peri areas

Diaper rash nursing interventions

· Promptly remove soiled diapers

· Clean with non-irritating cleanser

· Expose area to air

· Apply skin barrier: petroleum ointment, zinc oxide ointment, aluminum acetate solution

- Do NOT wash off skin barrier with each diaper change

- DONT use corticosteroids