Pediatric Neurological Alterations

**The parents of an infant who has just had a ventriculoperitoneal shunt inserted for hydrocephalus are concerned about the infant's prognosis and ongoing care. The nurse should explain that: A. the prognosis is excellent and the shunt is permanent B. the shunt will need to be revised as the child gets older. C. during the first year of life, any brain damage that has occurred is reversible. D. hydrocephalus is usually self-limiting by 2 years of age and the shunt will then be removed.

B. the shunt will need to be revised as the child gets older.

Initial treatment of the patient with status epilepticus

1. ABCs 2. administer oxygen 3. IV access 4. IV administration of antiepileptic agents

postnatal care of child with spinabifida

1. prevent infection, observe for CSF leakage 2. perform neuro assessment 3. broad spectrum antibiotics 4. observe for abnormal extremity movement, reflexes 5. observe for IICP, meningitis, shock

Treatments for hydrocephalus

1. surgical removal of obstruction (ie: tumor) 2. placement of shunt to allow drainage of CSF

How is retinoblastoma treated?

1. enucleation (removal of eye) 2. external beam radiation 3. plaque radiation therapy 4. chemotherapy

Clinical manifestations demonstrated by 36 months of age

1. inability to maintain eye contact 2. avoidance of body contact 3. language delay 4. limited functional play, strange interactions with toys 5. self abusive behaviors 6. usually cognitively impaired 7. savants excelling in a particular area such as music, memory, math

Home care of the postop patient for repair of spina bifida

1. involve parents in care when coping 2. positioning 3. feeding 4. skin care 5. range of motion exercises 6. signs of complications - urinary, orthopedic, neurologic 7. breastfeeding encouraged for those who wish to 8. planning for future - type of work, sexual relationships, bearing children

General clinical manifestations of hydrocephalus in infancy

1. irritability, lethargy 2. infant cries when picked up or rocked, quiets when still 3. persistence of early infantile reflexes 4. normal reflex/responses fail to appear

The nurse is aware the child with down syndrome will likely need special care in these areas

1. proper positioning due to rag doll limbs 2. careful feeding due to tongue and drooling 3. often constipation due to poor GI motility

After a seizure, the nurse should

1. time the postictal period 2. check for breathing, check position of head and tongue 3. keep child on side 4. remain with child 5. no foods/liquids until fully alert and swallowing reflex 6. call EMS if necessary 7. look for medical identification, determine factors occuring before onset 8. check head and body for injuries

Causes of intravascular hemorrhage

1. vascular formation 2. tumor 3. trauma 4. birth asphyxia 5. low birth weight 6. respiratory distress 7. use of drugs

Postop care for the child having surgery for a brain tumor

1. vital signs every 15-30 minutes until stable 2. temp - hyperthermia risk 3. have cooling blanket ready in case of hyperthermia 4. if cooling measures, monitor temp closely for hypothermia 5. monitor for IICP, meningitis, respiratory infection 6. neuro checks

Autism is a complex developmental disorder. Diagnostic criteria for autism include delayed or abnormal functioning in which area(s) before 3 years of age? (Select all that apply.) A. Parallel play B. Social interaction C. Gross motor development D. Inability to maintain eye contact E. Language as used in social communication

B. Social interaction D. Inability to maintain eye contact E. Language as used in social communication

**A school-age child has recently been diagnosed as having a seizure disorder. The parents express a concern about what will happen at school if the child has a seizure there. The parents are afraid other children will make fun of their child. The recommendations by the nurse would include the suggestion that: A. the child always wear a medic alert bracelet B. the parents talk with the teacher about how to handle the situation C. the nurse explain the pathophysiology of seizures to the child so his self esteem will not be affected. D. the parents make an appointment with a psychiatrist to talk about their concerns.

B. the parents talk with the teacher about how to handle the situation. Rationale: These other responses are not appropriate in this case as the parents are concerned with self-esteem of the child. The psychiatrist may be consulted if child shows symptoms of altered self-esteem, but is not required based on the information provided.

If a shunt for a patient with hydrocephalus becomes infected, the nurse will anticipate

1. removal of shunt 2. external shunt for drainage 3. IV antibiotic treatment 4. placement of new shunt

What are risks associated with status epilepticus

1. respiratory failure 2. death

Clinical manifestations of retinoblastoma

1. white eye reflex - whitish glow - "leukocoria" (most common sign) 2. strabismus (second most common) 3. red, painful eye, often with glaucoma 4. severe permanent visual impairment (late sign)

Signs of increased ICP post-op shunt placement for hydrocephalus indicates

obstruction of shunt

Nursing care for shaken baby syndrome

1. ABCs 2. spinal cord immobilization 3. prevention of hypoxemia by monitoring O2 sat 4. monitor for changes in LOC, feeding, activity level 5. prevent hypotension - monitor BP, fluids 6. monitor for IICP - avoid suctioning 7. mannitol 8. elevate HOB to 30 degrees 9. avoid hypoglycemia

A 10-year-old client presents with weakness in legs and history of the flu. The medical diagnosis is Guillain-Barré syndrome. It would be imperative that the physician be informed if the nurse observes: A. weak muscle tone in feet B. weak muscle tone in hands C. increasing hoarseness D. tingling in the hands

(FYI only) C. increasing hoarseness

Emergency measures of care of the unconscious child

1. ABCs 2. stabilize spine when indicated 3. treat shock 4. reduce ICP if present

Clinical manifestations of bacterial meningitis

1. abrupt onset of symptoms 2. fever, chills 3. headache 4. vomiting, nausea 5. change in mental status 6. photophobia 7, back pain, nuchal rigidity *usually preceded by upper respiratory infection 8. Kernig sign 9. Brudzinkski sign 10. irritability and agitation

If the nurse notes leakage at the incision site, what should the nurse do?

obtain a specimen to be tested for glucose, which would indicate it is CSF

The child with Reye's syndrome is at risk of

seizures, coma, increased ICP, herniation, death

Atonic seizures

1. "drop attacks" 2. sudden momentary loss of muscle tone 3. loss of consciousness only momentarily 4. often suddenly falls to ground, can't put hands out 5. head may droop forward several times 6. usually occurs after waking up in morning

When do the following reflexes disappear? 1. sucking and rooting 2. palmar grasp 3. plantar grasp 4. tongue extrusion 5. tonic neck 6. moro 7. babinski

1. 3-4 months, can persist up to 1 year 2. 3-4 months 3. 8 months 4. 4-5 months 5. 3-4 months (over 6 months sign of cerebral pasly) 6. absent at 6 months 7. 1 year

Febrile seizure

1. 6-months to 3 years, rare after 5 years 2. core temp increases to 102.2F 3. seizure occurs while temp is rising 4. seizure usually over before the child arrives in the ER

What education should the nurse provide family concerning home treatment for seizures?

1. CPR training for family members 2. rectal diazepam for intractable seizures 3. activity restriction on individual basis 4. safety devices - helmets, no swimming alone 5. make caregivers and teachers aware 6. instruct to put something under head during seizure 7. medication side effects 8. folate and vitamin D supplementation - due to deficiency 9. no milk with phentoin

Diagnosis tests for neuroblastoma

1. CT scan 2. bilateral bone marrow aspiration and biopsies to locate tumor mass and metastasis 3. MRI, bone scan, MIBG 4. lab studies 5. urinary excretion of catecholamines (neurotransmitters)

Diagnostic tests for seizures

1. EEG - most valuable for evaluating seizure disorder 2. MRI, CT 3. lab tests - glucose, electrolytes, BUN, Calcium (metabolic disturbances) 4. tox screen 5. lumbar puncture - for suspected meningitis

Infantile spasms

1. almost always have developmental delays 2. usually occur during first 6-8 months of life 3. series of sudden, brief, symmetric muscular contractions 4. may or may not have loss of consciousness 5. sometimes flushing, pallor, or cyanosis 6. jack-knife like flexions 7. no post-ictal drowsiness

Preventative measure for bacterial meningitis

1. Hib vaccine (H influenza type B) 2. types A, C, Y, and W-135 vaccine 3. pneumococcoal conjugate vaccine for all children starting at age 2 months

Two types of hydrocephalus

1. non-obstructive (communicating) 2. obstructive (non-communicating) - obstructed CSF flow

posterior fontanel closes by

2 months

Down's syndrome is related to an extra chromosome on this chromosome

21

A nurse observes the sudden appearance of fixed and dilated pupils. This is A. a neurologic emergnecy B. a normal finding C. could be abnormal. The nurse should re-evaluate in 5 minutes. D. expected following a seizure

A. a neurologic emergnecy

Brudzinkski sign

when patient supine, passive flexion of neck causes flexion of lower extremities

**Clinical manifestations of increased ICP in children

1. headache 2. vomiting (with or without nausea) 3. seizures 4. diplopia, blurred vision

Types of intracranial infections

1. meningitis - bacterial, viral, tuberculous 2. encephalitis

The nurse observes pinpoint pupils. What might the nurse suspect?

1. opiate or barbiturate poisoning 2. brainstem dysfunction

The nurse observes dilated, fixed pupils. What might the nurse suspect?

1. paralysis of cranial never III secondary to pressure from herniation of brain through the tentorium 2. could also occur with hypothermia, anoxia, ischemia, poisoning with atropine-like substances, or prior instillation of mydriatic drugs

Three classifications of seizures

1. partial 2. generalized 3. unclassified epileptic seizures

Treatment for the child with strabismus

1. patch on stronger eye 2. surgery for weak eye 3. be aware of child's self esteem

Following a head injury, signs of brainstem involvement include these signs

1. periodic/intermittent gasping respiration with slowing pulse 2. widening pulse pressure 3. extreme fluctuation in BP

Neuro checks inlcude

1. pupillary reaction to light 2. LOC 3. sleep patterns 4. response to stimuli

side effects of antiepileptic medication

1. gingival hyperplasia (with Dilantin) 2. coarsening of facial features 3. liver function changes 4. anemia

Major causes of seizures in children

1. high fever - occuring as fever rises, not because it is high 2. infection 3. head trauma 4. hypoxia 5. toxins 6. cardiac arrythmias

Complications caused by intravscular hemorrhage

1. hydrocephalus 2. brain death 3. motor deficit 4. MR

Problems associated with spina bifidia

1. hydrocephalus 2. paralysis 3. orthopedic deformities - hip dysplasia, club foot 4. genitourinary abnormalities

signs and symptoms of cerebral palsy

1. hypertonia or hypotonia 2. scissoring of legs 3. absence of reflexes, extended presence of reflexes 4. failure to meet developmental milestones 5. slurred speech 6. difficulty swallowing 7. visual and hearing defects 8. seizures 9. digestive issues 10. speech impediment

Signs and symptoms of intraventricular hemorrhage

1. increased ICP 2. sudden deterioration in condition 3. apnea 4. cyanosis 5. hypotonia 6. decreased hematocrit 7. bulging anterior fontanel 8. separated sutures 9. seizures

Risks of ICP monitoring

1. infection 2. hemorrhage 3. malfunction 4. obstruction *it is an invasive procedure

Care instructions for parents

1. inform parents of progress 2. explain diagnostic procedures and therapies 3. educate on salicylates - refrain from using products with salicylatess

Types of ICP monitoring

1. intraventricular catheter with fibroscopic sensors** gold standard 2. subarachnoid bold (Richmond screw) 3. epidural sensor 4. anterior fontanel pressure monitor

Manifestations of simple procedures in infants

1. lip smaking 2. chewing 3. swallowing 4. excessive salivation 5. impaired consciousness, but purposeful movements *may or may not have aura

Nursing care for the patient with intraventricular hemorrhage

1. measure head circumference daily 2. assess fontanels and suture lines frequently 3. decrease noxious stimuli 4. maintain head midline 5. monitor/treat pain

Nursing care for the child with Autism

1. minimum holding or touching 2. avoid extraneous auditory and visual distractions 3. pay careful attention to eating habits, hoarding

Assessments for patient with brain tumor

1. neuro checks along with vital signs 2. head circumference 3. observe for headache, vomiting, and seizure activity 4. observe gait daily for tiliting of head or other changes in posture

Clinical manifestations of neuroblastoma

1. pain 2. abdominal mass crossing midline - not a good sign! 3. hypertension 4. low-grade fever 5. malaise, weight loss, diarrhea 6. limp 7. proptosis - "raccoon" eyes (preorbital ecchymosis) 8. blueberry muffin sign - bluish nodules due to presence of clusters of blood-poroducing cells in skin *half of patients may have few symptoms, other half are very ill appearing

How is cerebral palsy medically managed?

1. pain management - valium, baclofen pump 2. muscle spasm reduction - botox injections, baclofen pump 3. surgical tendon release, surgical contracture correction 4. ankle/foot braces

Emergency seizure care

1. protect airway - roll on side 2. protect from injury 3. do not move or forcefully restrain in tonic-clonic seizure, but do ease to ground if sitting 4. nothing in mouth 5. time the event and document characteristics 6. if possible, isolate/provide privacy 7. pillow or folded blanket under head 8. loosen restrictive clothes, remove eyeglasses 9. clear hazardous objects 10 jaw thrust for tongue if tongue causing choking *DO NOT: restrain, put anything in mouth, give food or liquids

Nursing care for the patient with bacterial meningitis

1. quiet, dim room to minimize stimuli 2. side lying position if nuchal rigidity, otherwise without pillow and HOB elevated 3. avoid actions that cause pain or increase discomfort 4. assess for fever before giving tylenol or ibuprofen - can mask fever 5. frequent observation of vitals, neuro signs, LOC, urinary output 6. fluids/nourishment determined by status 7. emotional support to family

Presenting signs of shaken baby syndrome

1. retinal hemorrhage 2. generalized flu like symptoms 3. unresponsiveness 4. vomiting 5. irritability 6. poor feeding 7. listlessness 8. seizures 9. visual impairments 10. developmental delays 11. hearing loss 12. mild, moderate, or severe cognitive impairments

How is Doll's head maneuver performed?

1. rotate child's head quickly to one side and then to the other 2. look for conjugate (working together) movement of eyes in direction opposite to head rotation

Late signs of hydrocephalus

1. seizures 2. increased pulse pressure, decreased heart rate 3. altered respiratory pattern 4. blindness from herniation of optic disc 5. decerebrate rigidity

Lab tests used to assess cerebral function

1. serum - glucose, CBC, electrolytes, culture if fever, toxicology 2. fundoscopic exam for papilledema 3. imaging - CT, MRI, echoencephalography, ultrasound, nuclear brain scan, PET 4. lumbar puncture 5. EEG 6. X-ray - skull fractures, dislocations, suture lines, degenerative changes

Clinical manifestations of Reye's syndrome

1. severe and continual vomiting 2. changes in mental state 3. lethargy 4. irritability 5. confusion 6. hyperreflexia

Types of head trauma

1. skull fracture 2. contusions 3. intracranial hematoma 4. diffuse injury

Classifications of cerebral palsy

1. spastic - hypertonicity 2. dyskinetic - wormlike movements 3. ataxic - disturbed coordination

Nursing care for the patient with a head injury

1. stabilize spine until cord injury is ruled out 2. assess pupils 3. NPO until instructed otherwise 4. monitor for bleeding from nose or ears - CSF possibly 5. monitor for change in LOC, agitation 6. no analgesics until LOC baseline established 7. look for bulging fontanels in infants, measure head circumference 8. awaken child twice during night 9. implement seizure precautions

Clinical manifestations of encephalitis

1. sudden or gradual onset 2. malaise, fever, headache 3. dizziness, apathy, lethargy 4. neck stiffness 5. ataxia, nausea/vomiting, tremors 6. speech difficulties, mutism 7. altered mental status

myoclonic seizures

1. sudden, brief contractures of a muscle(s) 2. no postictal state 3. may or may not be symmetric 4. may or may not include loss of consciousness 5. often occur when falling asleep 6. may be mistaken as exaggerated startle reflex

How is neuroblastoma treated?

1. surgical resection 2. chemotherapy 3. radiation 4. stem cell rescue - poor overall survival rate seen with this

Syndroms associated with autism

1. tuberous sclerosis 2. metabolic disorders 3. fetal rubella syndrome 4. haemophilius influenzae 5. meningitis 6. structural brain

A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold; that "He's like a rag doll. He doesn't cuddle up to me like my other babies did." The nurse's best interpretation of this lack of clinging or molding is that it is: A. a sign of maternal deprivation. B. a sign of detachment and rejection. C. suggestive of autism associated with Down syndrome. D. the result of the physical characteristics of Down syndrome.

D. the result of the physical characteristics of Down syndrome.

Medications used to treat status epilepticus

1. IV diazepam - first line 2. IV lorazepam - first line - preferred because of rapid onset 3. fospheytoin then phenobarbital if benzos ineffective 4. valproate - antiepileptic (no respiratory compromise)

Post-op assessment for the patient who received a shunt for hydrocephalus includes

1. assess pupillary dilation - pressure causes dilation on side with pressure 2. blood pressure - hypoxia to brainstem causes vitals changes 3. assess for infection** greatest risk postoperatively 4. assess for abdominal distention 5. inspect for leakage at incision site

Hallmarks of concussion

1. confusion 2. amnesia

Treatment for intraventricular hemorrhage

1. spinal/ventricular taps 2. diuretics 3. seizure suppression

A 3-year-old child is status postshunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.) A. Personality change B. Bulging anterior fontanel C. Vomiting D. Dizziness E. Fever

A. Personality change C. Vomiting E. Fever

**A 7-year-old child has just been diagnosed with a seizure disorder. The nurse practictioner has prescribed carbamazepine (Tegretol) 500 mg/day. The nurse should teach the parents that common side effects of this medication include: A. dizziness and headache B. hives and aching joints C. diaphoresis and vomiting D. blurred vision and papular skin rash

A. dizziness and headache

The nurse who is concerned about increased intracranial pressure in an infant should assess for: A. irritability. B. photophobia. C. pulsating anterior fontanel. D. vomiting and diarrhea.

A. irritability.

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. The MOST appropriate nursing assessment in this case is: A. reactivity of pupils. B. doll's head maneuver. C. oculovestibular response. D. funduscopic examination to identify papilledema.

A. reactivity of pupils.

Health promotion/disease prevention is an important role for nurses to prevent spinabifida. It would be most important for the nurse to explain that women of childbearing age should: A. take folic acid supplements during pregnancy B. be immunized for rubella and rubeola C. avoid pregnancy after the age of 45 D. not have children with a man who also carries the spina bifida genetic trait

A. take folic acid supplements during pregnancy

Reye Syndrome (RS)

Acute encephalopathy associated with other organs. Characterized by: 1. fever 2. profoundly impaired consciousness - cerebral edema 3. disordered hepatic function - fatty changes in liver 4. profuse, effortless vomiting 5. varying degrees of neurologic impairment

A 3-month-old infant has been admitted with a diagnosis of encephalitis. The first nursing priority would be to assess: A. pulillary reaction B. level of consciousness C. ability to maintain airway D. blood glucose level

C. ability to maintain airway

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. The PRIORITY of nursing care is to: A. initiate isolation precautions as soon as the diagnosis is confirmed. B. initiate isolation precautions as soon as the causative agent is identified. C. administer antibiotic therapy as soon as it is ordered. D. administer sedatives/analgesics on a preventive schedule to manage pain.

C. administer antibiotic therapy as soon as it is ordered. Antibiotics are the priority function; pain should be managed if it occurs.

What effect can strabismus have on the patient who is neurologically compromised?

Can cause eyes to appear normal

A 5-year-old male child has bilateral eye patches that were put in place after surgery yesterday morning. Today he can be allowed to get out of bed. The MOST important nursing intervention is to: A. reassure Adam and allow his parents to stay with him. B. allow him to assist in feeding himself. C. speak to him when entering the room. D. orient him to his immediate surroundings.

D. orient him to his immediate surroundings.

**An 18-month-old child is observed having a seizure. The nurse notes that the child's jaws are clamped. The priority nursing responsibility at this time would be: A. start oxygen via mask B. insert padded tongue blade C. restrain child to prevent injury to soft tissue D. protect the child from harm from the environment

D. protect the child from harm from the environment

Cranial nerves

OOOTTAFVGVAH 1. olfactory - smell 2. optic - vision 3. oculomotor - eyelid and eyeball movement 4. trochlear - eye movement 5. trigeminal - chewing, face/mouth sense/move 6. abducens - eye movement 7. facial - facial expressions, tears/saliva 8. vestibularcohlear - hearing, equilibrium 9. glossopharyngeal - taste, corotid BP 10. vagus - digestion, slows HR, aortic BP 11. accessory - trapezius, swallowing movement 12. hypoglossal - tongue movement

Why does the nurse observe for abdominal distention in the patient postop following shunt placement for hydrocephalus?

To assess for peritonitis or postoperative ileus as a complication of distal catheter placement.

Status epilepticus is defined as

a seizure lasting more than 30 minutes or series of seizures without regaining premorbid LOC

What effect does carbon dioxide have on intracranial pressure?

carbon dioxide is a potent vasodilator and increases cerebral blood flow and ICP

Posttraumatic srabismus indicates damage to this cranial nerve

damage to cranial nerve VI

Doll's head maneuver is performed to assess for

dysfunction of the brainstem or oculomotor nerve (III)

What is especially important with strabismus?

early diagnosis to prevent blindness

Treatment of spina bifida

early surgical closure - in 12-18 hours/24-48 hrs

What lab level would you expect with Reye's syndrome?

eleveated ammonia

hyperopia

farsightedness - ability to see objects at a distance

If first and second line treatment for status epilepticus fails, what is the next line of treatment?

general anesthesia with continuous infusion of midazolam, propfol, or pentobarbital *may need to be intubated, continuous EEG monitoring

When is lumbar puncture dangerous?

in presence of increased ICP - can cause brainstem herniation

Head circumference by age

increases by 1.5 cm monthly for 6 months

amblyopia

lazy eye, loss of visual acuity despite optical correction

How is Reye's syndrome diagnosed?

liver biopsy

strabismus

malalignment of the eye

Neuroblastoma

malignant extracranial solid tumor. Sites of growth: 1. abdomen 2. head 3. neck 4. chest 5. pelvis

What is retinoblastoma?

malignant intraocular tumor

Myopia

nearsightedness - ability to see objects clearly at close range but not at a distance

Difference between spina bifida occulta and spina bifida cystica

occulta - defect not visible externally cystica = visible defect with external saclike protrusion

Clinical manifestations of spina bifida occulta

often no observable manifestations 1. skin depression or dimple 2. port wine angiomatous nevi 3. dark tufts of hair 4. soft subcutaneous lipomas 5. bowel and bladder sphincter disturbances 6. disturbance in gait with foot weakness

Following a head injury, a child who has drowsiness, fever, or basilar skull fracture should be suspected of having

posttraumatic meningitis

What is the main goal in medical management of hydrocephalus?

relieve hydrocephalus, bypass blockage and drain fluid from ventricle to area where it can be reabsorbed

Upon neuro checks for a child following surgery for a brain tumor, the nurse notes sluggish, dilated, or unequal pupils. The nurse should

report immediately - may indicate increased ICP and potential brainstem herniation *medical emergency*

Classic sign of shaken baby syndrome

retinal hemorrhage

What causes intraventricular hemorrhage?

rupture of part of a the vasculature in the ventricles, resulting in bleeding in the brain

Glasgow coma scale score that is defined as a coma

score of 8 or lower

A common report by parents of a child who end up having retinoblastoma

strange light in the eye

Cause of Reye's syndrome

suspected connection between use of aspirin (salacylates) to treat fever with varicella or influenza -salicylates also in pepto-bismol and alka-seltzer

What is the major risk associated with head trauma

swelling - important to minimize risk of increased ICP

Seizures are classified as epilepsy when

there are two or more unprovoked seizures

Why is head of bed kept flat in the post-op patient with hydrocephalus?

to prevent too-rapid reduction of intracranial fluid

Phases of the tonic-clonic seizure

tonic - lasts 10-20 seconds 1. eye rolling and loss of consciousness 2. tonic muscle contractions 3. apneic, may become cyanotic clonic - lasts 30-50 seconds 1. intense jerking movements 2. maybe have incontinence 3. risk of impaired airway

Hydrocephalus

ventricles fill with fluid and push brain outward

Clinical manifestations of hydrocephalus in early infancy

1. abnormally rapid head growth 2. bulging fontanels (esp. anterior) 3. dilated scalp veins, serated sutures 4. thinning of skull bones

Initial therapeutic management of acute bacterial meningitis

1. isolation precautions 2. antimicrobial therapy - IV*** NURSING PRIORITY 3. restrict hydration 4. maintain ventilation 5. reduce IICP 6. management shock by restoring blood volume and maintaining electrolyte balance 7. control seizures with antiepileptic drugs 8. control temperature 9. treat complications

How is bacterial meningitis diagnosed?

1. lumbar puncture is gold standard/definitive test 2. measurement of spinal fluid pressure 3. expected results - white count elevated, glucose reduced, protein increased

Nursing management of hydrocephalus

1. measure head daily in infants at largest point 2. gently palpate fontanels and suture lines for signs of bulging, tenseness, and separation 3.

Nursing care for the patient with hydrocephalus

1. monitor vitals 2. neuro checks 3. avoid sedation 4. position on non-operative side 5. monitor for signs and symptoms of infection, leakage of operative site 6. administer IV antibiotics as ordered 7. pain management 8. head of bed flat, unless IICP, raise!

Other care concerns for the unconscious patient

1. mouth care 2. skin integrity 3. artificial tears or lubricating ointment q1-2 hrs 4. urinary catheter 5. record daily BMs, use stool softeners 6. positioning to minimize IICP and aspiration prevention

Nursing measures to reduce increased intracranial pressure

1. positioning to avoid neck compression, head midline, head of bed elevated 30 degrees 2. child may be propped to one side or other 3. alternating-pressure mattress 4. frequent clinical assessment 5. avoid activities that may cause pain or emotional stress, which can increase ICP p. 1426

Cerebral function assessment includes

1. size and shape of head, including fontanels 2. symmetry in movement of extremities 3. excessive tremulousness or frequent twitching 4. high pitched piercing cry 5. inability to suck or swallow 6. abnormal eye movements 7. spontaneous activity and postural reflex activity

The nurse observes widely dilated and reactive pupils. What might the nurse suspect?

1. usually occurs after recent seizure 2. eye trauma

Types of shunts used in treating hydrocephalus

1. ventriculoperitoneal - drains fluid from ventricles to peritoneal cavity or 2. ventriculoatrial (VA) shunt - drains to right atrium of heart

**The nurse is providing discharge instructions for a child who has suffered a head injury within the last four hours. The nurse will recognize the need for additional teaching when the mother states: A. "I will call my doctor immediately if my child starts vomiting." B. "I won't give my child anything stronger than Tylenol for headache." C. My child should sleep for at least 8 hours without arousing after we get home." D. I recognize that continued amnesia about the injury is not uncommon."

C. My child should sleep for at least 8 hours without arousing after we get home." Rationale: Discharge instructions will include the necessity of waking the child to check for neuro status throughout the night vomiting could be a sign of increasing intracranial pressure and should be reported narcotics not given after head injury amnesia for events surrounding injury may be permanent

The nurse places the young child scheduled for a lumbar puncture in a side lying position with head flexed and knees drawn up to the chest. The mothers asks why the child has to be positioned this way. The nurse explains the rationale for the positioning is that: A. pain is decreased through this comfort measure B. injury to the spinal fluid is prevented C. access to the spinal fluid is facilitated D. restraint is needed to prevent unnecessary movement

C. access to the spinal fluid is facilitated

Upon performing a physical assessment of a 7-month-old child, the nurse notes an abnormal finding that could suggest cerebral palsy. The finding suggestive of cerebral palsy is that the child has: A. no head lag when pulled to a sitting position B. no moro or startle reflex C. positive tonic neck reflex D. absence of tongue extrusion

C. positive tonic neck reflex Rationale: Moro, tongue extrusion, and tonic neck reflex are all neonatal reflexes that should have disappeared by this child's age. Lack of head lag indicates good motor development. Developmental delay or presence of neonatal reflex are some of the earliest cues to cerebral palsy.

During a well-child visit for an 8-month old girl, her parents express concern that their older child was already sitting alone at this age. The child was born 6 weeks premature but had no major difficulties during the neonatal period. The best response of the nurse to the parents is: A. "your observations are good. Your child is demonstrating a developmental delay and probably has cerebral palsy." B. "you shouldn't jump to conclusions. All children are individuals, and it is not fair to compare one child to another." C. "you have nothing to worry about. Your child's development is completely normal." D. Can you tell me more about how your child is feeding and turning over?"

D. Can you tell me more about how your child is feeding and turning over?"

**A 4-year-old child is being evaluated for hydrocephalus. An early indication of hydrocephalus in the child would be: A. bulging fontanels B. rapid enlargement of the head C. shrill, high-pitched cry D. early morning headache.

D. early morning headache. Rationale: head enlargement, bulging fontanels wouldn't be observed after 12-18 months due to closure of sutures. Shrill, high pitched cry is late-stage symptom.

The Glasgow Coma Scale is used to measure neurological functioning. Which of the following criteria would indicate the lowest level of functioning for an infant or child? A. confused B. irritable, cries C. eyes open only to pain D. no response to painful stimuli

D. no response to painful stimuli

True or false? Dexamethasone is used to treat aseptic (nonbacterial) meningitis.

False

True or false? Isolation precautions are necessary with encephalitis.

False.

Pain management post-op hydrocephalus

acetaminophen with or without codeine

Nursing alert: Any tests that require head movement are not attempted until

after cervical spine injury has been ruled out (ie: Doll's head maneuver)

What ongoing assessment is important for the infant with bacterial meningitis?

frequent assessment of open fontanels because subdural effusions and obstructive hydrocephalus can develop as complication of meningitis

Indications for ICP monitoring

glasgow coma scale score less than 8 with: 1. traumatic brain injury with an abnormal head CT scan 2. deterioration of condition

Ineffective thermoregulation indicates disorder of

hypothalamus and brainstem

What is hydrocephalus

imbalance in production and absorption of CSF in the ventricular system, in which production is greater, causing accumulation in the ventricular system and causing IICP and passive dilation of the ventricles

Encephalitis

inflammatory process of the CNS, usually by viral cause

Discomfort can be reduced by these nonpharmacologic interventions

keep environment stimulus free: 1. dim lights 2. no loud noises 3. limit visitors 4. prevent sudden jarring movements (banging into bed) 5. proper positioning 6. prevent straining from coughing, vomiting, suctioning, defication *these reduce risk of increasing ICP

The nurse observes unilateral fixed pupils. What might the nurse suspect?

lesion on the same side

Earliest indicator of improvement or decline in neurological status

level of consciousness

Causes of nonbacterial (aseptic) meningitis

many different viruses - most common is enteroviruses

Nuchal rigidity may indicate

menigneal irritation

Continued nursing care for the unconscious child includes

observation of 1. LOC 2. pupillary reaction 3. vital signs 4. nuchal rigidity 5. oculovestibular, corneal blink, and cough/gag reflexes 6. Glasgow coma scale

Important history information to gather when evaluating an infant or young child

pregnancy and delivery history such as infections, cigarette or alcohol consumption, drug use, toxin exposure, trauma, metabolic insults

How is bacterial meningitis transmitted?

1. droplet infection from nasopharyngeal secretions 2. vascular dissemination of other bacterial infection 3. direct infection after penetrating wounds, skull fractures, lumbar puncture, surgical procedures, spina bifida, foreign bodies such as shunt

Nursing care for the patient with cerebral palsy

1. encourage caloric intake 2. frequent rest periods 3. save environment (they can fall easily if preoccupied) 4. assist with communication 5. prevent aspiration - adaptive feeding, g-tube 6. encourage good dental hygiene

Clinical manifestations of spina bifida cystica

1. flaccid, partial paralysis of lower extremities 2. incontinence, constant dribbling of urine 3. lack of bowel control 4. kyphosis, scoliosis, hip dislocation, subluxation

Therapeutic management of Reye's syndrome

1. early diagnosis** 2. aggressive supportive therapy 3. care measures for the child with altered consciousness and IICP 4. prevent dehydration and cerebral edema - monitor I&O 5. monitor coagulation labs for prolonged bleeding due to liver dysfunction, as well as LFT

What are absence seizures?

1. brief loss of consciousness 2. minimal or no alteration in muscle tone 3. often unrecognized due to little change in child's behavior 4. usually between 4-12 years of age, ceases at puberty 5. abrupt onset with 20+ attacks daily 6. often mistaken for inattentiveness or daydreaming *no incontinence, usually doesn't fall, but may drop object

Those with down syndrome commonly have these concomitant conditions

1. congenital heart problems 2. respiratory tract infections due to weakened immunity 3. facial features - protruding tongue, small nose, round small skull, low ears, inner epicanthal folds, brushfield spots in eyes (speckles) 4. varying levels of cognitive alterations - mild to severe

Late signs of increased ICP

1. decreased LOC 2. *bradycardia 3. decreased motor response to command 4. decreased sensory response to painful stimuli 5. fixed and dilated pupils 6. papilledema 7. decerebrate or decorticate posturing 8. Cheyne-Stokes respirations 9. widened pulse pressure 10. Cushing's triad: HTN, bradycardia, apnea 11. coma

Long-term survivors of retinoblastoma are at risk of developing

1. decreased visual acuity 2. facial disfiguration 3. secondary tumors (osteogenic sarcoma)

Nursing care during febrile seizure

1. avoid tepid baths, no ice - causes shivering and metabolic output 2. use antipyretics (but won't stop seizure) *call 911 if seizure lasts more than 5 minutes

What is cerebral palsy?

1. believed to be due to prenatal brain abnormalities 2. nonprogressive motor disorder of CNS that results in alteration of movement and posture

Patients with brain tumors should be observed for symptoms of Cushing's triad, which include

1. bradycardia 2. hypertension 4. irregular respirations

Reflexes disappear by:

1. doll's eyes reflex - 1 month 2. hand grasp - 3. primitive reflexes - 4 months

Deep coma is indicated by a Glasgow coma scale score of

3

The nurse is planning care for a school-age child with bacterial meningitis. The plan should include: A. keeping environmental stimuli at a minimum. B. avoiding giving pain medications that could dull sensorium. C. measuring head circumference to assess developing complications. D. having child move head side to side at least every 2 hours.

A. keeping environmental stimuli at a minimum.

A school age child begins to have difficulty with his school work without real cause, the child is in good physical health, well adjusted and seems to have many friends. His grades have always been good but are beginning to slip. The school nurse was contacted because the child was experiencing headaches and he has been getting up out of his seat, randomly, to go to the front of the class room. She assesses the child and finds his eyes are aligned correctly and he can identify 2/5 letters correctly on each line of the eye chart in both eyes. The chart is at 20 foot distance. A. The child has clear signs of hyperopia B. The child has clear signs of myopia C. The child has clear signs of strabismus D. The child has clear signs of amblyopia

B. The child has clear signs of myopia

A child in the clinic exhibits reduced visual acuity in one eye despite appropriate optical correction. The nurse expects the child's health care provider to diagnosis the child with: A. myopia. B. hyperopia. C. amblyopia. D. astigmatism.

C. amblyopia.

The MOST appropriate nursing interventions when caring for a child experiencing a seizure include: (Select all that apply.) A. restraining the child when a seizure occurs to prevent bodily harm. B. placing a padded tongue between the teeth if they become clenched. C. avoid suctioning the child during the seizure. D. describing and documenting the seizure activity observed. E. applying supplemental oxygen after inserting an artificial oral airway.

C. avoid suctioning the child during the seizure. D. describing and documenting the seizure activity observed. RATIONAL: The child should not be restrained, because this may cause an injury. Nothing should be placed in the child's mouth, because this may cause an injury not only to the child but also to the nurse. To prevent aspiration, the child should be placed on the side if possible to facilitate drainage.

Now that the nurse identified the issue her next response should include: A. inform the teacher and delegate the responsibility of informing the parents to him/her B. send the child home with a note explaining the problem C. contact the parents with a referral for a visual exam and document ADPIE D. provide the child with a pair of glasses from lost and found because he is in a lower socio-economic status

C. contact the parents with a referral for a visual exam and document ADPIE

The nurse is providing client education for a family whose child has cerebral palsy and is receiving baclofen epidural therapy to control spasticity. Which of the following is most important for the nurse to include in the discussion? A. the drug acts to inhibit the neurotransmitter GABA B. the child should be able to run with normal gait after insertion of the pump C. parents must bring the child back to the clinic on a regular basis to have more medicine added to the pump D. parents can be taught to regulate the dosage on a sliding scale

C. parents must bring the child back to the clinic on a regular basis to have more medicine added to the pump

**A newborn has been admitted to the unit with a myelomeningocele. Preoperative concern would include: A. measure the head circumference on a daily basis B. preventing increased intracranial pressure by laying the baby in semi-Fowler's position C. positioning the infant on his abdomen to protect the spinal defect D. monitoring the child for signs of irritability and vomiting.

C. positioning the infant on his abdomen to protect the spinal defect

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should include that: A. parental protection is essential until the child reaches adulthood. B. cognitive impairment is to be expected with hydrocephalus. C. shunt malfunction or infection requires immediate treatment. D. most usual childhood activities must be restricted.

C. shunt malfunction or infection requires immediate treatment. Rationale: Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the developmental age of the child.

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is: A. absence seizure. B. generalized seizure. C. status epilepticus. D. simple partial seizure.

C. status epilepticus.

The genetic testing of a child with Down syndrome (DS) showed that it was caused by translocation. The parents ask about further genetic testing. The nurse's BEST response for the parents is: A. "No further genetic testing is indicated." B. "The child should be retested to confirm diagnosis of DS." C. "The mother should be tested if she is over age 35." D. "The parents can be tested themselves because the child's condition might be hereditary."

D. "The parents can be tested themselves because the child's condition might be hereditary." Rationale: The child does not require further genetic testing, but parents and siblings do. Retesting is not necessary because the diagnosis has been validated with chromosome testing. This type of chromosome abnormality occurs in children of parents of all ages. The parents and any siblings should be tested. Down syndrome resulting from a translocation may be inherited. This type of chromosome abnormality presents issues for future pregnancies.

Use of fosphenytoin and phenobarbital puts the child at high risk for

apnea

Following surgery for a brain tumor, the child begins to regress to a state of lethargy and irritability. The nurse recognizes this is a sign of

increasing ICP - potentially caused by hemorrhage, cerebral edema, or meningitis

When giving benzos to treat status epilepticus, what does the nurse need to monitor closely?

vitals that indicate respiratory depression

Who is Reye's syndrome common among?

1. children under 15 years 2. while recovering from a viral illness - usually influenza or varicella

How is encephalitis diagnosed?

1. clinical findings 2. idenification of specific virus/causative agent 3. CT scans normal in early stage 4. serologic testing - blood sample as soon as possible

Signs of CSF infection

1. elevated temperature 2. poor feeding 3. vomiting 4. decreased responsiveness 5. seizure activity

Clinical manifestations of hydrocephalus in later infancy

1. frontal enlargement or bossing 2. depressed eyes 3. setting sun sign (sclera visible above the iris) 4. pupils sluggish with unequal response to light

Nursing considerations in nursing care for the child with ICP

1. gentle range of motion exercises, nothing vigorous 2. plan any disturbing procedures when osmotherapy and sedation are used 3. minimize environmental noise 4. careful assessment of pain cues 5. suctioning and percussion contraindicated 6. avoid hypoxia and valsalva maneuver *suctioning only if concurrent respiratory problems

Clinical manifestations of hydrocephalus in childhood

1. headache upon awakening, improvement following emesis or upright posture 2. papilledema, strabismus, ataxia, irritability 3. lethargy, apathy, confusion, incoherence/vomiting (possible projectile vomiting)

Severe encephalitis is manifested by

1. high fever 2. disorientation/stupor/coma 3. seizures, spasticity 4. ocular palsies 5. paralysis

Therapeutic care of encephalitis

1. hospitalized immediately for observation 2. treatment is supportive 3. control of cerebral manifestations 4. adequate nutrition and hydration 5. close monitoring for neurologic injury - cerebral edema, seizures, abnormal fluid/electrolyte balance, aspiration, cardiac and respiratory arrest

**A 15-year-old wrestler who suffered a concussion after being thrown on his head during a match was seen in the emergency room for assessment and observation. After providing the parent with discharge instructions about post-concussion syndrome, the nurse knows that the parents have understood the instructions if they state they: A. will keep an eye on the child when he wrestles in a meet tomorrow. B. plan to speak with his teachers about the injury. C. should call their primary physician for an antiemetic prescription if he has any vomiting. D. will check him every four hours during the night and have him bend his head to his chest.

B. plan to speak with his teachers about the injury. *vomiting should be reported but is not treated with antiemetic

Parents of a 10-year-old boy with mild cerebral palsy ask the nurse about having the son join a Boy Scout troop that meets after school. The boy attends a regular grade school class. The nurse knows that: A. the rigors of most scout events would be physically beyond this child's capability. B. scouting can provide children of all abilities with opportunities for recreation and socialization. C. it would be embarrassing for the child to be different from the other boys and lower his self-esteem. D. it is more important that the child conserve his energy for doing schoolwork.

B. scouting can provide children of all abilities with opportunities for recreation and socialization.

**A school age child begins to have difficulty with his school work without real cause. The child is in good physical health, well adjusted, and seems to have many friends. His grades have always been good but are beginning to slip. The school nurse was contacted because the child was experiencing headaches and he has been getting up out of his seat, randomly, to go to the front of the classroom. She assesses the child and finds his eyes are aligned correctly and he can identify 2/5 letters correctly on each line of the eye chart in both eyes. The chart is at a 20-foot distance. A. the child has clear signs of hyperopia B. the child has clear signs of myopia C. the child has clear signs of strabiscmus D. the child has clear signs of amyopia

B. the child has clear signs of myopia

A child with hydrocephalus is increasingly irritable, lethargic, and having seizures, changes in vital signs, and feeding behavior. These signs may indicate A. improving condition B. worsening condition C. expected outcomes D. concurrent respiratory distress

B. worsening condition

Now that the nurse identified the issue her next response should include: A. inform the teacher and delegate the responsibility of informing the parents to him/her. B. send the child home with a note explaining the problem. C. contact the parent with a referral for a visual exam and document ADPIE. D. provide the child with a pair of glasses from lost and found because he is in a lower socio-economic status.

C. contact the parent with a referral for a visual exam and document ADPIE.

What testing should be performed 6 months after recovery from bacterial meningitis?

auditory evaluation because hearing loss is common

True or false? The patient with dulled sensorium should be kept NPO.

true otherwise give clear liquids and progress diet suitable for age as tolerated

Kernig sign

when supine patient cannot extend knee more than 135 degrees, pain felt in hamstrings

**Following surgery for the insertion of a shunt for hydrocephalus, the infant demonstrated irritability, high-pitched cry, elevated pulse rate, and temperature of 40 degrees C (104 degrees f). These symptoms are consistent with which of the following postoperative complications? A. shunt obstruction B. increased intracranial pressure C. decreased intracranial pressure D. infection

D. infection

If suctioning is necessary for the child with IICP, what should the nurse do?

1. hyperventilation with 100% O2 2. brief periods of suctioning 3. monitor O2 sat while suctioning

Behavior signs of increasing ICP

1. irritability, restlessness 2. drowsiness, indifference, decreased physical activity and motor skills 3. complaint of fatigue, somnolence, increased sleeping 4. lethargy 5. inability to follow commands, memory loss 6. weight loss

The family who has a child with a chronic health problem such as spina bifida experience "chronic sorrow" through the child's life. The nurse can anticipate that this will be more prevalent when: A. the child is admitted to the hospital for a planned procedure B. the child reaches the age of "developmental milestone" that the child cannot attain C. the child attains independence by attending school D. a sibling is born without any health problems

B. the child reaches the age of "developmental milestone" that the child cannot attain

In the older child, this is a valuable indicator of increasing ICP

change in LOC