Exam 4 Families with Children: Neurosensory/Neuromuscular
A nurse is performing a neurologic assessment on an adolescent. Which of the following responses should the nurse expect the adolescent to exhibit when assessing the trigeminal nerve? Select all that apply. Clenching teeth together tightly Recognizing sour tastes on the back of the tongue Identifying smells through each nostril Detecting facial touches with eyes closed Looking down and in with the eyes
clenching teeth facial touches
Teaching the guardian of a client who has hearing loss. Which technique is recommended to facilitate communication with the child? Exaggerate pronunciation of each word. Keep hands still when speaking Speak at child's eye level Avoid using facial expressions when speaking
eye level
A nurse is teaching a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? Select all that apply. Febrile episodes Hypoglycemia Sodium imbalances Low blood lead levels Presence of diphtheria
febrile hypoglycemia sodium imbalances
Assessing the visual acuity of a group of school aged children. Which action should the RN take? Position child with heels at a line 6m away from the snellen chart. Allow each child to wear his/her glasses during the exam Start screening by covering each child's right eye Begin by having each child read the largest line of letters at the top of the snellen chart.
glasses
A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?
side lying, with legs pulled up and head bent down onto the chest (the client undergoing an LP is positioned lying on the side, with legs pulled up to the abdomen and the head bent down onto the chest . This position helps open the spaces between the vertebrae)
A nurse is in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? Stabilize the child's neck. Clean the child's laceration with soap and water. Implement seizure precautions for the child. Initiate IV access for the child.
stabilize neck
A nurse is assisting with the development of an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? Select all that apply. A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)
B & D
Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is: A. Prone for two hours to prevent aspiration, should she vomit. B. Semi-Fowler's so she can watch TV for five hours and be entertained. C. Supine for several hours, to prevent a headache. D. On her right side to encourage return of CSF
C
Treatment for Viral Meningitis: Acetaminophen w/codeine for pain/fever
LUMBAR PUNCTURE TO DIAGNOSE Definitive diagnostic test Void prior to procedure Apply Lidocaine/Prilocaine to site; 45 min to 60 min before Can be sedated with fentanyl and midazolam Spinal needle inserted in subarachnoid space/between L3/L4 or L4/L5 Provider collects 3-5 tubes of CSF Positioning: side lying with head flexed, knees drawn up to chest Assist with maintaining position Distraction methods as necessary Pressure & an elastic bandage applied after collection of fluid Monitor for bleeding, hematoma, infection Remain in bed for 4-8 hr in flat position to prevent leakage & spinal headache Headache is an expected side effect immediately after LP
A nurse is caring for an adolescent who has a closed head injury. Which of the following findings should the nurse identify as manifestations of increased intracranial pressure (ICP)? Select all that apply. Report of headache Alteration in pupillary response Increased motor response Increased sleeping Increased sensory response
HA, pupillary response, sleeping
A nurse is assessing a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect to find? Depressed anterior fontanel Constipation Presence of the rooting reflex High-pitched cry
High-pitched cry
Education
Instruct family on effective ways to communicate with the child Touching, cuddling, stalking, assisting with care as appropriate
Client is having tonic-clonic seizure. Nurse should take which of the following actions? SELECT ALL THAT APPLY A.Restrain client B.Maintain airway. C.Turn client to side. D.Place tongue blade in mouth E.Protect client from injury.
B, C, E
Visual impairment: nursing care
-normal to bright light for reading -assess infants and children for visual impairment and identify children at risk -observe for bahviors that suggest a decrease in loss of vision -promote child's optimal development and parent -child attachment-identify safety hazards, and prevent injury to the eyes -provide information regarding laser surgery for clients who have myopia, hyperopia or astigmatism -orient the child to the surroundings and provide a safe environment -promote independence and meeting developmental milestones while assisting with play and socialization
A child is suspected of having amblyopia ("lazy eye"). To help diagnose this disorder, the child will undergo which test? 1. Snellen's test 2. Near vision test 3. Weber's test 4. Peripheral vision test
1
Clinical Manifestations: Newborns: no illness present at birth, progresses within a few days NO nuchal rigidity, No Brudzinski's Poor muscle tone, Weak cry, Refuses feeding Poor suck, Vomiting, Diarrhea Late Finding- Bulging Fontanels & supple neck 3 months to 2 years: High-pitched cry with seizures Irritability Fever Poor Feeding vomiting Bulging Fontanels Possible neck rigidity
2 years to adolescents: Seizures- often initial finding Fever/chills Headache Vomiting Nuchal rigidity Septic joints LOC changes- irritability, restlessness, drowsiness, delirium, stupor, coma + Kernig's sign (resistance to extension of the child's leg from a flexed position) + Brudzinski sign (flexion of extremities occurring with deliberate flexion of the child's neck) Rash present for meningococcal infection
A 3-year-old child is status post-shunt 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, C, E
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care? Select all that apply a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.
A, E, F
Head injury: priority assessment
ABG's, intubation PRN-GCS and LOC -C-spine -normal ICP 1-10 -monitor V/S, LOC, PERRLA, ICP, motor activity, sensory perception and verbal responses -assess clear fluid draining from ear and nose
Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal (Tonic-Clonic) seizure? A. Crackles in the lungs B. Cardiac dysrhythmia C. Fever D. Abdominal tenderness
C
The adolescent patient shows symptoms of meningitis: nuchal rigidity, vomiting, fever, and lethargy. How should the following test be prepared by the nurse? A. Blood culture. B. Throat and ear culture. C. CAT scan. D. Lumbar puncture.
D
The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision
D
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take? A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue. B. The nurse should help the mother restrain the child to prevent him from injuring himself. C. The nurse should call the operator to page for seizure assistance. D. The nurse should clear the area and position the client safely.
D
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: a. Posturing. b. Focal neurologic signs. c. Vital signs. d. Level of consciousness.
D
The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate (extensor) posturing and interprets that this change in the child's condition indicates which finding? A. An insignificant finding B. An improvement in condition C. Decreasing intracranial pressure D. Deteriorating neurological function
D
The nurse should recommend medical attention if a child with a slight head injury experiences: a. Sleepiness. b. Headache, even if slight. c. Vomiting, even once. d. Confusion or abnormal behavior
D
HEARING IMPAIRMENTS affect speech and the ability to clearly process linguistic sounds.
infant: -lack of startle reflex-failure to respond to noise -absence of vocalization by 7 months -lack of response to the spoken word-failure to localize sound by 6 months older children: -using gestures rather than talking by 15 months -failure to develop understood speech by 24 months -yelling to express emotions -irritability due to inability to gain attention -seeming shy or withdrawn-inattentive to surroundings -speaking in monotone-need for repeated conversation -speaking loudly for situation
A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? Select all that apply. Uses monotone speech Speaks loudly Repeats sentences Appears shy Is overly attentive to the surroundings
monotone loud appears shy
Caring for a client immediately post op from a ventriculoperitoneal shunt. Which intervention should the nurse include in the plan? Monitor pupils every 8 hours Lay patient on the nonoperative side Keep HOB elevated to 30 degrees Check bowel sounds each shift.
nonoperative side
Providing teaching to parents of a child with strabismus. Which instruction should be provided to prevent development of amblyopia? Patch the unaffected eye Administer mydriatic eye drops daily Obtain prescription glasses Administer antihistamines
patch unaffected eye
A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? Moro Plantar grasp Stepping Tonic neck
plantar
Caring for a 5 year old child who has a fever & begins to seize. Which action should the RN take? Give tylenol 240mg po immediately after the seizure Sponge the skin with a mix of cold water and rubbing alcohol Administer rectal diazepam if seizure is longer than 2 minutes Place in side lying position
side lying
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen
4
A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask: A. "Do you have any problems seeing different colors?" B. "Do you have trouble seeing at night?" C. "How are you doing in school?" D. "Do you have problems with glare?"
C
A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? A. Nausea B. Irritability C. Bradycardia D. Headache
C
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. Maintain neutropenic precautions B. No precautions are required as long as antibiotics have been started C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics D. Maintain enteric precautions
C
Clinical manifestations of increased intracranial pressure (ICP) in infants are: SATA a. Low-pitched cry. b. Sunken fontanel. c. Diplopia and blurred vision. d. Irritability. e. Distended scalp veins. f. Increased blood pressure.
C, D, E
The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? Select all that apply a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone
C, D, E
Viral Meningitis/Aseptic Not contagious Requires supportive care for recovery
Cerebral Spinal Fluid Findings: CLEAR Normal or slightly elevated protein Normal glucose Gram stain -
Bacterial Meningitis/Septic DROPLET precaution until 24 hrs after antibiotics initiated Gown, gloves, mask and face shield Patient wears a mask if they leave the room Visitors need a mask
Cerebral Spinal Fluid Findings: CLOUDY Elevated WBCs Elevated Protein Decreased Glucose Gram stain +
Risk Factors for Seizures | Single Occurrence • Unknown Etiology • Febrile/Fever Episode • Cerebral Edema • Intracranial Infection / Hemorrhage • Brain Tumor / Cyst • Anoxia | Lack of O2 • Toxins or Drugs • Lead Poisoning • Tetanus, Shigella, or Salmonella
Clinical Manifestations / Assessment Tonic - Clonic Seizure • Onset without warning Most prevalent type Tonic Phase | 10 - 20sec -stiffening of muscles & loss of consciousness Eyes Roll Upward Loss of Consciousness Contraction of Entire Body Arms Flexed Legs, Head, Neck Extended - Mouth snaps shut and tongue can be bitten - Thoracic and abdominal muscles contract - Possible piercing cry, flushing - BP & HR Increases - Loss of Swallowing Reflex and increased salivation - Apnea can lead to Cyanosis
An important nursing intervention when caring for a child who is experiencing a seizure is to: a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration.
A
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A. Obtaining history information from the parents B. Instituting droplet precautions C. Orienting the parents to the pediatric unit D. Administering acetaminophen (Tylenol)
B
A child with a ventriculoperitoneal (VP) shunt complains of headache and blurry vision and is now experiencing irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's best response. A. "Give her some acetaminophen and see if her symptoms improve. If they do not improve, bring her to the pediatrician's office." B. "You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction." C. "It is common for girls to have these symptoms, especially prior to beginning their menstrual period. Give her a few days and see if she improves." D. "You are likely worried that she is having problems with her shunt. This is very unlikely as it has been working well for 9 years."
B
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension
B
The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.
B
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant? Select all that apply a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations
B, D, E
Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? A. Observing and taking down data on all seizures B. Assuring safety and protection from injuring C. Assessing for signs and symptoms of increased intracranial pressure (ICP) D. Educating the family about anticonvulsant therapy
C
A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? Select all that apply. Headaches Photophobia Difficulty reading Difficulty focusing on close objects Poor school performance
HA Difficulty reading Poor school performance
A nurse is reviewing the cerebral spinal fluid analysis for a group of clients who have suspected meningitis. VIRAL OR BACTERIAL Sort the following analysis findings by the nurse into the correct meningitis category. Cloudy color Elevated protein content Negative gram stain Clear color Decreased glucose content Normal glucose content Positive gram stain
Cloudy color- bacterial Elevated protein content- bacterial Negative gram stain- viral Clear color-viral Decreased glucose content- bacterial Normal glucose content-viral Positive gram stain- bacterial
Post-Op • Monitor for S/S of Increased ICP • Measure Head Circumference Daily • Monitor Anterior Fontanelle for Size & Fullness • Watch Behavior • Meds Antibiotics & Analgesics • Malfunction | Increased ICP Vomiting Irritability Poor Appetite High-Pitched Cry Bulging Fontanel • Prevent Infection • Shunt Over-Drainage | Drain too much Headache Dizziness Nausea
Complications: • Malfunction / Failure • Infection | Most Serious Change in LOC Fever No Appetite Sleep Disturbances Signs of Increased ICP • Peritonitis |bc infection of blood or Peritoneum Monitor Bowel Sounds | Hypoactive = +
Visual impairments - both partial sight and legal blindness. - Common visual impairments in children include myopia, hyperopia, astigmatism, anisometropia, amblyopia, strabismus, cataracts, and glaucoma. Partial impairment: 20/70-20/200 Legal blindness: 20/200 or worse
Expected Findings for Visual Impairments Myopia- nearsightedness Sees close objects clearly, but not objects in distance S/sx: headache, vertigo, eye rubbing, difficulty reading, clumsiness (frequently walking into objects) Poor school performance Hyperopia- farsightedness Sees distant objects clearly, but not objects that are close Not usually detected until age 7 Astigmatism Uneven refractive curvatures in vision in which only parts of letters on a page can be seen S/sx: headache, vertigo Appearance of normal vision because tilting the head enables all letters to be seen Anisometropia Different refractive strength seen in each eye S/sx: headache, vertigo, excessive eye rubbing Poor school performance
Amblyopia - lazy eye Reduced visual acuity in one eye Treat primary visual defect Strabismus: esotropia-inward deviation of eye & exotropia-outward deviation of eye; cross-eyed Abnormal corneal light reflex or cover test Sx: misaligned eyes, frowning, squinting, headache, dizziness, diplopia, photophobia, crossed eyes Difficulty seeing print clearly One eye closed to enable better vision Head tilted to one side Cataracts Gray opacity of the lens which prevents light from entering eye Decreased ability to see clearly Possible loss of peripheral vision S/sx: nystagmus, strabismus, absence of red reflex Infant: inability to reach and grab objects
Glaucoma Increase in ocular pressure in eye & loss of peripheral vision Perception of halos around objects S/sx: red eye, excessive tearing (epiphora), photophobia, spasmodic winking (blepharospasm), corneal haziness, enlargement of eyeball (buphthalmos), pain, red reflex of eye will appear gray to green
Increased Intracranial Pressure Clinical Manifestations: Infants: Bulging Fontanels Distended Scalp Veins Separation of Cranial Sutures Irritability / Restlessness Increased Sleeping High-Pitched Cry Poor Feeding Setting-Sun Sign: Eyes downward, can see sclera above Children: Nausea / Forceful Vomiting Headache Blurred Vision Increased Sleeping Inability to follow simple commands Decline in school performance Seizures
Late Signs: Alteration in Pupil Response | PERRLA Posturing Decorticate Decerebrate Decreased Motor response Optic Disc Swelling Coma Decreased LOC Cushing's Triad: Cheyne-Stokes/Hypertension/Wide Pulse Pressure/Bradycardia
Post-Seizure Side-lying position to prevent aspiration & to facilitate drainage of oral secretions Check breathing, VS, position of head & tongue, & perform neuro checks Assess head & body for injuries, including mouth Reorient & calm client if agitation or confusion Maintain seizure precautions Note time of postictal period NO food or liquids until completely awake and swallow reflex has returned Encourage client to describe period before, during, & after seizure activity Determine if client experienced an aura- indicate the origin of seizure in brain Try to determine possible trigger Document onset, duration of seizure, & client findings/observations prior to, during, and following seizure LOC, apnea, cyanosis, motor activity, incontinence
Medications | Antiepileptics • Diazepam • Phenytoin • Carbamazepine
Priority Nursing Interventions/Plan of Care ABCs- intubation as needed Stabilize spine- C spine precautions until ruled out Monitor V/S, LOC, pupils, ICP, motor activity, sensory perception, & verbal responses use GCS/PERRLA Maintain patent airway; mechanical ventilation if needed Oxygen to maintain O2 sats > 95% Padded restraints for clients who have agitation to prevent injury Actions that will decrease ICP Keep head midline & HOB 30 degrees Avoid extreme flexion/extension/rotation of head & maintain in midline neutral position
Minimize oral suctioning Nasal suctioning is contraindicated Avoid coughing & blowing the nose| increases ICP Ventriculoperitoneal shunt- direct removal of obstruction & drain CSF Insert & maintain indwelling catheter Admin stool softener to prevent straining|NO valsalva maneuver Provide calm, restful environment- Limit visitors, minimize noise, & dim lights Use energy-conservation measures Alternating activities with rest periods & cluster nursing care Seizure precautions & safety Side rails up/padded, & call light within reach Findings to Report- Clear fluid drainage from ears/nose = CSF leakage
Assess Infant Reflexes: Sucking/Rooting - Disappears after 3-4 mo. - Stroke cheek, newborn turns head to that side Tonic Neck- Fencer position Disappears after 3-4 mo. Turn head quickly to one side; Arms/legs on facing side extended Palmar Grasp Disappears after 3-4 mo. Finger in baby's palm; baby grabs finger
Moro/Startle Reflex Disappears after 6 mo.* Fall backward to an angle of 30º | Extend + abduct arms to catch self Plantar Grasp Disappears after 8 mo.* Finger at the base of newborn's toes; Baby curls toes downward Babinski Disappears after 1 year* Stroke outer edge of sole towards toes | up Stepping Disappears by 4 weeks
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? Place the client on NPO status. Prepare the client for a liver biopsy. Position the client dorsal recumbent. Put the client in a protective environment
NPO risk of aspiration
Performing a neuro exam on a 15 month old. Which finding should the RN expect? Negative babinski Presence of the moro Absence of corneal reflexes Positive palmar grasp
Negative Babinski
hearing impairment: nursing care
Nursing Care Assess children for hearing impairment Promote speech development, lip reading, use of cued speech (hand gestures with verbal communication) Encourage socialization and use of aids to promote independence Flashing light when doorbell or phone rings Telecommunication devices Closed captioning on TV Refer child and family to community support groups Use sign language or an interpreter if appropriate when working with a child who has hearing loss Always talk to child NOT interpreter Assess gait/balance for instability Assist with use of hearing aids Store batteries in safe place If whistling sound present Turn down volume or readjust hearing aid in ear Parent Education Methods to prevent further damage Complications Delayed growth and development Assist fam to obtain & access appropriate assistive devices
Discharge Teaching post VP Shunt • Age-appropriate Activities as tolerated • Normal Lifestyle as possible • Contact Sports PROHIBITED • Routine Medical Checkups • Do not Blow Nose/Cough
Patient / Parent Teaching § Wear Helmets / Seat Belt § Educate on S/S of Increased ICP § Never Shake Baby- Shaken Baby Syndrome
VP Shunt | Ventriculoperitoneal Shunt: Shunt placed to DECREASE ICP Drains CSF to an extracranial Compartment- usually Peritoneum.
Pre-Op • Assess Head Circumference / Fontanelles, Cranial Structure / LOC / Irritability / Altered Feeding Habit / High-Pitched Cry • Firmly Support Head & Neck • Small Frequent Feedings | Decrease Risk of Vomiting
Clonic Phase | 30 - 50 sec; up to 30 min- rhythmic jerking Violent Jerking Movements of the body Trunk & Extremities Experience Rhythmic Contraction & Relaxation Foaming in the mouth Incontinence of urine and feces Movement Gradually slows to a stop Postictal State | 30 min- confusion, sleepiness, & possible agitation Semi-conscious, arouses w/ Difficulty Confusion Fine Motor Impairment Lack of Coordination Vomiting, Headache, Visual/speech Impairment Sleeps for Several Hours, tired & sore muscles No Recollection of Seizure
Priority Nursing Interventions Seizure Precautions Pad side rails of bed, crib, & wheelchair Keep bed free of objects that could cause injury Have suction & oxygen equipment available During a Seizure Protect from injury If on floor, place blanket under head - Turn child to a side-lying position to decrease risk of aspiration - DO NOT attempt to restrain - DO NOT attempt to open jaw or insert an airway during seizure activity - Can damage teeth, lips, tongue - Do not put anything in the mouth - Remove child's glasses - Remain with child - Note onset, time, and characteristics of seizure - Remain calm & reassure caregivers
Nerve Names: Oh Oh Oh Tiny Tits And Fancy Vodka Gives Vincent A Hardon Nerve Class: Some Say Marry Money But My Brother Says Big Boobs Matter Most I Olfactory - Infants- Difficult to test - Children & Adolescents- Identifies smells through each nostril individually II Optic - Infants- Looks at face & tracks with eyes - Children & Adolescent- Has intact visual acuity, peripheral vision, & color vision III Oculomotor - Infant- Blinks in response to light & pupils are reactive to light - Children & Adolescent- Has no nystagmus & PERRLA is intact IV Trochlear - Infant-Looks at face & tracks with eyes - C/A- Has ability to look down & up with eyes V Trigeminal - Infant- Has rooting & sucking reflex - C/A- Able to clench teeth together & detects touch on face with eyes closed VI Abducens - Infant- Looks at face & tracks with eyes - C/A- Able to move eyes laterally toward temples; side to side
VII Facial - Infant- Has symmetrical facial movements - C/A- Has ability to differentiate b/w salty & sweet on tongue & has symmetrical facial movements VIII Acoustic - Infant- Tracks a sound & blinks in response to loud noise - C/A- Does not experience vertigo & has intact hearing IX Glossopharyngeal - Infant- Has an intact gag reflex - C/A- Has an intact gag reflex & is able to taste sour sensations on back of tongue X Vagus - Infant- Has no difficulties swallowing - C/A- Speech clear, no difficulties swallowing, & uvula is midline XI Accessory - Infant- Moves shoulders symmetrically - C/A- has equal strength of shoulder shrug against examiner hands XII Hypoglossal - Infant- Has no difficulty swallowing & opens mouth when nares are occluded - C/A- Has a tongue that is midline, able to move tongue in all directions with equal strength against tongue blade resistance
Treatment for Bacterial Meningitis IV antibiotics ASAP Dexamethasone Initial management of for Increased ICP Most effective against Hib infections - Acetaminophen w/codeine
Vaccines to prevent Meningitis: HiB- 2, 4, 6 months of age 12-15 months of age PCV- 2, 4, 6 months of age 12-15 months of age Meningococcal
MENINGITIS- BACTERIAL vs VIRAL
Viral (aseptic) meningitis usually requires supportive care for recovery. Bacterial (septic) meningitis is a contagious infection. Prognosis depends on how quickly care is initiated.
Visual impairment: Testing Pre-school visual acuity
Yearly ScreenSnellen Letter / Tumbling E / Picture Chart -20 ft from chart -Wear Glasses | If applicable -Cover one eye | read each line of chart -4/6 Characters is a Pass PER LINE | Top to Bottom -Repeat with other Eye
SEIZURES
abnormal, involuntary, excessive electrical discharges of neurons within the brain.
Priority Nursing Interventions:
Droplet Isolation as soon as meningitis is suspected. Petechiae/RASH present = immediate care/isolation /Meningococcal Meningitis Seizure precautions- give anticonvulsants Monitor V/S, Urine Output, fluid status, pain level, neuro status Newborns & infants - monitor head circumference & fontanels for presence of or changes in bulging Correct fluid volume deficits & restrict fluids until evidence of increased ICP & blood sodium levels within expected ranges Maintain NPO status if client has decreased LOC Decrease environmental stimuli by quiet environment & dim lights Cool environment No pillow Maintain safety (keep the bed in a low position, implement seizure precautions) Comfort measures Keep room cool & position: slightly elevate HOB/30 degrees, can also be side-lying to reduce neck discomfort
