NURS 6500 Exam 2

Myelomeningocele

Most severe form of neural tube defect, type of spina bifida cystica Visually obvious at birth Newborn is at increased risk for meningitis, hypoxia, and hemorrhage Paralysis, orthopedic deformities, and bladder and bowel incontinence are often seen with myelomeningocele The presence of neurogenic bladder and frequent catheterization puts the child at an increased risk for UTI, pyelonephritis, and hydronephrosis- may result in long-term renal damage if managed inappropriately

History taking: a neurologic problem/concern

N/V Changes in gait Visual disturbances Headaches Recent trauma Changes in cognition Changes in consciousness, including any loss of consciousness Poor feeding Lethargy Increased irritability Fever

Decerebrate posturing

Occurs with damage at the level of the brainstem -Posturing where neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign Most severe. "De-cer-e-brate....is REALLY not great" (as a way to remember which one is worse...decerebrate or decorticate.)

Autism Spectrum Disorder (ASD)

Onset infancy or early childhood One child in 88 is affected by ASD Ranges from mild (eg., Asperger syndrome) to severe Impaired social interactions and communication or stereotypic behaviors They may fail to develop interpersonal relationships and experience social isolation Many children with autism are intellectually disabled, requiring lifelong supervision, though some are gifted

Pediatric Glasgow Coma Scale

A popular scale used to standardize degree of consciousness. It consists of three parts: eye opening, verbal response, and motor response

Sunsetting eyes

A sign of increased intracranial pressure Able to see white all above the iris

The nurse is caring for an adolescent who says, "I'm sick of this. I wish I weren't aliveanymore." What is the best response by the nurse? A. "Have you thought about hurting yourself?" B. "I often feel sad and sick of things." C. "Do your parents know about this feeling?" D. "Are you trying to escape your problems?"

A. "Have you thought about hurting yourself?"

At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds: A. A rapid increase in head circumference B. Increase in weight since last visit C. Sunken fontanels D. Narrow sutures

A. A rapid increase in head circumference

Which of the following are warning signs of autism? Select all that apply. A. Not babbling by 12 months B. Not pointing or using gestures by 12 months C. No single words by 16 months D. No two-word utterances by 12 months E. Losing language or social skills at any age

A. Not babbling by 12 months B. Not pointing or using gestures by 12 months C. No single words by 16 months E. Losing language or social skills at any age

Spina bifida

All neural tube disorders that affect the spinal cord

Phenobarbital

Anticonvulsant Assess for excessive sedation Long half-life. Monitor serum levels to ensure therapeutic dosing.

Carbamazepine

Anticonvulsant Monitor serum levels to ensure therapeutic dosing; toxicity can occur even with levels slightly above therapeutic range.

Phenytoin

Anticonvulsant (IV and PO) Monitor serum levels to ensure therapeutic dosing. Be aware that gingival hyperplasia appears most commonly in children and adolescents.

Developmental delay

Any significant lag or delay in physical, cognitive, behavioral, emotional, or social development Routine developmental screening can assist in early identification Most common delays Language and cognitive skills Fine and gross motor skills

A child is diagnosed with bacterial meningitis. When reviewing the results of the cerebrospinal fluid evaluation, which of the following would the nurse expect to find? Select all that apply. A. Decreased leukocytes in CSF B. Elevated CSF pressure C. Cloudy appearance D. Decreased protein in CSF E. Elevated glucose in CSF

B. Elevated CSF pressure C. Cloudy appearance

A nurse is obtaining the history from a parent of a child who experiences absence seizures. Which of the following would the nurse expect the mother to describe? A. Brief, sudden onset with muscles that become tense B. Loss of motor activity accompanied by a blank stare C. Sudden, brief jerking motions of a muscle group D. Loss of muscle tone and loss of consciousness

B. Loss of motor activity accompanied by a blank stare

Which of the following would be included in the therapeutic management of a child with autism? A. Administer medications to cure the disorder B. Write a goal that the child will reach optimal functioning possible C. Individualize care D. Keep a highly structured environment E. Allow the use of music therapy and sensory integration techniques

B. Write a goal that the child will reach optimal functioning possible C. Individualize care D. Keep a highly structured environment E. Allow the use of music therapy and sensory integration techniques

The nurse is assessing a 2-month-old for signs and symptoms of increased intracranial pressure. Which of the following would the nurse expect to assess? Select all that apply. A. decreased blood pressure B. Increased appetite C. Bulging fontanel D. Resistance to being held

C. Bulging fontanel D. Resistance to being held

A 6-month-old infant is admitted to the hospital with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be: A. Educate the family on ways to prevent bacterial meningitis. B. Assess the infant's fontanels. C. Initiate appropriate isolation precautions and begin intravenous antibiotics. D. Encourage the mother to hold the infant and feed her.

C. Initiate appropriate isolation precautions and begin intravenous antibiotics.

Red flags a child may have a learning disability

Cannot speak in sentences by 30 months of age. Does not have understandable speech 50% of the time by age 3 years. Cannot sit still for a short story by 5 years of age. Cannot tie shoes, cut, button, or hop by 6 years.

Early signs of increased intracranial pressure

Changes in level of consciousness, irritability Headache Vomiting, possibly projectile Blurred vision, double vision (diplopia) Dizziness Decreased pulse and respirations Increased blood pressure or pulse pressure Pupil reaction time decreased and unequal Sunset eyes Seizure activity

Decorticate posturing

Characterized by upper extremities flexed at the elbows and held closely to the body ("core") -lower extremities are externally rotated and extended Occurs with damage of the cerebral cortex Not as bad as decerebrate

Which of the following is a sign of Down's Syndrome? A. Tall stature B. Hypertonic C. Large head D. Oblique palpebral fissures

D. Oblique palpebral fissures

A 10-year-old child is admitted to the hospital due to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention? A. Prevention of injury by placing a tongue blade in the child's mouth B. Prevention of injury by removing the child from his bed C. Prevention of injury by restraining the child D. Prevention of injury by placing the child on his side and opening his airway

D. Prevention of injury by placing the child on his side and opening his airway

The nurse is conducting an assessment of a 5-year-old boy. During the assessment, the nurse notes that the child does not maintain eye contact or speak. The nurse suspects an autism spectrum disorder. Which additional finding would help support the nurse's suspicion? A. The child is highly active and inattentive B. The child has a long face and prominent jaw C. The child has a slight decrease in head circumference. D. The child constantly opens and closes his hands

D. The child constantly opens and closes his hands

Late signs of increased ICP

Decreased motor and sensory responses Bradycardia Irregular respirations Cheyne-Stokes respirations Decerebrate or decorticate posturing Fixed and dilated pupils Lowered level of consciousness

Anencephaly

Defect in brain development resulting in small or missing brain hemispheres, skull, and scalp Majority of infants will be stillborn. If not, most anencephalic infants die within hours to several days of birth The infant is usually blind, deaf, unconscious, and unable to feel pain. Nursing mgmt is supportive in nature and focuses on comfort measures for the dying infant

Spina bifida occulta

Defect of the vertebral bodies without protrusion of the spinal cord or meninges Not visible externally and in most cases has no adverse affects

Positional plagiocephaly

Flattened back of skull Asymmetry in head shape without fused sutures. Since the inception of the "back to sleep" program there has been a dramatic increase Therapeutic management: generally conservative, such as changing the infant's position, encouraging "tummy time," and avoiding excessive use of the car seat for infant seating outside of the automobile Some infants may benefit from the use of a molding helmet.

Mgmt of ASD

Goal is for the child to reach optimal functioning -Individualized behavioral and communication therapies highly structured educational environment Stimulants may be used to control hyperactivity Antipsychotic medications are sometimes helpful with repetitive and aggressive behaviors Nursing care: remember no two individuals are the same Partner with parent - find out how child communicates Prepare child for procedures - use of visuals, soft voice, one person speaks at a time

Microcephaly

Head circumference that is >3 standard deviations below the mean for the age and sex of the infant May be congenital or may be acquired and develop in the first few years of life Generally results in intellectual disability due to the lack of functioning brain tissue

Signs of ICP in children

Headache Nausea and forceful vomiting Seizures Drowsiness, lethargy Diminished physical activity Inability to follow simple commands

Instructions for parents of child with seizures

If child has seizure: Remain calm Ease child to the ground Tight clothing loosened Place child on one side Do not restrain the child Remove hazards in the area. Do not forcibly open jaw with tongue blade or fingers. Document timing and movements noted.

Hydrocephalus

Imbalance in the production and absorption of CSF Not a specific illness- results from underlying brain disorders. CSF accumulates within the ventricular system and causes the ventricles to enlarge and increases in ICP to occur May be congenital or acquired.

Bacterial Meningitis

Infection of the meninges Serious in children- can lead to brain damage, nerve damage, deafness, stroke, and even death Requires rapid assessment and treatment. The infant may display an opisthotonos position (arching head back), older child may complain of neck pain --Infant: a bulging fontanel may be present, Kernig and Brudzinski signs can indicate irritation of meninges Petechial, vesicular, or macular rash may be seen

Signs of ICP in infants

Irritability, poor feeding High-pitched cry, difficult to soothe Fontanels: tense, bulging Cranial sutures: separated Eyes: setting-sun sign Scalp veins: distended

ADHD (Attention-Deficit Hyperactivity Disorder)

Is the most common neurodevelopment disorder of childhood, affecting nearly 10% of school-age children Characterized by inattention, impulsivity, distractibility, and hyperactivity Cause unidentified, may be alteration in the dopamine and norepinephrine neurotransmitter system

LOC (level of consciousness)

LOC is the earliest indicator of improvement or deterioration of neurologic status

Meningocele

Less serious form of spina bifida cystica Meninges herniate through a defect in the vertebrae The spinal cord is usually normal and there are typically minor/no associate neurologic deficits Tx: surgical correction of the lesion

Craniosynostosis

Premature closure of the cranial sutures

intracranial pressure (ICP)

Pressure inside the skull and thus in the brain tissue and cerebrospinal fluid (CSF) Measured in mm of mercury (mmHg)

Initial nursing mgmt of child with myelomeningocele

Preventing trauma to the meningeal sac and preventing infection before surgical repair of the defect Use sterile saline-soaked non-adhesive gauze or antibiotic-soaked gauze to keep the sac moist Immediately report any seepage of clear fluid from the lesion- could indicate an opening in the sac and provide a portal of entry for microorganisms Position the infant in the prone position or supported on the side to avoid pressure on the sac

Encephalocele

Protrusion of the brain and meninges through a skull defect. Results from failure of the anterior portion of the neural tube to close. Prognosis: including the extent of complications and cognitive deficits, depends on size and location of the encephalocele and involvement of other brain structures.

Care of the hearing impaired child during hospitalization

Reassess understanding of instructions given Supplement with visual and tactile media Communication devices Picture board Common words and needs (food, water, toilet)

fetal alcohol syndrome (FAS)

Results from in utero alcohol exposure, can cause intellectual disabilities with varying severity Typical facial features include low nasal bridge with short upturned nose, flattened mid face, long philtrum with narrow upper lip, short palpebral fissures Poor coordination, skeletal abnormalities Microcephaly Failure to thrive Hearing loss

Cerebellar function tests

Romberg: Ask child to stand still with eyes closed and arms down by the sides. Observe the child for leaning, indicating cerebellar dysfunction Heel-to-shin: heel on the opposite knee, and run it down the shin Rapid alternating movements: pats the thighs with the hands, lifts them, turns them over, pats the thighs with the back of the hands, and repeats Finger-to-finger: touches the examiner's finger with the index finger, then touches his or her own nose

Visual impairment management

Safe environment Reassurance Orient child to surroundings Encourage independence Consistency of team members

Neural tube defects

Serious birth defects of the spin and the brain --include disorders such as spina bifida occulta, myelomeningocele, meningocele, anencephaly, and encephalocele. The neural tube closes between the 3rd and 4th week in utero. The cause of neural tube defects is not known, but many factors such as drugs, malnutrition, chemicals, and genetics can adversely affect normal CNS development. Second most common birth defect contributing to infant mortality and disability.

Common diagnostic tests done for patient with seizures

Serum glucose, electrolytes, and calcium - to rule out metabolic causes LP - to rule out meningitis/encephalitis Skull x-rays - to check for fracture/trauma Head CT/MRI - to check for bleeds/tumors EEGs - seizure type Video EEGs - to see the child's behavior with seizure

Teaching CG how to assess closed head injury at home

Stay with the child for the first 24 hours and be ready to take the child to the hospital if necessary Wake the child every 2 hours to ensure they move normally, wake enough to recognize the caregiver, & respond to the caregiver appropriately Closely observe the child for a few days Call the provider or bring child to ER if child exhibits any of the following: Constant headache that gets worse Slurred speech Dizziness that does not go away or happens repeatedly Extreme irritability or other abnormal behavior

Breath holding spells

The child stops inhaling and exhaling or hyperventilates, the brain becomes anoxic, and child becomes cyanotic and may pass out Benign behavior of childhood, although it is extremely frightening for parents Normally seen in children 1 to 3 years old Usually triggered by the child becoming angry or stressed after not getting his or her way or as a reflexive response to fear, pain, or being startled

Fragile X syndrome

The most common inherited cause of intellectual disability Outcome of a mutation of a gene on the X chromosome

Febrile seizures

The most common type of seizure seen in children less than 5 years of age. Usually associated with a rapid rise in core temperature to 39C (102.2F) or higher

Ventriculoperitoneal shunt -care of

Treat hydrocephalus, a (VP) shunt catheter is placed in an enlarged ventricle. shunt diverts the flow of cerebrospinal fluid (CSF) within the central nervous system to the peritoneum, where CSF is now absorbed across the peritoneal membrane into the body's circulation. Monitor: S/s increased ICP Neurologic status closely LOC and vital signs

Down Syndrome congenital anomalies

Trisomy 21 40% - 45% heart defects: Renal, Hirschprung, tracheoesophageal fistualAltered immune function Musculoskeletal Muscles: Hypotonic Joints: Hyperextensible Atlantoaxial instability: 15%-20% Sensory Growth: weight vs height Sexual development Decreased life expectancy

Epileptic spasm such as infantile spasms

Type of epileptic spasm seen in infancy Presents as symmetrical flexing or extending, in variant clinical patterns, of the neck, arms, legs, and trunk Majority of infants have some brain disorder before seizures begin.