Pediatrics Exam #3

Renal Replacement: Peritoneal dialysis

Automated PD most common dialysis tx in children 1.) Benefits: - Constant removal of wastes minimizes detrimental effects on growth and development; - Minimizes interruptions of general activities, school - Requires less fluid and dietary restriction 2.) Complications: Less dialysate draining then dwelled, infection, peritonitis, leakage, pain, imbalanced nutrition Dialysis can be HD, continuous, and/or peritoneal dialysis In children requiring dialysis, the first line intervention is peritoneal dialysis. This method of dialysis uses gravity to infuse a pre-warmed diasylate solution into the perioneal cavity, which then facilitates fluid, electrolyte, and glucose exchange using osmosis, and after a period of time, gravity is then again used to remove this fluid. Starting any kind of dialysis can be frightening; initiation of peritoneal dialysis requires the surgical insertion of a peritoneal catheter, for instance. But the benefits of PD are that there isn't any pain associated with accessing the catheter after insertion; it allows for "continuous" removal of wastes and thus minimizes growth and development impacts of the disease (I put this in quotes because we're not talking about 24/7 filtration, but it's more continuous than the alternative of hemodialysis), and allows for continued engagement in school and other socialization activities. The major risks involve infection of the catheter site or the peritoneal cavity, but there are others as well. It is usually done at home, which means the family needs a LOT of education here - sterile technique, catheter care, method of infusion, signs of complications, and what to do when these arise at the very least. And the family requires a lot of support - you can imagine it's straining when a parent becomes a healthcare provider for their child, and children too still feel the affects of life interruption, social interruptions, body image and self-concept.

Concussions: Emergent imaging

most likely needed if there's skull fracture, neck injury, concussive seizures, or sustained unconsciousness or change in level of consciousness

Hemodialysis is also a safe option, but not our first choice. It's primarily reserved for those who are

not good candidates for PD, either because they don't have the resources to manage it, or they've had multiple infections while using it. It requires the implantation of either a portacath or a fistula, both of which can also be anxiety producing when obtained, and can be painful to access, so appropriate care should be taken to enact needle pain protocols prior to each procedure - which are usually required for 3-4 hours/procedure, 3x/week. You can imagine that this can really cramp someone's style - you have to be near a center that can provide the procedure, it takes you out of school, you often feel kinda gross afterwards, and even when you're not actively receiving hemodialysis you still have to be careful not to cause injury to the fistula or portacath. Nurses have a really important role in implementing hemodialysis in children, and it goes beyond the usual monitoring for disequilibrium syndrome or monitoring labs and I&Os - we also should be actively engaged in stimulating the child developmentally - playing games with them, reading books, talking or providing other distractions, or helping with homework.

Postpericardiotomy syndrome

not uncommon autoimmune response to damaged myocardium/pericardium or blood in pericardial sac Usually happens w/in days to weeks of surg (most commonly 2-3 wks) High fever (104), fatigue, anorexia, nausea/vomiting, +/- chest pain mild tx: bed rest and NSAIDS major tx: corticosteroids, +/- pericardiocentesis

Developmental Effects of Immobilization: General

outlet for anxiety and other negative emotions, gives a means for control and autonomy. Can lead to isolation, boredom, feelings of being forgotten. Can also result in emotional difficulties, regression, and substantial family dysfunction (taxes resources and coping abilities).

Automatisms

particularly important to note for assessment in infants - eye movements, lip smacking, tongue thrusting, repetitive blinking, sucking - signs of a seizure in infants

Confusion

the inability to think clearly; Disorientation

Compression (compartment) Syndrome: The 6 P's

Pain Pulselessness Pallor Paresthesas Paralysis Pressure

Developmental Dysplasia of the Hip (DDH)

- Abnormal development of the hip that affects the femoral head, the acetabulum, or both - Categories: 1.) Complete: femoral head outside the acetabulum 2.) Subluxation: femoral head is partially dislocated 3.) Unstable: the femoral head can be pushed out from the acetabulum 4.) Other dysplasias: the acetabulum is flattened

Musculoskeletal system: Differential Diagnosis

- Accidental trauma vs non accidental trauma - What are signs of child abuse? - suspected abuse or neglect = file a 51A - Other skeletal issue as the etiology for the fracture? - How is this evaluation conducted and what are the associated physical findings?

Seizure Disorders

- Electrical discharges due to excessive concurrent firing that causes involuntary movement, alterations in behavior & sensation - Underlying disorder, structural defect, brain injury, electrolyte imbalance, infection, toxins, endocrine dysfunction, brain tumor - Causes: Anything that can effect CNS function

Kawasaki Disease

- Acute systemic vasculitis - Diagnosis = Fever > 5 days with 4-5 clinical criteria a.) Extremities: edema, erythema (palms and soles), subacute desquamation of hands and feet b.) Bilateral conjunctival injection (inflammation) without exudate c.) Oral mucous membranes: erythema of lips, oropharyngeal redness, strawberry tongue d.) Polymorphous rash e.) Cervical lymphadenopathy - Cardiac concerns = Coronary artery dilation and aneurysms and risk for MI - Majority of cases are children < 5 y/o - Consider with any cases of fever >5 days - Unknown cause, thought related to viral exposure - Fever unresponsive to antibiotics and antipyretics (usually not helpful)

GU Infections: Urinary tract infections

- Ascending infections of one or more structures of the urinary tract - Cystitis and pyelonephritis - Typical species: E. Coli, Klebsiella, Proteus mirabilis - extremely common in childhood, particularly among infants (girls<boys, uncircumcised boys<circumcised boys). They occur when there's an infection in one or more of the structures in the urinary track, causing an inflammatory process in the region. - When we think of the classic UTI, we're most often thinking of cystitis, or infection related inflammation of the bladder; but we can also see pylonephritis, or infection related inflammation of the upper urinary track and kidneys. A protracted period without adequate treatment of a cystitis can also result in progression to include pylonephritis as the offending bacteria travels through the ureters. - This is most commonly seen in the outpatient context, but when it progresses to pylonephritis, it may require an admission for IV antibiotics & fluids, and monitoring for improvement. - The most common bacterial culprits are e.coli, klebsiella, and p. mirabillis, although we can also see a couple different types of staph and enterococcus too. In children, the most common bacterial origin is the GI system - ie, via fecal matter. This is important to remember, as it can inform recommendations for prevention (clean the perineal area well!) and treatment (antibiotic choices), as well as suggest other conditions to consider (ie, constipation). - Other precipitating factors include urine stasis, which starts to present around the time of preschool if a child already has demonstrated bladder sphyncter control - they are starting to make friends, and have activities to partake in that they might not want to stop, even long enough to use the restroom. Children who have neurogenic bladder - for example, some kids born with spina bifida, particularly those who take anticholinergic medications to help with retention - are also at high risk for UTI. Kids who wear synthetic underwear - that is, underwear made from polyester or other non-cotton material, girls who are sexually active (and girls in general), and as noted before, boys who are uncircumcised, are also at higher risk. - In general, the role of the nurse is to identify symptoms, collect lab specimens and assess their findings, educate about medications used for treatment, and emphasize prevention strategies

Infective Endocarditis

- Bacterial colonization of damaged endocardium - Can result in HF when affecting a valve, embolus if dislodged - S & S = recurrent low grade fever, fatigue, weakness, weight loss - Medical treatment: blood culture, IV abx, valve replacement - Nursing treatment: physical assessment, abx administration, telemetry monitoring, education for prevention - Damage to endocardium comes first, from surgery or turbulent blood flow - Bacteria can be introduced by dental procedure, medical procedure, indwelling catheter - Most common S & S presented here

Nursing Management: Parent Teaching & Discharge: DDH

- Cast care - Harness teaching - Limb assessment - Bathing - Safe movement - Car transport - Diet - Support, resources

Pediatric Renal Transplant

- Definitive treatment for ESRD - Donors come from living relative or cadaver - Primary goal is long term survival of grafted tissue = immunosuppression usually with corticosteroids with cyclosporine or tacrolimus ad mycophenolate mofetil - Long term transplant immunosupp drug s/e: HTN, growth restriction, cataracts, risk for infection, obesity, characteristics of Cushing, and hirsutism - Immediate signs to alert HCP: fever, swelling/tenderness of grafted area, dim UO, elevated BP, elevated creatinine

Osteogenesis Imperfecta Overview

- Eight variations on a common connective tissue disorder - Characterized by fragility of, and deformities in, bone and bone growth ¤ May be 1st identified with a fracture ¤ Xray shows evidence of old breaks and healing, possibly epiphyseal abnormalities ¤ May result in gross motor development delays - Parents may be suspected of child abuse - Other classic symptoms: blue sclera, short stature, hearing loss in adolescence

More info about Nephrotic Syndrome

- Etiology most common: minimal change nephrotic syndrome (MCNS) - Risk for renal failure Nephrotic syndrome is a condition where the glomeruli are inappropriately permeable to proteins, usually for no apparent reason. Most often, it is of an idiopathic cause. Increased permeability to protein means that excess protein ends up in the urine, resulting in one of the two classic signs of the condition: frothy urine. In addition, it sets of a cascade of pathophysiological events that result in the second classic sign: significant, body-wide edema. These kids frequently have noticeable facial edema, and rapid fluctuation in the location of fluid from the torso into the extremities. BUT! Counter-intuitively, these patients also appear HYPOVOLEMIC! This is because, by pulling more protein out the body, we also change the intravascular oncotic pressure (remember that without the bigger particles in the blood stream, there is less force pulling fluid in); and in response to this, the body tries to compensate by increasing intravascular pressure, which increases hydrostatic pressure (more pressure from fluid pushing against the vessel wall means more gets pushed out!). So were we think of the classic kidney disease patient as being hypertensive, these patients are often normotensive to hypotensive depending on how well they're compensating. They are also hyperlipidemic, for reasons we don't totally understand. Other Signs & Symptoms include: Pallor, malaise, irritability, anorexia, hematuria, decreased urine output, sometimes respiratory distress if we end up with fluid in the pleural space of the lung. In addition to a history and physical, laboratories are the primary means of confirming the diagnosis. We see excessive proteinuria on UA, low albumin in our LFTs, possibly low sodium in our basic metabolic panels, and as we said, hyperlipidemia. These patients may also have renal biopsies to evaluate for changes to the tissue. This is generally a condition of exacerbation and remission, so when outside of an exacerbation period, most or all these parameters may be basically normal. The goals for treatment are to induce remission when an exacerbation has started, to restore fluid in the vascular compartment, and to prevent future exacerbations that over time, may cause enough damage to the kidney to result in kidney failure.

Bladder Exstrophy

- Eversion of the posterior bladder through the anterior bladder wall and Lower abdominal wall - MS, urinary, reproductive, and intestinal defect - One of the 3 defects that defines exstrophy-epispadius complex: bladder exstrophy, epispadius, cloacal exstropy (bladder exs, exstrphy of lg intestine through abdominal wall defect, anal atresiam omphalocele, colonic hypoplasia, anomalous genitalia, and spinal dysraphism

Purposes of Traction

- Fatigue muscles and reduce muscle spasms to facilitate realignment - Realign the distal and proximal ends of the bone to facilitate healing - Immobilize until there has been realignment and the patient can be splinted or casted - Prevent or improve contracture deformity - Immobilization of specific areas

Management of CHD

- Improve cardiac function - Remove fluid, where appropriate - Decrease the demand on the heart - Improve and/or maintain oxygenation - Monitor afterload reducers, where appropriate - Decrease respiratory distress - Optimal nutrition - Will look different depending on the CHD and the individual patient

Musculoskeletal Effects of Immobilization

- Loss of muscle strength - Bone demineralization - Loss of joint mobility and contractures - Tissue breakdown: a.) Decrease in circulation especially at skin over bony prominences b.) Assess for prolonged redness and later decreased temp in area, blistering, or purplish color - So much of the physiology of growth and strength is stimulated by weight bearing activities - think about WALL-E and the people not walking or being exposed to gravity. Without this, there are serious consequences for development.

Traumatic injuries: Fractures

- Manifestations: swelling, pain, deformity, diminished use, +/- bruising, severe muscular rigidity, crepitus. - Diminished use would manifest as changes in activity like not walking, for example - The younger the child (provided good nutrition and no MS d/o) fractures heal quickly - Epiphyseal Injuries (Salter-Harris Classification) Diagnostics Xray Lab work RBC destruction: Low Hct, Hgb, increased bili, - Muscle damage: Increased creatinine. Alkaline phosphate, lactic dehydrogenase - Tissue injury: increased WBC, neutrophils Inflammatory process) Infection (later) increased leukocytes, fever

Obstructive uropathies

- Many places for obstructions to the flow of urine - Degrees of upstream dilation, and damage is seen - With severe obstruction, and even with relief, can lead to chronic kidney disease and renal failure with dialysis as the only method of cure - Growth, and fluid/lyte balance, are a concern for these infants (think of them essentially having renal failure)

Open Heart Surgery: Post-Operative Family Education

- Medication - Wound Care = Keep wounds clean & dry, no oils or lotions, don't soak in bath until sutures out etc., avoid rubbing. - Activity = Gradually & carefully increase activity as tolerated by child. Nothing strenuous, rough, or potentially injurous for 6 weeks. school w/in 3 weeks but no backpack for much longer - Diet = Encourage good nutrition for growth & development, bowel consistency - Immunizations = no live vaccines w/in 5-6 months if blood product was received. - Prophylactic ABX for dental care in some cases - Dental Care - Discomfort - Behavioral issues - When to call the healthcare provider = Call w/ s&s infection, postpericardiotomy syndrome - Tylenol or ibuprofen for pain - Not uncommon for children to experience nightmares, overdependence, separation anxiety, PTSD - reassure security and promote healthy means of child self-management of feelings

Conditions Causing ICP

- Neural Tube Defects (Spina Bifida) - Chiari Malformations - Hydrocephalus - CNS Infections (Encephalitis, Meningitis) - Epidural Hemorrhage & Subdural Hematoma - Cerebral Edema

Musculoskeletal system: Post-operative assessment

- Neurovascular = CSM = Circulation, sensation, and motion - 6 P's of compartment syndrome (Pain, Pressure, Pulselessness, Pallor, Paresthesia, Paralysis) - all of the standard post-op care: VS, pain, etc. When to introduce fluids, food, etc., infection monitoring

Traction Care: Nursing Implications

- Position child in alignment to maintain correct line - Check weights to confirm accordance with orders - Keep skin dry, wrinkle free sheets, pressure reduction mattress - Active ROM, positioning (may require supervision) - Check ropes for fraying, knots, bolts for tightness - Care of the immobilized child - Pin care for those with pin-site traction Moving away from this through alternative technologies and surgical procedures Application of pull to body part for gradual realignment of fractures Reduce fracture through position and muscle tiring Position bone ends to promote healing Besides setting up a fracture - usually a complicated or comminuted fracture - to heal correctly from a positional standpoint, it also assists in removing the surrounding musculature from complicating the healing process. Stretching the muscle means that the fibers are effectively in a pre-contraction position, but are unable to contract due to the force of the weights. Thus, they cannot contract in ways that would misallign the bones and cause deformity during healing. You do not need to know the specific types of tractions, more important is knowing the principles of traction and nursing care implications Skeletal traction is NEVER released by a nurse outside of direct supervision by a higher level practitioner. Pin care: assessed for infection and cleaned daily (maybe weekly if stable) after the first 48-72 hrs (more frequent <72 hrs). Clean with dilute chlorihexidine solution, concentric circles discarding swabs between each circle. Great table page 957 in text

Medical Interventions of Increased PBF Conditions

- Really small, no symptoms: may wait and see if it spontaneously closes - Pretty small, some symptoms: plug it (septal occluder or coils) - Cardiac catheterization - Too big to plug: Patch it (Dacron patch or pericardial patch) = Open heart surgery - PDA only: indomethacin or ibuprofen a.) prostaglandin inhibitors - only effective in preterm/<5kg infants b.) Closure in cath lab c.) Surgical closure Not all kids with these defects will require intervention; many are followed for spontaneous closure if they do not have symptoms. If symptoms are apparent (or, in older children, sequella of an untreated defect are apparent), then we'll either plug it or patch it. For kids with more complex anatomy, palliation (a procedure to make things better but not fix it) may come first à less likely than complete repair. For kids with AV Canal defects, more extensive intervention than just patching might be necessary to reconstruct the valves. For newborns with a PDA that remains open, a medical intervention might be used. Indomethacin or ibuprofen are pharmacotherapies: usually administered 1-2 doses/day over 2-3 days, watch for impairment of blood flow to brain, GI, and kidneys. Nursing care here? Cardiac cath care, or post-open heart surgery care.

Lethargic

- Reduction in responsiveness, but still spontaneously acting - Opens eyes to directed speech, responds appropriately but falls right back to sleep

Congenital Heart Disease

- Review maternal risks p. 741 - Increased r/f CHD among sibs, genetics, associations - Circulatory changes at birth and changes in hemodynamics

Acquired Musculoskeletal Conditions

- Scoliosis

Once we suspect a UTI, how do we confirm it?

- The first step is obtaining a urine sample. In children with urinary continence, we can obtain a clean catch specimen, ideally first void (which is not always a straight forward endeavor, if you've ever tried to do this with three, four, or five year old!). In infants and toddlers who have not yet been potty trained, a sterile straight catheterization is the most effective way of obtaining a specimen, and should that fail, a suprapubic bladder aspiration (sometimes you'll see a bag urine attempted, but this is logistically challenging and often unsuccessful). Both of these are invasive, with aspiration being the more invasive of the two; this is a sterile procedure where a needle is inserted through the abdomen directly into the bladder and any urine therein removed by aspiration. This is usually reserved for children who are very dehydrated, where there is so little urine that it couldn't be collected by straight cath. I've included a link here on the slide to a great video demonstration - but just a heads up that you'll have to sign into the library to access it. - Once we've obtained the specimen, then the gold standard for identification is urinalysis and urine culture. Sometimes you'll also see a urine dipstick used in the primary care setting; this is a point of care test that can give a rapid assessment of whether many of the cells and other elements tested for by urinalysis are detectable, particularly white blood cells and some bacteria. Bacteria love alkaline environments, so this finding on urinalysis suggests that conditions are right (urine is usually a little acidic). We might also see blood (frank or occult), white blood cells, nitrites, and sometimes even a little glucose or ketones (although this is not common). Positive findings on urinalysis are an indication to treat, but we'll still perform a culture to confirm both the presence of bacteria and the sensitivity of that bacteria to the antibiotic prescribed. In clean catch samples, a positive finding is where there are >100 000 of a single bacterial type; for cath or aspirated urine, we only need 10 000 of a single bacterial type to confirm. Frequently you'll see that multiple bacteria are reported; this is usually indicative of a contaminated specimen. - As I mentioned before, when patients start to present with recurrent UTI, we'll see the addition of imaging to assess for structural or pathological causes. For instance, renal and bladder ultrasound can give a basic assessment of anatomy; a VCUG may be done to assess for reflux; this is when contrast dye is injected into the bladder, and the patient is then instructed to urinate while the tech takes images the flow patterns using xray; and a DMSA could be performed to identify damage to the kidneys (ie, scarring) and areas of poor function though the administration of a radioactive isotope that then differentially attaches to locations of injury in the kidney.

What is typically the first sign of a UTI?

- Sometimes UTIs are identified without symptoms, more commonly in patients who require routine urinalysis (this could be part of monitoring unrelated conditions, identified uretal obstructions or reflux, or in patients who lack sensation in this system). More often, however, there is some sign or symptom that suggests the presence of bacteria, resulting in diagnositic testing. These signs are not the same across the developmental spectrum - children younger than two years old may present nonspecifically (that is, their symptoms may not explicitly implicate an issue in the GU system), and often very differently than older children. The more "classic" symptoms of UTI become more the rule as children move through school age and adolescence. - So for instance, children under two may be identified based on abrupt behavior changes noted by the parents (like irritability, lethargy, or loss of appetite), or unusual signs noted during diaper changes (foul smelling urine, persistent diaper rash, diarrhea, perhaps abdominal distention). Children under two who present with seizure activity, with or without the presence of a fever, can expect a workup to rule out UTI; likewise, children this age with a high fever and signs of toxicity (that is, they look and behave very sick), otherwise unexplained by the presence of other signs or symptoms, will also likely be worked up for UTI. - In children older than two years, we start to see the classic symptoms of urinary urgency & frequency, pain or burning with urination, and frank blood in the urine. Remember in our conversation about enuresis a few weeks ago, UTI can present as a loss of urinary continence in children who've previously achieved this, particularly in the younger ages; this age group is also more likely to complain of abdominal pain. - Since we frequently see cystitis and pylonephritis simultaniously, we'll frequently see a combination of symptoms. Those which really define the additional severity of a pylonephritis are a high fever, chills, and costovertebral angle tenderness (which often presents as severe back pain).

Scoliosis

- Spine that has a lateral S- or C-shaped curve - Classic signs: ¤ Truncal asymmetry ¤ Uneven shoulder height ¤ One sided rib hump ¤ Prominent scapula - diopathic (most common) or Compensatory - Diagnosis: inclinometer reads > 10-15º = Other S&S >40º - Interventions ¤ Non-surgical = Bracing: Milwaukee, Boston, lateral electric surface stimulator ¤ Surgical> 40º: Harrington rod - Spine curvature causes compression of parts of the disks and ribs on concave side, extension on convex side - Can cause compression of thoracic cavity - pain in the back and hips, SOB, easy fatigue - Prognosis based on early identification - Often first presents in puberty with growth spurt - so think about this from the DEVELOPMENTAL perspective https://medlineplus.gov/ency/imagepages/19465.htm Definitive diagnosis using XR Curve < 10 degrees are variation, not scoliosis Must rule out other conditions like syringomelia, diastematimyelia, or tethered cord that may also have pain, sacral dimple, hairy patches, cutaneous vascular changes, absent or abn reflexes, bowel or bladder incontinence, left thoracic curve Front: Midline & Symmetric Spine Equal shoulder height Equal open area between arms and sides

Congenital Abnormalities

- Talipes Equinovarus (Club Foot) - Developmental Dysplasia of the Hip (DDH) - Osteogenesis Imperfecta

Open Heart SurgeryPost-Operative Floor Nursing Care

- Telemetry - Pain management - Coughing & Deep Breathing = Stuffed Animal/Pillow Splinting and Spirometry/bubble blowing - Fluids, Nutrition & Elimination - Activity vs. Rest These are obviously all in addition to continued physical assessment.

Risk factors of Urinary tract infections

- Urinary stasis - Constipation - Poor hygiene - Tight or synthetic underwear, or swimwear - Sexual activity (females mostly) - Uncircumcised males - Anatomic risks (see next slide)

Genitourinary Disorders: Diagnostic testing

- Urine culture and sensitivity - Renal and bladder ultrasound (US) - Testicular US - Plain XR (KUB) - Voiding cystouretherography (VCUG) - Radionuclide (nuclear) cystogram - Radioisotope imaging (renal scans) - MRI - CT - Cystoscopy - Renal Biopsy - Urodynamics

Ketogenic diet

- VERY high fat (up to 80% of calories) - Causes ketosis from the burning of fat instead of carbohydrates for energy; may have an anticonvusive effect in some affected individuals - Requires very strict adherence to be effective - Can cause hypoglycemia, acidosis, diarrhea short term - Can cause kidney stones, hyperlipidemia longterm - Weight loss, constipation common

Open Heart SurgeryPost-Operative Assessment

- Vitals - Temperature - O2 Sat - Level of Consciousness - Peripheral perfusion - Respiratory effort - Arrhythmias - Cardiac output - S & S infection - Monitoring incision site

Cyanotic CHD

- decreased pulmonary blood flow - Tetralogy of fallot (ToF) - Tricuspid atresia - Mixed blood flow: a.) Transposition of the great arteries (TGA) b.) Total anomalous pulmonary venous return (TAPVR) c.) Truncus arteriosus d.) Hypoplastic left heart syndrome

Anatomic risks: Vesicoureteral Reflux (VUR)

- different places where obstructive uropathies can occur (grade V is most severe) - these are conditions where one or more of the valves that would typically allow for the passive flow of urine are stenosed, or never developed in the first place. - This results in a backup of urine somewhere along the stream (could be right at the pelvis, in a couple points along the ureter, or the urethral spyncter). - The backup of fluid can cause hydronephrosis, which will compromise glomerulofiltration, urine concentration, and the function of the renal tubules. - This leads to sodium retention, metabolic acidosis secondary to compromised excretion of hydrogen ions, increased risk of UTI, and glomerular cell death. Left unaddressed, ongoing damage can lead to renal scaring and eventually chronic renal failure.

Post operative pain: K.B. (44 kg) reports pain in her right leg, a 7/10 on the FACES scale. The reference dose for IV morphine is 0.05-0.1 mg/kg q4-6 hours She is written for 3 mg of morphine IV q4 hour Is this the appropriate dose? What are some developmentally appropriate distraction techniques while the pain medication is being administered?

- dose range = 1 mg - 2 mg - do not give dose and call provider - in the mean time: TV, parent present, coloring

Acyanotic CHD

- increased pulmonary blood flow (PBF) - ASD - VSD - PDA - AV Canal - Obstructed blood flow from the ventricles: a.) Coarctation of the aorta b.) Aortic stenosis c.) Pulmonic stenosis

Hydrocele

- sac of clear fluid in the scrotum - communicating vs noncommunicating

Testicular Torsion

- twisting of the spermatic cord causing decreased blood flow to the testis - surgical emergency = testes can die - one testes is usually a different size and color, firm, and can be painful

Cryptorchidism

- undescended testicles - should descend by about 6 months old, if not then surgery

Vesicostomy

- urinary diversion - Small, temporary, opening usually between the pubic bone and the umbilicus - Drains urine - Created case of a bladder outlet obstruction (such as posterior uretheral valve, PUV) - Also created if the child has a neurogenic bladder - Usually created during infancy or early in childhood - Vesicostomy drains into the diaper. No additional care is required. - typically this is created in infancy or early childhood, depending on reason

Ureterostomy

- urinary diversion - Urine bypasses the bladder and exits through a stoma - Created when urine cannot be eliminated appropriately via the bladder - Myelomeningocele - Bladder removal (due to cancer, for example) - Spinal cord injury - Others

Expected Development in Infancy: 10 months

1.) Gross = Change from prone to sitting 2.) Fine 3.) Sensory 4.) Vocalization = May say one word 5.) Socialization and Cognition = Behavior associated with language Imitates facial expressions Interactive games Independence in feeding emerging Looks and follows pictures in a book

Expected Development in Infancy: 8 months

1.) Gross = Changes posture to reach an object 2.) Fine = Pincer grasp Let's go of objects with choice Reaching for out of reach toys 3.) Sensory 4.) Vocalization = Listens selectively to familiar words 5.) Socialization and Cognition = Responds to "no" Dislikes getting dressed, having diaper change

Expected Development in Infancy: 11 months

1.) Gross = Cruising 2.) Fine = Exploring objects Puts objects in a container sequentially Manipulates objects 3.) Sensory 4.) Vocalization = Imitates speech sounds 5.) Socialization and Cognition = Enjoys mastering tasks Reacts with frustration Rolls ball Shakes head "no" Anticipates familiar activities

Expected Development in Infancy: 1 month

1.) Gross = Flexed and head lag 2.) Fine = Hands clenched and strong grasp reflex 3.) Sensory = Quiets with voice Follow light to midline Startles with sound 4.) Vocalization = Crying Comfort noise during feeding 5.) Socialization and Cognition = Watch caregiver's face when talking

Expected Development in Infancy: 2 months

1.) Gross = Head control starting 2.) Fine = Hands opening 3.) Sensory = Fix and following starting Turns to sound 4.) Vocalization = Different cries Vocalizing Cooing 5.) Socialization and Cognition = Social smile

Meningitis

1.) Bacterial • Typically critically ill. Rapid onset • Temp instability, chills, headache, vomiting • Lethargy, irritability • Some are vaccine preventable • HIB Vaccine • Could occur after routine Respiratory, URI, ear infection • Higher risk conditions: immunosuppressed, VP shunt, cochlear implanted, intracranial trauma 2.) Viral • Mortality isn't as high as with bacterial meningitis. Abrupt or gradual signs • Fever, photophobia, headache, nuchal rigidity • Commonly 2° enterovirus, summer/fall • Assume bacterial until ruled out • Antibiotics Long term consequences: developmental delay, gross neurological defects, hearing loss Typically worse Fever for older than infants. For infants, may have fever or hypothermia

Meningitis: What kind of abx? Why corticosteroids?

1.) Broad spectrum, crosses BBB - made more specific with actual identification of causative agent 2.) Control inflammation = decreasing sequala

Observational Pain Scales

1.) CRIES - Crying, Requires O2, Increased vital signs, Expression, Sleeplessness 2.) NIPS (Neonatal Infant Pain Scale) - Expression, cry, breathing, arm and leg movements, arousal state 3.) FLACC - Face, Legs, Activity, Cry, Consolability Can be used in nonverbal patients, but difficult to tell the difference between hunger, anger, agitation, discomfort etc. Takes a while - need to watch for a minute or two to get an accurate assessment Most reliable for short, sharp, procedurally-based pain

Physical Assessment: DDH

1.) Clinical findings: - Newborn: positive Ortlani and Barlow maneuver, thigh fold asymmetry - Older child: Leg instability, limp, lateral spine deformity 2.) Etiology: Unknown. - Genetic, early gestational events, late pregnancy mechanical forces, postnatal shifting, estrogen exposure 3.) Treatment: - Mild: Pavlik Harness - Older: Traction - Severe: Surgical reduction, spica casting

Expected Development in Infancy: 5 months

1.) Gross = Head control complete Turn abd to back Feet to mouth 2.) Fine = Greater hand-eye coord. Bilaterally 3.) Sensory = Looks for dropped object briefly Examines objects 4.) Vocalization = Squealing 5.) Socialization and Cognition = Smile at self in mirror "holds bottle" Knows familiar people Finding body parts

LEVEL of Consciousness: Alertness vs. Orientation

1.) Alertness • Lethargic = Reduction in responsiveness, but still spontaneously acting • Opens eyes to directed speech, responds appropriately but falls right back to sleep • Obtunded = Arousable with some effort, but very, very sleepy - limited movement, goes right back to sleep state after • Opens eyes when shaken, but responses slowly and likely somewhat confused • Stuporous = Only arousable with very vigorous stimulation (ie, pain). deep sleep or unresponsiveness - again, does not retain alertness once stimulus is removed • Comatose = Unconscious and unarousable • Persistent Vegetative State = Permanent loss of cerebral cortex function 2.) Orientation • Confusion = Disorientation • Delirium = Confusion + hyperactivity, paranoia, & agitation Can't get to orientation if you don't have alertness disoriented - not oriented to person, or place, or time -- in preschool children or younger, we may assess this using measures of attentiveness, recognition of self, ability to respond appropriately to commands, and recognition of common objects. This may be challenging depending on what the child has been exposed to - animals and colors are often first recognized, sometimes vehicles like trucks, cars, planes - but this is most useful when knowing what - if anything - the parents have been emphasizing at home

Nursing Management: DDH

1.) Assessment: - Physical assessment - Family history - Birth history - Post-surgical assessment - Cast assessment 2.) Intervention: - Cast care = Post-cast weight - Developmentally appropriate stimulation - Pain control - Immobility care - Elimination - cast, immobility considerations

Fractures: Treatment

1.) Goals are to realign and reduce the bone - Immobilization may be indicated = Cast, Pins may be needed to hold multiple fractures, Pin care - Restore function - Prevent further injury 2.) Compression Syndrome: The 6 P's

Symptoms of a pediatric uti

1.) Cystitis a.) Children < 2 years = Fever, Poor feeding, vomiting, poor weight gain, lethargy, fever (+/-), persistent diaper rash (+/-), foul smelling urine, diarrhea, seizure, jaundice, abdominal distention (neonate); irritability (infants & toddlers) b.) Children > 2 years old = Urgency, frequency, dysuria, hematuria, cloudy urine, foul smelling urine, dehydration, abdominal pain, enuresis (incontinence), diarrhea, urinary hesitancy, mood change, suprapubic or flank pain (school age +); dribbling, straining, decreased force or size of stream (boys) 2.) Pyelonephritis = High fever, chills, abdominal pain, nausea vomiting, flank pain, costovertebral angle tenderness, moderate to severe dehydration

Open Heart Surgery: Pre-Operative Family Education

1.) Defect information = anatomy, physiology, etiology & influences, overview of course & tx, personal & example prognoses 2.) Operative Expectations = Ventilation needs, pain management, wound healing, activity progression 3.) Feeding (infant) = Breast ideal, ≤ 30min, 45° angle, may supplement w/ fortification or tube feeds 4.) Avoid infection - increases work, worsens hypoxemia = Immunizations + Palivizumab (RSV Vaccine) 5.) Genetics referral (parents) Preoperative home management can be very scary for parents, particularly when the child still has very complex anatomy and is being set home in hopes of growth prior to other palliative procedures. These are just some of the things you would want to talk to your parents about, but you'd definitely need to assess them for other home learning needs like what to do if their child has a tet spell etc. Withholding vaccinations if they receive or are anticipated to receive blood products shortly

Cerebral Palsy: Potential Signs

1.) Developmental milestone screening and listening to families is critical. • Irritability • Feeding difficulties 2.) < 6 months • Head lag, hypertonia or hypotonia, extension/arching, stiff/scissoring legs when picked up 3.) > 6 months • Does not roll, does not bring hands to midline, does not bring hands to mouth, lack of symmetry when reaching, hands persistently in a fist 4.) > 10 months • Uneven crawling, uncoordinated crawling • Lack of crawling

DI and SIADH

1.) Diabetes Insipidus (DI) • Inappropriately highly high U/O leading to hypernatremia and dehydration 2.) Syndrome of inappropriate anti-diuretic hormone (SIADH) • Inappropriately low or absent U/O leading to hyponatremia and water intoxication

Nephrotic Syndrome: Diagnostics and treatment goals

1.) Diagnostics - UA demonstrates significant proteinuria (3-4+) - LFTS: hypoalbuminemia - Lytes with either normal or hyponatremia - Hyperlipidemia 2.) Treatment goals: induce remission, restore intravascular volume, administer statins with elevated lipids, prevent complications such as infections

Cast Care

1.) Elevate: elevate the limb after applied to decrease swelling and increase venous return - no walking on the cast until given permission 2.) Circle staining = if blood or other drainage become apparent on the cast, circle edge and mark the time - watch for progression. 3.) Distal CSM assessment = q15-30min/1-2hrs, q1-2hrs/22hrs assess the limb or extremity distal to the cast - pulse, feeling, color, warmth, capillary refill, movement, swelling - compare to uncasted extremity if possible 4.) Cast edge irritation interventions = check for irritation and preserved skin integrity around cast edge - pull stockings over rough edges, or secure padding inside and pull over edge. 5.) Clean & dry - bag when bathing = self explanatory 6.) Nothing under the cast - no powders, ointments, objects = if you've ever had a cast, you know that it can get unbelievably itchy under there. DON't let your patietns or families try to aleviate that with lotions or powders, or by putting sticks or other objects in there. At best you could get skin irritation, at worst you might get something stuck that causes necrosis. You can't see what's going on in there. Be suspitious if you start to see irritation or changes in skin proximal or distal to the cast. 7.) Know when to call the provider = new or unusual odor; burning, tingling, numbness, new drainage, swelling/inability to move phylanges; cast slippage or cracking; new/unexpected fever or fussiness, particularly if unrelieved with repositioning; changes in exrtemity color or movement

Acute Post-Infectious Glomerulonephritis

1.) Etiology - 1-3 weeks after an infection - Immune complex deposition in the glomeruli. Vascular permeability increases. - Increased protein, RBCs, cast excretion - Sodium and water retention 2.) Clinical manifestations - Can be asymptomatic - Hematuria - Acute hypertension - Periorbital and pulmonary edema 3.) Diagnostic tests - Increased BUN and Cr - Increased WBC - Increased ESR - Positive antistreptolysin (ASO) titer - UA with hematuria, proteinuria, RBC casts

Meningitis: Evaluation and treatment

1.) Evaluation • Infectious/Sepsis Eval a.) CBC b.) Blood Culture c.) Urine culture d.) Lumbar puncture • Electrolytes • MR 2.) Treatment • IV antibiotics 14 - 21 days • Corticosteroids are controversial in presence of active infection • Maintain hydration = Fluids - maintain hydration but not enough to cause cerebral edema. • Avoid increased ICP • Complication Management a.) ICP (cerebral edema, hydrocephalous) b.) Seizures c.) DIC, Septic Shock d.) ARDS (acute respiratory distress syndrome) e.) SIADH How long does a blood culture take to come back do you think?

Management Pre/Post Medical Intervention: Cardiac Catheterization: Pre-Procedure

1.) Family Education: - Developmentally appropriate child prep - NPO - Void 2.) Assessment: - Baselines - vitals, pulses (popliteal & pedal), skin & cap refill assessment 3.) Psych Assessment: - Anxiety - Coping Cardiac catheterization may be done for diagnostic or intervention purposes, but even when diagnostics are the main goal, cardiologists are usually prepared to take interventional action - we're already taking the risk of undergoing the procedure, should be ready for whatever is found. This is the procedure that would be use to dilate stenosed valves, dilate and stent the aorta (coarctation), open holes between atria, and insert closure devices for ASD or PFO. Contrast dye likely contains iodine Diaper rash may be an indication to postpone procedure if femoral access is required 6-8hr NPO prior Dye can make people feel very warm or uncomfortable - it's not uncommon for general anesthesia to be necessary in children for this procedure so that it is well tolerated (in contrast to adults, where conscious sedation is more common)

Neural Tube Defects: Pre-operative management

1.) Goal is for birth at a center with pediatric neurosurgery and other needed subspecialties • Neurology • Urology • Orthopedics • PT/OT 2.) Infant is born • Prone positioned • Cover defect with moist sterile dressing 3.) Infant is transferred to the NICU • IV fluids started • IV antibiotics started

Expected Development in Infancy: 3 months

1.) Gross = Push-up in prone position 2.) Fine = Clutching objects 3.) Sensory = Following more 4.) Vocalization = Squealing with pleasure "Talking" and less crying 5.) Socialization and Cognition = Recognizes familiar faces Interested in surroundings

Expected Development in Infancy: 9 months

1.) Gross = Sit for prolonged periods Balance starting Pull-to-stand 2.) Fine = Dominant hand emerges Compare 2 objects 3.) Sensory 4.) Vocalization = Respond to simple verbal commands 5.) Socialization and Cognition = Likes pleasing parent Fears going to bed/being left alone

Expected Development in Infancy: 7 months

1.) Gross = Sits, leaning forward on hands Sitting indep. starts Bouncing when standing 2.) Fine = Transfer objects between hands Hand preference 3.) Sensory = Visual acuity improves Responds to name Depth awareness starts 4.) Vocalization = Chained syllables (Baba) "Talks" when others talk 5.) Socialization and Cognition = Upset when caregiver leaves Attracts attention with noise Peek-a-boo Biting Expects reactions

Neural Tube Defects: Infancy & Childhood

1.) Growth, Development 2.) Neurological assessment (daily HC initially) • Hydrocephalus is a concern = Better developmental outcomes in patients without hydrocephalus 3.) Developmental milestone attainment • May need assistive devices for mobility 4.) Skin integrity and safety 5.) Education • Signs of infection • Signs of increased ICP and shunt malfunction • Signs of a UTI • Bladder emptying = Straight cath and Ostomies

Treatment for Kawasaki's Disease

1.) IVIG - can decrease r/f coronary artery disease if given within 7-10 days - Anticoag for larger aneurysms 2.) Aspirin - 80-100 mg/kg - Dose divided every 6 hours 3.) Anticoagulation - Clopidogrel - Enoxaparin - warfarin

Developmental Effects of Immobilization: by age group

1.) Infants - deprives of the sensory stimulation that facilitates cognitive development 2.) Toddlers - removes ability to explore and imitate, limiting development of autonomy 3.) Pre-Schoolers - Initiative stems from ability to undertake it through movement 4.) School-Aged - Mastery strongly associated with physical activity and competition 5.) Adolescents - May result in separation from peers, dependency when independence is the goal

Prostaglandin E1 Administration

1.) Maintains fetal circulation - Bridge to cardiac surgery = Anything condition where there's no other way for oxygenated blood to get to the body 2.) continuous infusion 3.) Side effects: - Bradycardia or tachycardia - Vasodilation -> Hypotension - Respiratory depression - Apnea - Seizure activity - Hyperthermia

Medication Management of CHF: ACE inhibitors

1.) Major Purpose = Decrease afterload & preload 2.) Examples = Captopril 3.) Side Effects = Hypotension, cough, angioedema 4.) Nursing Mgmt = Monitor HR, BP, serum K, renal fxn labs, angioedema 5.) Parent Teaching = Notify provider if unusual swelling occurs (particularly facial) or other potential side effects arise, avoid licorice ACE: block angeotensin conversion, causes vasodilation (decreasing afterload) and reduces fluid retention by decreasing aldoserone secretion (decrease preload) Change positions slowly, do not increase potassium without provider input -Aldosterone blockade = potassium uptake normal/higher than usual - watch for hyperkalemia

Medication Management of CHF: Diuretics

1.) Major Purpose = Decrease preload 2.) Examples Furosemide 3.) Side Effects = n/v/d, ototoxicity, hypokalemia, uticaria, photosensitivity, hypotension 4.) Nursing Mgmt = Monitor BP, serum K & elecrolytes, renal fxn labs, I & Os 5.) Parent Teaching = May give with food or milk to decrease GI upset, avoid licorice Diuretics: blocks reabsorption of sodium, water follows (decreases preload) -If not potassium sparing (like spirnolactone), can cause hypokalemia = digoxin toxicity

Medication Management of CHF: Cardiac Glycosides

1.) Major Purpose = Improve contractility 2.) Examples = Digoxin (almost exclusively used) 3.) Side Effects = Arrhythmias/dysthymias, CNS effects (dizziness, lethargy), hyperkalemia, GI (n/v/abd pain/d), Δ in vision 4.) Nursing Mgmt = Monitor heart rate and rhythm (hold and contact provider asap if patient bradycardic at time of administration), periodic EKG, monitor serum K, Mg, Ca, renal fxn labs, & Dig levels 5.) Parent Teaching = Monitor pulse prior to administration (may not give if bradycardic), administer same time of day, do not give OTC medications or herbal supplements without approval, keep out of reach of children, interacts with some ABX Increases cardiac efficiency by increasing contractility (which increases cardiac output), decreases venous pressure (also increases cardiac output), and decreases heart size and general edema. Toxicity most likely with elevated K or low Mg or Ca May administer dig antibody

Medication Management of CHF: Beta Blockers

1.) Major Purpose = Improve systolic fxn, prevent remodeling 2.) Examples = Carvedilol 3.) Side Effects = Hypotension, bradycardia, dizziness, fatigue 4.) Nursing Mgmt = Monitor HR, BP, weight; watch for syncope; check liver and kidney fxn labs, glucose, cholesterol 5.) Parent Teaching = Do not abruptly discontinue, may cause fatigue, dizziness, and postural hypotension (standing) Beta blockers: not entirely clear from what I can tell what mechanism exactly helps for children, but in adults it's been shown to improve systolic function and prevent harmful cardiac remodeling.

Concussions

1.) Mild head injury common in children who participate in competitive sports and activities with high risk of falls 2.) Needs prompt identification, potentially urgent imaging 3.) Treatment: physical and neurocognitive rest, symptom management 4.) Nursing role: patient and family education, partnering with families to address school and athletic pressures • Go slow, allow time to heal; may take months to fully recover • Still recovering even after active symptomatic period • Very important not to go back to sport too quickly - Second impact syndrome can occur with multiple concussions in close succession • Know how to identify worsening s&s, when to call the MD

Diagnostics for suspected UTI

1.) Urinalysis - WBCs, RBCs, pH neutral or could be alkaline, + blood, + leukocytes, + nitrites, +/- glucose, +/- ketones 2.) Urine culture - Methods of collection a.) Clean catch, 1st void b.) Sterile urine culture is gold standard and can be done by straight cath or suprapubic tap - Findings = WBCs a.) Sterile culture > 10, 000 colony forming units (CFU) b.) Clean catch: > 100, 000 CFU to speciate later 3.) Infantile UTI or recurrent UTI in an older child - US - VCUG - Urodynamics - Dipsticks not always done now in patient - Usually one organism - Clean catch is not 100% reliable - Cultures are more difficult to interpret when nephrostomy tube is present or other indwelling devices or stomas

Management of Acute Post-Infectious Glomerulonephritis

1.) Monitor - VS - Lung sounds - Fluid, electrolytes, nutrition = Sodium intake, I/O, daily weight - Monitor electrolytes - Monitor for infection - Monitor skin integrity 2.) Treatment - IV fluids - Diuretics - Monitor for and treat hypertension - Encourage enteral nutrition - Balance rest and activity From a management standpoint, there isn't anything that we specifically do to address the immune complex issue - the body just has to work this out on it's own, and eventually it will clear. Most children, particularly those whose condition is identified early, will fully recover without long-term complications. Moreover, patients with reasonable blood pressures and urine outputs, and do not have severe hematuria or edema, can be managed at home; both medical and nursing management basically consists of supportive care to maintain or stabilize the child's hemodynamics in the meantime. What you see listed on this slide is a summary of the nursing interventions on our docket. Vital signs will need monitoring routinely q4-6, more frequently if the child has malignantly high blood pressures...skin and lung assessment will be important to assess the extent and locations of edema, which is typically moderate (in contrast to nephrotic syndrome, which is often substantial). Routine neuro assessment will be important too, given the potential for azotemia, and precautions to minimize falls and intervene on seizures may need to implemented. We may need to be administering IV fluids or antihypertensives. Fatigue is important to avoid, as these kids need substantial energy to heal, and resting periods may need to be explicitly implemented. Hopefully, monitoring closely for worsening will allow for rapid intervention and the prevention of long term complications.

Management of exacerbations from Nephrotic Syndrome

1.) Monitoring - VS, I/O, daily weight - Medications: a.) Corticosteroids b.) Loop diuretics - Lab monitoring: UA, spec gravity, electrolytes, LFTS, lipids - Skin integrity, abdominal girth - Monitor for infection 2.) Prevention and health promotion - Prevent infection - Promote rest and adequate nutrition - Psychosocial concerns Meds: teach/monitor about side effects Anxiety, depression, coping The first acute exacerbation often requires hospitalization, but relapses may be managed at home. The primary medical therapy is immunosuppression and inflammation management through the administration of corticosteroids, typically prednisone. Other medications may be required as well, including loop diuretics to remove fluid if edema becomes severe, or IV albumin to increase the oncotic pressure in the vasculature; these patients are also at high risk for secondary infection due to their general state of illness and the addition of the corticosteroids, so IV antibiotics may be required too. They are at particularly high risk for peritonitis when ascities is present, and varicella exposure can have particularly high morbidity and mortality in this population if exposed Where these patients are inpatient, we'll be monitoring routine vitals looking for concerning dips (or elevations, but more often dips) in blood pressure and indications of respiratory involvement, monitoring daily weights, abdominal girth, and I&Os for indications that the body is retaining more or less fluid, administering and monitoring for complications of pharmacotherapy, drawing and reassessing laboratories for signs of improvement or worsening, monitoring for skin breakdown, and for signs of infection. We are also using standard precautions to prevent infection, encouraging rest (these kids often don't need much encouragement to do this), encouraging adequate nutrition (they're often quite anorexic while acutely ill), and addressing any psychosocial needs.

NeuroMuscular Conditions

1.) Muscular Dystrophies 2.) Cerebral Palsy

Nursing Management: CHF

1.) Nursing Assessment (con.): - Strict I & O - Daily weights (same time) - Vitals, including temperature - Skin breakdown - Nutritional adequacy - Infection control 2.) Family Assessment: - Coping, anxiety, respite care needs 3.) Implementation: - Medication administration - Oxygen administration as ordered - HOB @ 45° - Turn q2 hrs or per protocol - Promote rest - Keep temperature normal - Foster development - Teach feeding technique - Discharge planning Major goals: increase contractility and decrease afterload (force of the left ventricle during systole, which is a factor of the pressure in the peripheral/pulmonary vasculature and the size of the ventricle itself), decrease preload (the amount of fluid the heart has to pump), decreasing cardiac and oxygen demands, and improving tissue oxygenation. Feeding: frequent and for short durations. Q3 hrs, don't wait for crying (sucking hands instead), may institute gavage feedings if child is too fatigued or has signs of excessive metabolic rate or work to start (high pulse or resp rate)

Cardiac Catheterization: Post-Procedure

1.) Nursing Intervention: - Direct pressure: 15 min - Pressure dressing thereafter - Bed rest: 4-6 hours supine, leg extended - Limited activity: 3 days - Fluids: IV, move to PO as tolerated 2.) Physical Assessment: - Bleeding/Dressing Assessment - I & O - S & S Infection 3.) Family Education: - S&S infection, bleeding, neuro/vascular complication, dehydration - Fluid encouragement - Quiet play Femoral artery access is pretty standard, although it might be bracheal or wrist - no matter what, artery intervention means LOTS of pressure to ensure blood flow stops. Encouraging fluids is important - avoidance of dehydration 2ndary to contrast/npo status, increased contrast clearance. Pressure dressing checks - q5/15; q15/60; q60 or as instructed.

Open Heart Surgery Types

1.) Palliative: - Examples: Pulmonary artery banding: minimizes pulmonary blood flow decreasing congestive heart failure - Anastomosed shunts: Decrease pulmonary blood flow for cyanotic infants 2.) Corrective - Intervention often early in life We've been talking about paliative versus corrective surgery. Palliative procedures make children better, but does not correct the underlying problem. Corrective procedures fix the underlying problem.

Talipes Equinovarus (Club Foot)

1.) Three areas of deformity: - Equinus (midfoot directed downward) - Varus (hindfoot turns inward) - Forefoot turns upwards (partial supination) 2.) Etiology: unknown. - Neuromuscular/vascular problems may be related - Genetic component, biochemical causes, or uterine positioning possible 3.) Correction: Serial Casting - Surgical correction if unsuccessful or to correct equinus Bone, muscle, and tendon involvement - small foot, shortened achillies, muscle atrophy (leg length normal) - Can be idiopathic, or associated with other conditions like congenital hip displasia or myelomeningiocele ASAP b/c small bones start to set (aka ossify) fast Parents of a child with clubfoot will have many questions. Can the condition be treated? Will the child be able to walk normally after surgery? Will parents need help caring for the infant? How much will surgery and other care cost? Will any subsequent children have a clubfoot?

Tonic-Clonic Seizures

1.) Tonic phase • Eyes deviation • LOC • Generalized, symmetric stiffness of entire musculature • Apneic/cyanotic • Salivation due to lack of swallowing 2.) Clonic phase • Violent jerking of extremities, trunk • Incontinence

Management for a UTI

1.) Treatment a.) Antibiotics - IV for neonates and pyelonephritis - PO: I.) Sulfamethoxazole-trimethoprim (Bactrim) for older infants and children II.) Amoxicillin clavulanate (Augmentin) III.) 2nd or 3rd generation cephalosporin - Encourage fluids, as appropriate - I/O if indicated - Pain and fever management 2.) Prevention - Risks based on anatomy can differ - Perineal hygiene - Promote fluids - Encourage routine urination - Cotton underwear - Antibx s/e: diarrhea, rash

Nursing Considerations for Osteogenesis Imperfecta

1.) Parent - Genetic counseling = Family may or may not be aware of the condition (spontaneous dominant mutation common); counseling will be required, its exact nature and recommendations for those who should receive testing will vary by family and type. - Child protection evaluation (abuse) = Can be very emotionally challenging for families, frequently they tell stories of the anger and frustration and hurt they feel around being accused of hurting their child. Need to support family while diagnosis and after is being made. - Condition management = teach family how to handle and care for child, importance of diet and physical activity and need to promote health and prevent injury. Goal is to create an environment wherein the child can be as normal as possible. Parents too will likely need emotional support, possibly financial. 2.) child - Risk for fracture handling = newborns and infants are at particularly high risk for fractures; should be very gentle when moving these babies. Can't lift legs to slip a diaper under their bottom, need to fully support the legs and hips while placing it. Should move them on a pillow when very little to effectively keep them splinted for support. Breaking a rib, their spine - devastating. - Cast, post-surg care = want to limit any compromise they experience from these interventions. Watch particularly for infections of the bone, ieosteomylitis - Physical activity & PT = strong muscles help protect weaker bones, weight bearing activities simulate bone strengthening and growth, and general lack of physical activity and short stature lead to overweight, which can increase risk for fracture and add additional health complications in the long term. Don't forget - don't use it, you'll lose it. - Nutrition - Health promotion = need to carefully watch growth, nutrition, hearing and dental screenings

Complications of Dialysis

1.) Peritonitis a.) Manifestations = Cloudy dialysate, abdominal pain, tenderness, leukocytosis, nausea or vomiting, fever, constipation b.) Cause = Staph infection, fungal infection, gram negative rods (risk is higher the longer a patient has had peritoneal dialysis, and the younger the child is) 2.) Pain a.) Manifestations = During inflow b.) Cause = Too rapid infusion, too large a volume of dialysate, encasement of catheter in a false passage, extremes in temperature of diasylate 3.) Obstruction a.) Manifestations = During outflow at emptying b.) Cause = Omentum entering catheter at end of outflow 4.) Leakage a.) Manifestations = Fluid around catheter, edema of penis or scrotal area secondary to leakage into abdominal subcutaneous tissue, fluid leakage to pleural spaces through diaphragm b.) Cause = Overfilling of abdomen, catheter that has migrated from peritoneal cavity 5.) Respiratory Symptoms a.) Manifestations = Shortness of Breath, decreased breath sounds in lower lobes, inadequate chest expansion b.) Cause = Abdominal fullness that compromises diaphragm movement, hole in diaphragm allowing dialysate into chest cavity This is a very thorough list of the acute complications seen in peritoneal dialysis. But even when things go well most of the time, during long term use of this method almost everyone will inevitably have experienced some type of infection at some point, and we can see scarring and stenosing around the abdomen as these children make it into adulthood.

Seizures: Management

1.) Pharmacology • Acute, Maintenance/Prevention • Maintenance is monotherapy unless other options exhausted. Can be targeted to seizure types • Routine blood monitoring for toxicity 2.) Ketogenic Diet 3.) Invasive Intervention (surgical procedure) • Vagus nerve stimulator • Deep probe monitoring • Focal resective surgery • Hemispheric surgery • Considered for intractable hemisphere disease • Corpus collastomy

Open Heart Surgery:Pre-Operative Care Assessments

1.) Physical Assessment = Full, findings dependent on defect: Signs & Symptoms of: - Poor Growth & Nutrition - CHF - Pulmonary HTN or Cyanosis - Acidosis - Tet episode 2.) Psych Assessment: - Parents - Stress - Anxiety - Coping - Loss of perfect child perception

Other nursing considerations for DDH (Post-surgical and Family Teaching)

1.) Postsurgical care - Pain management - Ice, elevation to affected limb - Time, serial casting appointments 2.) Family teaching - Cast & skin care - Mobility parameters = Crutches - Safety - car seats, booster seats, strollers - When to call provider = Slippage and Changes in skin - perfusion, etc.

Managing a Hyper-cyanotic Episode

1.) Prevention: - Avoid agitation - Prevent elevated metabolic states (illness) 2.) Treatment: - Remove irritating or painful stimuli - Place child in knee-to-chest position (on back or in arms for comforting) - Supplemental blowby O2 a.) In House: Call Clinician on Call, initiate urgent MD/NP team visit, follow protocol - Morphine administration - Fluid initiation b.) Outside of hospital: Keep calm, call 911 • Knee to chest position decreases Cardiac Output, assists in keeping blood nearer central CV system • If these interventions don't work, we may need to step it up with morphine, sedation, fluids, beta blocker (slow HR), Dopamine (increase systemic vascular resistance) • This is a pass to go to the OR because the child needs some sort of surgical intervention Parents should be educated about this along with what they should do in the event it occurs - including how long their child should be okay to cry, and going to the emergency room once it starts.

Physical Assessment: CHF

1.) Pulmonary Venous Congestion (S&S fluid in the lungs) - tachypnea - wheezing - crackles - Retractions (infants) - cough - grunting - nasal flaring - cyanosis - poor feeding/exercise intolerance - dyspnea 2.) Systemic Venous Congestion (S&S fluid inefficiently moving blood back to the heart) - enlarged liver - ascites - edema - wt gain - fluid retention - jugular vein distention 3.) Impaired Cardiac Output (S&S inefficiently moving blood out of the heart) - tachycardia - weak pulse - hypotension - prolonged cap refill - pallor - cool extremities - oliguria - easily tires - restless/irritability Although the initial signs of cardiac abnormality varies slightly by type, the reality is that any of them could progress to full-on heart failure. It's rare to see single-sided failure in kids; so any of these symptoms could arise.

Complications of a Urinary Diversions

1.) Stenosis - May require revision if significant and drainage is reduced as assessed with an ultrasound 2.) Bladder prolapse - Can happen during straining - Reduce when straining is over - Significant prolapse may require surgery

Medical intervention for DPBF conditions

1.) Stenotic valve: Open it up (balloon dilation) = Cardiac catheterization 2.) No valve a.) Palliate - Administer Prostaglandin E - Open hole between atria - Cardiac catheterization b.) Correct - Open heart surgery 3.) Tetralogy of Fallot: Will eventually need open heart surgery, immediacy depends on clinical presentation. Could require Prostaglandin E + open heart to palliate at birth if extremely severe; more likely not.

Tests of renal function

1.) Urine Tests - Physical tests = Volume, SG, osmolality, appearance - Chemical tests = pH, protein, glucose, ketones, leukocytes, nitrites - Microscopic tests= WBC, RBC, presence of bacteria, presence of casts 2.) Blood tests - BUN, uric acid, creatinine Obtaining urine from a child can be tricky. Determine if the specimen needs to be sterile, how much is needed, and if a mode interferes with results.

Pediatric Hemodialysis

1.) Used when - APD/CAPD isn't possible - Peritonitis - Family unable to manage PD 2.) Risks - Infection - Heparin - Hypotension - Rapid fluid and electrolyte exchange - Disequilibrium syndrome

Hyper-cyanotic Episodes: Assessment Findings

1.) VS - Tachycardia - Tachypnea - Low O2 2.) Respiratory - Dyspnea 3.) Skin - Cyanosis or pallor - Prolonged cap refill - Diaphoresis 4.) Neurological - Seizures - Loss of consciousness ALSO - viscous serum secondary to polycythemia puts kids at risk for thromboembolism, so a good neuro exam is important too to assess for cerebrovascular infarction Stimulus: Defecation, crying, feeding, pain. More common in AM

Initial ICP Management

1.) assessment • Neurological assessment • Respiratory assessment • Vital Signs: BP, HR, respirations, pulse ox, temperature • Sepsis evaluation 2.) Interventions • Maintain airway • Head midline, safe positioning • HOB elevated • Judicious fluid administration • Medication administration • Maintain normal temperature* • Safety • Environment = Quiet, low light, low stimulation

Neuro: Posture/Movement

1.) decorticate (flexor) 2.) decerebrate (extensor) In addition to the visual inspection of movement and reflexes, you should also document the existence of posturing. Here you see two very specific types associated with brainstem injury.

ICP Assessment

1.) early signs • Headache • Visual disturbance • Nausea/vomiting • Pupils unequal or sluggish • Sun setting Eyes • Changes in LOC 2.) late signs • Significant change in LOC • Decreased response to commands, painful stimuli • Change in pupil size and reactivity, fixed dilated • Posturing • Increased systolic BP and pulse pressure, Bradycardia, & Irregular respirations, Cheyne-Stokes = CUSHING TRIAD Vitals are particularly important here. May indicate septic shock, hypovolemic shock, and impending brain stem herniation

Symptoms and Complications with Decreased PBF

1.) symptoms a.) Stenosis or blockage of blood flow to lungs - murmur - enlarged liver (rare) b.) Hypoxemia - cyanosis - dyspnea - tires easily (including feeds) - diaphoresis w/ feeds - poor weight gain - clubbing (chronic) - developmental delay (chronic) 2.) long term complications - Cyanosis is a key early clinical feature, extent is dependent on how much blood is actually getting to the lungs & body, may worsen with PDA closure, often responds minimally or not at all to O2 administration - At risk for tet spells (aka hypercyanotic episodes), seizures, emboli, brain abscess - Prognosis: depends on extent of cyanosis, presence of other congenital defects, time of detection (in utero v. post-delivery) So we have increased blood flow and pressure in the vasculature of the lungs. Over time, this could develop into pulmonary hypertension; the right ventricle may undergo changes that increase its size and consequently decrease the amount of blood sent to the lungs; and a decrease in blood going to lungs may consequently increase the pressure in the systemic vasculature. The outcome is CHF. Knowing the signs of CHF is important, because we rarely see it effect just one side --> we'll get back to this in a bit. The primary symptoms we see early on are those listed above related to increased pulmonary venous congestion; we also have symptoms related to: -increased metabolic rate: tachycardia, diaphoresis (also related to difficulty eating), and poor weight gain. -Turbulent blood flow: murmur Based on this, what should our nursing interventions address? (think about it, and hold those thoughts!)

Symptoms and Complications of Decreased SBF

1.) symptoms: Impaired Cardiac Output - tachycardia - weak pulse - hypotension - prolonged cap refill - pallor - cool extremities - oliguria - easily tires - restless/irritability 2.) long term complications - Signs of impaired cardiac output are first to present = May quickly progress to HF if severe - AS at risk for sudden death from MI when worsening; Coarct at risk for hypertension, aortic aneurysm, ruptured aorta, & stroke - Prognosis: generally good, although each condition can be progressive and may require re-correction procedures So we have increased blood flow and pressure in the vasculature of the lungs. Over time, this could develop into pulmonary hypertension; the right ventricle may undergo changes that increase its size and consequently decrease the amount of blood sent to the lungs; and a decrease in blood going to lungs may consequently increase the pressure in the systemic vasculature. The outcome is CHF. Knowing the signs of CHF is important, because we rarely see it effect just one side --> we'll get back to this in a bit. The primary symptoms we see early on are those listed above related to increased pulmonary venous congestion; we also have symptoms related to: -increased metabolic rate: tachycardia, diaphoresis (also related to difficulty eating), and poor weight gain. -Turbulent blood flow: murmur Based on this, what should our nursing interventions address? (think about it, and hold those thoughts!)

Signs and Complications of Increased PBF

1.) symptoms: Pulmonary Venous Congestion - tachypnea - grunting - retractions - nasal flaring - tires easily (particularly w/ feeds) - crackles - wheezing - cough 2.) long term complications - Of note: not cyanotic early, but may become cyanotic later with progressing HF - At risk for pulmonary hypertension, right ventricular hypertrophy, and CHF - At higher risk of respiratory infection - Prognosis: generally good; depends on extent So we have increased blood flow and pressure in the vasculature of the lungs. Over time, this could develop into pulmonary hypertension; the right ventricle may undergo changes that increase its size and consequently decrease the amount of blood sent to the lungs; and a decrease in blood going to lungs may consequently increase the pressure in the systemic vasculature. The outcome is CHF. Knowing the signs of CHF is important, because we rarely see it effect just one side --> we'll get back to this in a bit. The primary symptoms we see early on are those listed above related to increased pulmonary venous congestion; we also have symptoms related to: -increased metabolic rate: tachycardia, diaphoresis (also related to difficulty eating), and poor weight gain. -Turbulent blood flow: murmur Based on this, what should our nursing interventions address? (think about it, and hold those thoughts!)

Hydrocephalus

A = Normal ventricular structure and anatomical locations B = Swollen ventricles filled with CSF. Note the bulging fontanels, the swollen appearance of the grey matter, and the mislocation of the cerebellum pressing down into the brain stem. Caused by either a congenital or acquired blockage of one of the ventricles

A caregiver calls the pediatric clinic and reports that their child is complaining of pain on the side of their abdomen, their urine appears bloody, their eyes are puffy, and they have a fever. The mother reports that the child had an upper tract respiratory infection 2 weeks ago. What does the nurse anticipate in this child's evaluation? Select all that apply. A. Obtain a urinalysis B. Obtain chemistries C. Obtain a CAT scan D. Obtain supplies for a lumbar puncture E. Prepare for peritoneal dialysis

A. Obtain a urinalysis B. Obtain chemistries

The nurse is doing d/c teaching for a family of a child that had an exacerbation of nephrotic syndrome. What will the nurse include? Select all that apply A. Wash hands to avoid infections B. Weekly weights are needed C. Medication therapy teaching D. If there is swelling, reduce salt E. Call the doctor if urine is frothy or your child is tired

A. Wash hands to avoid infections B. Weekly weights are needed C. Medication therapy teaching E. Call the doctor if urine is frothy or your child is tired

There's one ubiquitous test frequently used to help make a diagnosis of APIGN, and that's the ____ titer.

ASO Recall that titers are chemistries that identify the presence of antibodies to an antigen; in this case, the ASO titer identifies the presence of antibodies to Strep A. This would confirm a recent infection (the body doesn't maintain production of Strep A antibodies long-term, remember! Usually we start to produce antibodies in detectable quantities about a week after the start of the infection, peaking 3-5 weeks after infection). This is NOT indicative of a CURRENT Strep A infection; this would be detected by throat swab, and it would be rare for a child to still have an ongoing pharyngitis. Other lab abnormalities are listed here.

Self-Report Pain Tools

Accurate, for > 3 years old depending on developmental level

Increased pulmonary blood flow

Acyanotic and risk for features of heart failure

Truncus Arteriosus

All blood going to all systems comes from one artery. This one is generally very serious; only an estimated 10-30% survive after surgery, and there's no data on long term survival rates.

two types of abnormalities that increase the blood flowing to the lungs: Atrioseptal Defect (ASD) & Ventriculoseptal Defect (VSD)

Because there's higher pressure in the left side > right side, blood flows L à R; that blood then overfills the lungs. The extent of the symptoms of these defects depends on the size of the holes; children with smaller defects or fewer symptoms may be given time before closure to see if it closes spontaneously. If this does not occur, depending on the size of the defect, they may undergo cardiac catheterization to insert a closure device or an open surgery to place a patch.

Traumatic injuries: Plastic Deformation

Bone can bend up to 45 degrees in young children before breaking. The bone will straighten but not completely. The deformity will not be as pronounced on XR as fracture. Most commonly in ulna and fibula. Often assoc with fractures

Pain Assessment: For a developmentally appropriate 6-year-old, what kind of pain scale is most appropriate? A. Physiologic B. Observational C. Self-report D. None of the above

C. Self report (Faces) because of need to understand numbers, read words, vs interpret facial expressions

Other Traumatic Brain Injuries

Concussions

Delirium

Confusion + hyperactivity, paranoia, & agitation

Neural Tube Defects: prognosis

Consider it like a spinal cord injury Prognosis is based on the extensiveness of the spinal involvement and the level of the lesion - not necessarily symmetrical à may experience more deprivation or affectedness on one side than the other depending on which nerves are involved Spina bifida occulta not necessary without signal: dimple or depression, tuft of hair, lipoma, port wine stain. Could occur in singular, together, or not at all. Spinal cord be completely uninvolved, may not be; more involvement = more damage; possible for this to occur in occulta too (tethered cord). May be asymptomatic for a while but start to exhibit progressive gait change, muscle weakness, bladder or bowel involvement. Can be detected prenatally with alpha fetoprotein or high resolution US Surgical correction: fetal or within 24-72 hours

Dental ABX Prophylaxis

Infective endocarditis: low grade fever, fatigue, malaise - educate parents to tell provider if these occur within 2mo of surgery.

Decreased pulmonary blood flow

Cyanotic, hypoxic conditions - Pulmonary Stenosis - Tricuspid Atresia - Tetralogy of Fallot

Management of Nephrotic Syndrome: Long term/Chronic Care

Education is critical! 1.) Monitoring - Obtain and record daily urine protein = catch exasperation early - Weekly weights - Medication side effects = ACE inhibitors and Statins 2.) Prevention - Infection - Obesity - Fluid retention: no added salt While in remission, families still need to be vigilant in looking for signs of another exacerbation. This is primarily accomplished through keeping a log of daily urine dips for protein; three consecutive days of 2+ protein in the urine is often the indication for calling one's nephrologist for recommendations. When this is identified, PO corticosteroids will likely be prescribed on an outpatient basis, and an OV if it does not appear that the patient's condition is improving, or they show signs of worsening. Alongside the daily dipsticks will also be weekly weights. And they need to know about long term management of potential complications through the use of ACE inhibitors (kidney-protective) and statins (may be long term or only during exacerbations). Side effects of ACE include hypotension and hyperkalemia; statins typically do not have side effects in children (in stark contrast to the reports of adults that take them), but could have muscle effects and rhabdomyelitis. And of course, when corticosteroids are required, they have a number of side effects like hyperglycemia, decreases in bone density, weight gain and central obesity, hirsituism, and the 'buffalo hump.' These are important to keep in mind particularly when a patient is at an age when body image is being acutely developed. Patients should also take pains to avoid infection, to have a well balanced diet (although anorexic when acutely ill, they may be at risk for obesity during remissions due to compensation for foods not eaten when ill, and the effects of corticosteroid treatments), and to minimize sodium if there's particular concern for fluid retention. Long term, these kids with an idiopathic presentation typically have fewer exacerbations over time, and often do not have any exacerbations once they reach adulthood.

VP Shunt: Personality and behavior signs

Fever look in powerpoint

Symptom Identification & Management of CHF

Heart failure and cyanosis are the 2 more common concerns

Total Anomalous Pulmonary Venous Return (TAPVR)

Here, the pulmonary vein (remember, should bring blood from the lungs to the left atrium) is actually connected to the superior vena cava, meaning all oxygenated blood gets 'dumped' into the right ventricle (left side). This again requires some form of hole between the atria, ventricles, or PDA to allow for blood to get into systemic circulation, but even then the infant would be hypoxic (right side). PGE may make this condition worse

Transposition of the Great Vessels

Here, you see the aorta branches off the RIGHT VENTRICLE, and the pulmonary artery branches off the LEFT VENTRICLE, effectively creating two closed systems (one of only oxygenated blood, the other of only deoxygenated blood). If a child with this defect wasn't born with some form of hole between the two systems to allow for mixed blood flow, they'll go down hill fast; they'd need Prostaglandin E to keep the PDA open, and then some sort of quick correction (similar to TAPVR; here surgical intervention usually occurs between 1-3 weeks of age).

Salter-Harris Classifications

I do not expect you to memorize the different types individually, but you should know that any injury that involves damage to the growth plate (which are primarily types III-V) are particularly concerning and need urgent intervention to maintain as much bone growth capacity as possible; otherwise the result will be stunting of the growth of that bone, and possibly joint necrosis. Type 1 is the most mild, and type V is the most severe

When to call the prescriber? K.B.'s pain is unrelieved with elevation and pain medication. What is the nurse's priority action?

If pain meds did not work, you may be concerned for compartment syndrome. call provider

LEVEL OF CONSIOUSNESS: Infants

In infants, we need to use other means of assessing their mental status You'll notice that a lot of these are signs we've used to assess them in the past - sort of emblematic of how challenging it is to determine the etiology of newborn and infant issues If concerned about the neuro status of an infant, try a pacifier (or elicit sucking - depending on age) prior to offering bottle feedings

Disorders effecting the Glomeruli: Nephrotic Syndrome

Increased glomerular basement permeability to protein and alteration in kidney function 1.) Findings - Frothy urine due to proteinuria - Edema: especially around eyes, ankles, and feet - Weight gain, fatigue, loss of appetite 2.) Etiology - Congenital or genetic conditions - Systemic disease - Medications and toxins

abnormalities that increase the blood flowing to the lungs: patent ductus arteriosus (PDA)

It functions based on the same principles of the VSD & ASD. When a newborn has an Atrioventricular Canal (AV Canal), wherein there's a hole in the center of the septum where the mitral and tricuspid valves intersect, blood still travels R à L, but the extent of gradient depends on the size of the hole. Its closure is also more complex if there's extensive involvement of the valves.

Increased Intracranial Pressure (ICP)

It is exactly as it sounds - an increase in pressure within the skull.

Adult Congenital Heart Patients

Living, and longer: - Transition to adult providers - Birth/Contraception - Chronic CVD - Psych & Development - End of life care Your textbook is wrong re: TGA survivability without surgical correction. The condition is not conducive to life without some kind of correction, but it's not impossible that this correct is congenital in nature as well.

Assessment for a UTI

Many of these symptoms likely gained by history taking; but we can also identify them on physical assessment: - General inspection (irritability, lethargy) -Inspection of skin (rash, jaundice) -Inspection of urine -Observation of voiding behavior -Palpation for flank, abdominal pain; costovertebral angle tenderness, bladder fullness -Assessment of temperature

Interventions for Seizures

Many seizures don't require any emergency intervention at all; generally acute med intervention is administered (phenobarb for neonates, Ativan - depends on route availability) Monotherapy is the preference because of the addative side effects of multiple siezure meds - can be really debilitiating in themselves Inborn errors and disorders will likely requires pharmacotherpaty If intensive intervention is necessary: Use EEG to try to localize seizure activity region Then they penetrate suspected region through scalp, place probe, then provoke a seizure (lack of sleep etc) Needs someone to monitor them 100% of the time, to alert when seizures happen Then Deep probe monitoring might be placed - devices that are implanted deep in the brain and used to a.) identify the focal area of the seizure activity, and b.) stimulate the regions in a variety of ways depending on the device - continuous or seizure-only electrical activity, or regional cooling - or the area of the brain is removed (focal resective surgery) or the hemispheres are disconnected

Disequilibrium syndrome

Neurologic symptoms associated with hemodialysis, thought to be related to cerebral edema, is most likely to occur on the first dialysis treatment. Early symptoms: headache, nausea, disorientation, restlessness, blurred vision, and asterixis. Often self-limiting and dissipate within hours, but may progress to confusion, seizures, coma, and even death. May be prevented by taking steps to remove urea slowly.

Level of Consciousness: Glasgow Coma Scale

Not commonly used in infants. And many factors impact the score - trauma, illness, medications, condition Important thing to recognize: Three dimensions (eyes, verbal response, motor response) Score of 15 = best Score of 3 = worst, total unresponsiveness Score < 5 = high correlation with neurological brain death

Stuporous

Only arousable with very vigorous stimulation (ie, pain)

Coarctation of the Aorta

PGE Coarctation of the aorta technically isn't an abnormality of the heart - it's an abnormality of the aorta that usually arises just after the first three major branches off the aorta (not shown on the diagram). Although the anatomy is different, the presentation is similar to aortic stenosis. There's big thing that makes this condition stand out from the rest: the blood flow to the lower extremities is lower than that going to the upper extremities, which is reflected in a difference in pulse pressure (pulses may be weak in the lower extremities) and blood pressure (may be lower in the lower extremities than the upper extremities when the patient is supine). These potential differences between the upper and lower extremities are not characteristics of other congenital abnormalities; when the anatomy begins in the heart, blood pressure and pulse would be low systemically.

Cerebral Palsy: Pharmacologic Management

Pain management, reflux management 1.) Enteral a.) Dantrolene sodium b.) Baclofen c.) Diazepam (Valium) 2.) Injection a.) Botulinum toxin A (Botox) = Botox inhibits release of acetylcholine to reduce spasticity b.) Baclofen pump (into intrathecal space)

Persistent Vegetative State

Permanent loss of cerebral cortex function

Pulmonary Stenosis

Pulmonary stenosis is a narrowing of the pulmonary valve. It is a on a spectrum, meaning that a baby can have mild PS that resolves on its own, or severe PS that requires multiple balloon dilations. This is typically diagnosed in the neonatal period due to a presence of a specific murmur.

Traumatic injuries: Treatment of Sprains and Strains

R Rest I Ice C Compression E Elevation S Support Same treatment for both. w/in 1st 36 hours, want to elevate above level of the heart to decrease swelling/edema, keep iced (no more than 30 minutes at a time), wrap the ankle with the ice either together or separately for compression (helps to limit swelling and bleeding). If you do all these things, you have no choice but to rest! J Afterwards care should include exercises to regain strength and motion the ligament or tendon, progressive increase in weight bearing, and continued RICE. OTC analgesics used appropriately are okay. It is important that these are evaluated by a physician, particularly if pain or swelling does not subside or changes in some way - some tears need more intervention, or might involve bone or a fracture; knee injuries may require arthroscopy; casting is not impossible (although less common in these injuries).

Normal Congenital Anatomy & Hemodynamics

RA = right atria RV = right ventricle LA = left atria LV = left ventricle • Blood flows from body to vena cava -> RA -> RV -> Pulmonary artery -> Lungs -> Pulmonary vein -> LA -> LV -> Aorta to the body • Pressures in atria are lower than in the ventricles (remember, blood passively flows into both from either the vena cava or the pulmonary vein, so they can't have a higher pressure than those vessels or the blood wouldn't flow) • Pressures in on the left side of the heart are higher than those on the right side of the heart, to provide systemic circulation • Pressures in the vena cava and pulmonary vein approximately the same as the RA & LA • Do not worry about knowing the pressures exactly; just know the basic relative pressures. • Blood in the Vena Cava/RA/RV/Pulmonary Artery is deoxygenated Blood in the Pulmonary Vein/LA/LV/Aorta is oxygenated

K.B. is a 6-year-old that fell while playing in their background. - Their caregiver brought them to the ED for concerns including complaints of pain, refusing to bear weight on their right foot. - The caregiver has already tried basic measures. What are some basic measures?

RICES Initial Orders: - VS per routine, including pain assessment - NPO - IV fluid at D5 1/2NS at 42 mL/hour - Right foot XR - CBC and coags = Why CBC and Coags? bruising and swelling and there might be blood loss

Consistent mgmt. for increased ICP: nursing care

SHORT TERM GOALS: Maintain airway, limit activities that increase ICP, perfuse brain if necessary LONG TERM GOALS: Rehabilitiation to best possibile mobility, capable of self-care, regaining speech Assess for both CURRENT status & any CHANGES in statuses Maintain airway: O2 administration, be prepared for decompensation, mechanical ventilation care Fluid administration - ensuring blood volume for perfusion Medication administration - dependent on cause and severity of ICP - antibiotitics, osmotic diuretics, pain medications Thermoregulation - may be related to febrile illness or pressure on the thalamus/hypothalamus causing malfunction Safety - orientation, seizures Environmental - dark room, minimal stimulation depending on cause, cluster care if possible, HOB 0-30° Care of the Unconscious Patient Fluids if there's a perfusion pressure problem suspected Airway - regular and frequent checks of vitals, assessment of and intervention on metabolic imbalances, be ready with rescue devices, suction, and oxygen at bedside; child might be intubated or trached depending on the expected prolongation of the condition Safety - frequent checks for change in neurostatus, appropriate intervention for disorientation, keep bedrails up secondary to institutional policy, anticipate seizures = pad bedrails

Management of status epilepticus: table

Status Epilecticus is generally defined as continuous seizing lasting five minutes or longer, and in particularly intractable seizures may last more than 20 minutes. This is a medical emergency! The exact nature of SE and its severity may differ by seizure type, and can occur outside of a standing seizure disorder. Can be due to Once identified (definition of the time to begin preparations for this are institution dependent; may be 2-3 minutes), you're going to begin securing the patient. You're you're calling for backup (code or rapid response); opening the airway if necessary, giving O2, and ready to suction or bag the patient if necessary; you're hooking them to cardiac, O2, and BP monitoring; you're establishing an IV if you don't already have one. You or the team are checking glucose, electrolytes, and temperature, and addressing them appropriately; and you're giving the first of what will be a sequence of short acting meds to try and stop the seizing. If anyone here is ACLS certified, you'll recall that there's a standard sequence and timing for administration of epi, atropine, etc during cardiac arrest - similar here. Some meds cause apnea and hypotension, so be prepared for these.

VP Shunt

Surgical procedure Alleviates/corrects hydrocephalus It's a surgical procedure, so they'll get usual post-surgical care and neuro care - Child must remain SUPINE for a day or two, HOB gradually elevated -Otherwise there could be a rapid drainage of CF into the new cavity or space, which amongst other things causes dizziness and MASSIVE headache (same goes for the routine LP), and child may not be able to compensate in producing enough for function INFECTION is the most serious consequence here - aseptic technique is a big deal, and parents need to know how to clear/care/detect S&S

Expected Development in Infancy: 6 months

Teeth & Stranger-Danger 1.) Gross = Push-up to hands Standing assisted 2.) Fine = Finds dropped objects Manipulate small objects Holds bottle 3.) Sensory = Looks for objects Turn side-to-side and up and down 4.) Vocalization = Babbling single syllables Pleasure in making sounds 5.) Socialization and Cognition = Stranger danger starts Extends arms to be picked up Likes and dislikes Sound imitation Searches for dropped objects (Object permanence) Mood swings

Tetralogy of Fallot

Tetralogy of Fallot is a compilation of four (Tet or ToF) abnormalities: 1.) Pulmonic stenosis = decreased blood getting to lungs 2.) VSD = the blood coming from lungs (oxygenated) mixes with the blood in the RV (deoxygenated) = lower oxygen content in the blood getting to body; also further decreases blood to lungs 3.) Overriding Aorta = blood from both ventricles gets sent to the body (compounds the VSD problem) 4.) Right ventricular hypertrophy = less room for blood in the right ventricle The big take-away: Decreased blood to the lungs, then the little bit of blood getting oxygenated in the lungs comes out and gets mixed with deoxygenated blood before going to the body.

Acyanotic, Cyanotic, and Mixed Congenital Heart Disease

The defects that fall into each of these categories generally present in a similar way. If you're finding it really challenging to remember the anatomies themselves, at least be sure to know their names and the type of abnormality they fall into - knowing this should help guide you to appropriate interventions. On page 1449 of your book, there is a nice table that lists the defects in their respective categories. The difference is, in part, related to pulmonary blood flow (PBF) Mixed conditions need a place to mix and then there is a balance between cyanosis and HF

Hypoplastic Left Heart Syndrome (HLHS)

The left ventricle never fully develops, and the aortic valve either never develops or is severely stenosed. Now the pressure in the left heart is even greater because there's little/no outflow of blood to the body, so blood also travels across the foramen ovale back into the lungs. In the short term, these infants need a PDA to allow some systemic blood flow; there's also an increase in pressure in the lungs from the blood going across the PFO (pictured above). These children need a number of palliative surgeries over the first few years of life to increase systemic circulation, and almost half do not live past 5 years old. Those who do continue to survive against these odds will require a transplant.

Mixed Blood Flow Conditions

These conditions are all complex and rare. Presentations can vary substantially based on the presence of additional defects. I do not expect you to memorize these. As nurses, we're most concerned about treating the symptoms of these conditions - pulmonary hypertension, cardiomyopathy, and heart failure - which can occur before or after surgery. In addition, these patients may become candidates for heart transplants during their lifetimes. You should definitely understand these conditions/interventions and the nursing role in their management.

Types of Osteogenesis Imperfecta

Type 1 = most common and most mild, minimal bone deformities, fracturing may not occur until toddler years (ad) Type 2 = most severe, most affected, small limbs and chest, big head, soft skull, respiratory and feeding struggles; most do not live beyond neonatal period (ad) Type 3 = most severe among those who survive the neonatal period, similar to T2; fractures of the long bones may be present at birth, growth plates show substantial abnormalities (ad) Types 4-6 = moderate severity, varies by individual Types 7 & 8 = autosomal recessive inheritance, very severe presentations

Pathophysiology of Acute Post-Infectious Glomerulonephritis

The second of the glomerular diseases, post infectious glomerulonephritis, bears some resemblance to nephrotic syndrome. Here, too, we have a condition characterized by excessive permeability of the glomeruli that may result in urinary changes and edema - but what they are permeable too, and its cause, provide its distinction. While these patients may be asymptomatic, when they are symptomatic, they are very sick. They are spilling everything in their urine - particularly blood, which is rarely found in patients with nephrotic syndrome - and they may be acutely hypertensive, in a range expected of a hypertensive crisis. Not listed here, but found in at least half of patients presenting with this condition, is the presence of azotemia - which recall are the signs and symptoms of the buildup of nitrogen related wastes in the bloodstream from ineffective filtration, such as changes in mental status, tremors, excessive thirst, and uremic frost. When taking a history from these patient's families, oftentimes (although not always) they'll report that the child was ill just within the past 1-2 weeks prior to this acute worsening - typically a pharyngitis. That is because a some strains of group A strep - the same bacteria that causes throat infections, scarlet fever, and rheumatic fever - is also known to precipitate this condition. What happens, or that is, what is suspected to happen (as it's still not entirely clear what the exact mechanism is), is the antibody/antigen complexes made as the body fights the strep infection start to accumulate and lodge in the glomeruli as they filter the bloodstream. This starts an inflammatory process that heralds white blood cells to the area, which in some glomeruli then gums up the system such that filtration slows to a trickle; wastes do not get filtered out, and downstream, the tubules say "hey! Obviously we need more blood volume here!", resulting in the activation of the renin-angiotensin system, which I know you recall increases retention of sodium and fluid. In other glomeruli, the immune system seems to attack the immune complexes themselves, then damaging the glomerulousi and increasing their permeability to proteins, glucose, and red blood cells. If you're thinking that this presents a lot like a type of acute kidney failure, you'd be right - plus the added signs of kidney damage based on the urine chemistry.

Tricuspid Atresia

There are only a couple conditions that primarily decrease blood flow to the lungs. The simplest is tricuspid atresia, and the 'sister' conditions pulmonary stenosis and pulmonary atresia. All three decrease blood flow to the lungs either because a.) one of the valves that allows blood to flow from the right side of the heart to the lungs never developed (remember atresia = absence), or b.) the valve is so stiff that limited blood goes through (stenosis). Let's focus on tricuspid atresia (TA). In TA, the valve between the right atria and the right ventricle never developed (see above). So, no blood can get to the right ventricle, and thus it cannot get to the lungs... or anywhere else for that matter. In order to be conducive to life at the start, we have to either be born with correcting abnormalities, or have them artificially made (next slide) As you can see here, if there's a hole in the atria (either an ASD or a patent foramen ovale [PFO]), deoxygenated blood can get into the left atria. From there, it can make it to the body - but that's not a big help if it's unoxygenated. So we also need a whole between the right and left ventricles, to allow for some blood flow into the lungs. If they are born with the anomalies that create the effect above (that is, ASD and a VSD in addition to the tricuspid atresia, as an example), it's referred to as being "congenitally corrected"; if we surgically create holes in those places, it's called 'surgical palliation.' These children are said to be palliated, rather than corrected, because they'll eventually need a more complex procedure to keep them going long turn (permanently redirecting blood directly to the lungs from the vena cava - no need to memorize the procedures).

GU: Review of Anatomy

There can be abnormalities of the internal and/or external structures.

Heart Transplantation

Trading one disease for another 1.) Option for children with end-stage, complicated, or uncorrectable disease = Limited number of available organs and size needs to be concidered 2.) Short term mortality: acute rejection = Cyclosporin for immunosuppression 3.) Long term mortality: premature cardiac muscle aging = hyperlipidemia, vessel thickening 4.) Nursing Management: - infection control - immunization administration (NOT live) - growth and development promotion - suppression protocols - Family education

Comatose

Unconscious and unarousable

Decreased Systemic Blood Flow

Up to now we've been discussing conditions that result in either an excess of blood to the lungs, or a decrease in blood to the lungs. Now we're going to shift to a decrease in blood to the body. There are two primary conditions here: Aortic stenosis, and coarctation of the aorta.

Expected Development in Infancy: 12 months

Walk & Talk 1.) Gross = Walks with hand(s) held May stand alone briefly 2.) Fine = Attempting building with blocks Turn pages in a book 3.) Sensory = Follows rapidly moving objects 4.) Vocalization = 3-5 words besides "mama" and "dada" Understands verbal commands Imitates animal sounds 5.) Socialization and Cognition = Shows emotions Explores away from caregiver Security in familiar object(s)

Cranial Nerve Assessment

We want pupils to be equal, round, and reactive to light Probably checking pupillary reflex every shift - and more often with patients who have neuro concerns Cranial nerve assessment can help localize area of injury or condition, or the extent of an injury or condition - Remember that the cranial nerves branch off from different regions of the brainstem Pinpoint, blown, unilateral, bilateral Pinpoint generally in the setting of opiates Unilateral Reactive = Intracranial mass (A) Unilateral Fixed = herniation of the temporal lobe and compression of the oculomotor nerve (B) Bilateral Fixed Blown = herniation of brainstem (C) Bilateral Reactive Blown = atropine-like agents or sympathetic nervous system agonists (ex cocaine, amphetamine, LSD) The important thing to recognize here is that asymmetrical or unresponsive pupil = be concerned. Think of medications that can effect the response - such as dilating ocular drops for eye exams.

Renal Failure

You've had transplants with adult health, so read the section but it will not be covered on this test.

Opisthotonic Position

a hyperextention of the head to relieve discomfort - try to facilitate this position

Hypospadias

abnormal congenital opening of the male urethra on the undersurface of the penis

Postictal state

appears to relax, usually confused for extended period, poor movement/coordination, may vomit or complain of severe headache, changes in vision or speech, very tired, headache, no memory of period during event

Obtunded

arousable with some effort, but very, very sleepy - limited movement, goes right back to sleep state after

Systemic Effects of Immobilization

better table in powerpoint

Status epilepticus

continuous seizing, or multiple seizures with pauses not long enough to allow any recovery (will talk about momentarily)

Expected Development in Infancy: 4 months

intro to food 1.) Gross = Can sit when propped Roll back to side 2.) Fine = Bringing objects to mouth 3.) Sensory = Hand-eye coord. starting 4.) Vocalization = Laugh Vocalization changes with mood 5.) Socialization and Cognition = Fussing for attention Bored when alone Memory starts (recognizes bottle, for example)

What are some subjective symptoms of compression syndrome?

discomfort or irritability, particularly increasing, despite pain control measures that would have been expected to offer relief

Tonic-Clonic Seizures: Previously known as _______________

grand mal seizures

Gower's Sign

is a medical sign that indicates weakness of the proximal muscles, namely those of the lower limb

Aortic Stenosis

left-heart equivalent to pulmonary stenosis, which we discussed in the 'decreased pulmonary blood flow' section (it's one of the sister conditions to tricuspid atresia). The left sided equivalent to tricuspid atresia would be mitral atresia, although this is really rare - don't fret too much over it. I'm just drawing parallels to help you understand the left sided implications). Aortic stenosis results in decreased blood flow to the body because the valve is so stiff that limited blood goes through.

Concussions: Treatment

physical and neurocognitive rest - no school until the child can participate in activities that require concentration without symptoms (and reduced workload at school at first), no participation in sports or physical activity until able to do so without symptoms (will generally titrate back up to previous levels, usually takes at least 10-14 days before they are allowed to start this process). Screens and activities involving them are also considered cognative work - can be hard to get people to stop using these!

Neoplasm

pituitary involvement with benign adenoma Before fontanelle closure - 12 to 18 months. Before that, increased contents can be accommodated before signs of increased ICP. That doesn't mean You can see how this might spiral - damage to the brain can cause further injury to the brain Heme abn - we will cover in heme but include bleeding d/o, and anticoagulation

Signs/symptoms of a focal seizure

unilateral also - effect the opposite side of the effected hemisphere, relate to the part of the brain experiencing the seizure activity Focal seizures, particularly the complex ones, could progress into generalized seizures Has motor and sensory intervention Automatisms - particularly important to note for assessment in infants - eye movements, lip smacking, tongue thrusting, repetitive blinking, sucking

Etiologies of increased ICP

• A growth or neoplasm • Cerebral edema = Ex: Traumatic brain injury (TBI), hypoxic injury meningitis • Intracranial bleed = Prematurity, stroke, traumatic injury, heme abnormalities • Excess in CF production or a blockage or reabsorption = Ex: Myelomeningocele, Chiari malformation, hydrocephalus, meningitis

Seizures: Acute Nursing Management

• Assessment: Airway, color • Vitals: O2 sat, pulse, respirations (if safe to obtain) • Ensure safety • Side position, suctioning equipment, O2 mask, bag valve mask • Nothing in the mouth • Medication Administration: • Correct electrolyte abnormality • Glucose if hypoglycemic, for example • IV or PR Meds: • Benzodiazepines: Ativan, midazolam • Phenobarbital • Phenytoin • Seizure precautions: Siderails up & padded, mattress Call 911/emergency number May be different if child has seizure disorder plan - may not call if known disorder and <5 minutes or something The "in the community" information is also what you'd teach parents Basically keeping patient safe, monitoring breathing until help arrives In hospital, know your policies about what you're expected to do in the event of an expected or unexpected seizure -Call code? Call urgent team? Administer glucose before arrival of other professionals? -Giving IV meds: might be a push - can you give this? Know your baseline respirations, push slowly and monitor for respiratory change or cardiovascular collapse -Causes CSN depression - so these signs are those to watch for S/E for phenobarb and phenyt: allergic rash (d/c med). Sleepy, mood or behavior change (usually intermittent), ataxia, brief O2 requirement

Infant Specific ICP Assessment: What do you think would be an issue for these infants in the pre-intervention phase?

• Bulging fontanels, lack of normal pulsation • Widely split sutures • Increased head circumference in short amount of time, out of proportion to their weight and length gains • Dilated scalp veins • Irritability • Changes in LOC • Shrill, high-pitched, weak cry

Arnold Chiari Malformation

• Cerebellum herniates through skull at base of brainstem • Compresses the ventricle behind the cerebellum, leading to hydrocephalus • 80 - 90% of Spina Bifida children will have hydrocephalus; most 2° ACM II Essentially the cerebellum & brain stem herniates through the hole at the bottom of the skull where the spinal column enters into the lower brainstem (ACM I à just cerebellum, can be acquired, somewhat less serious; also types III & IV - rare) Also compresses the ventricle behind the cerebellum, thus hydrocephalus Since this area of the brain controls respiratory function and swallowing reflexes, the biggest immediate issue is compromise here - breathing, aspiration - but it could be asymptomatic as well Important to identify early for early intervention

Cerebral Palsy: Management

• Early intervention • Treatment is individualized • Rear facing in car restraint as long as possible • Potential need for surgical feeding tube placement • Orthopedic management a.) Tendon lengthening, ankle-foot orthoses (AFO), spinal fusion b.) Surgery for children that do not respond to less invasive management c.) Timing is dependent on the child, but generally the older the child, the better

Neural Tube Defects

• Failure of neural tube to close, or splitting of already closed tube, during gestational weeks 3-5 • Major etiology: antenatal folic acid deficiency • Other factors: Anti-epilepsy drugs, malnutrition, genetics, more • Prognosis: Variable Major decrease in incidence when grain products became fortified with folic acid by law in the late 1990s May be multifactorial, genetic, radiation or chemically based - many things.

Anti-epileptic drugs (AEDs)

• Frequently used: a.) Phenobarbital: frequently need vitamin D and folinic acid supps. Levels need to be monitored. = Monitor for drug reaction (rash) b.) Carbamazepine, Valproic Acid, Gabapentin, Lamotrigine, Topiramate, Levetiracetam, Oxcarbazepine c.) Side effects: lethargy, inattention, memory difficulties, twitching, double vision • Adherence extremely important • No alcohol • Needs dose adjustment with weight gain • Teratogenic, interactions with oral OCPs

Physiologic effects of increased ICP

• Manifestations depend on whether the AF is open or closed • If open, increased ICP can be insidious • If AF is closed = Increased pressure decreases cerebral blood flow - Decreases oxygen & nutrient delivery, leads to cell death - Cell death releases toxins (amino acids, electrolytes) - Decreased perfusion also decreases removal of toxins - Inflammatory response increases permeability of blood-brain barrier - Brain is vulnerable to insults from infections, systemic neurotoxins, other particles that may lead to worsen edema

Seizures: Nursing Management: Chronic (Home Safety Measures)

• Minimize fall risk • Wear helmet if LOC occurs • Care around potentially unsafe exposures • No standing around hot surfaces/open flame, for example • Avoid exercise where you could fall from high places • No swimming alone, and no swimming with uncontrolled seizures • Shower rather than bath • Medical Alert Bracelet = Teen and medical alert bracelet - potential issues

Febrile Seizures

• Most common neurologic disorder of childhood • Seizure during 1st 24 hours of fever (>/= 38° C/100.4° F) • 9 mo - 5 yr olds, peaks 12-18 months • Simple = <15 min, no reoccurrence w/in 24 hrs • Complex = >15 min, reoccurs w/in 24 hrs usually these are pretty benign, and generally do not last long enough to require any intervention for the seizure itself. They're more likely to happen in younger children (between 1-2 years old, but can be as old as 5), with very high fevers (>39 degrees C/103F), with fevers from infections, in children with genetic suseptability, and in children of a couple different ethnic groups (like japanese and pacific islanders). Some vaccines are also associated with a higher risk of febrile seizures, like MMR and TDaP. Treatment is the same as with other seizures if it lasts 5 minutes or more, but they frequently do not; the best way to treat febrile seizures is to treat the fever itself with antipyretics. Children who have a febrile seizure are at higher risk than others of having another febrile seizure, but are only slightly more likely to be at greater risk than the general population to develop another type of seizure disorder.

Duchennes

• Muscle fiber degeneration, fibrosis, and muscle wasting related to fat infiltration and replacement with connective tissue • Etiology: Genetic, X-linked • Effects boys only* • Onset: usually 3-4 years of age • Muscle hypotonia, weakness - increasing difficulty performing previously easy motions/movements • Common for growth and development to be slow prior to diagnosed onset • Classic indication: Gower's sign Children may waddle when they walk, or engage in toe walking; weakness causes frequent falls Elevated serum muscle enzyme (CK) may be an early indication too. *Penetrance is an issue here - some girls who are carriers can have mild symptoms too

Hyper-cyanotic Episodes ('Tet' spells)

• Stimuli causes irritation/pain/increased activity • Increased O2 needs • Increased HR & Resp rate, decreased SVR • Blood moves quickly from LV to body, Pulmonary Valve occludes • Blood returns to RV, but cannot pass to Pulmonary Artery • Rapid onset cyanosis, diaphoresis, change in LOC Hypercyanotic episodes are major complications specific to conditions of decreased pulmonary blood flow (particularly Tetrology of Fallot, hence 'tet' spells). Blood doesn't get into the lungs because it's quickly sent out to the body, but the abnormal anatomy keeps it from coming back into the lungs - so it gets 'stuck' so to speak in systemic circulation.

Cerebral Palsy

• The most common motor disability in childhood a.) Caused by hypoxic ischemic injury b.) Congenital or acquired • A group of disorders affecting movement, balance, and posture. • Caused by abnormalities in the way a brain developed • Symptoms vary widely and can impact one or more of the following: a.) Spasticity (stiffness) b.) Dyskinesia (uncontrolled movements) c.) Ataxia (balance and coordination issues)

Surgical Interventions for increased ICP

• Tumor resection • Endoscopic third ventriculostomy (ETV) and Choriod Plexus Cauterization (CPC) • Ventriculoperitoneal shunt (VP Shunt) • Ventriculoatrial/Ventriculopleural shunting of CSF • External ventricular drain • Burr holes or craniotomy • Decompressive craniectomy Tumor resection = malignancies Ventriculoperitoneal/Ventriculoatrial/Ventriculopleural Shunting = hydrocephalus Burr holes or craniotomy = bleeds, abscesses (hole in skull over affected area, tube placed for drainage) Decompressive craniectomy = removal of skull segment to allow for swelling without compression

Partial Seizures

• Uni-hemispheric • Simple - No aura, no LOC, <30 seconds • Complex - Aura, change or LOC, 30 sec - 5 min, emotional response, Automatisms