Presented by Marlene Meador RN, MSN, CNE

 Head to torso ratio  Cranial bones- thin, pliable, suture lines not fused  Brain vascularity and small subarachnoid space  Excessive spinal mobility  Wedge shaped cartilaginous vertebral bodies

 LOC & behavior  Vital Signs and respiratory status  Eyes  Reflexes and motor function  Cranial nerve function Modified Glasgow Coma Scale for ages 3 and younger

Increased Intracranial Pressure- IICP or ICP Infants  Irritability & restlessness  Fontanelles / FOC  Poor feeding/sucking  Skull & scalp veins  Nucal rigidity, seizures (late signs) Children  Headache  Vomiting  Irritable, lethargic, mood swings  Ataxia, spasticity  Nucal rigidity  Deterioration in cognitive ability  Vital sign changes

 What assessment findings should the nurse monitor?  What emergency equipment should the nurse have on hand at all times for a child with IICP?

 What diagnostic procedures would the nurse anticipate for this child?  What priority interventions must the nurse include with respect to these diagnostic procedures? ◦ What specific teaching is required? ◦ What additional lab/serum tests would you anticipate?

Medications used to treat IICP: Corticosteroids  Anti-inflammatory  Contraindications- acute infections  Monitor I&O  Protect from infection  Add K+ foods  Discontinue gradually  Osmotic diuretic  Reduce fluid  Contraindications- intracranial bleeding  Monitor I&O carefully  Monitor electrolytes  Teaching

 What equipment is essential?  Vital signs & neuro signs  Additional assessment findings  Activity level  Hydration status  Positioning  Parent teaching

Nursing Care of the Pediatric Patient Experiencing a Seizure Disorder

 Febrile- rapid temp rise above 39°C (102°F)  Generalized- loss of consciousness, involves both cerebral hemispheres onset at any age  Tonic/Clonic- impaired consciousness, abnormal motor activity, posturing, automatisms  Absence- may confuse with daydreaming or inattentiveness

 EEG  CT, MRI  Lumbar puncture  CBC  Metabolic screen for glucose, phosphorus and lead levels

 Assessment findings  Priority interventions ◦ Prevention ◦ During seizure ◦ Following seizure McKinney has detailed Nursing Care Plan

 Phenobarbital- CNS depressant- assess for sedation, VS, serum levels, ◦ Teach- S&S of toxicity, no ETOH, adhere to regime  Carbamazepine- sedative/anticonvulsant ◦ hold med if lab values = ◦ Teach- S&S of toxicity  Phenytoin- anticonvulsant ◦ Safety measures- on-hand equipment ◦ Teach- oral care, sun exposure

 What is most important nursing intervention when a child is experiencing a seizure?  What is most important teaching regarding seizure medication?

Nursing Care of the Child with Meningitis

Meningitis Bacterial  Potentially fatal; abx given prophylactically if bacterial suspected. May kill within 24 hrs  C/S take 72 hrs to process  Infants at greatest risk  Nuchal rigidity  Severe headaches  Contagious Viral  Same s/s but milder and shorter duration  May follow a viral infection  May be accompanied by rash  Nuchal rigidity  Ataxia  Not contagious

 Why does bacterial meningitis present more of a risk than viral meningitis?  How do the manifestations of meningitis differ between infants and young children

InfantChild/Adolescent  Fever (not always present)  Poor feeding  Vomiting  Irritability  Seizures  High-pitched cry  Fever  Headache  Photophobia  Nuchal rigidity  Altered LOC  Anorexia/ vomiting  Diarrhea  Drowsiness

 What findings differentiate between bacterial and viral meningitis?  What specific interventions does the nurse include for this procedure? ◦ Monitor VS & neuro VS ◦ LOC ◦ Teaching

 Ceftriaxone Sodium (Rocephin®)- who must receive this medication?  Cefatoxime Sodium (Claforan ®)-  Dexamethasone- special nursing care  Antipyretics

 What intervention must the nurse initiate to protect the patients and staff when a diagnosis of bacterial meningitis is suspected?

Hydro= Water Cephaly= of the head/brain

 What priority nursing assessment of a newborn monitors for this condition?  What assessment findings occur in the older child?  What diagnostic measures confirm this diagnosis?

 LP-dangerous  MRI; CT scan  Skull X-ray  Measure FOC  Provide for safety, informed consent, support for child and family, accurate H&P

 Shunt placement- surgical procedure to place a tube that drains CSF into the atrioventricular or peritoneal cavity.  Atrioventricular- drains into atrium (not used as frequently)  Ventricular peritoneal- drains into the peritoneal cavity

 Pre Operatively: ◦ Baseline VS, monitor for IICP, ◦ What teaching/interventions for parents?  Post-op: ◦ Monitor shunt function (how?) ◦ Positioning and activity ◦ VS, neuro VS & I&O ◦ Teaching

 Home care needs  S&S of IICP  S&S of infection  S&S of seizures  Emergency numbers of Pediatrician & neurosurgeon  Refer to home care, social services and support groups

 Most common defect of the CNS  Occurs when there is a failure of the osseous spine to close around the spinal column. What common nutritional supplement is encouraged for all women of childbearing age?

 What common nutritional supplement is encouraged for all women of childbearing age?  Discuss the 3 types of neural tube defects: ◦ Spina bifida occult ◦ Meningocele ◦ Meningomyelocele

 Visualization of the defect  Motor sensory, reflex and sphincter abnormalities  Flaccid paralysis of legs- absent sensation and reflexes, or spasticity  Malformation  Abnormalities in bladder and bowel function

 Immediate surgical closure  Prior to closure keep sac moist & sterile  Maintain NB in prone position with legs in abduction preoperatively

Pre-Operative:  Meticulous skin care  Protect from feces or urine  Keep in isolette

 Assess surgical site  Monitor VS and neuro VS  Institute latex precautions  Encourage contact with parents/care givers  Positioning  Skin Care

 Antibiotic therapy  Prevent UTI  Education  Emphasize the normal, positive abilities of the child

Priority nursing diagnosis and interventions:  At risk for infection- ◦ Protect ◦ Position  At risk for injury- ◦ Protect ◦ Position

Cerebral Palsy

 Static Encephalopathy- spastic CP most common type (80%) ◦ Nonspecific term give to disorders characterized by impaired movement and posture ◦ Non-progressive ◦ Abnormal muscle tone and coordination

 Jittery (easily startled)  Weak cry (difficult to comfort)  Experience difficulty with eating (muscle control of tongue and swallow reflex)  Uncoordinated or involuntary movements (twitching and spasticity)

 Alterations in muscle tone ◦ Abnormal resistance ◦ Keeps legs extended or crossed ◦ Rigid and unbending  Abnormal posture ◦ Scissoring and extension (legs feet in plantar flexion) ◦ Persistent fetal position (>5 months)

 EEG, CT, or MRI  Electrolyte levels and metabolic workup  Neurologic examination  Developmental assessment

 Increased incidence of respiratory infection  Muscle contractures  Skin breakdown  Injury

 Anatomy predisposes infant/young to injury  Pathophysiology of “Shaken Baby Syndrome ”

 Assessment findings-  Immediate nursing interventions-  Legal implications  Why is it not prudent for the nurse to discuss suspicions of abuse with the parents or primary caregiver?

 Not clearly understood  Characterized by impaired social, communicative, and behavioral development  Usually noted in the first year of life

Pervasive Developmental Disorders / Autism Home Setting  Reduce environmental stimuli  Communicate via age- appropriate touch & verbalization  Keep toys or other items out of reach if child uses them for harmful self-stimuli  Ritualistic ADLs  Encourage therapists & support groups Acute Care Setting  Keep at least 1 constant caregiver. Encourage parents to stay with,keep room quiet & limit number of staff  Anxiety/aggression when touched by strangers  Constant monitoring by nurse or parents  Allow to maintain rituals of ADLs  Encourage therapists & support groups

Nursing Care of the Pediatric Patient with Down Syndrome

 Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation

 Failure of chromosomes to separate  Advanced maternal age  No other socio-economic or geographic factors have been identified

 Primary concern with cardiac and GI anomalies  What are the most obvious indications of Down’s Syndrome in a newborn

How does the nurse promote health of the child with Down’s syndrome?  Primary focus on the parents and care givers to provide support and achieve a realistic view of the child’s capabilities  Support siblings  Refer to family counseling services  Support parents in feelings of guilt and chronic sorrow

Contact Marlene Meador RN, MSN, CNE