1. Neurological Disorders in the Pediatric Patient
Page 361 of syllabus
This unit examines children who are handicapped with developmental delays resulting form CNS disorders or congenital anomalies. Many of these children require long-term, specialized nursing care. A primary nursing function is to assist the parents with recognizing the realistic potential of their child—Focus on the Positive** exam question

2. Why is the CNS function so important?
What does it do?
What happens with impairment?
What affects the degree of disability?
What does it do? Communication system, retains memory of stimulus, stimulus results in motor response
What happens when it is impaired: decreased senses (vision, smell, taste, hearing, touch)
Degreee of disability depends on the location and amount of damage

3. Changes to be noted in pediatric neurological disorders
Reflexes: may be hypo/hyper
LOC: may have altered mental status
Cranial nerves:
I, III
II, IV, VI
III, VIII
V,VII
IX, X
I, III: pupillary: light causes constriction; CN I provides smell
II, IV, VI: oculocephalic eyes held open and head turned side to side. Eyes gazing staight up indicate intact cranial nerves
III, VIII: oculovestibular: inject ice water into ear canal..eyes deviate toward the irrigated ear indicate intact CN
R/O cervical spine injury before doing this. TM must be intact…this is done by a physician
V, VII: corneal cornea is gently swabbed with sterile cotton swab. A blink indicates intact V and VII
IX, X: gag: pharynx is irritated with tongue depressor or cotton swab. Gagging response indicate intact CNs
Cranial nerves: general. Cranial nerve 1: olfactory nerve. Cranial nerves: the eye 1 – pupils, acuity, fields. Cranial nerves: the eye 2 – fundi. Cranial nerves III, IV, VI: eye movements. Cranial nerves: nystagmus. Cranial nerves V and VII: the face. Cranial nerve VIII: auditory nerve. Cranial nerves IX, X, XII: the mouth. Cranial nerve XI: accessory nerve

4. Neuro assessment, cont. Vital signs:changes in BP, HR
Eyes: changes in pupils,focus,gaze
Behavior: subtle
Respiratory status: assess 1st
Motor function: movement? Spontaneous?
Skin: dry vs. diaphoretic
Systolic may increase; widening pulse pressure (explain), bradycardia
Eyes: pupillary responses changes, focus and gaze when head turned (doll’s eyes)
Behavior: may be subtle, but changes in responsiveness
Resp status: stridor, retractions
Motor function: movement, spontaneous and on command
Skin: dry vs. diaphoretic

5. p in text; the maximum score is 15, indicating the best level of neurologic functioning. The minimum is 3, indicating total neurologic unresponsiveness

6. Neurological System of Children
Top Heavy
Cranial bones- thin, not well developed
Brain highly vascular with small subarachnoid space
Excessive spinal mobility
Wedge-shaped cartilaginous vertebral bodies
Top heavy- think about the inability of the newborn to control head movement. As the child matures they gain strength in the neck muscles and begin to demonstrate muscle control
Cranial bones- if cranial bones were developed and suture lines fused, the fetus could not pass through the birth canal, and the brain could not grow within a fused skull. What would this cause? (ICP)
Highly vascularized- the dura matter is easily separated within the subarachnoid space- Shanken Baby syndrome??? Well this is one contributing facto. This is s one of the reasons that amusement parks have height limits for many rides.
Spinal mobility- provides for flexibility at birth and during childhood but contributes to spinal cord injuries
Wedge-shaped cartilaginous vertebral bodies- can cause malformation if the rest of the body grows faster than the spine (we will discuss the primary deformity in a later lecture- do you know what it is called?)

7. Assessment findings in children with neurological dysfunction

8. Increased Intracranial Pressure (ICP)
Reflects the pressure exerted by the blood, brain, CSF and any other space-occupying fluid or mass (tumors)
Pressure sustained at 20mm Hg or higher
Changes in pressure present with altered assessments other than normal
In the skull 10% is CSF; 10% blood; 80%brain
The findings depend on the age of the child
For the infant, poor feeding, irritability, lethargy, bulging fontanel, high-pitched cry
For the child, headaches, diplopia, mood swings, slurred speech, n/v

9. Decorticate rigid flexions of arms and legs: refers to flexion of the upper extremities and extension of the lower
Decerebrate: extension of the upper extremities with internal rotation of the upper arms and wrist. The lower extremities will extends, with some internal rotation noted at the knees and feet. This type indicates damage to more areas of the brain, such as the midbrain, or pons.
The progression from decorticate to decerebrate posturing usually indicates deteriorating neurologic function and warrants physician notification..
Pg. 1671

10. Altered Mental Status Mnemonic = Mitten
Metabolic
Infections
Toxins
Trauma
Endocrine
Neurological/Neoplasm
Metabolic- hypoglycemia. What major organ requires sugar for food? Hyperglycemia-just like in adults, elevated blood sugars cause damage to brain cells as a result of what? Elevation in serum keytones -- keytoacidosis (what does that do to the brain?) Acts as a toxin to brain cells (what other organs are damaged here? Liver, Kidney, lungs) Hyponatremia- less than 135 mEq/L of blood usually found with dehydration (vomiting or diarrhea)… Diabetic ketoacidosis, burns, renal disease
Infections- meningitis, brain abscess, viral encephalitis
Toxins- fetal alcohol syndrome, Alcohol (consumed by the child), carbon monoxide, barbiturates, narcotics, lead, & nicotine- young children sometimes eat the contents of cigarette butts…Also toxins from parasites- boy at Metz
Trauma- subdural hematoma Shaken baby syndrome and birth trauma- or anoxia of birth
Endocrine- severe hypothyroidism DKA
Neurological/Neoplasm- tumor, post-ictal (after stroke or seizure), ICP, Hydrocephalus, seizures, cerebral palsy, myleomenigocele

11. Assessment: Infant Irritability and restlessness
Full to bulging fontanelles
Increase in FOC
Poor feeding, poor sucking, projectile vomiting
Distension of superficial scalp veins
Nuchal rigidity and seizures (late signs)
What NB assessment do we perform with respect to IICP? FOC Why? Form a baseline up to 3 yrs

12. Assessment: Child early signs-
Irritability, lethargy
Sudden change in mood
Headache, poor feeding
Vomiting
Ataxia
Nuchal rigidity
Deterioration of cognitive ability

13. Assessment Child: Late signs
Changes in Vital signs
Seizures
Photophobia
Positive Kernig’s sign
Positive Brudzinski’s sign
Opisthostonos
Vital signs- (increase systolic pressure accompanied by widening pulse pressure indicates brain stem perfusion this response is called Cushing’s response and is found as a late sign of ICP) ** write down Cushing’s
Photophobia- light increases the headache. Keep room darkened and avoid bright exam lights
Kernig’s-with the child supine and hips flexed, child will resist attempts to extend leg or complain of severe pain
Brudzinski’s sign- when the child is supine and examiner flexes the child’s head forward, knees and hips flex involuntarily
Opisthostonos- (o pisth os tonus)prolonged severe spasm of the muscles causing the back to arch acutely, the head to bend back on the neck, heals to bend back on the legs and the arms and hands to flex rigidly at the joints.

14. Therapeutic Intervention: Nursing care
Medications
Corticosteroid
Decadron
Osmotic diuretic
Mannitol
What is the purpose of these medications???

15. Nursing Care Minimize activity Monitor IV rate Place in semi-fowlers
Monitor VS, Neuro VS, and behavior
Treat for pain
Organize care
Educate parents
Purpose of these measures is to decrease the IICP
The reduction of ICP is accomplished with adequate sedation/quiet environment, HOB degrees, foley, seizure control Mannitol, barbiturate coma, C-collar
Keep the pt quiet with decreased stimuli (dark room, with picture books, soft toys, no running rowdy games) Keep visitors to quiet minimum but having mother/father present provides security and decreases anxiety making quiet care easier
Crying, Coughing, sneezing, vomiting- cause increase in ICP
Dehydration places these children at greater risk of emboli so keep them properly hydrated with careful monitoring of IV and I&O- too much fluid dilates blood vessels and places pressure against brain tissue.
Educate parents on S&S of IICP*** ,appropriate activities, expectation of outcome (prognosis) and any long-term care required.

16. Critical Thinking
What would you expect as a first sign of IICP in an infant?
What would you expect as an initial sign of IICP in a 10 year old child?
Irritability and restlessness; bulging fontanelles, increase in FOC
I\Irritability, lethargy, sudden change in mood, h//a, vomiting

17. Hyperfunction/Hypofunction
Pediatric Seizures
Epilepsy vs. “seizure episode”
Status epilepticus
Febrile seizures- occur as a result of rapidly increasing core temperature (101.8 F– 38.8C)
General seizures- occur as a result of insult of the nervous system
Epilepsy is currently defined as the occurrence of a seizure disorder repeatedly…not just one episode
Febrile in preschool age children primarily; increased risk after one of having seizures with each febrile episode; therefore the child may be maintained on Phenobarbital during illnesses in which fever is present

18. Clinical Manifestations
Generalized: Tonic-clonic- loss of consciousness(formerly called grand mal)
Absence seizures-may have minor motor-atonic (formerly called petit mal)
Partial seizures- partial simple or partial complex (may be focal or r/t tumors)
Focal (partial) seizures, p consciousness impaired immediately or gradually after a simple partial onset; lasts 30 seconds up to 5 minutes. Abnormal motor activity, twitching, loss of tone, involuntary lip smacking lip chewing, sucking.
Generalized (tonic/clonic
Generalized tonic-clonic seizures- usually last seconds.
Child loses consciousness
Jaw clenches, abdomen and chest become rigid and may emit a cry or grunt a s air is forced through the taunt diaphragm
Pale
Eyes roll upward or deviate to one side
Loss of sphincter control
Increased salivation
Jerky movements begin
Drowsy and sleep afterwards

19. Diagnostic Tests: EEG CT, MRI Lumbar puncture CBC
Metabolic screen for glucose, phosphorus and lead levels
You want to monitor for hyperglycemia; glucose is not good for the brain….can increase cerebral edema

20. Jitteriness –vs- Seizure
Jittery
Responsive
Gaze Okay
Seizure
Not responsive to stimuli
Abnormal gaze
If a parent states their child day-dreams often what would you tell them? Exam question
Are they easily “awakened” from the day dream? How often do they occur, what time of day or activity most common?

21. Goals:
What is the primary nursing goal when caring for the individual experiencing a seizure?
What preventive measures does the nurse provide?
How does the nurse maintain the airway of an individual experiencing a seizure?
What is the priority nursing intervention following a seizure?
Primary nsg goal focuses on maintining airway patency, ensuring safety, administering meds and providing emotional support
B. Side rails padded, helmets to protect heads in case of fall, medical alert bracelet
C. Nothing is placed in the mouth during a seizure! Turn child on side for secretions to drain, monitor to ensure adequate oxygenation, give O2 for O2 sats <95%
D. Provide emotional support. Loss of control of body movements and possible loss of consciousness make seizures frightening and difficult to accept of the child, parents and other family members. There may be bowel and bladder loss as well

22. Long term goal for children with seizure disorders
Identify the cause and eliminate the seizure with minimum side effects using the least amount of medication while maintaining a normal lifestyle for the child

24. 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
We are going to focus on two types of Meningitis-
Meningitis is an inflammation of the meninges of the brain caused by a pathogen entering the CNS resulting in a toxic response. The most common infectious process of the CNS, meningitis is caused by a variety of bacteria and viruses. Meningitis may occur as a primary infection or as a complication of neurosurgery, trauma, systemic infection, or sinus or ear infection.

25. Assessment and diagnostics: Bacterial Meningitis
Streptococcus pneumoniae most common pathogen
Diagnostics: LP, CSF eval (↑ WBCs, gram stain +)
Treatment: ABCDs, cerebral edema, seizure control, abx, steroids
Prevention: Vaccination (HiB, Pneumococcal vaccine)
D is for disability

26. Assessment and diagnostics: Viral Meningitis
May be preceded by viral infection, rash
Diagnostics: LP, CSF eval (mildly ↑WBCs, negative gram stain)
Treatment: self limiting; resolves in 7-14 days, monitored in hospital until ABCs are stable
Medications: antivirals (Acyclovir)

27. Diagnostic Tests: Lumbar Puncture Serum Glucose Level Blood Cultures
Lumbar puncture- expect to find increased pressure, increased protein, decreased glucose (because the bacteria consumes the glucose to live), A culture of the CSF for specific growth- ** Final report takes 72 hours** Why is this significant? How long does Neisseria take to kill? Dangerous because of the potential for herniating the brainstem with a sudden release of pressure
Serum glucose level- why would you want to take a serum glucose level ½ hour prior to LP? To formulate baseline
Blood cultures- to identify specific systemic bacteria or viral infections.

28. Nursing Care for diagnostics of possible meningitis
Lumbar puncture
ASO titer
CBC/electrolytes/serum glucose
LP: monitor VS, neuro VS and behavior as sited earlier. Place on cardioresp monitor, sedation, and prepare child and parents for procedure
Blood draws: done in the “oowie” room….never in pateint room. ASO titer will be elevated for previous infection; gram stains will be determined, cultures.
With bacterial meningitis the serum glucose level will be higher than the glucose level of the CSF
Therapeutic levels of abx

29. Cephaly= of the head/brain
Hydrocephalus
Hydro= Water
Cephaly= of the head/brain
Hydorcephalus is a defect of the ventricles of the brain that results in an inability to maintain a balance in the production and absorption of cerebral spinal fluid (CSF). The CSF accumulates in the ventricles and compresses the brain against the skull.

30. Etiology and Pathophysiology:
Congenital anomalies
Trauma
Unknown causes

31. Types of Hydrocephalus
Non-communicating or Obstructive
Communicating
Non-communicating- the CSF cannot flow within the ventricles, this builds up pressure on each side
Communicating- the problem is outside the ventricular system and there is an inability to absorb the CSF within the subarachnoid space.

32. Clinical Manifestations
Infants- prior to fusion of cranial sutures
FOC increased at birth
Changes in assessment of skull
Forehead
Eyes
Behavior changes
After closure of cranial sutures:
Eyes
S & S of ICP
FOC- measure at birth and again in 24 hours, at 2 week visit, and every pedi visit until 1 year. The FOC will increase in Hydrocephaly
Changes in assessment of skull- frontal enlargement or bossing, head larger than face. The Fontanels will bulge and protrude, the suture lines will widen palpably
Forehead- forehead enlarges, skin stretches and becomes translucent, veins become prominent
Eyes- the bridge between the eyes widens, and the eyes may become depressed, or bulge.
Behaviors- Shrill cry, lethargy or irritability and what other s&s of IICP??
High pitched cry, sunken eyes, lethargy, poor feeders, mental retardation
Setting sun eyes- sclera visible above the iris and or depressed, Pupils sluggish with unequal response to light
Headache and N&V
Setting sun eyes- sclera visible above the iris and or depressed, Pupils sluggish with unequal response to light Headache and N&V

33. Diagnostic Tests LP MRI/ CT scan Skull X-ray FOC Transillumination
LP- dangerous due to infection and the potential for herniating the brain stem
MRI-
Transillumination: Areas filled with abnormal air or fluid will light up when they should not. For example, in a darkened room, the head of a newborn with possible hydrocephalus will light up when this procedure is done.

34. Interventions: Surgical
Shunting to bypass the point of obstruction by shunting the fluid to another point of absorption
Atrioventricular- polyethylene catheter placed from the lateral ventricle to the right atrium.
Ventricular peritoneal shunt polyethylene cath placed under the skin from the lateral ventricle to peritoneal cavity. Fluid drains and is absorbed across the peritoneal membrane and into the body circulation.

36. Complications of Shunts
Infections
Blocked shunts
Seizures
What would cause the seizures?

37. Nursing Interventions
Monitor VS and neurological status
Assess functioning of the shunt
Assess operative site
Assess for infection
Positioning of the patient
Activity of patient
Promote nutrition
Education
VS- and neuro status- same as for IICP Report signs of IICP
Functioning of shunt- should show an immediate decrease in signs & symptoms after the surgery. If the shunt malfunctions, the patient will have an immediate return (may be gradual) so must assess frequently and thoroughly. Report FOC (size)measure q 2-4 hours post=op fullness, tension, and bulging fontanels.
Operative site- assess dressing for drainage and intactness, assess and monitor outline of drainage on dressing, observe for type of drainage (is it CSF?) Notify MD for excessive drainage or S&S of CSF.
Infection- check for fever, tenderness, inflammation, nausea, vomiting,
Position of patient- elevate head of bed to MD’s orders- monitor*** position on non-operative side
Bed rest for hours** keep child quiet to prevent IICP
Promote nutrition & monitor I&O– why so important??
Education- instruct parents on
Signs & symptoms of ICP
Shunt infection
Assist in adaptation to shunt
Follow up community resources
Monitor development
Refer to appropriate specialists

38. Critical Thinking
What is the most important assessment data on a child who has just had a shunt placement for hydrocephalus?
What is the most important teaching for the parents or caregivers?

39. Spina Bifida Most common defect of the CNS
Occurs when there is a failure of the osseous spine to close around the spinal column.
Congenital neural tube defect resulting in incomplete closure of the vertebrae and neural tube during fetal development. The Etiology is unknown, linked to genetic predisposition or maternal deficiency in what essential nutrient??? Current research into viral origins is not conclusive.
Three classifications of spina bifida;
spina bifida occult- not visible usually requires no treatment may appear as a tuft of hair or sacral dimplemost common on L5 to S1. Often goes undetected
spina bifida cystica- Meningocele– meninges of spinal cord extend through opening in the spine (treated by removal of sac or re-placement within the spinal column. Usually does not result in paralysis
Spina bifida cystica-myelomenigocele– involves the spinal cord, nerve roots, spinal fluid and meninges. Degree of neurological dysfunction related to anatomic level of defect and nerves involved. Usually at lumbar or lumbosacral area (these children usually have no bowel/bladder control ever)
These children have varying degrees of abnormalities. Ranging from flaccid paralysis of legs, spasticity, deformities (due to muscle imbalance) scoliosis, decreased sensation and reflexes, vasoconstriction of lower limbs.
90% have hydrocephalus

40. Types of spina bifida
Meningocele: sac filled with spinal fluid and meninges
Myelomeningocele: more severe, sac filled with spinal fluid, meminges, nerve roots and spinal cord.
Nearly 80% of children with myelomeningocele develop hydrocephalus

41. Spina bifida is a congenital disorder (birth defect) in which the backbone and spinal canal do not close before birth. In severe cases, this can result in the spinal cord and its covering membranes protruding out of an affected infant's back. Spina bifida may also be nearly inconsequential, or may be reparable through surgery

42. Clinical Manifestations:
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
Malformation Lower limb deformities- due to muscle imbalance
Dislocation of hip
Scoliosis
Abnormalities in bladder and bowel function
Vary from normal to ineffective
Due to depression of sympathetic activity

43. Diagnostic Tests: Prenatal detection Ultrasound Alpha-fetoprotein
Following Birth:
NB assessment
X-ray of spine
X-ray of skull
AFP- elevations between weeks gestation (optimum)- al women of childbearing age should take which vitamin?? Early detection allows for repair while fetusstill in utero.

44. Surgical Intervention
Immediate surgical closure
Prior to closure keep sac moist & sterile
Maintain NB in prone position with legs in abduction preoperatively
Surgical closure- ASAP to prevent infection, morbidity and additional injury. possibly with skin grafts to prevent rupture with leakage and possible meningitis
Prone position to prevent trauma to sac, and legs abducted to prevent increasing pressure and further herniation of sac.
Important to encourage attachment and bonding with the newborn. Teach parents how to hold and comfort the NB

45. Nursing Interventions:
Pre-OP:
Meticulous skin care
Protect from feces or urine
Keep in isolette
Prone position- decrease pressure on sac- prevent further trauma
Proper abduction of legs- use towels or blankets to support proper alignment
Assess for skin breakdown on knees- may use a sheepskin
Keep pathogens away from sac to prevent contamination- may use collection bag or plastic wrap to keep area free of feces or urine
Keep in Isolette to maintain warmth

46. Post-Op Nursing Interventions
Assess surgical site
Monitor VS and neuro VS
Institute latex precautions
Encourage contact with parents/care givers
Positioning
Skin Care
Assess surgical site for drainage– what do you expect to find? Notify MD for what type of drainage?? Observe for meningitis
Monitor VS especially temp for s&s of infection. Important to monitor neuro vital signs to assess for IICP
Latex precautions page 376 –378
Positioning to prevent and minimize deformity, keep on side or prone position. Reposition q 2 hours and perform ROM (take care to avoid fracturing fragile bones). Keep hips in slight to moderate abduction to prevent hip dislocation

47. Nursing Interventions cont...
Antibiotic therapy
Prevent UTI
Education
Emphasize the normal, positive abilities of the child
Antibiotics- to prevent meningitis
UTI’s are frequent because of the necessity for frequent caths.
Avoid contamination with stool
Do NOT Crede- intermittent cath as ordered
Encourage fluid intake to dilute urine
Observe for S&S of infection
Education- assess ability of parents to provide necessary long-term care
S&S of ICP, hydrocephalus or infection
Teach essential aspect of care- allow extra time for preperation
Encourage questions and expression of feelings (they may need to mourn the loss of the expected “perfect” NB)
Methods of promotion infant stimulation
Initiate communication with members of multidisciplinary team
Stress realistic expectations for lon-term outcome and abilities of the child

48. Critical Thinking
Would you expect a 5-year-old with meningomyelocele to have bladder/bowel sphincter control?
Which type of neural tube defect is most likely to have no outward signs or symptoms?

49. Cerebral Palsy (CP)
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
CP- is characterized by difficulty with muscle control due to an abnormality in the extrapyramindal or pyramindal motor system (motor cortex, basal ganglia, cerebellum).
CP occurs as a result of damage to the motor system either prenatally, perinatally, or postnatally. CP is the most common permanent disability of childhood.
Causes include
per 1000 births
Premature delivery most important determinant
Hypoxic insult
Prenatal brain abnormalities

50. Assessment 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)

51. Assessment cont... Alterations in muscle tone Abnormal posture
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)
Spasticity may cause abnormal increased muscle development in arms and legs as a result of constant tight flexion (exam question!)
Reflex abnormalities include-
Persistence of tonic neck reflex > 6 months
Abnormal continuation of moro >2 months, plantar and palmer grasps
May have seizures, sensory impairment and developmental delay

52. Diagnostic Tests: EEG, CT, or MRI
Electrolyte levels and metabolic workup
Neurologic examination
Developmental assessment
Electrolyte levels- increased metabolism R/T high expenditure of calories with intense movement and difficulty feeding/drinking)

53. Complications Increased incidence of respiratory infection
Muscle contractures
Skin breakdown
Injury
EXAM Question:What is most common complication and why? Frequent resp. infection- because of increased salivation, difficulty swallowing and aspiration pneumonia!

54. Goals & Interventions:
Early detection
There is no cure. Early detection and treatment by a multidisciplinary healthcare team increases the long-range prospect for improvement and prevention of complications.
Promote optimum functioning within the individual child’s abilities!

55. Head Injuries

56. Concussions: Assessment and Nursing Care
Grades 1-3: higher the number, more severe the injury
Involves transient impairment
“Second impact syndrome:
Assess and manage according to grade
Treatment is supportive
Usually observed in the ED
If unconscious > 5 minutes, may be admitted
Removal from sports ranges from 1 wk-entire season
See pg for the grades
“second impact syndrome”: receiving a 2nd concussion before complete recovery from the first. Results in acute brain swelling, neurologic or codnitive deficits. HS athletes have a slower recovery time from brain injuries than college or adult athletes.

57. Nurse as Provider: Care Plan
Brian, 10 years old, sustained a head injury when he collided with a tree while riding his bicycle.He did not have on a helmet. He is now unconscious in the PICU and is receiving an intravenous drip of Mannitol, central venous pressure monitoring, EEG and ECG monitoring, is being mechanically ventilated, and has a urinary catheter. Brian's parents have just arrived on the unit. How can the nurse prepare the parents for Brian's appearance? What are Brian's immediate needs? Fill in the appropriate steps of the Care Plan below for Brian for the next 24 hours.
Assessment and Diagnosis
Planning and Implementation
Evaluation
Assessment and Diagnosis: VS, esp. resp., LOC, posturing, Minimize activity, Monitor IV rate
Place in semi-fowlers, Monitor VS, Neuro VS, and behavior, Treat for pain, Organize care
Educate parents. NSG DX: Ineffective Breathing Pattern r/t neuromuscular dysfunction associate with ICP
Planning and Implementation: maintain cardiopulmonary function, prevent complications, promote recovery and provid emotional support. Observe breathing patterns and check color and LOC. Check the pulse oximeter; O2 sats should be maintained over 95%
Evaluation: cerebral perfusion pressure is maintained at an adequate rate to sustain oxygenation of the brain; muscle function is maintained and physical deformities prevented, parents are supported through the child’s acute phase and the child’s school performance is monitored and appropriate educational resource are provided to support the child’s learning

58. CASE STUDY: The nurse is assigned to an 14-year-old female who is being observed after a head injury sustained while playing soccer. She lost consciousness for a few minutes when it happened.
What should the client and her parents be told about the recovery time after a concussion?
What should the client and her parents be told about playing soccer again?
What should the nurse tell the parents and the client about second impact syndrome?
What can the family do to assess her symptoms at home and determine if she is ready to play competitive sports again?

59. Mental Retardation
“Significant sub average, general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period”.
American Association of Mental Deficiency
Causes of MR vary: genetic, chromosomal, biochemical, viral, infections, intoxication, trauma, metabolic, prematurity, intracranial hemorrhage or the presence of a brain tumor. Classified as mild, moderate, severe or profoundly retarded, my have physical disabilities and congenital defects. Early detection allows for early intervention with the multidisciplinary healthcare team. Assessment takes place throughout the developmental years, especially in the early school years.

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

61. Nursing interventions/education
Home setting
-reduce environmental stimuli
-communicate age appropriately;
use of touch and verbalization
-safety with toys and articles that could be harmful
-routines: ritualism with ADLs
-long term care to include therapists and support groups
Acute care setting
-keep one constant caregiver; room quiet as possible
-may become aggressive when touched by a stranger; refer to parents for communication techniques
-monitor for safety at all times: removing tubes, etc.
-encourage to include therapists and support groups in care

62. Down syndrome
Trisomy 21- the most common chromosomal abnormality resulting in mild to profound mental retardation

63. Assessment Primary concern with cardiac and GI anomalies
What are the most obvious indications of Down’s Syndrome in a newborn?
p Facial: flattened occiput, eyes depressed nasal bridge, mongoloid slant of eyes, thick epicanthal folds; white specking of iris
Mouth protrusion of tongue; high arche palate
Ears: low set. Neck,large fat pad; hands: broad, short fingers, transverse palmar crease (Simian crease); abnormalities of fingers and feet. Abd: protruding with umbilical hernia common; cardiac: congenital heart disease and murmur
The nurse should be suspicious of cardiac problems if Downs suspected.

64. Goals and Interventions
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