NS2P1 PEDS Mod 5: Neuro & Sensory

• => Viral meningitis
• Self limiting
• Sensitive to light
• Vomiting
• Headache
• Nuccal rigidity (neck stiffness)
• Diagnosis spinal tap
• -provide supportive care and they eventually get over it.
• -associated with viruses such as mumps, paramyxovirus, herpes and enterovirus

• =>Bacterial meningitis
• Life-threatening!! Hemo Influenza Type B Vaccine prevents this.
• -very very sick: diagnosed by spinal tap, pretty rapid
• Interventiions: Aggressive antibiotic therapy
• Fluid support
• Monitor neurological status: Most serious form meningococcal, Contacts should be treated with Rifampin-most serious form is meningococcal meningitis:-BLindness, deafness,development delay, death after the infection recovery-vaccines can prevent this:

=>Diagnosis: bacterial meningitis is made by testing CSF obtained by lumbar puncture; the fluid is cloudy with increased pressure, increaed WBCs, protiein and decreased glucose levels

• -most commonly : haemophilus Influenzae type B
• - transmitted by droplets from nasopharyngeal secretionsf 2 months

=> Assessment: Fever, chills, headache, N/V/Diahrrhea, altered LOC, bulging anterior fontantel, Positive Kernig's sign (inability to extend the leg whe the thigh is flexed entriorily at hills) and Brudzinksi's sign (neck flexion causes adduction and flexion movements of lower extremities in children and adolescendts, Muscle or joint pain (meningococcal infection-along with Petechial or purpuric rashes), pneuomcoccal meningtis -ear chronically drains

• => interventions:
• 1. Respiratory isolation for at least 24 hours AFTER antibiotics
• => Antibiotics and antipyretics

3. Neuro assess, changes in LOC, signs of thrmboemboli, monitor for hearing loss,

4. Pneumococcal conjugate vaccine rcommended at age 2 months

• Dura Mater
• Arachnoid
• Pia Mater (out to in)

=> inflammation of the brain parenchyma and often of the meninges, affects the cerebrum, brainstem and cerebellum.

-Most offten caused by a viral agent, although bacteria, fungi or parasites also may be involved.

-Viral encephalitis is almost always preceded by a viral infection

- from Contaminated H2O, drug use and measles; Abobiruses, echocirus, polio, herpes zoster, mumps, chicken pox,

• => Assessmment: lesions, travelling, fever/ n/v, Nuchal ridgidity, changes in LOC, ICP increased signs,
• -Kernig's or Brudzinksi's sign

=>Intervention: Assess for increased ICP, LOC, TCDB, Elevate HOB, Inflammation of brain lining

 Reyes syndrome: is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver, a definite diagnosis is made by a liver biopsy

-exact cause is unclear, most commonly nfollows a viral illness such as influenza or varicella

-DONT administer aspirin (esp for children with a febrile illness, varicella or influenza)

-Instead use tylenol.

-Early diagnoisis and aggressive treatment are important; the goal of treatment is to maintain effective cerebral perfusion and control increasing ICP.

• => Assessment:
• 1. History of systemic viral illness 4-7 days before onsent of symtpotms.
• 2. Fever. N/V
• 3. Signs of altered Hepatic function such a s lethargy
• 4. Progressive neruo deteroiation
• 5. Increased blood ammonia levels.

=> Interventions: Provide rest and decrease stimulation in envirnoment, asses neuro, monitor LOC and signs of Increased ICP, monitor I&O, and signso of bleeding, impaired coagulation (bleeding time)

ASA related, which is why we recommend children less than 18 years not take aspirin.

Encephalopathy

Liver rapidly replaced by fatty tissue and so they bleed, Require intracranial monitoring to decrease the pressure in the brain and to monitor them for disseminated intervascular coagulation b/c liver produces the clotting factors, so fat isn't producing clotter factors so naturally, they bleed!

Replace clotting factor with albumin? Bleed for IV site, ET tube, oozing blood from various places because no clotting factors.

To Rapid progression

decrease increase of brain pressure

Monitor for DIC

Replace clotting factors

Cause Malfunction in the brain’s electrical system resulting from cortical neuronal firings.

Manifestation determined by the site of firing.

May result in unconsciousness or altered consciousness, involuntary movement, changes in perceptions and posture.

=> Description: Excessive and unorganized neuronal discharges in the brain that activate asscoiated morotr and sensory organs; classified as generalized, partial, unclassifiad.

-Types: Tonic, clonic, absence, myoclonic and atonic.

-Partial seizures arise from a specific area in the brain and cause limited symtoms

=> Assess: Determine child's history, ask child about aura, monitor for apnea and cyanosis

=> Interventions:

• 1. Ensure airway patency, suction equipment, O2 avialable
• 2. Time the seizure
• 3. Ease child to floor, in side-lying positiion
• 4. Place billow under head or on your lap
• 5. Remove restrictive clothing, eyeglasses,
• 6. clear the area of any hazards, don't place anything in their mouth
• 7. Observe for incontinence and document occurence.

-condition characterized by two or more unprovoked seizures. Seizussres aare a symptom of an underlying disease process.

Must be determined if epileptic or non-epileptic.

Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures.

Temp gets very high and they have a seizure, give parents info about ibuprofen, tylenol, baths with water to play

-Chronic seizures: no O2 the brain

-Antiseizures: sedatives, give the lowerst possible amt; problem b/c you want productivity, not have them sleep.

• =>Treatment
• Objective Control Seizure and reduce frequency
• Single drug therapy is recommended
• Meds such as Tegretol, Dilantin (old medication, you need excellent denal hygiene), Cerebyx, Valporic Acid, Neurontin, Lamictal and Felbatol.

• =>Nursing Care
• Observe and Describe Seizure
• Detailed history taking
• Protect child from Injury
• Long term physical care and importance of drug therapy
• Parents need to be warned about possible behavioral changes-
• -most common ped sizures: Petite mal.
• -If can't be controlled by medication, then they put electrodes in brain to monitor to see where it's firing and may remove that part of brain if possible. But sometimes too deep.

• Infantile
• Aberrant firing of brain synapses
• Most common pediatric seizure is petit mal
• If seizures can’t be controlled with medication brain mapping and removing abberant firing area
• Goal is to control seizures
• If seizures can’t be controlled will progress to brain damages
• -mental retarddation cerebral palsy: if they get sick, then seizure activity increases, so encourage to get all their vaccinations.

• Sutures fused at birth
• Surgical opening of sutures so brain can grow

• Abnormally small brain b/c head is abnormally small.
• Mental retardation
• die from immobility not craniosynastosis!, develop strictures, venastasis, must be repositioned

-reflux b/c they're being fed but not moving around so digestive enzymes errode the cardiac sphincter, acid reflux goes into lungs lungs and aspiration & pneumonia.

-Life expectancy 5 yr.

• CSF unable to drain from brain due to blockage: meningitis, myelomeningocele
• -put a cath into ventricle and drains into peritoneum NOW
• -child stays out at that percentile they're entire life, stays steady, shouldn't increase.
• -due to blockage.
• -cath bores into bone, drains out of a tube..calibrated thing connected to a bag to drain, measure hourly output, drains as pressure increases in the brain. VP shunt; goes into peritoneum and drains into the heart and rest of body, use to do ventricular atrial shunt which used to be plastic

-bacterial colonization.

-shunt infections especially with plastic

-Inflammation

Essential instruction of S&S shunt infection: fever, change loc, vomiting, headache --> take them to ER immediately.

-Shunt Infections: fever, especially if plastic..they will remove shunt if infected, by drilling hole in head, cranial monitor and drain the CSF.

• -migh have to drain everyother day with a syringe
• -treat with IV antibiotics and monitor until infection is gone

• => My notes:
• -Impalance of CSF absoption or production caused by malformations, tkumors, hemmorhage, infectiions or trauma-> results in large head and increased ICP

-assess: head circumference, puldging fonntanels, dilated sclam veins, setting sun eyes in infant

-Surgical interventions: Ventriculoperitoneal shunt: csf drains into the epritoneal cavity from the lateral ventricle'

-ventriculoatrial shunt: CSF drains into right aftrium of the heart from the lateral vent.

-pre-op: montio I/O, small feedings, egg crate mattress

-post op: monitor vitals/neuro signs, keep child flat to avoid rapid reduction of Intracranial fluid, if increase ICP: elevate HOB 30 degs

how you measure it, monitor probe in subarachnoid space.

-externalize the shunt until the infection is clear, once clear, reinternalize the shunt

• -kids notorious
• Impetigo untreated can lead to glomerulonephritis
• Orange crusty skin lesions

Penicillin abx x 10 days (PO, not topical)

If infection extensive will require hospitalization

• At home use own towels, b/c very contagious, should be segregated.
• -heals w/o any scarring

contagious bacterial infection of the skin caused by B-Hemolytic stretpococci or staph or both, occurs most commonly during hot, humid mounths

-can occur due to poor hygiene, can be primary infection or secondarily (injured site/ bug bite)

-common sites: face, around mouth, hands, neck and extermities

-lesions begin as vesicles or pustules surrounded by edema and redness--purulent fluid.

-lesions progress to an exudative and crusting stage, and eventually serious vesicular fluid becomes cloudy and vesicles rupture.

=> Assessment: Lesions, Erythema, Pruuritus, Burning,

• => Intervention:
• -Institute contact iso
• -let lesions to air dry
• -child must daily bath with antibacterial soap
• -apply warm saline or other prescribed compresses to the lesions two or three times daily, with mild soap/water to remove crusts
• -Oral antibiotics
• -secondary infection of glomerulonephritis**-Use separate towels, linens, and dishes

-Group of kidney disorders characterized by inflammatory injury in the glomerulus as an immunological reaction -> desscruction and sclerosis of glomeruli and eventual loss of kideny function

-antercependent B-Hemolytic Strep infection to pharynx/skin

-Complications: kidney failure, hypertensive encephalopathy, pulm edema, heart failure

-Assess: Decreased urinary output, hematuria, pallor/letharge, HTN, proteinuria, Azotemia (BUN and creatine elevation)

• Treat with rid, kwell, all members of the household. Apply and wash after 8 hr. Wash all linens and clothing after treatment
• -living in unclean environments-lay eggs.. ew.
• -rid and kwell.

• => Lice: "Pediculosis capitis"
• -most common site: occiptial area, behind ears, nape of necks, eyebrows
• -incubation of lice eggs (nits): 7-10 days
• -Lice can survive 48 hours from host
• -interventions: use extra fine tooth nit comb, don"t share combs, change bedding daily (clean in hot water and in 20 min dryer) and continue this for one week, caccume furtniture and carptes daily,

=> Scabies:

• -parasitic skin disorder caused by infesttation of Sarcoptes scabiei (itch mite); endemic among school cildreen, eggs hatch in 3-5 days
• -asses: pruritic papular rash, Burrons into the skin (gine graish red lines that may be difficult to see)
• -Interventions: Use Elimite, Lindate (scabicide),

• Watch for allergic rx
• Treat with benadryl
• Secondary infections from scratching; watch for secondary infections

• => Cat scratch disease
• Lymphadenopathy after being scratched by cat
• Treat symptoms and watch for secondary infections
• -enlarged spleen
• -Ibuprofen, fluids

• => Human Bites: Watch for high risk for secondary infection.
• -notorious in preschoolers

=> Behavior disorderd characterized by developmentally inappropriate degrees of inattention over activity and impulsivity. Childhood problemsinclude lowered intellectual development, some minor physical abnormalities, sleeping disutbances, behavioral or emotional disorders, and difficulty in social relationships. Early diagnosis is important to prevent impaired emotional and psychological develoment. Diagnosis is estabilished on the basis of self reports, parent/teacher reports, and use of assessment tools.


=> Assessment:

• 1. Fidgets with hands or feets or squirms in seet
• 2. Easilly distracted with external or internal stimuli
• 3. Difficulty with following through on instructions
• 4. Poor attention span
• 5. Shifts from one uncompleted task to another.
• 6. Talks excessively
• 7. Interrupts or intrudes on others
• 8. Engages in physically dangers activities w/o considering possible consequences.

• => Interventions:
• 1. Provided parents info and ecnourage support.
• 2. Treatment: behavioral therapy, meds, maintainng a consisten environment, and approppriate classrooom placement.
• 3. Behavioral therapy focuses on preventing undersirable behavior
• 4. maintain a consisten home and classroom environment, and provide environmental and physical safety measures.
• 5. Promkote self esteem
• 6. Stimulant meds: SE's include appetitie supression, weight loss, nervousness, ticks, insomnia, increased BP

• Abnormality of firing of brain synapses
• Child unable to complete tasks and pay attention, become distracted easily
• Generally of high intelligence. Can make great plans, but has difficulty with completion
• Consistency in routineSit in front of room

• => Medications: ritalin, dexedrine, cylert; Side effects: growth suppression and decreased appetite
• -Suggest drug holiday

• This is a disorder of brain function accompanied by intellectual and social behaviorIncludes Autism, Asperger’s syndrome and pervasive developmental disorder
• Typically noticed between 24 to 48 months
• -Complex neurodevelopmental disorders of unknown etiology composed of qualitative alterations in social interaction and verbal impairment with repetitive, restricted, and steroetype behavioral patterns.

• =>Incidence
• 1/166 children
• More common in males
• Not related to socioeconomic level, race or parenting style

• => Etiology
• Genetic disorder of prenatal and postnatal period
• Immune and environmental factors may interact with genetic factors
• Strong evidence for autosomal recessive trait
• High recurrence in families that have one affected child
• Does not appear to be linked to immunizations as previously reported
• ASD associated with fragile X syndrome,metabolic disorders, fetal rubella
• -fragile x:
• -Fetal Rubella:

Recent retrospective reports Maternal and Paternal Ages > 40 years of age

• =>Clinical Manifestations
• Unique characteristics in social interaction:
• -Difficulty with eye contact and body contact
• -Delayed language
• -Limited functional play
• May have GI problems
• Manifestations unique from child to child> females than males have low intelligence
• Speech and language delay common
• Early recognition improves outcome

• => Prognosis
• Severely disable condition
• Some children improve with acquisition of language skills
• Prognosis most favorable with development of language skills by 6 and IQ’s >50

• => Nursing Care
• Most promising highly structured and I
• Intensive behavior modification
• When hospitalized, parents essential in planning care and should stay if possible
• Decrease stimulation by giving private room
• Minimum holding and eye contact may be necessary to decrease outbursts
• Children with ASD need to be introduced to new thing slowly
• They have a hard time organizing behavior and redirecting energy so they need to be told directly what to do

• => Family Support
• It involves entire family and becomes a family disease
• Alleviate guilt and shame by emphasizing what is known from a biological standpoint
• Parents should be referred to the Autism Society of America
• Local and state departments of mental health and developmental disabilities
• As much as possible the family is encouraged to care for the child in the home.
• As the child approaches adulthood the family may require assistance in locating long term placement facilities

characterized by imparied movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system; most common: spasstic cerebral palsy: upper motor neuron type of muscle weakness.

• =>Assessment:
• exterme irritability and crying, feeding difficulties, abnormal motor performance, alteration of muscle tone, stiff and rigid arms or legs, delayed developmental milestones, persistences of primitive infantile relflexes (moro-startled/falling reflex), seizures may occur

• => Interventions:
• goal: early recongition and multidisciplinaty teama approach: physical, Occupational, speech, educationa and recreation therapy
• -participatiion in school programs
• - provide safe, appropriate toys for the chld's developmental age level
• -position child upright after meals
• -meds: antiseizures?
• -disorder you see in children

• =>Causes
• -Prenatal: Drug use, Infections, Poor diet
• -Intranatal: Birth trauma, Fetal anoxia
• -Post-natal: Infections, Trauma

• -vast: caused by prenatal events: birth trauma, birth inducing, fetal monitoring
• -csections.

Multidiscipline plan of care: speech therapy, OT, PT, nursing, medicine

Promote the child to become the best they can be!

Defect in spinal column and spinal contents protrude at defect sites

• => Spina bifida occulta:
• 20% of population in US; seen missing vertebrae in chest xray
• Lack of vertebrae but no protrusion
• -posterior vertebral arches fail to close in the lumosarcral area
• -spinal cord remains intact and usually is no visible
• -Meninges are not exposed on the skin surface
• -Neuro deficits are not usually present

=>Spina bifida cystica:

• Sac contains only CSF no spinal column contents /:
• -Protorustion of the spinal cord or its meninges or both occurs
• -Deffect resutls in incomplete closure of the vertebral and neural tubes, resulting in a saclike protrusion in the lumbar or sacral area with variying degrees of Nervous tissue involvement
• -Defect can include meningocele, myelomeningocele, lipomeningocele and llipomeningomyelocele

Protrusion involves meninges and a saclike cyst that contains csf in the midline of the back, usually lumbosaccral area, spinal cord isn't involved nor any neuro deficits. :)

Description: Protrusion of the mininges, CSF, nerve roots, and a portion of the spinal cord occurs. The sac (defect) is covered by a thin membrane prone to leakage or rupture. Neuro deficits ARE evident!!Spinal contents protrude; High risk for infection

Prompt surgical removal of sac and contents and defect closed

• May have no nerve intervention distal to defect
• May be unable to walk

• In and out catheterizations
• Obesity
• Children are of normal intelligence
• Many also have hydrocephalus and will require a shunt.
• Promote growth and development
• Many of these children are wheelchair bound
• -kids placed on abdomen when born and whisked off to surgery, cut out defect, sew them back up.
• -cathetherize the pouch..

Central Nervous System Defect results from failure of the neural tube to close during embryonic development.

• => Interventions:
• 1. Evaluate the Sac, measure lesion
• 2. Mnitor Neuro assess, Increased ICP (hydrocelphalous development possibility)-meausre head cirucum
• 3. Protect sac, cover with a sterile, moist (moral saline), non adherent dressing to main the sac moisture
• 4. Change dressing on regular schedule with aseptic technique
• 5. Assesess sasc for signso of infection
• 6. Place in prone positions, head turned to one side for feeding
• 7. Bladder-clean, intermittent cath

-note: child high risk for allergy to latex and rubber products b/c of the frequent exposure to latex.

Classifications: Mild, Moderate, Severe, Profound

Goals for care is to promote growth and development

Protected under American with disabilities act

All human beings progress in the same order: sit before walk, some progress farther than others

Goal: living as independently as possible

Trisomy 21, Low set ears, Simian crease, Flat faces, Diagnosed by checking DNA of cells

• Mentally retarded- Degree of retardation varies
• At risk for cardiac anomalies and at risk for leukemia due to higher incidence of infections immune system compromised

-Increased AFP: Spina Abifida

-Decreased AFP: Downs.

Goal of care to become the best they can be!

Complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus and ankle equinus

• Incidence 1-2/1000
• Boys twice affected as girls
• Diagnosis on ultrasound or at birth
• Congenital, idiopathic, and true club foot requires surgical intervention

• => Management
• Goal of treatment: Painless stable foot
• Some respond to treatment readily
• Serial casting is begun shortly after birth stays in place for 8-12 weeks
• Failure to achieve normal alignment requires surgical intervention

• => Nursing Care
• As for any child with a cast: Observe skin and circulation
• Parents need to understand the overall
• Involves pins and surgical intervention
• Surgical release of tendons

• Most common osteoporosis syndrome in children
• -also known as brittle bone disease or Lobstein syndrome,'[1] is a congenital bone disorder characterized by brittle bones that are prone to fracture. People with OI are born with defective connective tissue, or without the ability to make it, usually because of a deficiency of type I collagen

• =>Five types
• Varying degrees of bone fragility
• Deformity
• Fractures

=> Diagnosis of OI is based on the clinical features and may be confirmed by collagen or DNA testing. There is no cure for OI. Treatment is aimed at increasing overall bone strength to prevent fracture and maintain mobility.

Management: Supportive

• => Nursing Care:
• Careful handling
• Both parents require education on how to handle the child-stage 2 most severe for infants.

• Self limiting idiopathic avascular necrosis of femoral head
• -pain associated with necrosis.
• -occurs when blood supply is temporarily interrupted to the ball part (femoral head) of the hip joint. Without sufficient blood flow, the bone begins to die — so it breaks more easily and heals poorly.
• Affects children 2-12 most common in boys 4-8 years

=> Legg-Calve-Perthes disease occurs when too little blood is supplied to the ball portion of the hip joint (femoral head). Without an adequate blood supply, this bone becomes unstable, and it may break easily and heal poorly. The underlying cause of the temporary reduction in blood flow to the femoral head is still unknown.

• => Signs and symptoms of Legg-Calve-Perthes disease include:
• Limping
• Pain or stiffness in the hip, groin, thigh or knee
• Limited range of motion of the hip joint
• Legg-Calve-Perthes disease usually involves just one hip. Disturbance of circulation to femoral capital epiphysis that produces aseptic necrosis of femur head
• Onset insidious with intermittent limp

• => Management
• Goal to keep femur head in contact with acetabulum
• Initial Tx rest
• Abduction brace (little doll)
• Conservative treatment may continue
• Surgical reconstruction and containment procedure

Prognosis self-limitingNursing care refer for treatment

Spontaneous displacement of femoral epiphysis; s an unusual disorder of the adolescent hip. It is not rare. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty. Observed in males and obese children

• => Treatment
• avoid further slipping
• The goal of treatment, which requires surgery, is to prevent any additional slipping of the femoral head until the growth plate closes.
• If the head is allowed to slip farther, hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24 to 48 hours.Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.A screw is inserted to prevent any further slip of the femoral head through the growth plate.(Courtesy of John Killian, MD, Birmingham, AL)

Fixing the femoral head with pins or screws has been the treatment of choice for decades.Depending on the severity of he child's condition, the surgeon will recommend one of three surgical options.

Placing a single screw into the thighbone and femoral epiphysis.

Reducing the displacement and placing one or two screws into the femoral head.

Removing the abnormal growth plate and inserting screws to aid in preventing any further displacement.http://www.youtube.com/watch?v=hX8zYiJ2HI8 (see video)

-kid limps after bb gameSurgical treatment varies with degree of displacement

=> Three dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib assymmetry, and hypokyphosis of the thorax. Usually diagnosed during preadolescent growth spurt.

-Surgical: spinal fusion-thoracospopic surgery

-Non surgical: bracing

• => Assess: assymmetry of the ribs when child bends forward at waits and hangs arms
• -Radiographs

• =>Interventions: montior curvature progression
• => Braces: slows curvature progression, prescribed to be worm 16-23 hours a day
• => Postop: Log rolls, encourage TCDB, monitor for incontinence and infection Complex spinal deformity in 3 planes
• Classified by age of onset
• Head and hips are not aligned

• => Management
• Observation and x-rays
• Boston and Wilmington braces: Compliance difficult
• Surgical intervention realignment ande straightening with internal fixation and instrument combined with bony fusion

• => Nursing Care
• Pre-op: X-rays
• Post Op: Monitored in ICU, Log roll, Pain Control, Most patient walking by second or third day, Discharge in a week