Hydrocephaly
Name 3 postoperative nursing interventions
o Assess for signs of ICP
o Protect from infection
o Depress shunt “pump’—as ordered by surgeon
o Positioning—sunken fontanelle (flat), bulging fontanelle (semi fowlers), & prevent pressure on post operative site
o Assess and provide for pain control
o Assess abdomen (malabsorption)
Observe for signs of increased ICP
List collaborative strategies to minimize the impact of interpersonal violence.
o Treat underlying injury(s)
o Report suspected interpersonal violence—legal requirement
o Refer victim to a safe house
o Provide emotional support
o Consider collaborative practice referrals (social work, counseling, etc)
Decreased stigma
Name two early and 2 late signs/symptoms of CO2 poisoning
Early— headache, shortness of breath with mid exertion, nausea, vomiting, headache, alteration in mental status
Late— changes in color (cherry-red skin, pale, bluish with reddish mucous membranes), cardiac and respiratory irregularities
REMEMBER pulse oximetry readings will be normal
Nursing care of a child who has a brain injury resulting from shaken baby syndrome.
Monitor the following—-
o Pain stimuli response
o LOC
o Arousal awareness
o Cranial nerve response
o Motor response
o Posturing
o Pupil response of the eye
o Bulging fontanels
o Scalp vein distention
o Ataxia (spasticity of lower extremities)
Moro or tonic neck withdrawal reflexes
A doctor will most likely order these two tests to assess the CSF to potentially diagnose hydrocephalus within the newborn.
Transillumination &/or Echoencephalography
Describe surgical treatment for hydrocephaly and how it works.
Ventriculoperitoneal shunt— CSF is carried to another area of the body, typically the peritoneal cavity. Where it will be absorbed and excreted.
Name two categories of interpersonal violence
o Child abuse & neglect
o Elder abuse & neglect
o Youth violence
o Bullying
o Intimate partner violence
o Sexual violence
A patient may suffer when they repeatedly ingest or absorb harmful substances. Parents must be mindful of this substance, specifically a child between 18 months and 3 years of age.
Lead Poisoning
Name three physical features of an infant with fetal alcohol syndrome—
o Microcephaly
o Low birth weight
o Small stature
o Thin upper lip
o Small palpable fissure
o Flat nasal bridge
Poorly formed groove at center of upper lip
A female client comes in with a compound fracture in her right numerous. While assessing the client, you notice signs of abuse. There are signs of old and new wounds. She is timid and paranoid. What is your first intervention?
Ask if the client is safe at home, gather information, and report.
Describe parent education for hydrocephaly.
o Signs that indicate shunt malfunction
o How to pump the shunt
o Signs of shunt malfunction in a child
o Symptoms of ICP
o Signs & symptoms infection
Describe what a nurse would see during an assessment on a client who is a victim to interpersonal violence. Specifically comorbid conditions and injuries.
o Traumatic brain injury in children <1 year old
o Shaken baby syndrome
o Learning disabilities
o Blindness
o Seizure
o Paralysis
o Abdominal injuries—internal bleeding
o Burns from scalding water
Burns with stocking or circular pattern
Name two early and 2 late signs/symptoms of CO2 poisoning
Early— headache, shortness of breath with mid exertion, nausea, vomiting, headache, alteration in mental status
Late— changes in color (cherry-red skin, pale, bluish with reddish mucous membranes), cardiac and respiratory irregularities
REMEMBER pulse oximetry readings will be normal
Two ways Down Syndrome is diagnosed.
Clinical manifestation
Chromosomal analysis
You find a person unconscious in their car inside of a closed garage with the car running. What is your first action?
Get oxygen in— open garage then get them out
Differentiate between acquired and congenital defect of hydrocephalus
Acquired
o An obstruction
o A sequel are of infection (encephalitis or meningitis)
o Perinatal hemorrhage
Congenital
o Neural tube defects
Most often caused by failure of neural tube to close at either the cranial or caudal end of the spinal cord
List consequences of interpersonal violence
o Physical injury
o Sexual trauma
o Unintended pregnancy/gynecological complication
o Violence during pregnancy
o Intentional or unintentional death
Mental Health— PTSD, depression, mental illness exacerbated by exposure to violence
List contradictions to live virus vaccines
o Immunocompromised state
o pregnancy
o Bacteria or meningitis
o Immunocompromised caregiver
o Corticosteroid therapy or immunosuppressive drugs
History of high fever after vaccinations
Name 3 signs/symptoms of fetal alcohol spectrum disorder
o Difficulty in school
o Smooth ridge between nose and upper lip
o Shorter height
o Smaller head size
o Low birth weight
o Hyperactive behavior
o Difficulty paying attention
o Learning disabilities
o Speech language delays
o Intellectual disability or low IQ
o Poor reasoning/judgement skills
o Sleep/sucking problems as an infant
o Vision/hearing problems
Problems with heart, kidneys, bones
A client comes into the office complaining of muscular incoordination and convulsions. They have had weakness, abdominal pain, and vomiting for weeks. They have run several tests, an X-ray and a urine test. The patient has lead settling within their bones and excreted in their urine. What is the diagnosis?
Lead poisoning
Describe the early and late signs of ICP within infants and adults.
Early signs
o Adults— headache or change in consciousness
o Infants—irritability, lethargy, poor feeding, may have a bulging fontanelle, & high pitched cry
Late signs
Cushing’s triad, hypertension, bradycardia, changes in respiratory pattern (decreased respirations)
List prevention to minimize the impact of interpersonal violence.
Primary prevention— Education is designed to reduce the rates of violence
Secondary prevention—
o Increases identification of women, children, and family’s experiencing interpersonal violence
o Increase safety
o Reduce abuse
o Improve clinical and social outcomes
Screening tools
Describe some safety measures for the hospitalized child.
Bracelet applied upon admission to nursing unit
Parent/guardian given a bracelet that matches the child’s identification number
ID bracelet must be verified before any med, treatment or procedure is provided
Identify child by a ID bracelet and nothing else
Keep crib sides up at all times when a child is unattended in bed
Name 5 symptoms of NAS.
o Irritable, high pitched cry,
o Excessive yawing and sneezing
o Wakefulness
o Tight/tense muscle tone
o Overactive reflexes
o Seizures
o Body tremors (principal sign)
o Hyper irritability (principle sign)
o Poor sucking & feeding
o Poor weight gain
o Fussiness
Excessive crying/high-pitched cry
An expecting mother who is 37 years old and her husband come in for a 10 week ultrasound. The OB explains to the couple there are some risks with a geriatric pregnancy. What is a risk within a geriatric pregnancy? What is an invasive test to confirm the possibility?
Down Syndrome, quad screen (blood test) or ultrasound (nuchal translucency)