I Can See Clearly Now... subjectively and objectively
Three assessment findings the nurse would expect to find in a 6 month old infant with hydrocephalus.
What are bulging anterior fontanel, poor feeding, fatigue/lethargic, high-pitched cry, increasing head circumference, sunsetting eyes, vomiting, separating cranial sutures
A condition where a newborn has a sac in the lumbosacral area containing CSF, meninges, nerve roots, and the spinal cord. This condition is referred to as:
What is a myelomeningocele.
Assessment finding of the pupils when ICP rises causing compression of the 3rd cranial nerve.
What is dilation or dilated with sluggish or absent constriction.
as ICP rises pupils dilate and become sluggish or absent constriction. Fixed and dilated pupils usually indicates brain death.
Nursing priority when a child has a seizure.
What is protecting child from injury.
Teaching caregivers "stay, safe, side" will help them respond when their child experiences this medical emergency.
What is a seizure.
The nurse uses the Glasgow coma scale to obtain information related to this assessment of neurological functioning.
What is level of consciousness.
While assisting a provider with a lumbar puncture, the most important intervention for the nurse is:
A. Ensuring informed consent is signed.
B: Placing child in a side lying knee-chest position.
C: Monitoring cardiorespiratory status during procedure.
D: Labeling specimens properly and delivering to the lab asap.
What is C: Monitoring cardiorespiratory status during procedure.
A child with a head injury is being assessed and the nurses notes a change in his level of consciousness. The nurse identifies this as an early sign of...
What is increasing ICP.
An appropriate nursing action during a tonic-clonic seizure is:
A: Restraining flailing extremities
B: Placing padding between the teeth.
C: Observing the type of movements and duration of seizure.
D: Placing child in supine or prone position
What is observing the type of movements and duration of seizure.
Key component that should be included in every pediatric teaching plan.
Involving the family in the plan of care.
Position with noted flexion of the arms, internal rotation of legs, and plantar flexion of the feet.
What is Decorticate posturing.
This illness may be indicated when CSF is cloudy, high in protein, low in glucose and full of leukocytes.
What is bacterial meningitis.
A child recovering from a VP shunt placement becomes lethargic, confused, and complains of a headache. The nurse suspects this complication.
Blockage of the VP shunt causing increased ICP.
A temporary unilateral weakness that can last for 30 minutes to 36 hours after a seizure
What is postictal paralysis.
Teaching expectant mothers to take folic acid during pregnancy can help reduce this neuro-tube defect.
What is spina bifida.
A child presents with fever and nuchal rigidity after having nasopharyngitis several days prior. Based on this assessment data, the nurse's next action is...
What is to place the child in droplet and contact precautions for possible meningitis infection until it is ruled out.
Assessment of a 6 month old infant is positive for the Moro reflex, delayed developmental milestones, poor feeding, difficulty diapering due to stiffness and crossing of legs. The nurse relays this information to the provider for suspicion of this disorder.
What is cerebral palsy
The nurse places a patient with increased ICP in this position.
Semi-Fowlers with HOB 30 degrees.
Rationale: this facilitates venous drainage and therefore reduces ICP.
Three seizure precautions that should be in place when there is risk for seizures.
What are padded bed rails, oxygen mask and bag valve mask at bedside, emergency meds readily available, patent IV site, administer medication on time, bed in low position, teach family diagnosis and treatment.
Teaching parents to avoid giving children salicylates will help prevent this neurological disorder.
What is Reyes Syndrome.
Assessment test where child stands with the eyes closed and heels together. Falling or leaning to one side is abnormal.
What is the Romberg test or positive Romberg sign.
A mother brings her 3 year old son in for evaluation over concerns he walks on his toes, falls frequently, and has difficulty getting up to stand after playing on the floor. The nurse identifies the assessment findings as possible early signs of this disorder.
What is DMD.
What is the most significant neurological assessment for a child <2 years old when assessing for increased ICP?
A: Poor feeding.
B: Mood swings
C: Slurred speech.
D: Head circumference.
What is D: Head circumference.
All of the answers are associated with increased ICP in infants and/or children, but head circumference is the most significant.
Two maintenance seizure medications and two emergency seizure medications.
What are phenytoin, Keppra, phenobarbital for maintenance. What are nasal versed, IV ativan, rectal diazepam (diastat) for emergencies.
Teaching parents to keep their infant's Pneumococcal Conjugate Vaccine (PCV) and Haemophilus influenzae type b (Hib) up to date will help prevent this dangerous neurological infection.
What is meningitis.