PEDS QUIZ 5 Studyguide PDF

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QUIZ 5 STUDYGUIDE

Neuro Seizures  Abnormal involuntary, excessive electrical discharges of neurons in brain  Epilepsy o Chronic o 2 unprovoked seizures at least 24 hr apart OR single unprovoked seizure in 10 years following 2 unprovoked  Risk factors o Seizures  Some unknown  Fever  Meningitis  Cerebral edema  Intracranial infection or hemorrhage  Tumors or cysts  Anoxia (extreme hypoxia)  Toxins  Lead poisoning, arsenic poisoning, PKU  Tetanus, Shigella, salmonella  Hypoglycemia, hypocalcemia, alkalosis, hyponatremia, hypernatremia, hypomagnesemia o Epilepsy  Trauma  Hemorrhage  Congenital defects  Anoxia  Infection  Toxins  Hypoglycemic injury  Uremia  Migraine  Cardiovascular dysfunction  Assessment findings o Generalized  can occur anywhere in brain & cross hemispheres  Tonic clonic  Can really assess this one  Absence  Myoclonic  Atonic o Partial (focal/local)  occur particular hemisphere of brain  Simple Partial Seizures (Motor)  Aversive seizure

 Rolandic seizure Sensory S/S of Simple Partial Seizures  Tingling/ numbness or pain in one area of body  Motor development such as hypertonia or posturing  Psychomotor seizures (Complex Partial Seizures)  Altered behavior  Impaired consciousness  Confusion  Aura o West syndrome (infantile spasms)  Rare disorder- more common in boys (peak between 3-7 months)  Very small lasting few seconds but can have up to 150 seizures/day o Can go un noticed until develop delay !!  Sudden, brief, symmetrical muscle contraction  Flexed head, extended arms  Eye deviation  LOC  Flushing, pallor  Cry or giggle before or after  Can occur as a single event or in clusters up to 150 seizures  Developmental Delay o Brain can’t grow & develop with overload electrical discharges o Once delays occur its hard to REVERESE o Child will fall behind  Head lag persists  Rolling over might not start  Hand to hand transfer objects might not develop 

 Diagnostics & labs o Electroencephalogram (EEG) – main one  Records electrical activity during sleep, awake, & with simulation or hyperventilation o MRI  Inflammation, tumors, malformations o CT scan  Inflammation, malformation, hemorrhage, infarction o Lumbar puncture  Cerebral spinal fluid to show infection (meningitis)  Treatment & medication o Prior to seizure they might get an AURA (warning a seizure is coming) o Seizure precautions o During seizure (mainly tonic clonic b/c you can see it)

Protect from injury  If on floor, place blanket under head  Maintain patent airway  Loosen restrictive clothing (ex. Tye)  Remove necklace  Turn to side lying position  Bed in lowest position, clear area  Do not restrain  NPO – nothing in mouth  ALWAYS have O2 & suction bedside  Administer O2 (face mask)  Suction around mouth NOT inside  Note onset, duration, & characteristics  IF lasting more than 1-2 mins, STOP SEIZURE  Benzodiazepine – IV or IM or rectal (NOT PO) o Diazepam (valium), lorazepam (Ativan) o Patient w/ epilepsy is sent home w/ rescue benzodiazepam (rectally) if seizure lasting longer than 1-2 mins o After seizure  Maintain side lying  Maintain seizure precautions  Perform neuro checks  Note time of postictal period  They will be sleepy & tired  MAINTENANCE DAILY medication for seizures  They don’t stop seizure when happening  Antiepileptic drugs/ Anticonvulsant drugs – PO (orally) o Diazepam o Phenytoin o Carbamazpine o Valproic acid o Fosphenytoin sodium o Toprimate o Lamotrigine o Clonazepam 

Hyperbilirubinemia  An elevation of the serum bilirubin levels resulting in jaundice o Bilirubin normal range  0.2-1.4  When baby goes home after born & had elevated bilirubin levels they have to come back after 72 hrs to be seen by pediatrician to check weight & if bilirubin levels got worse  2 types

o Physiological  Jaundice is benign  Occurs after first 24 hours of life  Start to see changes in skin & sclera (yellow)  Feed baby to bind bilirubin so it can be excreted  If bilirubin is too elevated  phototherapy o Pathological  Occurs within the first 24 hours of life  Severe  Often due to ABO or Rh factor incompatibility  if baby is blood type O & mom is type A or B or anything other than O and mom’s blood gets into baby system during delivery  baby sees own blood type as FOREIGN & breaks down RBC that LEADS TO elevation in bilirubin = jaundice o assess for jaundice in sclera 

If bilirubin is too elevated  phototherapy

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O blood universal donor AB blood universal receiver o most rare type Patient has blood type A can get A/O o Most common Patient has blood type B can get B/O Patient has blood type AB can get A/B/AB/O o Least common Patient has blood type O can only get O

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 Assessment findings o Yellowish tint to skin o Family history o Hypoxia o Hypothermia o Hypoglycemia o Metabolic Acidosis o Lethargy o Poor feeding o Hypotonic o Temperature instability  Complications o Kernicterus  Bilirubin encephalopathy  Inflammation of brain that leads to neurological complications

 It crosses blood brain barrier  If not treated or prevented = brain damage !  Phototherapy helps prevent this o Dehydration  Treatments o Phototherapy as prescribed  Maintain eye mask to protect retinas and corneas  Keep undressed except for a diaper  Avoid lotions, ointments, powders (increase risk for burn)  Check eyes every 4 hours for inflammation or injury  Reposition every 2-3 hours to expose entire body to light  Consistently seen by ophthalmologist o Assess vital signs  Check Temperature every 4 hours  watch for hyperthermia or increased temp b/c sweating = dehydration! o Maintain fluid  Every 3 hours  Watch for dehydration from phototherapy o Assess skin for jaundice  Sclera  Darker skin = inside palms or press down on cheek/abdomen to blanch skin & it shows yellowish tint o Encourage bonding with parents o Encourage breast feeding o Feed frequently (every 3-4 hours)  Also position near sunlight (not direct)  Helps prevent elevation in bilirubin  Take eye mask off during feeding to promote bonding

Head injuries  More common in children than adults  Biggest concern if head injury produces swelling/inflammation in brain & increases intracranial pressure (ICP) o Patient had head injury & lead to laceration within brain & lead to bleeding, blood is taking up same in brain = ICP o Patient has head injury & where they hit themselves has soft tissue = ICP o Patient has inflammation, excess fluid, bleeding, soft tissue swelling, edema = can produce ICP !!!!!!  Types of head injuries o Concussion  Trauma to brain (ex. Fall, shaking baby) o Contusion  Bruising of the brain, usually secondary to trauma

o Laceration  Cut with potential of bleeding in brain (ex. Tearing of cerebral tissue)  Several different injuries to head = Skull fractures o Usually caused by trauma – accidental or nonaccidental  Important to get health history & investigation (make sure stories match) o Linear skull fracture Most common fracture indicative of abuse  Where they in a motor vehicle accident? o Basilar skull fracture bruising (ecchymosis) around eye or behind ear (mastoid level) o Depressed skull fracture something falls on brain/skull causes depression or due to injury  Risk factors o Lack of supervision o Inappropriate/absent safety practices o Improper use of safety devices  Assessment findings o Dizziness o Diplopia o Vomiting o Amnesia (loss of memory) o Loss of consciousness o Changes in vital signs o Bulging fontanels o Headache o Cheyne- stokes respirations o Decortication o Decerebration

 Complications o Brain herniation  try to prevent  So much pressure in brain & it goes down to spinal cord = brain death !!!!!  Brain stem controls HR & RR  Treatment & medications o How to prevent  Supervised  Wear helmets, protective equipment  Wear seat belts  Avoid dangerous activities  Riding bike at night w/o a light  Driving under influence  Driving fast  Never shake a baby  Avoid coughing & blowing nose  Keep head midline with bead elevated 30 degrees  Turn every 2 hours, avoid flexion extension, rotation = use roller to help move  Minimize oral suctioning. NO nasal suction o Monitor vitals

o Minimize stimulation  These ALL cause stimulations in brain & makes brain work harder  Playing videogames  Watching T.V.  Being on phone  Reading o Monitor neuro status  Glasgow coma scale (best way to assess neuro)  3-15 higher number, better patient is  >8 = associated with brain death  Eye response (open eyes or blink) o Responses have to be voluntarily (no pupil reflex)  Verbal response (name? year? Where are you?)  Motor response (squeeze my hand)  Check pupils  Assess cranial nerves  DON’T LET CHILD SLEEP FOR 10 HR WITHOUT ASSESSING !!!  Have to wake child up throughout night to assess neuro!!! o Administer O2 o Decrease ICP o Check for CSF leakage  If its leaking out of brain/skull where do you see it?  Nose or ear  How do we know its CSF?  Presence of glucose o If cerebral edema is present  Severe: Mannitol (diuretic)  Mild concussion:  Positioning  Monitoring  Minimization of stimulation o If patient has sudden change in level of consciousness, they become   Unresponsive  Unaware of surroundings  Start vomiting  THEY NEED MEDICAL ATTENTION !!! ICP IS WORSENING POST HEAD INJURY Increased intracranial pressure (ICP)  Assessment findings  What are thing we want to avoid doing to prevent increase of ICP o Coughing

o Bending forward o Suctioning (CBT) o Crying o Elevation in stimulation

Hydrocephalus  Increased cerebral spinal fluid in the brain o Ventricle is unable to reabsorb spinal fluid = excess amount of CSF o Over time this causes = ICP !!!!!!!!!  Assessment findings o High pitch cry o Bulging fontanels o Dilated scalp veins o Macewen sign

o o o o o o o

Headache (old enough)-early sign Setting sun eyes Enlarged head Irritable Lethargic Poor feeding Lower extremity spasticity

 Treatment & medications o VP shunt (ventriculoperitoneal shunt)  Chronic – you have forever  Catheter placed in ventricle (internally) threaded down to peritoneal cavity so CSF can be drained  Problems with shunt  Patient can outgrow it (revise it)  It can migrate  Become infected  If patient starts to show signs of hydrocephalus = shunt isn’t working – always assess them !!! o Can use external shunt in acute situations, potential brain bleed o EVD shunt

PKU (Phenylketonuria)  PKU is an inherited metabolic disorder in which the newborn lacks the enzyme phenylalanine hydroxylase o This enzyme converts phenylalanine into tyrosine o The lack of this enzyme leads to  Accumulation of phenylalanine in the newborn’s bloodstream and tissues causes cognitive impairment, edema, microcephaly, neuro impairment, behavioral problems  Autosomal recessive trait o Both parents carriers  Child has 25% getting it (disease)  Child has 50% being carriers  Child has 25% not having disease/carriers  Main goal = reduce amount of phenylalanine that enters body o Diet modification (as soon as diagnosed & within 7 days of birth)  Avoid high in protein (you want low)  Meats, dairy, diet coke, coke zero, artificial sweeteners (aspartame), eggs, dry beans, nuts  About 25-30 mg/kg o Cant breastfeed – milk has phenylalanine in it  If mom hasn’t adopted the diet, she can breastfeed for comfort/bonding (1x/day) but can’t give baby ONLY breastmilk – that can’t be their only source of nutrition o Give low phenylalanine formula  Monitor phenylalanine level  Goal is between 2-8 mg/dL. o Sapropterin (Kuvan)  helps breakdown phenylalanine  Could be given with diet modification

 Assessment findings o Growth failure o Frequent vomiting o Irritability o Musty odor to urine o Microcephaly o Heart defects o Blue eyes, very fair skin, light blonde hair  Screening occurs during pregnancy o Maternal screening checks if you have trait for PKU o Newborns are screened by heel stick/Guthry test & drop blood into circles to test  Wait at least 24 hours before doing – THEY NEED TO EAT (milk) first  Complications o Cognitive Impairments o Hyperactivity o Bizarre behavior o Head banging

Meningitis

 Pathophysiology o Inflammation of cerebrospinal fluid & meninges (connective tissue cover brain & spinal cord) o Causes  Viral  Need supportive care  Cytomegalovirus, herpes, HIV, arbovirus, enterovirus  Bacterial  Contagious & worsening prognosis  More severe  Early treatment can cure this  Meningococcal, streptococcus pneumoniae (pneumococcal), haemophilus influenzae type B (Hib), E.coli o *Hib & PCV administered at 2 months = infants before 2 months at higher risk!*  Assessment findings o Newborn – more observable symptoms  No illness present at birth but progresses over the first few days  Poor muscle tone  Weak cry  Poor suck  Refuses feeding  Vomiting  Diarrhea  Bulging fontanels are a late sign (ICP sign) o Infants to toddler (3 months-2 year) – more observable symptoms  Indicative of ICP –(increased intracranial pressure)  High pitch cry (late symptom)  Bulging fontanels (late symptoms) – closure 12-18 months  IF severe – sun set eyes (late symptom)  Increased head circumference (late symptom)  Bradycardia  Distended scalp veins  Seizures  Irritability  Nausea, vomiting  Respiratory changes  Fever  Possible nuchal rigidity (stiff neck)  Poor feeding  Vomiting  Brudzinski’s sign and Kernig’s sign NOT RELIABLE for diagnosis o 2 years-adolescents – more subjective b/c they’re older to say it  Indicative of ICP  Headache (have to be old enough to tell you)-early sign  Irritability

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 Nausea, vomiting  Seizures  Bradycardia  Respiratory changes  Diplopia Stiff neck (nuchal rigidity) Restlessness  Can progress to drowsiness, delirium, stupor Photophobia Positive (+) Brudzinski’s  Flexion of extremities with flexion of neck Positive (+) Kernig’s  Resistance of extension of child leg from a flexed position Fever and chills Petechiae or purpuric rash (red-purple)

 Diagnostics & labs o Lumbar puncture (#1)  Spinal needle inserted into subarachnoid space L3/L4 or L4/L5  Measures spinal fluid pressure & collects CSF  Void prior to procedure

Topical anesthetic (lidocaine & prilocaine)area 45 min-1hr prior SIDE-LYING (lateral) recumbent position (head flexed & knees drawn up to chest)  Pressure & an elastic bandage are applied to puncture site  Monitor for bleeding, hematoma, infection  CSF Findings cerebral spinal fluid shows:  Bacterial o Cloudy color o Elevated WBC o Elevated protein o Decreased glucose o Positive gram stain  Viral o Clear color o Slightly elevated WBC o Normal/slightly elevated protein o Normal glucose o Negative gram stain o CT scan & MRI   Show inflammation of meninges  

 Treatment & Medication o Prevention  Vaccinations (PCV & Hib @ 2, 4, 6 months & again 12-15 months)  MCV (meningococcal) 11-12 y/o with booster at 16 y/o o Haemophilus type B can cause epiglottitis also!!  Tripod position, drooling  Appropriate handwashing  Stay away from sick people o DROPLET PRECAUTIONS  Can withdraw these once on antibiotics for minimum 24 hours  Private room or room w/ client who have infection from same microorganism  Have own designated equipment in room  Wear mask (provider/visitor) o Monitor vital signs, Neuro exam o Monitor infant head circumference & fontanels o Fluids  Correct fluid volume deficits then restrict o NPO IF decreased level of consciousness o Decrease environmental stimuli  Visual, auditory – adds pressure  Position away from nurse station (loud there)  Dim lights  Reduce work of the brain for them

Avoid straining & coughing, crying, bending forward, suctioning, chest physiotherapy o Provide comfort measures  Semi fowlers position (NO pillow), side lying OK to reduce neck discomfort o Safety  bed in low position & seizure precautions o Medications  Antibiotics IV  For bacterial  Steroids  Reduce inflammation  Analgesics  Treat pain & check temp before administering 

Reye syndrome  Swelling of liver & brain (cerebral edema) o Cerebral edema cause ICP (anything that increases pressure in brain)  Peak is seen during flu season o Kids get fevers from flu so parents give aspirin = BAD!  Risk factors o Aspirin (salicylate) use – do NOT use for treating pain/fever  Aspirin causes cerebral edema o Following a viral illness (influenza, gastroenteritis, varicella, chicken pox)  Findings o Infant ICP  Bulging fontanels  Widening cranial suture lines  High pitch cry  Distended scalp veins  Irritability  Bradycardia  Increased head circumference  Lethargy, decrease level of consciousness  Seizures  Vomiting o Children  ICP  Headache (early sign if old enough)  Lethargy, confusion, delirium, diplopia (double vision)  Irritability  Vomiting, nausea  Bradycardia  Decrease level of consciousness  Decreased school performance  Combativeness

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Seizures

 Lab values & diagnostics o Elevated liver enzymes  Alanine aminotransferase (ALT)  Aspartate aminotransferase (AST)  Risk for BLEEDING b/c liver dysfunction !!! o Elevated blood ammonia o Altered blood electrolytes o Liver biopsy  Liver tissue sent to lab via large bore needle  Check clotting studies are within normal limits prior o Lumbar puncture  Collect cerebral spinal fluid to rule out meningitis  Treatment & medications o Prevent aspirin use & teach to check over counter meds for it o Monitor for ICP o Maintain hydration  IV fluids & maintain input/output o Position in semi (low) fowler to reduce ICP  Head of bed elevated 30 degree  Keep head in midline neutral position

 Avoid extreme flexion, extension, rotation o Decrease stimuli & monitor pain  Ibuprofen is OK for over 6 months age for myalgia o Monitor coagulation & prevent hemorrhage  Prothrombin time, coagulation time, INR ratio are PROLONGED b/c of liver dysfunction  How can we treat for potential bleeding?  Vitamin K o Improve clotting o Osmotic diuretic  mannitol  Decreases cerebral edema (swelling)  Watch for ICP !!  Only administered in ICU – severe

Renal R kidney & L kidney Right kidney is lower b/c liver is on top Left kidney is used for renal biopsy Can you live with 1 kidney? o YES o 1 kidney should compensate for the other  Ureters o 2 ureters empty to bladder  1 Bladder  1 Urethra o Urine exits body    

Renal assessment  Normal o Filter out toxins & waste in body  Excrete it via urination o Maintain fluid balance  Hold onto sodium  Daily weight  fluid retention  1 kg = 1 L (1000 mL)  Ins & outs (I&Os) o Maintain acid base balance o Helps production of RBC  Erythropoietin excretion in bone marrow o Vital signs  BP o Labs BMP is important  Creatinine (best measure of kidney function)  Gold standard:...