Peds GI, GU, neuro

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3 protective coverings of the brain?: Dura, arachnoid and pia (from outer to innermost)
Primary site of CSF production is_________?: Choroid plexus in the brains ventricles
Reabsorption of CSF occurs within the _________.: Arachnoid villi
Functions of the cerebellum:: Maintenance of posture & coordination of voluntary motor responses
Functions of the medulla oblongata:: Reflex centers of swallowing, vomiting, coughing, respiratory center
Functions of the hypothalamus:: Secretion of antidiuretic hormone, appetite control center, and regulation of body temperature
Functions of the cerebral cortex:: Learning, thinking, memory and speech
Hydrocephalus: may be either communicating or noncommunicating and congenital or acquired.
Communicating Hydrocephalus: No kind of obstruction but there is a decrease in absorption of CSF
Noncommunicating Hydrocephalus: 99% of keds: some sort of obstruction: will probably need a shunt for the rest of their life. Ventricles within brain dilate when it fills with fluid b/c it isn't allowed to drain appropriately.
communicating Hydrocephalus: congenital structural defects: Dandy walker syndrome: congenital obstruction that causes fluid to accumulate (of flow out of ventricles)
Arnold-Chiari Malformation: defect in posterior fosfa that allows hernia in the cerebrum. S/S- difficulty speaking, & balance
Congenital Hydrocephalus: born with it
Acquired Hydrocephalus: Most common: result from complication of prematurity: bleeds in head: Spina bifida
Hydrocephalus: EARLY manifestations Infant: Larger head circumference, bulging fontanel, larger suture lines, translucent forehead skin, prominent scalp, poor feeding and irritability
Hydrocephalus: LATE manifestations Infant: Sun setting eyes, bossing of forehead(forehead sticks out), vomiting, poor feeding,
Hydrocephalus: VERY LATE manifestations Infant: Increased BP, decreased HR, shrill high pitched cry, pupils sluggish, & unresponsive to light
Hydrocephalus: EARLY manifestations Child: Frontal headache: worse in a.m. and sitting upright helps, N/V (increased ICP), restlessness, ataxia, irritability, sluggish pupil response
Hydrocephalus: LATE manifestations Child: Change in reasoning skills, lethargy, seizures, increased visual disturbances, decerabete posturing (rigid extension)
Diagnosis of Hydrocephalus: Head circumference: done until age 3 and plotted of growth chart.
CT, MRI, ultrasound & plain skull X-rays
Goal of Treatment with Hydrocephalus: Based on preventing further CSF accumulation and reduce disability and death
Treatments of Hydrocephalus: A catheter of shunt is placed in the ventricle and passes the CSF to the peritoneal cavity, atrium of the heart, or the pleural spaces.
Ventriculo-peritoneal shunt: A valve on the shunt prevents fluid from draining too much, allows fluid to drain only when pressure gets to high
2 biggest problems with VP shunts: Infection(ventriculitis) and shunt failure.
Hydrocephalus: VERY LATE manifestations Child: Cushings triad
Signs of infection with VP shunt: Changes in responsiveness and irritability. Also low grade fever, malaise, headache, and nausea. Measure an infants head circumference daily when shunt failure is suspected.
Hydrocephalus nursing care: Do not stretch or strain the neck muscles, infant is prone to vomiting so small, freq. meals, HOB is elevated gradually, VS Q2-4hours, kid may develop a seizure disorder.
Symptoms of shunt malformations: Increased head circumference, infant: full fontanel, swelling ro redness along shunt tract, irritability, vomiting, headache, lethargy, seizures, personality changes, and change in academic performance
VA shunt: shunt to the atria of the heart: usually not the first choice, done usually when VP has had a problem
Spina Bifida: Neuro tube defect with incomplete closure of the vertebrae and neural tube
Spina Bifida Occulta: L5 or S1: May have a dimple, tuft of hair, or a dermoid cyst at the tail bone (may never know about it), some kids have problems with ambulation, or bowel/bladder control. Mildest form of SB
Spina Bifida cystica: A defect occurs in closure of the posterior vertebral arch with protrusion through the bony spine.
Meningocele: spinal cord, nerve roots
Myelomeningocele: More serious
Meningocele: A spinal fluid-filled meningeal sac protrudes through a vertebral defect and is associated with no abnormalities of the spinal cord. The spinal cord and spinal root are in normal position.
Myelomeningocele (Myelodysplasia): A spinal-filled meningeal sac containing a pertion of the meninges, spinal cord, or nerve roots protrudes through a vertebral defect. Fluid leakage may also occur as the lesion is poorly covered with imperfect tissue.
Myelomeningocele (Myelodysplasia) vs Spina bifida: Myelomeningocele- refers to a malformation of the spinal cord and spinal canal.
Spina bifida- refers to a defect in one or more vertebrae through which spinal cord contents can protrude
Spina Bifida Patho: Cause unknown, associated with maternal folic acid deficiency, virus, genetic predisposition. Occurs during week 4 of gestation.
Spina Bifida Manifestations: r/t the level of defect and size of defect. Paralysis of lower extremeties, sensory defects, flaccid lower extremeties, decreased bowel and bladder control (in infants: constant dribble), hydrocephalus
Spina Bifida Nursing care: Feed the infant with the head turned to one side until surgery has been performed, comfort with tactile stimulation such as touching, patting and cuddling.
Spina Bifida Assessments: Frequently asess VS and be alert for s/s of infection, also responsiveness and post-op the level of pain. Monitor distal extremities for swelling and circulation
Complications of Spina bifida: UTI's, intermittent caths, skin breakdown (decreased sensory), bladder disfunction can lead to renal disease, latex allergies, scoliosis,
Spina Bifida Diagnosis: Prenatal alpha-protein levels of amniotic fluid at 16-18 wks gestations, fetal ultrasound, and CT after delivery (done to see what's in sac: spinal roots or only fluid)
Treatment Spina Bifida: Pre-op: Immediate surgical closure (to decrease trauma, and infection)
Pre-op interventions- baseline head circumference, assess anterior fontanel (bulging), and steril saline dressings over sac, assess muscle tone and mvmnt (need baseline), maintain temp (moist dressing; probably need heat), prone position: less contamination from dribbling urine or stool.
Treatment Spina Bifida: Post-op: Prone or sidelying position, Antibiotic ordered to prevent infection, observe for infection or hydrocephalus, avoid contamination of surgical site from bowel and bladder, neuro assessment of extremities, orthopedic mngmnt early to enhance functioning and prevent complications, observe for CSF leakage: (check to see if there is glucsoe and if there is it's CSF)
Spina Bifida interventions: Braces to support joint position, diet should ensure adequate calcium and Vit. D to minimize risk for osteoporosis and weight-bearing activities should be encouraged.
Spina Bifida Diet: If child has latex allergies avoid foods like bananas, avocados, papaya, kiwi.
Diet high in fiber and increase fluid intake to prevent constipation and UTI, adequate calcium and Vit. D
Complications with Spina Bifida: Loss of motor and sensory function of abd and lower extremities, scoliosis, incontinence, hip abnormalities, hip dysplasia, hydrocephalus, learning problems, ADD, memory and organization problems and problems with numerical reasoning
LOC: altered levels classification: Confusion: disoriented to time, place or person.
Delirium: confusion, fear, agitation, hyperactivity or anxiety
Obtunded: limited response to the environment; the child falls asleep unless given verbal or tactile stimulation.
Stupor: response to vigorous stimulation only; the child returns to the unresponsive state when the stimulus is removed.
Coma: severely diminished response; the child cannot be aroused even by painful stimuli.
Decorticate posturing: internal drawing up of upper extremities
Decerebrae posturing: arms extended and totate outward
Definition of increased ICP: a disturbance of intracranial pressure with ICP sustained at 20mmHg or higher
Etiology of increased ICP: Tumors, hematomas, trauma, hypoxia, inflammation, mal-absorption of fluid, communication problem within the system.
Manifestations of increased ICP: Infants-tense bulging fontanels, high pitched cry, irritability, setting sun eyes, poor feeding, increased head circumference, distended scalp veins.
Children-Headache(b/c no open fontanel), N/V, blurred vision, seizures, diplopia, mood swings, papilledema, altered LOC.
Diagnosis of increased ICP: CT, MRI, Electrolytes, ABG, CBC, EEG, X-rays
Decorticate or decerebrate posturing: these positions are assumed after injury or damage to the brain. Decorticate is associated with lesions above the brainstem and decerebrate is associated with lesions of the brainstem.
Late signs of increased ICP: Significant decrease in LOC, Cushings triad, and fixed and dilated pupils.
Cushings triad: Increased systolic BP and widened pulse pressure, bradycardia, and irregular respirations
Glasgow Coma Scale: Eye opening: 4 spontaneous, 3 to loud noise, 2 to pain, and 1 no response
Verbal response: 5 smiles, coos, cries appropriately; 4 irritable, cries; 3 inappropriate crying; 2 grunts, moans; 1 no response
Motor response: 6 spontaneous; 5 withdrawls to touch; 4 withdrawls to pain; 3 abnormal flexion (decorticate); 2 abnormal extension (decerebrate); 1 no response
Management of increased ICP: Reduction of volume of CSF, preservation of cerebral function, avoidance of situation that increase ICP (prolonged crying, pushing)
Treatment of increased ICP: HOB elevated 30 degrees, maintain good oxygenation, reduce crying and agitation, diuretics, I&O, electrolytes (cluster care)
Neuro assessments: evaluate pupil size & reactivity, eye movements, and motor function, monitor VS, anticipate seizures may occur
Failure to Thrive: < 3rd-5th %ile for ht and wt
Drop > 2 major %tiles or 1 standard deviation
< normal daily gram weight gain
3 categories of Failure to Thrive: Organic FTT- physical factors
Non-organic FTT- environmental
Mixed FTT
Failure to Thrive pyschosocial factors: Brain growth and cognitive development is a BIG concern
Manifestations of Failure to Thrive: Wt <3-5 %tile, hypotonia, weakness, listlessness, loss of sub-q tissue, developmental delays, THE LAST THING TO DROP ON THE GROWTH CHART IS HEAD CIRCUMFERENCE= chronic malnutrition.
They also avoid eye contact and touch, expressionless face, repetitive self-stimulating behavior, and NO stranger anxiety
Failure to Thrive Diagnosis: GROWTH RETARDATION, health and diet hx, physical exam to r/o organic causes, developmental and family assessment, "diagnosis by response" (to r/o other problems-ensure adequate caloric intake if wt increases then its FTT)
Management of Failure to Thrive: REGARDLESS OF CAUSE-REVERSE MALNUTRITION!!! Treat medical problems, catch-up growth
Nursing considerations with Failure to Thrive: Assessment/history, Education: nutrition, and growth and development, be a role model, positive reinforcement-support parents.
Pyloric Stenosis: hypertrophy of the circular muscle results in stenosis of the passage between the stomach and the duodenum
Pyloric Stenosis Diagnosis: Hx and physical exam, radiographic/ultrasound studies, barium study, Lab findings: hypochloremic metabolic alkalosis. Symptoms appear 2-4wk after birth
Manifestations of Pyloric Stenosis: NONBILIOUS PROJECTILE VOMITING, visible gastric peristalic waves, hyperactive BS, palpable pyloric "olive", irritability, signs of dehydration, metabolic alkalosis
Treatment of Pyloric Stenosis: Pyloromyotomy
Pre-op: IV fluids to correct fluid and electrolyte imbalances, correct acid-base balance, NG to decompress stomach
Pylorotomy: Longitudinal incision through the circular muscle fibers of the pylorus
Nursing considerations for Pyloric Stenosis: Monitor urine specific gravity, weigh diapers, b/c gastric contents are high in K+ hypokalemia can result. Daily wts, don't lift legs to change diapers.

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