Exam 3 NR 328 Study guide latest updated

Nursing measures for a lumbar puncture Requires consent, sterile fashion Dealing with the tubes for a lumbar puncture three different tubes sometime more, make sure you LABEL which is the first specimen and so o ...

Nursing measures for a lumbar puncture Requires consent, sterile fashion Dealing with the tubes for a lumbar puncture three different tubes sometime more, make sure you LABEL which is the first specimen and so on Position for lumbar puncture Side lying Position for babies and lumbar puncture do not hyperflex or extend the neck, be sure they have an open airway, put more pressure on the back or butt Lumbar punctures show Inceased WBC, decreased glucose, elevated protein, increased ICP, and positive culture for menengitis Lumbar puncture? Bacteria is made of protein and it eats the glucose Always wear? A mask you never know what youre in contact with Older children and signs of increased ICP Change in LOC, irritability, vomiting, headache, motor dysfunction, unequal pupil response, seizures, decline in academics, personality changes Infants s/s of Increased ICP Irritability, lethargy, increased head circumference, bulging fontanels, widened suture lines, sunset eyes, high pitched cry scalp veins Early sign of ICP increase Tachycardia Late sign of increased ICP bradycardia, failure to follow command Fixed and dilated pupils what med are they on? or brain death impending cushing reflex when the pulse pressures are widened (ex: 200/68) What is an early most important indicator of change in neuro status? LOC Parent can detect change Mom states baby has blank stair and doesnt get excited over favorite toy exc Priorities with MVA A= airway c-spine mobilization B=breathing C= circulation D= disability E= environment/exposure F= full set of vitals , five interventions, family presence G- Give comfort measure H- head to toe exam I Inspect Circulation carotid artery, 2 ivs, any bleeding Disability LOC and pupils Enviorment/exposure warm the room up expose them Five interventions EKG, pulse ox, foley, blood work, NG tube or oral gastric NOTHING IN NOSE TILL CT COMES BACK Inspect look at back Brudzinski sign When the child lies down and you bring the head up and the legs rise up due to menginal irritation Kernig sign when the kid lays down and you flex the knee at 90* and straightening causes pain due to menginal irritation Care for child with infectious meningitis Wear a mask, gown, gloves for the first 24 hours once antibiotics is started, Droplet precautions, keep the lights dim, keep the noise level down, measure head circumference, implement seizure precautions, Head of bed slightly elevated with client on side if prescribed, Monitor I/Os Monitor hydration status and IV therapy carefully fluid retention is common Viral meningitis treat the symptoms, frequently caused by immunizations Activities that increase ICP Suctioning, coughing, straining and turning Reye syndrome Caused from a viral illness and giving aspirin Reye syndrome Dx Liver biopsy Reye syndrome care Monitor for S/s of increased ICP, I/Os assess coagulation factor (PT, PTT) monitor for bleeding Nursing care for a seizure Maintain airway turn client on side, do not restrain client, protect head, if in chair lower to floor, may need a helmet, time the seizure, do they breath how long is it, What are seizure precautions Reduce enviormental stimuli, pad side rails, suction equitment, oxygen ready, Child has a seizure at home how do we administer meds rectally inject the med into the rectum and be sure to squeeze the butt checks as best as possible If meds do not work? Ketogenic diet (very fatty diet), vagus nerve simulator( children >12) or surgery (very last resort) Meds for tonic clonic seizures phenytoin (dilantin) carbamazepine (Tegratol), phenobabital (luminal) and fosphenytoin (Cerebyx) Meds for absence seizure ethosuxmide *Zarontin), valproic acid (depakene) Do not take phenobabital with? milk take on empty stomach Tonic seizure eyes roll upwards, lose consciousness, stiffen, tonic contractions of body. See apnea, may see cyanosis Clonic seizures jerking movement, with contraction and relaxation of extremities. May last from seconds to > 30 min. Status epilepticus series of seizures not allowing time to regain consciousness in between, or a single seizure lasting > 30 min. Can lead to death. Absence Brief loss of consciousness, with minimal or