Exam 3 NR 328 Study guide latest updated

Nursing measures for a lumbar puncture - ANSWER Requires consent, sterile fashion Dealing with the tubes for a lumbar puncture - ANSWER three different tubes sometime more, make sure you LABEL which is the first speci ...

Nursing measures for a lumbar puncture - ANSWER Requires consent, sterile fashion Dealing with the tubes for a lumbar puncture - ANSWER three different tubes sometime more, make sure you LABEL which is the first specimen and so on Position for lumbar puncture - ANSWER Side lying Position for babies and lumbar puncture - ANSWER 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 - ANSWER Inceased WBC, decreased glucose, elevated protein, increased ICP, and positive culture for menengitis Lumbar puncture? - ANSWER Bacteria is made of protein and it eats the glucose Always wear? - ANSWER A mask you never know what youre in contact with Older children and signs of increased ICP - ANSWER Change in LOC, irritability, vomiting, headache, motor dysfunction, unequal pupil response, seizures, decline in academics, personality changes Infants s/s of Increased ICP - ANSWER Irritability, lethargy, increased head circumference, bulging fontanels, widened suture lines, sunset eyes, high pitched cry scalp veins Early sign of ICP increase - ANSWER Tachycardia Late sign of increased ICP - ANSWER bradycardia, failure to follow command Fixed and dilated pupils - ANSWER what med are they on? or brain death impending cushing reflex - ANSWER when the pulse pressures are widened (ex: 200/68) What is an early most important indicator of change in neuro status? - ANSWER LOC Parent can detect change - ANSWER Mom states baby has blank stair and doesnt get excited over favorite toy exc Priorities with MVA - ANSWER 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 - ANSWER carotid artery, 2 ivs, any bleeding Disability - ANSWER LOC and pupils Enviorment/exposure - ANSWER warm the room up expose them Five interventions - ANSWER EKG, pulse ox, foley, blood work, NG tube or oral gastric NOTHING IN NOSE TILL CT COMES BACK Inspect - ANSWER look at back Brudzinski sign - ANSWER When the child lies down and you bring the head up and the legs rise up due to menginal irritation Kernig sign - ANSWER 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 - ANSWER 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 - ANSWER treat the symptoms, frequently caused by immunizations Activities that increase ICP - ANSWER Suctioning, coughing, straining and turning Reye syndrome - ANSWER Caused from a viral illness and giving aspirin Reye syndrome Dx - ANSWER Liver biopsy Reye syndrome care - ANSWER Monitor for S/s of increased ICP, I/Os assess coagulation factor (PT, PTT) monitor for bleeding Nursing care for a seizure - ANSWER 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 - ANSWER Reduce enviormental stimuli, pad side rails, suction equitment, oxygen ready, Child has a seizure at home how do we administer meds - ANSWER rectally inject the med into the rectum and be sure to squeeze the butt checks as best as possible If meds do not work? - ANSWER Ketogenic diet (very fatty diet), vagus nerve simulator( children >12) or surgery (very last resort) Meds for tonic clonic seizures - ANSWER phenytoin (dilantin) carbamazepine (Tegratol), phenobabital (luminal) and fosphenytoin (Cerebyx) Meds for absence seizure - ANSWER ethosuxmide *Zarontin), valproic acid (depakene) Do not take phenobabital with? - ANSWER milk take on empty stomach Tonic seizure - ANSWER eyes roll upwards, lose consciousness, stiffen, tonic contractions of body. See apnea, may see cyanosis Clonic seizures - ANSWER jerking movement, with contraction and relaxation of extremities. May last from seconds to > 30 min. Status epilepticus - ANSWER series of seizures not allowing time to regain consciousness in between, or a single seizure lasting > 30 min. Can lead to death. Absence - ANSWER Brief loss of consciousness, with minimal or no loss of muscle tone. May be difficult to diagnose. Atonic seizures - ANSWER ("drop" attacks) - sudden, brief loss of muscle tone Myoclonic seizures - ANSWER variety of disorders with brief contractures of muscles; no loss of consciousness or postictal state Infantile spasms - ANSWER occur with other cerebral anomalies and developmental delays. Poor physical and mental prognosis. Tonic-clonic (grand mal) - ANSWER Aura, LOC, tonic phase: generalized stiffness of body, apnea, cyanosis, clonic phase: spasms followed by relaxation, pupils dilated and nonreactive, incontinence, post seizure: disorientated, sleepy Absence seizure (petit mal) - ANSWER Onset between 4 and 12, lasts 5-10 seconds, child appears inactive, daydreaming, poor school performance Febrile seizure - ANSWER Seizure during the temperature rise >101.8* Hydroencehpalitis signs child - ANSWER Headache on awakening, Emesis, Strabismus, Papilledema, Ataxia, Decreased LOC, Apathy, Incoherent speech Hydroencehpalitis signs infant - ANSWER Head enlargement - may also see bulging fontanels, tense, nonpulsatile fontanels, dilated scalp veins & separated sutures Frontal protrusion & depressed eyes; eyes may be rotated downward ("setting sun" sign) Behavior - irritability, lethargy, poor feeding, or lower extremity spasticity Reflexes - delayed development, or persistent infant reflexes Glosgow Coma Scale children - ANSWER Post op care for a child with ventriculoperitoneal shunt - ANSWER Positioning - position on unaffected side, flat or elevated HOB per MD order Assessments - neuro assessments; note S/S increased ICP, S/S peritonitis; infection; I & O Post-op treatments - antibiotics; skin care; pertinent assessments Family support/education Findings of down syndrome - ANSWER Small head Flattened forehead Low-set ears Upward slant to the eyes Protruding tongue Hypotonia (decreased muscle tone) Transverse palmar crease Underdeveloped nasal bone