7. Nursing Diagnoses Risk for injury Risk of infection Risk for ineffective cerebral tissue perfusion Risk for impaired skin integrity Risk for imbalanced nutrition: less than body requirements Impaired family processes
8. Nursing interventions Assess infant’s neurologic status closely. Watch for increasing irritability or lethargy. Measure and record head circumference every 4H. Assess anterior fontanelle for tenseness and bulging. Position infant with the head if the bed elevated 15º to 30° and maintain in neutral position. Monitor V/S q2H Administer O2 as ordered. Monitor I and O. Administer diuretics as ordered. Encourage mother to breast-feed. Position properly with head supported. Avoid flexion or hyperextension. If vomiting occurs, encourage mother to attempt to refeed the infant. If vomiting persists, anticipate the need for enteral or parenteral nutrition.
9. Nursing interventions Wash head daily with repositioning q 2H Encourage parents to verbalize feelings. Teach parents signs and symptoms of increasing ICP.
10. Post operative nursing care Elevate head of bed to 30° Infants are not turned to lie on the side of the shunt Assess for signs of increasing ICP Assess for signs of infection Keep NGT in place. Introduce fluids gradually after NGT is removed. Observe for constipation
13. Anencephaly Occurs when the upper end of the neural tube fails to close in early uterine life Diagnosed by elevated AFP in maternal serum or on amniocentesis Confirmed by sonogram.
15. Microcephaly Disorder in which brain growth is so slow that it fails more than three standard deviations below normal on growth charts. Causes: Intrauterine infection (rubella, cytomegalovirus, toxoplasmosis) Severe malnutrition or anoxia in infancy
16. Spina bifida ("split spine") a developmental birth defect involving the neural tube: incomplete closure of the embryonic neural tube results in an incompletely formed spinal cord. the vertebrae overlying the open portion of the spinal cord do not fully form and remain unfused and open
17. Spina bifida Categories: spina bifida occulta spina bifida cystica (myelomeningocele) meningocele The most common location of the malformations is the lumbar and sacral areas of the spinal cord
18. Assessment: varying degrees of paralysis absence of skin sensation poor or absent bowel and/or bladder control curvature of the spine (scoliosis) most cases there are cognitive problems hydrocephalus
19. Types Spina bifida occulta Occulta is Latin for "hidden." no opening of the back, but the outer part of some of the vertebrae are not completely closed The skin at the site of the lesion may be normal, or it may have some hair growing from it; there may be a dimple in the skin, or a birthmark
20. Spina bifida cystica (myelomeningocele) most serious and common form the unfused portion of the spinal column allows the spinal cord to protrude through an opening in the overlying vertebrae meningeal membranes that cover the spinal cord may or may not form a sac enclosing the spinal elements
21. Meningocele least common form Meninges covering the spinal cord herniate through the unformed vertebrae Protrusion may be covered with a layer or skin just the clear dura
24. Medical-Surgical Treatment no cure for nerve damage Closure of the opening on the back if spina bifida is detected during pregnancy, then open fetal surgerycan be performed
25. Nursing diagnoses Risk for infection Risk for impaired cerebral tissue perfusion Risk for impaired skin integrity Impaired physical mobility
26. Pre-operative care Place infant in supine If in side lying, place a towel or pillow in between the infant’s legs Place a piece of plastic below the meningocele on the child’s back like an apron and secure it with a tape Apply a sterile wet compress of saline, antiseptic, or antibiotic gauze over the lesion Keep infant warm assess for seepage of any clear liquid
27. Post operative care Place infant in supine until the skin incision is healed Same careful precautions are observed. Assess for signs of increased ICP
29. Cerebral Palsy A group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction.
30. Cerebral Palsy Cause is UNKNOWN. Associated with low birth weight, prebirth, or birth injury Intrauterine anoxia and direct birth injury may contribute to the development of CP Occurs in 2:1000 births
31. Types of Cerebral Palsy Spastic S/Sx: Hypertonic muscles Abnormal clonus Exaggerated DTRs Abnormal reflexes (eg. Babinski) When held in ventral position, arching of back and abnormal extension of arms and legs are observed Failure to demonstrate parachute reflex when lowered suddenly Scissor’s gait Hemiplegia, tetraplegia or paraplegia astereognosis
32. Types of Cerebral Palsy Dyskinetic or Athetoid S/Sx: Abnormal involuntary movement Athetoid means “wormlike” Early in life, child is limp and flaccid. Later, in place of voluntary movements, the child makes slow, writhing motions. Drooling Speech impairment Choreoid movements Disordered muscle tone (dyskinetic)
33. Types of Cerebral Palsy Ataxic S/Sx: Awkward, wide based gait Unable to perform finger-to-nose exam or perform rapid, repetitive movements or fine coordinated motions. Mixed
34. Assessment History PE-all forms of CP may have sensory alterations Strabismus visual perception problems Visual field defects Speech problems deafness
35. 25% to 75% of children with CP are cognitively challenged. 50% have recurrent seizures.
36. Physical findings that suggest CP Delayed motor development Abnormal head circumference Abnormal postures Abnormal reflexes Abnormal muscle performance or tone
37. Nursing Diagnoses Deficient Knowledge Risk for disuse syndrome Risk for delayed growth and development Risk for imbalanced nutrition: less than body requirements Risk for self-care deficit Impaired verbal communication
48. Manifestations C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete dependency for ADLs.C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.
49. Diagnostic: Clinical evaluation: absence of reflexes, flaccidity, loss of sensation below injury level Spinal x-ray: vertebral fractures, bony overgrowth CT scans/MRI: evidence of cord compression and edema or tumor formation
51. Central Cord Syndrome Central cord syndrome is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly. This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord
52. Anterior cord syndrome an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioceptionand vibration sense remain intact..
53. Brown-Séquard Syndrome usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injur, there is a loss of motor function, vibration, and light touch. Contralaterally, there is a loss of pain, temperature, and deep touch sensations.
54. Assessment ACTIVITY/REST May exhibit: Paralysis of muscles (flaccid during spinal shock) at/below level of lesionMuscle/generalized weakness (cord contusion and compression)
55. Assessment CIRCULATIONMay report: PalpitationsDizziness with position changesMay exhibit: Low BP, postural BP changes, bradycardiaCool, pale extremitiesAbsence of perspiration in affected area
56. Assessment ELIMINATION May exhibit: Incontinence of bladder and bowelUrinary retentionAbdominal distension; loss of bowel soundsMelena, coffee-ground emesis/hematemesis
60. Assessment NEUROSENSORY May report: Absence of sensation below area of injury, or opposite side sensationNumbness, tingling, burning, twitching of arms/legsMay exhibit: Flaccid paralysis (spasticity may develop as spinal shock resolves, depending on area of cord involvement)Loss of sensation (varying degrees may return after spinal shock resolves)Loss of muscle/vasomotor toneLoss of/asymmetrical reflexes, including deep tendon reflexesChanges in pupil reaction, ptosis of upper eyelidLoss of sweating in affected area
61. Assessment PAIN/DISCOMFORT May report: Pain/tenderness in musclesHyperesthesia immediately above level of injuryMay exhibit: Vertebral tenderness, deformity
62. Assessment RESPIRATION May report: Shortness of breath, “air hunger,” inability to breatheMay exhibit: Shallow/labored respirations; periods of apneaDiminished breath sounds, rhonchiPallor, cyanosis
63. Assessment SAFETYMay exhibit: Temperature fluctuations (taking on temperature of environment)SEXUALITYMay report: Expressions of concern about return to normal functioningMay exhibit: Uncontrolled erection (priapism)Menstrual irregularities
64. Nursing Diagnoses Ineffective breathing pattern High risk for disuse syndrome Impaired physical mobility Altered sensory perception Risk for infection Altered elimination Risk for impaired skin integrity Ineffective individual coping Powerlessness
65. NURSING PRIORITIES 1. Maximize respiratory function.2. Prevent further injury to spinal cord.3. Promote mobility/independence.4. Prevent or minimize complications.5. Support psychological adjustment of patient/SO.6. Provide information about injury, prognosis and expectations, treatment needs, possible and preventable complications.
66. Therapeutic management: Surgery- laminectomy or fusion for decompression and stabilization, wound debridement, placement of cervical tongs or halo traction for stabilization, tracheotomy for mechanical ventilation as needed medications: massive corticosteroid therapy to improve outcome, vasopressors for shock, prophylactic antibiotics for open wounds, analgesics for pain, anticoagulants to prevent emboli and thrombus formation, anti anxiety to reduce emotional stress.
67. Therapeutic management c. General: a. initial: 1. spinal stabilization with backboard or cervical collar on initial transport 2. MV if necessary 3. monitor cardiac status, blood gases, neuro V/S, I&O, V/S 4. maintain skeletal traction and body alignment 5. reposition and turn every 2hrs 6. passive ROM 7. monitor bowel and bladder function, skin integrity and avoid extreme temperatures
68. Therapeutic management b. Long term 1. bowel training 2. bladder training 3. PT to diminish orthostatic hypotension, increase strength and endurance, decrease muscle spasticity, prevent contractures 4. OT to aid adaptation of ADLs 5. respiratory therapy 6. recreational therapy 7. speech therapy 8. case mgt for needed resources 9. long term medical ff up 10. counseling of individual and family support adaptation
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71. Prevention and promotion: Daily skin inspections Diligent use of bowel and bladder programs to prevent bowel obstruction and UTI Influenza and pneumonia vaccines to prevent respiratory complications Early recognition and treatment of urinary tract and respiratory problems
72. DISCHARGE GOALS 1. Ventilatory effort adequate for individual needs.2. Spinal injury stabilized.3. Complications prevented/controlled.4. Self-care needs met by self/with assistance, depending on specific situation.5. Beginning to cope with current situation and planning for future.6. Condition/prognosis, therapeutic regimen, and possible complications understood.7. Plan in place to meet needs after discharge.
81. Nursing interventions Position in supine without pillows Place in isolation Ensure strict medication compliance Observe for signs and symptoms of increasing ICP Monitor I and O with specific gravity of urine Assess senses
85. Reye’s Syndrome Acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs, pancreas, and skeletal muscle. Occurs in children 1-18 years of age Both sex are equally susceptible Cause Unknown but generally occurs after a viral infection such as varicella and influenza If child was treated with salicylate such as acetylsalicylic acid (aspirin) during the viral infection
87. Postpoliomyelitis Syndrome Complication of previous poliomyelitis virus (epidemic occurred in USA during 1940’s and 1950’s); persons who recovered are re-experiencing manifestation of acute illness in their advanced age Pathophysiology: Process is unknown Manifestations: Fatigue, muscle and joint weakness, loss of muscle mass, respiratory difficulties, and pain Diagnosis: By history and physical examination Treatment: Involves physical therapy and pulmonary rehabilitation Nursing Care: Involves emotional support and interventions to deal with dysfunction; ADL, safety are including in interventions
88. Rabies Rhabovirus infection of CNS transmitted by infected saliva that enters the body through bite or open wound Critical illness almost always fatal Source often is bite of infected domestic or wild animal Incubation is 10 days to years
89. Rabies Manifestations occur in stages Prodromal: wound is painful, various paresthesias, general signs of infection; increased sensitivity to light, sound, and skin temperature changes Excitement stage: periods of excitement and quiet; develops laryngospasm and is afraid to drink (hydrophobia), convulsions, muscle spasms and death usually due to respiratory failure
90. Rabies Collaborative Care Animal that bit person is held under observation for 7 – 10 days to detect rabies Sick animal are killed and their brains are tests for presence of rabies virus Blood of client may be tested for rabies antibodies
91. Rabies Post-exposure treatment Rabies immune globulin (RIG) is administered for passive immunization Client often has local and mild systemic reaction; treatment is over 30 days Treatment of client with rabies: involves intensive care treatment Health Promotion Vaccination of pets Avoid wild animals, especially those appearing ill Follow up care for any bites
92. Tetanus (lockjaw) Disorder of nervous system caused by neurotoxin from Clostridium tetani, anaerobic bacillus present in the soil Contract disease from open wound contaminated with dirt, debris Has high mortality rate Incubation is usually 8 – 12 days Manifestations Stiffness of jaw and neck and dysphagia Spasms of jaw and facial muscles Develops generalized seizures and painful body muscle spasms Death occurs from respiratory and cardiac complications
93. Tetanus (lockjaw) Diagnosis is made on clinical manifestations Clients with disease are treated in intensive care with antibiotics, chlorpromazine (Thorazine) and diazepam (Valium ) for muscles spasms Health Promotion Active immunization with boosters given at time of exposure Passive immunization is given to persons who are not adequately immunized
94. Botulism Food poisoning caused by ingestion of food contaminated with toxin from Clostridium botulinum, anaerobic bacteria found in soil Contracted by eating contaminated foods usually improperly canned or cooked Untreated death rate is high Pathophysiology: Bacteria produce a toxin, which blocks release of acetylcholine from nerve endings causing respiratory failure by paralysis of muscles
95. Botulism Manifestations Visual disturbances Gastrointestinal symptoms Paralysis of all muscle groups Effecting respiration Diagnosis Based on clinical picture Verified by laboratory analysis of client’s serum and stool Testing the suspected food
96. Botulism Treatment Administration of antitoxin Supportive treatment including mechanical ventilation and systemic support in intensive care unit Health Promotion Teaching clients to process foods properly when home canning Boiling foods for 10 minutes which destroys the toxin Not eating spoiled foods
