N427: Test 7

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N427: Test 7 by Mind Map: N427: Test 7

1. Mental Health

1.1. Developmental disability

1.1.1. Definition Any significant delay in development Physical Cognitive Behavioral Emotional Social Usually manifests before age 22 & is indefinite Relative to typical sequence/timing of development

1.1.2. Disorders Not related by etiology Have a common feature: developmental delay Gross motor Fine motor Language Social-adaptive

1.2. Cognitive impairment

1.2.1. Definition Any mental difficulty Intellectual ability Adaptive behavior Significantly below average "Mental retardation" (negative term)

1.2.2. Etiology Familial Social Environmental Organic "Biological" Earlier = more severe Usual cause of severe impairment Can be identified in 2/3 of cases Many disorders Unknown

1.2.3. IQ ranges 55-70 = mild 35-50 = moderate 20-35 = severe <20 = profound

1.2.4. Early signs Non-responsive Irritable Slow, poor feeding Poor eye contact during feeding Diminished spontaneous activity

1.2.5. Intervention ASAP!! Maximize potential Start when CNS is malleable/responsive Routine G/D screen for all pediatrics!

1.2.6. Prevention Primary Avoid triggering conditions No parental rubella infections Current vaccines Genetic counseling Education Secondary Early ID, tx to prevent cerebral damage Prenatal diagnosis and/or carrier ID Newborn screening Tertiary Minimize long-term consequences Early ID Rehab Parental education Preschool Counseling

1.2.7. Ultimate goal Promote optimum development As individuals, w/i family and community

1.2.8. Health maintenance Same as other kids Reinforce AG r/t accidents Treat acc. to developmental age May be more difficult to detect illness

1.3. Sensory impairment

1.3.1. Hearing Vocabulary Hard of hearing Deaf Etiology Family history Anatomic malformation LBW Maternal prenatal drug abuse Ototoxic drugs Chronic ear infections Severe prenatal asphyxia Perinatal infections Cerebral palsy Down's syndrome* Environment Pathology Conductive HL Conductive-type HI Sensorineural HL Mixed CS Loss Central auditory imperception Therapy Medical Nursing Prevention Genetic counseling OTM care Prenatal measures Avoid triggers Maternal nutrition

1.3.2. Vision Can't be corrected w/standard Rx Partial sight Legal blindness Etiology Perinatal infection Trauma Meningitis Retinopathy of prematurity Trauma Other disorders Unknown causes Types of dysfunction Refraction errors Cataracts Glaucoma Trauma Nursing assessment Infancy Childhood Nursing care In-patient care Prevention Emergency injuries Foreign body Chemicals/UV Hematoma Penetrating vs. non-penetrating

1.3.3. Deaf/blind Profound effects on development Motor milestones usually achieved Other development usually delayed "Finger spelling" vs "Tadoma method" Developing future goals Communicating ability Movement ability in infants

1.4. Communicative impairment

1.4.1. Definition Inability to receive or process speech Inability to represent concepts or symbols Inability to transmit and use symbols May need alternative communication

1.4.2. Etiology Cognitive impairment** Other causes

1.4.3. Types Language Overview Disorders Speech Disorders

1.4.4. Autism Spectrum disorder Neurodevelopmental w/brain dysfunction Intellectual and behavioral Males > females Unknown cause (genes?) Onset before age 3 usually 5 types Diagnostic criteria Communication impairments Impaired reciprocal social interaction** Behavioral abnormalities Cognitive impairments (3/4 of cases) May have: Other manifestations Repetitive behaviors Extreme intolerance Emotionally labile* Fascinated w/repetitive words or songs Don't accept change Don't pick up on social/emotional cues Nursing care Wide variation in response Most promising treatment Medications In-patient care Family support

1.5. Anticpatory guidance

1.5.1. Proactive, development-based counseling

1.5.2. Focuses on child's need at each stage

1.5.3. Practical, contemporary info before major milestones

2. Neurological (Lee)

2.1. A&P review

2.1.1. Brain Protected by skull Covered in meninges Dura mater Arachnoid Pia mater CSF circulates Made by choroid plexus Shock absorber Nutrients & wastes Maintains ICP Forms very early By 4th week >> neural tube Lots of things can go wrong

2.1.2. Skull Softer as an infant Fontanels Anterior: Closed by 18-24 mo Posterior: Closed by 2-3 mo Sutures Begin to harden @ 6 mo Fuse until age 12 Heaviest part of body Center of gravity Where babies tend to land when they fall Weak neck muscles for support

2.1.3. Spinal cord Greater mobility b/c slower ossification Serious risk for C1/C2 compression fracturers in neonates

2.1.4. Nervous system Nerve cells Born w/full amount Immature Glial cells, dendrites Increase until age 4 Brain growth until age 12-15 Myelination Incomplete @ birth Cephalocaudal progression

2.2. Pressure

2.2.1. CPP: Needed to perfuse the brain

2.2.2. ICP: Force exerted by brain, CSF, blood in skull Components Brain tissue 80% Blood 10% CSF 10% (compensatory relationship) Normal is 5-15 mmHg

2.2.3. Controlled by cerebral vessels Decreased CO Increased ICP Constricted neck vessels

2.3. IICP

2.3.1. Early signs Headache Diplopia/blurry vision Vomiting (w/o nausea) AM nausea (esp for brain tumors) Sluggish pupils Slight change in LOC/VS Possible seizures Infant signs Tense, bulging fontanel Irritable/non-consolable High-pitched cry Poor feeding Sun-setting eyes (pressure on orbits) Separated sutures Increased fronto-occipital circumference

2.3.2. Late signs Decreased LOC (coma) Altered pupils Unilateral dilated: mass Fixed dilated: impending herniation** Decreased sensory/motor responses Posturing Decorticate Decerebrate Opisthotonus Periodic/irregular RR OMINOUS sign of brainstem dysfunction Will progress to apnea if IICP isn't resolved

2.4. Nursing care

2.4.1. Baseline data

2.4.2. S/S IICP

2.4.3. I&O SIADH Low or no UOP Edema Overhydration Neurogenic DI Polyuria Polydipsia High Na+ Low specific gravity

2.4.4. Dark, quiet room

2.4.5. Limit stress/painful activities

2.4.6. HOB 30

2.4.7. Head/neck midline & neutral**

2.4.8. Seizure precautions for all

2.4.9. Mouth care

2.4.10. Turning

2.4.11. Passive ROM

2.4.12. Skin care

2.4.13. Stool softener r/t constipation

2.4.14. Suction sparingly (increases IICP)

2.4.15. O2 at the bedside

2.4.16. Nutrition S/S overfeeding Distension Gagging Coughing Vomiting

2.4.17. Family support Encourage involvement Explain all procedures Unrealistic expectations Chronic sorrow

2.5. Seizure disorders

2.5.1. Abnormal electrical discharges Involuntary movement Behavior and sensory alterations

2.5.2. Generalized Etiology Diffuse electrical activity Both brain hemispheres Spreads simultaneously through cortex, brain stem Bilateral & symmetrical Sub-types Tonic-clonic Absence Myoclonic Lennox-Gastaut syndrome Infantile spasms

2.5.3. Partial Pathology Abnormal electrical activity 1 hemisphere or region of cerebral cortex Spread regionally Manifestations r/t lobe affected Manifestations Begins w.aura or abrupt behavioral alteration May progress to generalized seizure Etiology Lesions or tumors AVMs Scar tissue r/t previous brain sx Simple Onset at any age Causes Less <30 seconds Manifestations Complex Onset age 3 - adolescence Immediate impaired consciousness Lasts 30 sec to 5 min Manifestations

2.5.4. Febrile Generalized w/fever (>102F) & acute illness Flu Strep throat OM Occurs during temp rise Need antipyretics on hand Rarely treated w/anticonvulsants Recurs in 30-40% of kids

2.5.5. Status epilepticus Continuous or recurrent seizures lasting >20 min W/o return to baseline neuro state Compromises airway BMR rises Nursing care Airway*** O2 VS if you can Watch O2 sats NG tube r/t aspiration Anti-pyretics IV access ASAP

2.5.6. Seizure meds Phenobarbital Phenytoin Dilantin Tegretol Depakote Lamictal Topamax Keppra Trileptal

2.5.7. Safety Showers only Don't bathe alone Stay with them Drug serum levels r/t anti-seizure meds Helmet No open flames Avoid areas that increase fall risk Surgery to remove affected area

2.5.8. Medication safety No abrupt DC Don't crush or chew May empty capsule into food Have sedating effects Must adjust dosage w/g

2.6. Meningitis

2.6.1. Bacterial Definition Inflammation of meninges R/T bacterial infection More serious than viral Often fatal Risk groups Infants, newborns R/T infection risk R/T complications Potential for deficits Secondary to OM Sinusitis Cellulitis of head/neck TB Septic arthritis Surgery or trauma Pathophysiology Bacteria in blood >> CNS >> subarachnoid Inflammatory process begins Manifestations Infants Children CSF changes Nursing care Respiratory isolation (!!) Immediate antibiotics Complications

2.6.2. Viral Characterized by increased BCs & protein in CSF Usually caused by enterovirus Symptoms resolve in 3-10 days Manifestations Appear less ill Irritable Fever HA Photophobia GI distress UR symptoms Maculopapular rash S/S meningeal irritation Treatment Aggressive until bacterial cause ruled out On RR isolation for at least 48 hrs

2.7. Encephalitis

2.7.1. Inflammation of the brain Usually viral r/t mosquitos Epidemic in summer

2.7.2. @ Risk for seizures

2.7.3. Supportive care Have IICP >> ICU >> floor

2.7.4. Manifestations Fever Irritability HA Bulging fontanel AMS >> coma

2.8. Reye Syndrome

2.8.1. Acute encephalopathy or cerebral dysfunction R/T toxic injury or anoxic insult Associated w/ASA Salicylate >> toxin Mitochondrial liver dysfunction >> Multiple OF + high brain ammonia

2.8.2. Poor prognosis w/high fatality rate

2.8.3. Manifestations Cerebral edema Hypoglycemia Fatty liver V Neuro S/S Progressive lethargy Seizures RR arrest

2.9. Headaches

2.9.1. Overview Biggest side effect of ASA May be benign or r/t structural cause

2.9.2. Migraine Triggers Stress Foods Caffeine Salt Glutamates Menstruation Oral contraceptives Fatigue or hunger Manifestations Uni or bi, frontal or temporal Pulsating or throbing Sensitivity to light and sound N/V Can be helped by sleep Treatment Analgesics NSAIDs Sumatriptan Avoid triggers Relaxation Biofeedback

2.9.3. Tension HA Triggers Stress Insecurity Family conflict Manifestations Bilat, dull, achy "Band around the head" Pain in sdrs, neck No aggravating factors Treatment R&R Analgesics NSAIDs Ice pack

2.9.4. Rebound HA R/T med overuse (ASA) Manifestations Dull, frontal area Uni or bi Occurs 5+/wk Variable severity, location Increasing frequency, intensity Treatment Withdrawal of all HA meds Clonidine r/t withdrawal Substitute meds that don't cause RHA

2.10. TBI

2.10.1. Any trauma to the head >> Change in LOC Anatomic abnormality of the brain

2.10.2. Leading CODD in kids

2.10.3. 90% of injury-related deaths are r/t TBI

2.11. Brain injury

2.11.1. Blunt or penetrating

2.11.2. Coup (initial) and contracoup (rebound)

2.11.3. Secondary injury d/t biochem, cellular response

2.11.4. Variable by age group Infants SBS Abuse Falls MVC Toddlers Falls MVCs School-age MVCs Sports Diving Teens MVCs (drug/alcohol) Sports Firearms

2.11.5. Manifestations Loss of consciousness >10 min = severe >> W/ S/S IICP d/t Seizures Projectile vomiting HA Confusion Loss of balance/altered gait Amnesia r/t incident

2.11.6. Sub-types Intracranial hematoma Subdural Epidural Both can cause herniation Concussion (mild TBI) Caused by direct blow Secondary to Causes AMS, but not necessarily LOC Three grades of severity

2.12. Skull fractures

2.12.1. Linear Just a crack Most common No treatment needed Impact to large area Overlying hematoma Soft tissue swelling

2.12.2. Depressed Break causes fragments >> depress into tissue Associated w/post-injury seizures

2.12.3. Compound Exposed cranial bone Surgical debridement

2.12.4. Basilar At base of skull Has dural tear & transient CN damage Nursing care Battle sign behind mastoid Black eyes CSF leakage through ear or nose NG tube contraindicated

2.13. Spinal cord injury

2.13.1. 2 per 100,000 children Usually cervical 60% cervical 20% thoracic R/T MVC or falls

2.13.2. Gliding r/t incomplete ossification For children <9 yrs old VC can lengthen about 2 inches SC can only lengthen 1/4in w/o a tear Limited swelling = reversible Severed or torn = permanent

2.13.3. Complete or incomplete Complete = permanent Higher = more severe

2.13.4. Consequences hTN Incontinence Poor thermoregulation Spinal shock Loss of reflexes Flaccidity Some return after 72 hrs Neurogenic shock Loss of vasomotor tone ANS compromised

2.13.5. Aggressive treatment Fix swelling ASAP Maintain function Rehab

2.14. Submersion injury

2.14.1. Definitions Drowning vs. near-drowning Submersion injury = when child survives

2.14.2. Risk groups 1-4 yo Males 15-24 yo

2.14.3. Pathology Panics & tries to swim Aspirates small amount of water in oropharynx Laryngospasm Hypoxia*** (more panic, hypoxia >> water swallowing & vomiting) Aspiration** (reflex inspiration >> aspiration) Hypothermia*

2.14.4. Complications Neurologic impairment common Submerged <5-10 min Resuscitated at the scene >> Few symptoms & consequences ALWAYS transport to hospital for 24hr

3. Neurological (Jackson)

3.1. Microcephaly

3.1.1. Cranial size way smaller than average Small brain size Growth frontal lobe severely stunted

3.1.2. Two forms Primary Genetics Toxin exposure Secondary After birth Infections Trauma Metabolic disorder Maternal anorexia in 3rd trimester Genetic conditions

3.1.3. Manifestations Autistic behavior to mild motor impairment Mental retardation Decerebrate posturing Complete unresponsiveness

3.2. Hydrocephalus

3.2.1. CSF 500 mL/d Poor reabsorption >> enlarged ventricles

3.2.2. Pathology Communicating Normal CSF flow Impaired absorption Non-communicating Blockage

3.2.3. Manifestations Fetal death in utero C section required r/t HC Rapid increase in HC Signs of IICP Early signs Bulging fontanels Can't hold up head Poor feeding Irritable/lethargic Late signs Apnea/brady Shrill, high-pitched cry Sunsetting eyes Will not feed Vomiting

3.2.4. Diagnostics Prenatal ultrasound Daily HC Ultrasound, CT, MRI

3.2.5. Intelligence borderline in 1/3 cases

3.2.6. VP Shunt Therapeutic management Head/abdominal incisions Tubing redirects excess CSF to peritoneal cavity Premedicate w/antibx Complications Mechanical Infection Nursing care Daily HC Pre-op care Post-op care Discharge

3.3. Neural tube defects

3.3.1. Anencephaly No brain, only brain stem

3.3.2. Encephalocele Herniated brain/meninges Defect in skull >> sac on head

3.3.3. Spina bifida occulta "Hidden split spine"

3.3.4. Meningocele Sac-like cyst of meninges filled w/CSF Protrudes from spine r/t VC defect Doesn't affect spinal cord

3.3.5. Myelomeningocele (SB) Pathology Unknown cause May be caused by environment Bowel/bladder control Muscle imbalance Hydrocephalus Arnold-Chiari II malformation Higher = greater dysfunction 80% are lumbar Nursing care At-birth Older kids Post-op Discharge

3.4. Craniosyntosis

3.4.1. Premature closing of sutures During first 18-20 mo Males > females

3.4.2. Three subtypes Scaphocephaly Saggital suture Restricted lateral growth Brachecephaly Coronal and saggital sutures Excessive lateral growth Positional plagiocephaly Asymmetric Flattening of occiput

3.5. Neonatal abstinence syndrome

3.5.1. Drugs readily cross placenta Fetal death LBW Small HC Prematurity Congenital anomalies Impaired G/D

3.5.2. Time for withdrawal Opioid 24-48 hrs post-birth Hypertonic Irritable Tachypnea Poor feeding High-pitched cry Seizures Barbiturate 4-14 days post-birth Cocaine/amphetamine Up to seven days after birth

3.5.3. Diagnostics Infant urine screen (just prior to birth) Infant meconium (last half of pregnancy) Positive urine Compare to L&D meds

3.5.4. Treatment Calm environment Certain meds Methadone Phenobarbital Diazepam Clonidine No breastfeeding if mom +

3.6. Neurofibromatosis (NF-1)

3.6.1. AKA "Von Recklinghausen disease"

3.6.2. Autosomal dominant genetic disorder Gene 17 Tumors adjacent to nerves Skin pigment alterations Bone deformities

3.6.3. Manifestations Cafe-au-lait spots Freckling in axillary/inguinal regions Lisch nodules Tan-brown Benign On iris of the eye DIAGNOSTIC Scoliosis Pain Blindness

3.7. Cerebral palsy

3.7.1. Overview Permanent movement/posture disorder Activity limitation Four types Spastic Dyskinetic Ataxic Mixed

3.7.2. Pathology Before birth Complication r/t prematurity Prenatal Genetic factors Fetal viral infection After birth Neonatal sepsis Hyperbilirubinemia CNS infection Brain injury

3.7.3. Manifestations Hypotonia Rigidity Spasticity Athetosis Ataxia Diplegia Quadriplegia

3.7.4. Nursing care High cal diet + fiber Skin care Physical activity Safety G/D Parental education Emotional support