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Perception and Coordination

COMMON PEDIATRIC MUSCULOSKELETAL PROBLEMS

Traumatic injury
– Soft tissue injuries to the muscles, ligaments, and tendons are common in children.
– In young children they occur from mishaps during play.
– For older children and adolescents, they occur during sports.

Soft Tissue Injuries

Contusions(bruise)
– Damage to soft tissue, subcutaneous structures, and muscles
– Injured area is ecchymotic (black and blue discoloration) due to
– blood leaking into tissues; swollen and painful.
Cannot tell how long injury occurred by the bruise.
o Immediate treatment is application of cold.

Sprains
– Occur when trauma to a joint is so severe that a ligament is partially or completely
torn or stretched. Usually involves damage to blood vessels, muscles, tendons, and
nerves.
o Child may describe a “snap, pop, or tearing”.
Ice immediately; do not apply for
more than 30 minutes
Therapeutic management of soft tissue injuries

The first 6-12 hours is the most

critical for almost all soft tissue
injuries.
Basic principles include RICE or ICES
R.I.C.E.: Rest, ice, compression,
elevation
I.C.E.S.: Ice, compression, elevation,
support
Reverse effects: vasodilation occurs
Elevate the extremity above heart level.
Torn ligaments, especially those in the
knee, are usually made immobile with a
cast or splint for 3-4 weeks.
Passive leg exercises, gradually
increased to active leg exercises,
begun as soon as sufficient healing has occurred.

Fractures
– Common injury at any age but more likely to occur in children and older adults
– Usually due to traumatic incidents at home, school, in a motor vehicle,
– or associated with recreational activities

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– Rarely occur in infants unless there is an underlying hematology disorder

– Toddlers- be suspicious of fractures at various stages of healing
– School-age children—usually due to bicycle-automobile or skateboard injuries
– Adolescents: bikes, motorcycles, sports

Common Fracture sites:

Forearm: falling on the outstretched hand.

Clavicle fractures are common
Hip fractures are rare

Typesoffracturesinchildren

1. Bends: Deformity without breaking (think of a young, green stick that won’t break, but it
bends)
2. Buckle fractures: Compression of the porous bone, raised or bulging
3. projection at site. (not broken all the way through)
4. Greenstick fracture: incomplete fracture, bone is angulated beyond limits of bend.
5. Complete fracture: Divides bone fragments
o Transverse: straight up and down
o Crosswise, at right angles to the long axis of the bone
o Oblique: Slanting but straight, between a horizontal and
o perpendicular direction (diagonal).
o Spiral: slanting and circular, twisting along the bone shaft
o Comminuted: broken into pieces (crushed).
o Closed or simple
o Open or compound (protruding through the skin)

Complete fractures

Transverse: straight up and down

o Crosswise, at right angles to the long axis of the bone
o Oblique: Slanting but straight, between a horizontal and perpendicular direction
(diagonal).
o Spiral: slanting and circular, twisting along the bone shaft
o Comminuted: broken into pieces (crushed).
Closed or simple
Open or compound (protruding through the skin)

Growth plate or Epiphseal injuries

 Weakest part of long bones

 Frequent site of damage
 Fracture may be through degenerating cartilage cells, without damage to growth
 Other fractures of the epiphysis may cause growth problems such as
 shortening of the limb

Associated problems with fractures in general

Muscles contract and spasm

Bones are pulled out of alignment
Severe hemorrhage in tissues, especially with femur fractures
Vascular injuries

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o Femur fracture may cause injury to sciatic nerve
o Bone marrow is high vascularized

5 P’s of Ischemia
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Paralysis

Nursing actions for fractures

Support the injured limb; splint, DO NOT MOVE OR STRAIGHTEN OUT THE BONE.
Ask the child to point to where it hurts
Ask the child to wiggle fingers or toes
Check distal pulses
Get historical information from someone who witnessed the injury if possible.

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Diagnostic Evaluation

History may be lacking!

o Young children cannot tell
o Older children may not tell the truth in fear of repercussions
Radiography is the most useful tool

Therapeutic Management of Fractures

Reduction: regain alignment and length; “setting bone”. Immobilization: retains

alignment and length
Restore function
Prevent further injury

Bone Healing and Remodeling

Rapidinchildren
– Due to thickened periosteum (the fibrous membrane that forms the covering of bones).
– Generous blood supply from bone marrow
– New bone cells are formed in immense numbers almost immediately after the injury—
immediate treatment is detrimental
Examplesofhealingtimesfor femoralshaftindifferentagegroups:
o Neonatal period: 2-3 weeks
o Early childhood: 4 weeks
o Later childhood: 6-8 weeks
o Adolescents: 8-12 weeks
o The general rule of thumb is that the younger the child is; the quicker the bones
heal.

Delays in healing

Gaps between fragments delays or prevent healing

Prompt healing with end-to-end apposition (two normally contiguous parts)
– Though, may cause bony overgrowth and greater length of extremity
Angulated deformity may remodel in young children. Careful reduction and follow-up to
prevent permanent disability.

Fracture Complications

1. Circulatory impairment
Absence of pulse, discoloration, swelling, pain
Report immediately to practitioner
Take steps to improve circulation (take action!)
o Loosen ace wrap
Most common lawsuits against nurses
2. Nerve compression syndromes

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Typically caused by blunt trauma

Pressure rises within this space with tight dressings or casts, hemorrhage,
trauma, burns, and injury
Most common symptoms
o First sign: Pain out of proportion to injury
o Second sign: Tenseness on palpation
o Third sign: motor weakness
3. Non-union
– Failure of bone fragments to unite
– Failure to unite due to any of the following:
Separation of bone fragments at fracture site
Hematoma (swelling of comprising a mass of extravasated
blood, usually clotted, caused by a break in a blood vessel)
Extra tissue between bone fragments
Necrosis of bone tissues or infection
Interruption of blood supply
Bone grafting may be required

4. Pulmonary emboli (fat, blood, and air)

– May not occur for 6-8 weeks after injury
– Fat emboli, first 24 hours usually in adolescents
– Signsandsymptoms:
Dyspnea
Chest pain
Onset of sudden pain
Nursinginterventions
First: Elevate the head
Second: Administer oxygen
Notify physician immediately

Cast care

*Risk for altered peripheral tissue perfusion related to pressure from cast
Expectedoutcomes:
1. No pain or numbness in extremity
2. Distal nail beds blanches and refills in less than 3 seconds
3. Pedal pulses palpable
4. Area surrounding case is warm and pink

Interventions:
Keep extremity elevated
Check circulation every 15 minutes during the first hour, every
hour for 24 hours, then every 4 hours thereafter
Assess for numbness or tingling (children under 6 or 7 may not be able to express this)
Edema that does not improve with elevation should be reported
Assess for the 5 P’s—if any of these symptoms are present,
requires immediate attention!
Can lead to permanent paralysis of extremity. Risk for impaired tissue integrity
related to pressure from cast
Edges of cast are usually covered by a fold of stockinet

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If no stockinet, adhesive tape strips are applied to prevent skin

irritation (petaling)
If the cast is surrounding the genital area, or there is any chance of
cast coming into contact with stool or urine, need to cover with
plastic. Prevention is very important as
once urine has penetrated a cast, there is no way to remove it.
Can clean cast with a damp cloth when soiled with food
Knowledge deficit related to cast care
Instruct parents/child on how to care for cast
Instruct on 5 P’s
Continued swelling could cause cast to become a tourniquet.
This is why we wait a day or two to cast
Parents should receive verbal and written instructions
Teach neuro/circulation checks to parent’s (5 P’s)
Document parent’s response to teaching. Always have parents re-
demonstrate

Cast removal

Most casts in place to 6-8 weeks

Removed with electric cast cutter
Skin usually looks macerated and dirty, a good bath will remove dirt.
– Atrophy will resolve in its own.
Once healing takes place, the extremity is as strong as before—but
children will usually favor the extremity.
Allow them to regain full use on their own time schedule.

Scoliosis

 Lateral (sideways) curvature of the spine

May involve all or only a portion of the spinal column
Functional scoliosis (in response to another condition)
o Occurs as a compensatory mechanism
o Usually due to unequal leg lengths
o Created a pelvic tilt that is C-shaped
o Must correct the initial problem
A lift placed in one shoe
Remind the child to maintain good posture (walking with book on
head 3 x daily for 10 minutes)
Sit-ups and push-ups are good exercises

 Structural scoliosis
Permanent curvature of the spine with damage to the vertebrae
Spine has an S-shaped appearance
Usually there is a family history
5x more common in girls than boys
Usually peaks between 8-15 years (school age)
Diagnosis is made on physical exam by having the child bend forward
X-rays confirm diagnosis
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Therapeutic management:
 If spinal curve is less than 20 degrees, no therapy except close
observation until the child reaches 18 years of age)
 If greater than 20 degrees, may use braces, traction, surgery, or
combination.

Nursing care of the immobilized child: Goals and interventions

Goal One: Increase physical mobility related to mechanical restrictions, physical disability
o Transport child by gurney, stroller, wagon, bed, WC from room to play room, lobby, or
other area as allowed
o Change position of bed in room
o Out of bed in chair, wagon, etc. as allowed
Goal Two: Assist child to maintain optimal autonomy
o Provide mobilizing devices (crutches, WC)
o Assist with acquiring specialized equipment
o Instruct in use of equipment
Encourage activities that require mobilization
Allow as much freedom as possible and encourage normal activities
Encourage child to participate in own care
Allow child to make choices

High Risk for Impaired Skin integrity

Goal: Maintain skin integrity

o Place child on pressure-reducing mattress
o Change position frequently, unless contraindicated
o Protect pressure points with proper positioning and cushioning
o Inspect skin surfaces for signs of breakdown
o Eliminate mechanical factures that cause friction
o Good skin care
o Gently massage skin area until contraindicated

High risk for injury

Child will experience no physical injury

o Teach correct use of devices (child and parent)
o Assist with moving and/or ambulating
o Remove hazards from environment
o Modify environment as needed
o Keep call button within reach
o Keep siderails up at all times
o Help child use bathroom or commode if possible
O Implement safety measures appropriate to child’s developmental stage
o Diversional activities

Muscular Dystrophies

The largest group of muscle disorders of childhood

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Three types:

Congenital myotonic dystrophy

o Begins in utero
o Newborn may already have significant myotonia (muscle weakness)
o Usually die before one year of age due to respiratory failure
Assessory muscles for respiration fail

Facioscapulohumeral Muscular dystrophy

 Begins after 10 years of age

 Facial weakness is the predominant symptom
 Very slow progression of symptoms Less disability than the other types Normal lifespan
is possible.

Pseudohypertrophic Muscular Dystrophy/ Duchenne’s Disease

Most common form of MD

Symptoms usually appear by age 3 years
Occurs only in boys
Late in meeting motor milestones
Muscle weakness gradually becomes more pronounced
Usually wheelchair-dependent by adolescence
Heart and respiratory failure may occur by early adulthood

COMMON PEDIATRIC NEUROLOGIC DISORDERS

Cerebral Palsy

A group of non-progressive disorders of upper motor

neuron impairment that result in motor dysfunction.
Can happen before, during, or after birth
Occurs 2:1000 births
Most common permanent disability of childhood

Incidence and Causes of CP

Most frequently associated with brain anoxia that leads

to cell destruction
o Symptoms can range from very mild to quite severe,
depending
on the extent of brain damage
Also can be caused by:
o Kernicterus (a form of jaundice from hyerbilirubinemia;
staining of the brain with bilirubin)
o Meningitis (viral is the most common)
Occurs most frequently in very low weight infants (born
prematurely),
or those small for their age.
o Their lungs haven’t been fully developed
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CP has increased over the past decade due to:

o Preemies are living longer
o Multiple births from artificial reproductive technologies
o Prenatal technology

Types of CP

Two main categories based in type of neuromuscular

involvement
o Pyramidal or spastic (50-70% of children with CP)
o Extrapyramidal (outside of the pyramidal tracts of the CNS)
Ataxic (awkward, unsteady gait)
Dyskinetic (defect in ability to perform voluntary
movement)
Athetoid (slow, irregular, twisting, snakelike
movements occur in the upper extremities, esp.
in the hands and fingers)
Mixed

Spastic or pyramidal CP

Pyramidal system: conveys nerve impulses that create

voluntary movements
Problems in this area result in:
o Hypertonicity: excessive tone in the voluntary muscles
o Abnormal clonus: rapidly alternating involuntary contraction
of skeletal muscle
o Exaggeration of deep tendon reflexes
 Abnormal reflexes such as a positive Babinski reflex
Continue to have neonatal reflexes past usual age
(tonic neck reflex) Arch their back and extend arms/legs
abnormally when held in a ventral suspension position
 Fail to do a “parachute” reflex if lowered suddenly (do not
extend arms/hands in front of self)
 Assume a “scissors gait” due to tight adductor thigh
muscles which cause their legs to cross when held
upright.
 May have tightening of heel cord which causes the child to
walk on toes; unable to stretch heel to touch the ground.
Spastic involvement may affect:
o Both extremities on one side (hemiplegia)
o All four extremities (Quadriplegia)
o Primarily lower extremities (paraplegia or diplegia)
Children with quadriplegia:
o Usually have impaired speech
o Swallowing is difficult—drool, problems eating
o May have cognitive impairment
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Extrapyramidal CP

Extrapyramidal nerve tract conveys nerve

impulses that effect autonomic movements:
o Help coordinate body movements
o Maintain skeletal muscle tone
o Play major role in equilibrium
Ataxia (defective muscular coordination)
Dyskinetic (a defect in the ability to perform
voluntary movements) Athetoid—“wormlike”
o Limp and flaccid muscles as an infant
o Later, child makes slow, writhing motions (in place
of voluntary
muscles)
o May involve all four extremities, face, neck,
tongue
o Due to poor tongue and swallowing movements,
child may have
poor speech and problems with drooling
* Concerned about aspiration
o With emotional stress, involuntary movements may become
become irregular and jerky.

Ataxic
o Children have an awkward, wide-based gait
o On neurologic exam, unable to touch finger-to-nose or due
rapid,
repetitive movements
Mixed
o Combination of more than one condition listed above
Diagnostic evaluation for diagnosis of CP
Neurological exam History—especially born prematurely Ultrasound of
brain
CT scan
MRI

Physical findings that may suggest CP

 Delayed motor development
 Abnormal head circumference (head is typically larger) Abnormal
postures
 Abnormal reflexes
 Abnormal muscle performance and tone
 25-75% of children have cognitive defects may have visual problems
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Medical management of CP
Overall goal—develop a rehabilitation plan to promote optimum
function
Multidisciplinary teams
o OT, PT, Speech
 As child grows, would include therapeutic exercises, splints,
braces
 Antispasmodic drugs may also be used (Baclofen), but may
have little effect
 Surgery to lengthen heel tendons may be done
 Wheeled walkers or scooter boards
 Cerebellar pacemakers may decrease spasticity in some
children
o Also called Baclofen pumps

Nursing Diagnoses

 Altered growth and development

 Impaired physical mobility
 Self-care deficits
(bathing/toileting/dressing)
Self-esteem disturbance
 Impaired social interactions

General interventions

Promote maximal functioning of joints

Provide adaptive equipment for activities of daily living
o Modified utensils for eating
o Push panels for computer
o Electric switches for battery operated toys
Position to prevent contractures
o Perform active and passive ROM exercises, must
be done daily Provide adequate nutrition—often
have difficulty swallowing Encourage verbalization of
feelings about altered body image Encourage social
interaction with peers
Teach patient and family how to maintain
independence
Identify support groups

Long term care for CP

Sometimes children are not diagnosed with CO until

2-4 years later. This can be upsetting to parents.
Will need much support and education.
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Febrile convulsions

Seizures associated with high fever (102-104 degrees F)

Most common in preschool children or between 5 months and
5 years of age
Usually no more than 5-7 of these episodes occur in a child’s life

Seizure activity

Seizure usually lasts 15-20 seconds

Shows an active tonic-clonic pattern (alternately
contracting and relaxing the muscles)
EEG tracing usually normal
Usually a family history
Seizures subside once the fever is gone

Prevention of Febrile convulsions

Give Tylenol to keep fever below 101

Often fever develops during the night when
parent/caregiver is not with child
If child has one febrile seizure, no further treatment given other
than to
advise parents to administer Tylenol to keep fever below 101
If more than one seizure, child may be put on Phenobarbital
(controversial)

Therapeutic management of seizures

Teach parents that after the seizure subsides, they should:

o Sponge the child with tepid water
Do not put child in bathtub
Do not use rubbing alcohol or cold water
Do not give Tylenol right after the seizure (not
awake enough to swallow)

If unable to decrease temperature by sponging, advise parents

to:
o Put a cool washcloth on child’s forehead, axillary, and
groin area’s (which are temperature receptors)
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Healthcare facility will:

Determine underlying cause

Lumbar puncture to rule out meningitis
Antipyretic drugs
Antibiotic therapy if needed
Assure parents that febrile convulsions do not lead to brain
damage and child will be well.

Bacterial Meningitis

Infections or inflammation of the cerebral meninges (the

membranes covering the brain and spinal cord)

90% of cases are between 1 month and 5 years

Peak incidence is in the winter.
Causative organisms (95% of
cases)
o H. Influenzae (type B)
o Streptococcus pneumoniae
o Neisseria meningitis- epidemic form; droplet from
nasophargeal
secretions
MUST be put on droplet isolation

Pathophysiology of Bacterial meningitis

Pathologic organism spreads to the meninges from upper

respiratory tract or by lymphatic drainage from the sinuses.
Once pathogen enter the meningeal space, they spread rapidly
Produces an inflammatory effect that leads to thick
exudates that blocks CSF flow.
Brain becomes edematous, covered with purulent exudate.
Spreads VERY quickly through CNS

Clinical signs in Children and Adolescents

Usually have 2-3 days of a cold, upper respiratory

infection and occasionally and ear infection.
Become VERY irritable due to headache
May have convulsions photophobia.
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As the disease progresses, more signs of meningeal irritability
occurs:
o Positive Brudzinski’s (image on page 674)
When child’s head is flexed forward (while
laying on back), both hips, knees and ankles
flex. This shows meningeal irritation
o Positive Kernig’s (image on page 674)
Flex child’s hips and knee (while laying on back)Then
extend leg—this will cause pain, resistance and spasm
which indicate irritation.
o Nuchal rigidity occurs (neck stiffness)
o In the newborn—poor sucking, weak cry, lethargy

Diagnostic Evaluation—Lumbar Puncture

Obtained by history and analysis and CSF via Lumbar puncture

o Culture and gram stain identify causative organism
Blood cell count—WBC elevated
Lowered glucose
o Increased metabolic rate due to the body and brain trying to
fight off infection; draws glucose out of blood for energy.
Protein content increased
o Due to extra cells and metabolism occurring in the CNS.

Therapeutic Management

Medical emergency!
o Directly put on droplet isolation precautions
o IMMEDIATE antimicrobial therapy
o Hydration
o Ventilation (not in all cases)
o Reduction of increased ICP
o Management of shock and Disseminated intravascular
coagulation (DIC)
Tidbits on DIC: Normally, when you are injured, certain proteins
are turned on and travel to the injury site to help stop bleeding.
However, in persons with DIC, these proteins are abnormally active.
Small blood clots form throughout the body. Overtime, the clotting
proteins become "used up" and are unavailable during times of real
injury
This disorder can result in clots or, more often, bleeding.
Bleeding can be severe.
o Control of seizures, temperature.
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Increased Intracranial Pressure

Not a single disorder, but a sign that may occur with many neurological
disorders
One such cause is a brain tumor
The rate at which symptoms develop is:
o Cause
o Ability of child’s skull to expand to accommodate the increased
pressure
The younger the child, the more flexible the skull
o Location
o Size and growth rate of tumor
Children with open fontanels withstand more pressure than
older children

Signs of ICP:

Increased head circumference

o >2cm/month in the first 3 months
o >1cm/month in the 2nd three months
o >0.5cm/month for the ext six months
Fontanel changes
o Anterior fontanel tense and bulging; closes late
Vomiting
o Occurs without nausea (rarely with nausea)
o Occurs upon awakening in the morning or after a nap
The fluid is not moving when sleeping
o May be projectile
Eye changes
o Diploplia (double vision) from pressure on abducens nerves
o White of sclera evident over top of cornea (“sunset eyes”)
o Limited visual fields
o Papilledema (retinal edema—cannot see on physical assessment;
need special equipment)
Visual sign changes
o Elevated temperature and blood pressure (body regulators are
compressed)
o Increase in pulse pressure (the gap between the systolic and
diastolic)
o Decreased pulse and respirations due to the growing pressure on
brain stem which controls:
Cardiac rate and respirations
Pain
o Headache on awakening and standing. Increases with valsalva
maneuver) or holding breath
Each increased intrathoracic pressure
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Mentation
o Irritability, decreased level of consciousness, altered LOC Later
signs:
o Personality changes
o Seizures
o Head tilt (because of heavy tumor)
o Decreased LOC
o Decreased motor response to stimuli
o Decreased sensory response to painful stimuli
o Alterations in pupil size and reactivity
o Cheyne-stokes respirations
o Decerebrate or decorticate posturing
This is very bad

Glasgow coma scale

Most widely used of the pediatric coma scales

Standardized scale to describe and interpret the degree of LOC in
persons with brain injury
The lower the score, the deeper the coma
3 parts:
o eye opening
o verbal response
o motor response
highest score is 15
lowest score is 3
Medical management is based on these scores

Tumors

The most common solid tumor that occurs in children, secondary to

leukemia
Tends to occur between 1 and 10 years of age (5-years is the peak)
In children, tends to occur in areas of the brain where they are difficult
to remove.
Signs and symptoms due to increased intracranial pressure (ICP)

Treatment of Brain tumors

4-6 months may pass from first symptom before diagnosed diagnostic
tests:
o skull films
o bone scan
o MRI
o Cerebral angiography (difficulty getting dye through due to
abnormal vascularization)
o CT scan
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Therapeutic management of brain tumors

Includes a combination of surgery, radiotherapy, and chemotherapy

Preoperative care
o Will usually receive a stool softener—do not want child to strain
after their brain is operated on
o A portion of the head is shaved; very traumatic for adolescent
o If going to the ICU after surgery, have child meet the ICU staff.

Postoperative care

Positioning
o Depends on location of tumor; usually on the opposite side of
incision
o Bed is flat or slightly elevate.
o DO NOT lower the head of the bed
o Child will be very lethargic due to brain swelling
Assess VS every 15 minutes initially until stable. Eventually will
decrease to every 4 hours
Monitor IV fluids very carefully. Too much fluid can cause edema in the
brain
o We don’t want the child to be dehydrated, but we do want them
on the “drier” side
Prevent nausea and vomiting

Therapeutic management of ICP

Identify source and remove ASAP

Keep coughing, vomiting, and sneezing to a minimum
Place child in a semi-fowler’s position (infant seat for infants)
Monitor IV fluids very carefully
Meds:
o Corticosteriods (Decadron)—reduces inflammation
o Osmotic diuretic (mannitol)—pulls fluid out of tissues

Will usually insert foley catheter prior to administration for accurate

I & O’s

Hydrocephalus

 Caused by imbalance in production and absorption of CSF

 CFS accumulates within ventricular system of brain, producing
dilation of ventricles.
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Mechanisms of Fluid imbalance in Hydrocephalus

 Tumor of choroid plexus (the area that produces CSF in brain) may
cause increased secretion of CFS.
 Choroid tumors are rare, but structural malformations may cause
impaired absorption or obstruction to outflow of CSF. Imbalance of
secretion and absorption of CFS causes CFS to accumulate in the
ventricles, which dilate and compress against cranium
 Skull also enlarged
 Most are a result of developmental malformations (in ventricular
system)
 Usually presents in infancy, but can also be up to early childhood
 Other causes: infections, neoplasms, trauma, brain damage

Clinical manifestations of hydrocephalus

 Influenced by acuity of onset and presence of pre-existing structural

lesions
 In infancy, head grows at an abnormal rate
 Anterior fontanel tense, bulging, dilated scalp veins (due to the skin
stretching)

Manifestations of Hydrocephalus in childhood

 Caused by increased ICP

 Headache upon awakening with improvement following emesis or
upright posture
 Papilledema (edema and inflammation of optic nerve)
 Strabismus Ataxia Irritability/lethargy Confusion Incoherence

Diagnosis

 Head circumferences Associated Neuro signs CT, MRI, skull x-ray

 Dye inserted into ventricle through anterior fontanel—will not
appear in CSF from lumbar puncture if non-communicating

Therapeutic management

 Relief of hydrocephalus

Treatment of complications
 Management of issues related to psychomotor alterations
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Surgical treatment

Direct removal of obstruction if present (cyst, neoplasm, Hematoma) A

shunt is inserted under the skin the drain ventricles, may include a
reservoir to add medications and remove fluid.

More on Shunts…

Valves open at a predetermined intraventricular pressure and close

when the pressure falls below that level (prevents backflow) Ventriculo-
Peritoneal (VP) shunt is preferred for infants and young children
Ventriculo-Atrial (VA) shunt (ventricle to right atrium) reserved for older
children who have attained most of their growth and for children with
abdominal pathology (perforation of bowel, etc.)
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1. Mechanical obstruction within ventricles from tissue or exudates, displacement

related to growth, thrombus (clot)
2. Increased ICP and worsening of neurostatus
3. Infection—the most serious complication. May occur at any time but the greatest risk
is 1-
2 months after placement. (tubing colonized with bacteria)

Signs of CSF infection

- Elevated vital signs

- Poor feeding
- Decreased LOC
- Seizures
-

Postoperative Care after shunt

placement

Position on un-operated side

May need to keep flat to avoid too
rapid reduction of intracranial fluid
Observe for signs of increased
ICP
o If increased ICP occurs,
elevated the height of head
to 15-30 degrees to enhance
gravity flow through the
shunt
Monitor I & O’s carefully, may be on
a fluid restriction
Presence of bowel sounds
determined before feeding infant
with VP shunt (incase the bowel
was perforated at the time of
placement—do not want leaking
into the tube)

Associated Nursing Diagnoses

1. Potential for injury related to increased ICP

2. Potential for infection related to presence of mechanical drainage system
3. Altered family processes related to having a child with a chronic illness
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NEURAL TUBE DEFECTS

1. Spina Bifida: defect in closure of the vertebral column with varying degrees
of tissue protrusion
2. SpinaBifidaOcculta:
o Posterior vertebral arches fail to close in the lumbrosacral
area o Spinal cord remains intact and usually is not visible.
o Meninges are not exposed on the skin
surface o Neurological deficits are not
usually present
3. SpinaBifidacystica:
o Protrusion of the spinal cord and/or it’s meninges occurs
o Defect results in incomplete closure of the vertebral and neural tubes,
resulting
in a sac-like protrusion in the lumbar or sacral area, with varying degrees
of
nervous tissue involvement
4. Meningocele:
o Protrusion involves meninges and a sac-like cyst that contains
o CSF in the midline of the back, usually the lumbosacral area
o Spinal cord is not involved
o Neurological deficits are usually not present.

5. Myelomeningocele:
o Protrusion of meninges, CSF, nerve roots, and a portion of the spinal
cord occurs.
o The sac (defect) is covered by a thin membrane that is prone to
leakage and rupture
o Neurological deficits are present.

Clinical Manifestations

Vary according to degree of spinal defect

 Neuro dysfunction related to anatomic level of defect and nerves involved
 Defective nerve supply to bladder often causes urine dribbling or overflow
incontinence
 Poor anal-sphincter tone; lack of bowel control and rectal prolapse There may be
saddle anesthesia with bladder and anal sphincter paralysis.
 May also have ortho involvement; joints, kyphosis, scoliosis, hip dislocations
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Diagnostic Evaluation

Ultrasound

Care of the Myelomeningocele Sac

1. Evaluate the sac and measure the lesion

2. Protect the sac; cover with a sterile, moist (normal saline) dressing. May include
an antibiotic in the solution. Change every 2-4 hours. Device to maintain body
temperature without clothing or covers that irritate the sac.
3. Place in prone position to minimize tension on the sac and the risk of
4. trauma; the head is turned to one side for feeding.
5. Assess for early signs of infection; elevated temperature, irritability, lethargy, nuchal
rigidity.

Associated Nursing Diagnoses

1. Potential for infection related to presence of infective organisms,

nonepithelialized meningeal sac
2. Potential for trauma r/t delicate spinal lesion
3. Potential for impaired skin integrity r/t paralysis, continual dribbling of urine or
feces
4. Potential for trauma r/t impaired cerebrospinal circulation
5. Potential for injury r/t neuromuscular impairment

***End of Perception and Coordination***

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