NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Neurological System

The central nervous system (CNS) (brain and spinal cord), the peripheral nervous system (cranial and spinal nerves), and the autonomic nervous system comprise the neurological system; together these provide control functions for the entire body.

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History.

  •  Birth history, developmental milestones, immunizations, and exposures.
  •  Recent trauma.
  • Current illness.

B. Level of consciousness.

  •  Interaction with environment.
  •  Glasgow Coma Scale score (infant or adult).

C. Size and shape of head (infants).

  • Size and quality of fontanelles and sutures.
  •  Recent acute increase in head circumference.

D. Assessment of motor function.

  • Symmetry of movements.
  •  Muscle tone and strength.
  • Tremors or twitching.
  •  Seizure activity.

E. Pupil size and reactivity, eye movements.

F. Cranial nerve (CN) assessment.

  •  Incorporate into other areas of physical exam when possible.
  •  Test CNs II, III, IV, VI (optic, oculomotor, trochlear, and abducens) together by checking pupils and having child follow light.
  •  Check CNs V, VII, XII (trigeminal, facial, and hypoglossal) together by having older child bite down, show teeth, and stick out tongue. Test younger infant’s ability to root for nipple, and check CN X (vagus) by observing ability to swallow.
  •  Test CN VIII (hearing) Rinne and Weber exam with tuning fork.
  •  Check CNs VII and IX (facial and hypoglossopharyngeal) by tasting sweet, sour, and bitter solutions (older children only).
  •  Test CN I (olfactory) in older children only.

G. Reflexes.

  •  Infant/persistent.
  •  Symmetry.
  • Presence of clonus.

H. Developmental exam.

  •  Obtain history from reliable caregiver.
  • Use evidence-based quality screening tools to evaluate attainment of major milestones (PEDS, ASQ).
  •  Use specific autism screening tool during toddler period (18 months).
  •  Communicate concerns/delays to other healthcare providers.

Pediatric Nursing: Newborn Reflexes

Focus topic: Pediatric Nursing

Pediatric Nursing

 

I. Behavioral history and assessment.

  •  Assess mood, eating, and sleep patterns; any recent changes.
  •  Assess ability to concentrate, school progress, and difficulty with relationships.
  •  Assess irrational or aggressive behavior especially with history of head trauma or CNS infection.
  •  Family history of behavioral disorders.

J. Respiratory pattern and vital signs.

  •  Assess altered respiratory pattern (cluster, ataxic, Cheyne–Stokes, apneustic).
  •  Evaluation of fever or signs of infection.

K. Indications of neurological problems.

  • Meningeal signs.
    a. Irritability, nuchal rigidity, opisthotonos.
    b. Positive Kernig’s and Brudzinski’s signs.
  • Seizures.
    a. History.
    b. Medications.
    c. Duration and assessment of motor involvement.
  • Signs of increased intracranial pressure (ICP).
    a. Altered level of consciousness (LOC).
    b. Irritability or lethargy.
    c. Headache, nausea, vomiting.
    d. Sunset eyes, bulging fontanelles, high pitched cry, poor feeding in infants.

Pediatric Nursing: Diagnostic Procedures

Focus topic  Pediatric Nursing

Client and family preparation must precede all procedures unless emergency. Nurses should be available to answer questions concerning the procedure and how the parents can help the client through the procedure.

Lumbar Puncture

A. Withdrawal of cerebrospinal fluid (CSF) by insertion of a hollow needle between lumbar vertebrae L3 and L4 or L4 and L5 into subarachnoid space to identify intracranial pressure, signs of infection, or hemorrhage. Fluid is analyzed for CSF chemistries, cell count, Gram stain, culture, and sensitivity.

B. Nursing responsibilities prior to procedure.

  •  Maintain baseline record of vital signs.
  •  Explain to the parents and child exactly what will happen.
  •  Ensure that consent has been obtained for the procedure.

C. Nursing responsibilities during procedure.

  •  Place child on side in knee–chest position with head flexed on chest.
  •  Help child remain steady in this position and reassure child throughout procedure.

D. Nursing responsibilities following procedure.

  •  Keep child flat in bed.
  •  Encourage fluid intake.
  •  If headache occurs when sitting up, return child to flat position and give analgesic.
  •  Observe neurological status for signs of deterioration.

E. Lumbar puncture (LP) should not be performed in clients at high risk for bleeding; extreme caution should be used if elevated ICP is suspected.

Computerized Tomography Scan

A. Provides visualization of neuroanatomy; differentiates tissue density compared to water.

B. Visualizes brain along vertical or horizontal plane from any axis.

C. Can distinguish hemorrhage, tumors, congenital abnormalities, and inflammatory or hypoxic processes.

D. May use contrast medium for enhanced views.

E. Nursing considerations.

  •  Client/family education about what to expect. Machine may provoke claustrophobia.
  •  Ensure that consent has been obtained prior to the procedure.

Pediatric Nursing: Assessment of Vital Signs

Focus topic:  Pediatric Nursing

  •  Client required to lie still during procedure. May require restraints or sedation.
  •  Assess carefully for allergy or anaphylaxis to contrast iodine based. Observe intravenous (IV) site carefully to avoid extravasation.
  • Recent evidence that repeated CT scans in young children may increase radiation related cancers. CT scans should be performed only for clearly delineated purposes.

Magnetic Resonance Imaging

A. Allows high-quality imaging of morphology of structures.

B. Distinguishes structures by response to radio frequency pulses in a magnetic field.

C. Tissue differentiation superior to other techniques.

D. Requires immobilization throughout procedure sedation and respiratory monitoring required for young clients.

E. Nursing considerations.

  •  Education of client/family about procedure and what to expect. Reassure older children.
  •  Ensure that consent has been obtained prior to procedure.
  •  Reinforce medical information as needed.
  •  Remove all metal items from the child before entering MRI room.
  •  Follow sedation protocol.
  •  Careful monitoring of vital signs, arterial oxygen saturation (SaO2), and respiratory status during procedure.
  •  Observe carefully for reaction to contrast medium.

Electroencephalogram

A. Provides information about electrical activity of cerebral cortex.

B. Used to assess neuronal functioning and to diagnose seizure activity; shows characteristic abnormalities for seizures.

C. Also may be used in part to determine brain death.

D. May be combined with simultaneous video recording.

E. Nursing responsibilities.

  •  Explain procedure and sensations to expect.
  •  Ensure that consent has been obtained prior to the procedure.
  •  Activities during procedure may include hyperventilation, sleep deprivation, and anti-seizure drug withdrawal.
  • Shampoo head afterward to remove all glue and gel.
  •  Clarify any misconceptions client does not receive shocks via leads, etc.

Electromyelogram

A. Records electrical activity in muscle fibers.

  •  Nerve conduction velocity is measured by placing needles in muscles and applying electrical current.
  •  May do computed tomographic (CT) myelogram or lumbar myelography. Contrast medium is injected into subarachnoid space to visualize structures around spinal canal.

B. Nursing responsibilities prior to procedure.

  •  Ensure that child is NPO 6–8 hours before procedure (follow sedation protocol).
  •  Maintain baseline record of vital signs and neurological status.
  •  Administer sedative as ordered.
  •  Educate client and family about sensations to expect (aches or needle pricks).
  •  Ensure that consent has been obtained.

C. Nursing responsibilities following procedure.

  •  Frequently observe neurological signs and vital signs and compare to baseline.
  •  Assure adequate hydration.
  •  Activity may be restricted.
  •  Watch for signs of infection or hematoma at insertion sites.
  • Slightly elevate head 30 degrees for at least 8 hours if contrast media is used for CT-myelography.

Angiogram

A. Radiopaque substance is injected into cerebral vasculature or its extra cranial sources to evaluate vascular anomalies, lesions, or tumors.

B. Nursing responsibilities prior to procedure.

  •  Ensure that consent has been obtained.
  •  Prep area where cannulization is to be made usually femoral or brachial.
  •  Ensure that child has no solid food for 6–8 hours prior to procedure.
  •  Keep baseline record of neurological and vital signs.
  •  Sedation usually necessary (occasionally anesthesia follow protocol).
  •  Observe closely for reaction to contrast medium.

C. Nursing responsibilities following procedure.

  •  Observe for changes in level of consciousness, transient hemiplegia, seizures, sensory or motor deterioration, or elevation of blood pressure with widening pulse pressure.
  •  Check circulation, movement, sensation (CMS) in extremity used adequate pulses, color, swelling, temperature.
  •  Encourage fluid intake.

 Pediatric Nursing: System Implementation

Focus topic:  Pediatric Nursing

For Infants

A. Record head circumferences, and graph results, at least every 24 hours.

B. Observe for changes in fontanelles.

C. Note activity level and interactions with significant others.

D. Observe for the continuous presence of sunset sign, high-pitched cry, feeding problems.

E. Observe for presence of all newborn reflexes. Note the symmetry of movement and the presence of hypertonia or hypotonia.

For Children

A. Note activity level and observe for changes in activity.

B. Control and prevent seizure activity. For specifications, refer to Seizure Disorders.

C. Carefully position child to prevent aspiration if vomiting is an actual or potential problem.

D. Check pupillary responses or movements at least every shift. Note presence of nystagmus or strabismus, abnormal responses.

E. Assess vital signs every 4 hours or more frequently if unstable.

F. Report I&O every 24-hour period.

G. Evaluate the nutritional status of the child if vomiting is present.

H. Provide sterile field for any treatment that involves an area with open entry to the nervous system.

I. Evaluate level of consciousness (see Neurological System, Medical–Surgical Nursing).

J. Assess child for presence of meningeal irritation.

  •  Kernig’s sign: Extension of leg causes spasm of the hamstring, pain and resistance when child is in supine position with thigh and knee flexed to right angle.
  •  Brudzinski’s sign: Flexion of head causes flexion of knees and both thighs at the hips.

K. Support the family through accurate reports of the child’s condition and by allowing the family to participate in the child’s care as much as possible.

L. Explain all procedures in truthful manner to the child. Allow time for questions.

Pediatric Nursing: Congenital Defects

Focus topic: Pediatric Nursing

Pediatric Nursing: Neural Tube Defects

Focus topic: Pediatric Nursing

Definition: Failure of posterior portion of lamina of bony spine to form, causing an opening in spinal column. Spina bifida and anencephaly are two most common forms. Spina bifida may involve (1) meninges and spinal fluid (meningocele) or (2) meninges, nerves, and spinal fluid (meningomyelocele). Neural tube defects (NTDs) occur in approximately 1 in every 1000 pregnancies in the United States.

Classification

A. Spina bifida occulta.

  •  Involves a bony defect only and does not involve the spinal cord or the meninges, not visible externally.
    2. Generally requires no treatment.

B. Meningocele.

  • Meninges of the spinal cord extend through opening in spine.
  •  Usually causes no paralysis.
  •  Treatment involves closure of sac.

C. Meningomyelocele.

  •  Nerves, meninges, and CSF protrude through defect in spine.
  •  This defect causes neuromuscular involvement, which can vary from flaccidity and lack of bowel and bladder innervation to weakness of lower extremities.

Assessment

A. May be detected prenatally by elevated concentrations of alpha-fetoproteins and by prenatal ultrasonography.

B. Assess for presence of hydrocephalus.

C. Assess neurological involvement.

D. Check urological involvement.

  •  Frequent bladder infections.
  •  Potential for progressive renal damage.
  •  Ileal conduit surgery is frequently required.
  •  Credé method of managing urinary retention involves systematic “milking” of the bladder at periodic intervals.

E. Assess for orthopedic involvement.

F. Evaluate bowel function.

Implementation

A. Prevention: American Academy of Pediatrics recommends consumption of 400 mcg of folic acid daily by all women capable of becoming pregnant.

  •  This can prevent 70% of NTDs.
  • Folic acid intake should increase to 400 mcg per day at least 1 month before becoming pregnant, and continue throughout the first trimester. Folic acid supplementation during the remainder of the pregnancy has been increased to up to 600–800 mcg/day.

B. Treatment dependent on severity of condition.

C. Neurological interventions.

  •  Observe for signs of hydrocephalus, a frequent complication.
  •  Measure head circumference at least every 24 hours.
  •  Observe for signs of increased intracranial pressure and signs of CNS infection (meningitis).
  •  Surgical closure performed as soon as tolerated. Until closure, the sac should be covered with a sterile, moist, non-adherent dressing (changed every 2–4 hours) and the infant kept in a prone position.

D. Urological interventions.

  • If child is catheterized, use sterile technique.
  •  Keep a careful record of intake and output.
  •  Teach parents Credé method if treatment is ordered.
  •  Observe for signs of urinary tract infection.
    a. Increased temperature.
    b. Foul-smelling urine.
    c. Cloudy urine with possible mucus.

E. Orthopedic interventions.

  • Provide opportunities for the child to exercise and develop unaffected areas, in conjunction with physicians and physical therapists.
  •  Prevent contractures through proper positioning.
    a. Provide foot brace to prevent foot drop.
    b. Provide support for legs to prevent external rotation of the hips.
  •  Implement range-of-motion (ROM) exercises.

F. Special considerations.

  •  Children with NTDs are especially prone to developing latex allergies. Exposure to latex should be limited or avoided in infants and throughout all treatment.
  •  Use of folic acid supplements in pregnancy has shown to decrease the incidence of NTDs.
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Pediatric Nursing: Hydrocephalus

Focus topic:  Pediatric Nursing

Definition: A condition in which the normal circulation of the spinal fluid is altered, resulting in pressure on the brain, deformity, and the progressive enlargement of the head. May occur as congenital defect or as the result of trauma, infection, or surgery.

Assessment

A. Assess for gradual enlargement of the head (no more than 2.5 cm per month). Below are approximate normal head sizes for comparison.

  •  35 cm at birth.
  •  40 cm at 3 months.
  •  45 cm at 9 months.
  •  At birth, the head size is 2 cm larger than the chest. Equals or exceeds chest until 2 years of age.

B. Check for separation of skull sutures.

C. Assess for sunset sign (sclera visible above iris).

D. Check for hyperactive reflexes.

E. Evaluate presence of irritability, failure to thrive, and high-pitched cry.

F. Assess for presence of projectile vomiting.

G. Prepare child and family for CT or MRI.

Implementation

A. Actions depend on the cause of increased pressure.

  •  Removal of part of choroid plexus to decrease production of cerebral spinal fluid.
  •  Shunting of the fluid out of the brain to the heart or to the peritoneal cavity.
  •  An endoscopic third ventriculostomy which allows CSF to bypass the third and drain into the fourth ventricle (for children older than 2 years).
  •  Removal of obstruction (mass lesion) to CSF flow.

B. Preoperative care.

  •  Prevent pressure sores on head by changing child’s position, placing child’s head on gel form or other skin  protective device, or by holding the infant.
  •  Provide good head support when the child is sitting in Fowler’s position.
  •  Promote optimal nutritional status.
  •  Keep eyes free of irritation.

C. Postoperative care.

  •  Observe for shunt malfunction and valve patency: Watch for progressive increase in head circumference and signs of increased intracranial pressure; evaluate pupils and eye movements carefully.
  •  Observe for infection: increased temperature, rapid pulse, irritability, nausea, or vomiting.
  •  Position child flat on unoperated side.
  •  Prevent postoperative complications: Turn every 4 hours, evaluate lung sounds, and assess for signs of infection.
  •  Administer antibiotics as ordered.
  •  Protect the operative site: Avoid pressure on the site; ensure sterile dressing changes.
  •  Maintain adequate fluid and nutritional status.
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