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Pediatric Systems Review: CNS and Musculoskeletal Conditions

Pediatric Systems Review: CNS and Musculoskeletal Conditions. October, 2008 Diane Kocisko , RN, BSN, CPN. Impaired Vision. 4 months =Binocular vision develops 6 months =mature vision The eye should be at the same level of the pinna. Vision Screening. Ages 3 yr. to 6yrs. Snellen test

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Pediatric Systems Review: CNS and Musculoskeletal Conditions

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  1. Pediatric Systems Review:CNS and Musculoskeletal Conditions October, 2008 Diane Kocisko, RN, BSN, CPN

  2. Impaired Vision • 4 months =Binocular vision develops • 6 months =mature vision • The eye should be at the same level of the pinna.

  3. Vision Screening Ages 3 yr. to 6yrs. Snellen test Lea symbol chart Over 6 yrs. Titmus machine-

  4. Eye Problems • Strabismus- Crossed eyes • Nystagmus- eyes that gitter back and forth • Observe the child’s behavior -Sitting close to the TV -May not meet mile stones or have delay in development.

  5. Observe behavior • Always afraid of falling? • Afraid to explore environment • Self stimulating behavior? Rocking of body? Eye rubbing? Squinting?

  6. Vision problems, what can you do? • Announce yourself when you enter the room • Explain what sounds the child will here during care/assessments. • Encourage learning through other senses. • Maintain safe environment. • Arrange furniture for safety and allow for a consistent environment.

  7. Amblyopia / “Lazy Eye” Can be from strabismus Disuse=vision loss Get care before 6yrs old (mature vision) TX: Patch the good eye and make the bad eye work.

  8. Conjunctivitis/ “pink eye” • Infection of the conjunctiva. • Child goes back to school after 24 hrs. on antibiotics. • TX: Hand washing to prevent spread of disease. Give ointment inner canthus to outer canthus. • Don’t share pillows, blankets, towels, or linens.

  9. Hearing • Influences speech and intellectual development • Conductive =middle ear • Sensorineural =inner ear/8th cranial nerve • Ear problem = kidney problem ****They develop at the same time in utero!!!!!

  10. Treatment for hearing problem: • Face to face communication • Speak clearly • Do not shout or exaggerate words • Is child paying attention when you speak? • Minimize extra noise • ****Use demonstration when explaining procedures/care.

  11. Mental retardation/cognitive impairment • Cognitive development takes place before 18 yrs. old • Also looks at adaptive behaviors

  12. Degrees of MR • Mild 50-55 to 70 (mental age 8-12) • Moderate 35-40 to 50-55 (mental age of 3-7) ---most with Downs • Severe 20-25 to 35-40 (mental age of a toddler) • Profound below 20-25 (mental age of an infant)

  13. MR (cont.) • Make patient goals reasonable and achievable. • Give directions in small steps • Safety! • Self-care skills

  14. Cerebral Palsy (CP) • Neuromuscular disorder • Most commonly seen in preemies Non-progressive Increased muscle tone Varying degrees of MR (Not all CP patients have MR)

  15. Signs/symptoms of CP • Dyskinetic-athetotic-worm like movements that go away when asleep No contractions • Ataxic-poor balance and wide gate • Contracture of extensive muscles. heel release Rigidity!!!! BACLOFEN please!!!

  16. CP nursing interventions • Increase calorie intake • Provide food that is easy to eat. soup….not the best choice, but can drink it through a straw finger foods are better • Decrease stimulation during meals ROM • Safe environment • Body alignment • Small steps when giving directions

  17. 1-2-3 Seizures • Sudden alteration in consciousness or in sensation, activity • Aura? • Neurons are misfiring • Epilepsy=2 or more unprovoked seizures in childhood.

  18. SZ nursing intervention • Safety • Pad side rails • Turn on side • Keep airway clear • Don’t put anything in mouth • Time it (how long do they last) • Give O2 as needed • Ativan anyone? Diastat teaching

  19. Dilantin (phenyltoin) • Med for seizures • Side Effects: gum hyperplasia • Hirsutism • GI distress • Anemia • Nystagmus • Sedating • Check Levels

  20. Increase intracranial pressure • Trauma to head or inflammation or increase CSF in head/not draining • Hydrocephalus? What size should the head be? Are cranial sutures closed?

  21. S/S of ICP • Headache • nausea/vomiting • Increase BP and decrease HR and decrease respiratory rate. (Cushing’s Triad) Unequal pupils or sluggish pupils Decrease LOC SZ

  22. ICP treatments • Elevate the head of the bed • Keep head mid-line • Sedation • Follow head circumference • Decrease fluid intake • ?hyperventilation…not the best thing • Mannitol------but don’t forget the FOLEY PLEASE, I like my bladder

  23. Hydrocephalus • Increase CSF in ventricles • Obstruction or non- communicating • Arnold-Chiari malformation- brain goes down the foramen and is squeezed near the cervical region.

  24. Hydrocephalus TX: • Is fontanel bulging? • VP shunt or external ventriculostomy Bag at ear level Skin care Assist with turns Pain issues? Monitor CSF color/amt.

  25. Intraventricular hemorrhage (IVH) • Rupture in vascular of head=bleeding in head • Common in preemies less than 32 wks • Daily head circumference • Assess vitals, fontanels, and H/H

  26. Neural tube defects • Folic acid in pregnancy prevents this! • Anencephaly-no cerebral hemisphere. Not compatible with life. • Encephalocele-herniation of brain through skull • Meningocele-sac-like cyst that contains meninges (not spinal cord)

  27. Myelomeningocele • Most common type of spina bifida • Spinal nerves are in a sac, instead of the spinal column. • Surgery-----within 48 hrs. • Can test amniotic fluid for Alpha Fetoprotein

  28. Myelomeningocele TX: • Watch for infection • Protect sack from rupturing • Keep clean • Keep moist with NS and gauze • Assess: movement above/below sack, I&O (neurogenic bladder), increased ICP, measure head circ. • HIGH INCIDENCE FOR LATEX ALLERGY

  29. MENINGITIS • Viral or bacterial? Isolate for 24 hrs. • Passed by droplets • HIB vaccine prevents meningitis • Quick….get the antibiotics!!!!! • Assess for increased ICP, brudzinski’s sign, stiff neck, cloudy CSF, CSF with high protein, and low glucose.

  30. Brain Tumors • Gliomas-most common brain tumor in kids • Usually seen in kids 5-10 yrs. Old • S/S Headache, change in vision, Headache in the early morning, increased ICP, DI

  31. Head Injuries • Accidental/purposeful trauma • Abuse? • S/S N/V headache, LOC, change in consciousness, GCS, clear nasal or ear drainage may be CSF, frequent neuro checks….Get a head CT to check for bleeding

  32. Reye Syndrome • From ASA • Toxic encephalopathy • Don’t give ASA with viral infections • Assess for: high ICP, vitals, CT scan • Intervention: decrease intake, and avoid aspirin in kids under 16.

  33. Lead Poisoning (plumbism) • Lead paint, soil, old homes, lead pipes • Levels of 10mg/dl or higher • Carries by RBC, displaces calcium, and imbeds in bone. • S/S N/V, constipation, abdominal pain, learning difficulty • Lead screenings • TX: chelation therapy

  34. Migraine Headaches • 3x more common in women • Can be triggered by hormone changes • May have blurred vision or aura • Goal is prevention and no one really knows what causes them. • Scary, uh?

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