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Rapid growth continues in early childhood and then slows during later childhood and adolescence

Brain growth
50% by 1 year
75% by 3 years
90% by 6 years
what does the Frontal lobe control:
personality, emotions, complex intellectual function, voluntary movement
Parietal lobe
sensory input-pain, pressure
Temporal Lobes
senses, language
Occipital lobe
Vision
Cerebrospinal Fluid
Cushions brain
—100-500 ml/day produced
Cerebral Blood Flow
Art pressure should be between 60-150mmHg
Intracranial Pressur

—Norm press: 0-12mmHg
Spinal column & Cord

—Cervical =7 vertebrae, lumbar= 5, sacral =1, coccyx=1
Hypercapnia
dilates cerebral arterioles, increases CBF
Hypocapnia
constricts cerebral arterioles, decreases CBF
Severe Hypoxia
 increases CBF
Hyperthermia
increases oxygen consumption
Hypothermia
decreases oxygen consumption
Blood Brain Barrier
certain conditions that cause cerebral vascular dilation disrupt the BBB:  hypertension, hypercapnia, hypoxia, acidosis
Differences in Child/Adult Brain

Head smaller but composes larger percentage of body mass  
Brain 67% of adult @ birth, 6yo= 90%  
Myeliniation completes 1st year  
Fontanels:      1. posterior: closes by 2-3mos      2. anterior: between 12-18 mos


—Cerebral Blood Flow & O2 consumption in children< 6 yo is almost twice adults
 
—↑ metabolic requirement consistent G & D
 
—Growth & the final form of the brain depends on development & multiplication of neurons
Increased Intracranial Pressure

—Enclosed system once the anterior fontanel closes.  There can be compensatory changes if needed by reduction in blood volume, decrease in production of CSF, increased absorption of CSF, shrinkage of brain mass by displacement of the intracellular and extra cellular fluid
S/S ⇧ICP early signs
Early Signs:
HA, N/V,
l change LOC
sunsetting eyes
seizures 
high pitch cry
bulging fontanelle
dilated scalp veins
wide sutures  irritability
S/S ⇧ICP late signs
Late Signs:
—↓LOC
—resp distress: ¡Cheyne-stokes
—fixed pupil w/ contralateral ext. flaccid/spastic  Cushing’s triad (very late):     1. bradycardia     2. Wide pulse pressure     3. ⇧ SBP
Neuro Assessment for ICP

—Changes in LOC
—Eyes:  --PERLA
—Motor response:  --Posturing:  decorticate (arms down and flex), decerebate
—Reflexes:
—Eyes ¡Brain Death Doll’s eyes Caloric Test / Oculovestibular response
Interventions for IICP

—Respiratory management – airway  
—Intracranial Pressure monitoring   Intraventricular catheter Subarachnoid bolt Epidural sensor Anterior fontanel pressure monitor Always use transducers without flush system

—Monitor Pituitary function in ICP what are you watching for
SIADH –head injury, meningitis, encephalitis, brain abcess, brain tumor, subarachoid hemorrhage
DI – head trauma
               DI         SIADH UO             increased         decreased SG                  decreased           increased Serum Na     increased            decreased
Neurological Injuries: Head Injury

what are you watching for?
Leading cause of death <35yo, (fall, MVA, bike)  
—Primary injury: at time of accident
—2ndary: response to trauma→i.e. cerebral edema, malignant brain edema (only in kids)   S/S: ↑ ICP, LOC Dx: CT, Xray, neuro exam Tx: C spine precautions, PICU, intubate, mannitol, HOB 30 degrees, craniotomies, drug induced coma
Seizures
Malfunctions of brain’s electrical function

Febrile: brief (<15 min), tonic/clonic, 6mos-5yo= quick drop in temp or quick rise in temp

Partial Seizures:       1. Complex  & 2. Simple       Generalized:       1. Tonic-clonic, 2. Absence, 3. Myoclonic,       4.  Myoclonic & akinetic   Status epilepticus:  
30 min       Infantile Spasms  
Partial Seizures

No aura occur at any age  
no loc

Complex:
—3yo-adol  
—aura, fear, déjà vu, smell/taste odor  
—visual hallucinations  
—loc not comp lost, stare into space, lip smacking, chewing, perseveration  
invol. movement of one ext, head or eyes  
buzzing sound, odd taste
Generalized Seizures
Tonic/clonic: (grand mal) any age, fall to ground, poss impair airway due to secretions, 30 sec-30 min –loc-know
 
  Absence: (petit mal), >4yo-adol, 5-10 sec, 20 times/day-- trans loc- know

Myoclonic: sudden, repeated contracture of muscles in head, ext, & torso, 2yo-adol, ususally when child is tired     - no loc- know
  Atonic/astatic-akinetic: (drop attack) 2-5yo, loc(know), head injury, wear helmut, assoc w/ brain abnorm, mental retard

intervention- maintain airway, have bag close because they hv depressed resp. rates


maintain airway, place on side, O2, poss IV, PR meds, Ketogenic diet,  poss surgery
Nervous System Structural Abnormalities

1.Hydrocephalus
 
2.Neural Tube Defects- spinal bifida   3. Craniosynostosis- suturs fuse early   4.  Arterovenous Malformation-
Structural Abnormalities: Hydrocephalus
Communicating: obstruction outside of  vent system, ↓ absorbtion CSF Noncommunicating/obstructive: blocking of CSF w/in vent system S/S:↑ head size, protusion of frontal region, widened space between eyes, bulging fontanelles, symptoms of ↑ICP Dx: CT, MRI Tx: Surgical, remove lesions, insert shunt
Structural Abnormalities:
Neural Tube Defects-Spina Bifida
Failure of osssesous spine to close during 1st 28 days, most in lumbar/sacral area, Higher deformity in spinal column→ ↑defects, joint deformities   2 forms: 1. SB occulta: not visibly externally               2. SB cystica: visible, external saclike protrusion                  a. meningocele: meninges & sp fluid, no nerves                      b. myelomenigocele: meninges, sp fluid, & nerves   Dx: ultrasound, amniocentesis Tx: neuro & plastic surgery, urology, no rectal temps OT, PT
Guillain-Barre Syndrome
Infectious polyneuritis, immune disease assoc w/ viral/bacterial infection, immunization, ascending demyelination   3 phases: acute: up to 4 wk                plateau: symptoms constant-days to wks                recovery: improve-few wks to mos   s/s: precede by flu/ST, rapid/gradual tenderness, flaccid, paralysis; incontinence, constipation

Tx: mech vent, immunogloblin, steroids   Nursing implications:  (know)
acute phase?
Plateau Phase?
Recovery phase?
Which of the following is an important consideration in understanding the reactions of parents when their infant is born with physical defects?
a)      Grief lasts until the defects are repaired. b)      Denial is a common maladaptive reaction. c)       The psychologic reaction is similar to that with the death of an infant. D) Reactions of health professionals to the birth of an infant do not affect parents’ reactions.


C, Parents need to grieve for the loss of the expected child.  They also must adapt to the needs of a child with physical defects and the additional demands this will place on the family.  (p. 393)
An infant who was born yesterday is scheduled for surgery tomorrow.  Which of the following interventions in the preoperative period will be the most helpful in assessing postoperative pain in this neonate?
a)       Assess neonate’s behavior. b)      Interview mother about neonate’s behavior. c)       Ask mother what measures comfort neonate. Assess neonate’s response after inducing pain.


A,  A preoperative assessment of the infant’s behavior is essential.  This provides a baseline against which to measure postoperative behavior.  Changes may indicate pain of unstable condition.  (p. 395)
An infant is born with anencephaly.  When discussing this condition with the parents, the nurse should know that:
a)      Many treatment options exist. b)      Immediate surgery is necessary. c)       The condition is incompatible with life. The child will have permanent disabilities.

C, Anencephaly is the most serious neural tube defect.  Both hemispheres of the brain are absent.  Anencephaly is incompatible with life.  Some infants with mature brainstem function can maintain vital functions for a short period.  (p. 400)
Which of the following problems is most often associated with myelomeningocele?
a)      Biliary atresia b)      Hydrocephalus c)       Craniosynostosis Tracheoesophageal fistula

B, Hydrocephalus is a frequently associated anomaly in 80% to 90% of children.  (p. 401)
Latex allergy is suspected in a child with spina bifida.  Appropriate nursing interventions include which of the following?
a)      Avoid using any latex products. b)      Use only nonallergenic latex products. c)       Teach family about long-term management of asthma. Administer medication for long-term desensitization

A, Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment.
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt.  Postoperative nursing care should include which of the following?
a)      Monitor closely for signs of infection. b)      Place child with operated side of head on the bed. c)       Pump the shunt reservoir often to maintain patency. Maintain Trendelenburg position to decrease pressure on the shunt.

A, Infection is the greatest hazard in the postoperative period.  The nurse is vigilant for signs of cerebrospinal fluid infection, including elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity.  (p. 414)
Which of the following clinical manifestations of developmental dysplasia of the hip would be seen in the newborn?
a)      Lordosis b)      Ortolani sign c)       Trendelenburg sign Telescoping of the affected limb

B, In the newborn period, the dysplasia usually appears as hip joint laxity.  During the Ortolani test, the examiner places forward pressure and then backward pressure on the trochanter.  If the femoral head is felt to slip, dysplasia may be present.  This test is most reliable from birth to 2 to 3 months. (p. 420)
A newborn with congenital clubfoot is being treated with successive casts.  The parents ask why so many casts are required.  The nurse should explain that:
a)      Casts are needed for traction. b)      Each cast is good for only 6 weeks. c)       Surgical intervention will not be necessary. They allow for gradual stretching of tight structures

D, Serial casting is begun shortly after birth and before discharge from surgery.  Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot.  Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.  (p. 424)
Which of the following is a major long-term problem for a child with cleft lip and palate?
a)      Faulty dentition b)      Nutritional deficits c)       Aspiration pneumonia Abnormally small maxilla

A, A comprehensive team approach is used for children with cleft lip and palate.  Extensive orthodontics and prosthodontics are usually required to correct the malposition of the teeth and other bony structures.  (p. 430)
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate.  The physician explained the plan of therapy and its expected good results.  However, the mother refuses to see or hold her baby.  Initial therapeutic approach to the mother should be which of the following? 
a)      Encourage her to express her feelings. b)      Suggest holding baby but without eye contact. c)       Restate what the physician has told her about plastic surgery. Recognize that attachment usually does not occur until after initial surgery.

A, For parents, cleft lip and cleft palate deformities are particularly disturbing.  The nurse must emphasize not only the infant’s physical needs but also the parents’ emotional needs.  The mother needs to be able to express her feelings before she can accept her child.  (p. 430)
The nurse assesses the neonate immediately after birth.  Esophageal atresia or tracheoesophageal fistula is suspected if which of the following is present?
a)       Jaundice b)      Absence of sucking c)       Hyperactive bowel sounds D) Excessive amount of frothy saliva in the mouth


D, Frothy saliva in the mouth and nose, drooling, choking, and coughing in a newborn are associated with esophageal atresia and tracheoesophageal fistulas.  (p. 435)
Which of the following is the earliest clinical manifestation of biliary atresia?
a)      Jaundice b)      Vomiting c)       Hepatomegaly D)  Absence of stooling


A, Jaundice is the earliest and most striking manifestation of biliary atresia.  It is first observed in the sclera, may be present at birth, but is usually not apparent until ages 2 to 3 weeks.  (p. 442)
The nurse is caring for a neonate born with an omphalocele.  Initial management after delivery includes:
a)      Beginning breast-feeding b)      Supine positioning with nasogastric feedings c)       Covering the omphalocele with saline-soaked gauze and plastic drape D)  Using radiant warmer to dry sac and maintain neutral thermal environment.


C, The sac is covered to prevent drying and excessive fluid loss from the neonate.  (p. 443)
An infant has just been born with a symptomatic congenital diaphragmatic hernia.  Care of the infant in the preoperative period should include which of the following?
a)       Feeding with sterile water only b)      Immediate endotracheal intubation c)       Bag and mask ventilation as needed D) Positioning with head and chest lower than abdomen


B, Many infants with symptomatic congenital diaphragmatic hernias require immediate ventilator assistance after birth.  Endotracheal intubation is essential.  (p. 446)
Hypospadias refers to which of the following?
a)      Absence of a urethral opening b)      Penis shorter than usual for age c)       Urethral opening along dorsal surface of penis D)    Urethral opening along ventral surface of penis


D, Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.  (p. 452)
Mr. and Mrs. Wilson have a newborn with ambiguous genitalia.  Tests are being done to assist in gender assignment.  The parents tell the nurse that family and friends are asking what caused the baby to be this way.  The nurse’s intervention should include which of the following?
a)      Explain the disorder so they can explain it to others. b)      Help parents understand that this is a minor problem. c)       Encourage parents not to worry while the tests are being done. Suggest that parents avoid family and friends until the gender is assigned.


A, Although ambiguous genitalia may appear as one entity, there are many causes.  It is essential that the parents understand the complex issues that are involved in gender assignment as they work with the multidisciplinary team.  (p. 458)
A young child has a intelligence quotient (IQ) of 45 would be described as which of the following?
a)      Mildly cognitively impaired but educable b)      Moderately cognitively impaired but trainable c)       Within the lower limit of the range of normal intelligence Severely cognitively impaired and completely dependent on others for care


B, Children are considered trainable and moderately cognitively impaired if their IQ falls within range of 36 to 49. (p. 909)
When a child with mild cognitive impairment reaches the end of adolescence, which of the following characteristics would be expected?
a)      Achieves a mental age of 5 to 6 years b)      Achieves a mental age of 8 to 12 years c)       Is unable to progress in functional reading or mathematics Acquires practical skills and useful reading and mathematics to an eighth-grade level


B, By the end of adolescence, the child with mild cognitive impairment can acquire practical skills and useful reading and math skills to a third- to sixth-grade level.  A mental age of 8 to 12 years is obtainable, and the child can be guided toward social conformity.  (p. 909)
When should children with cognitive impairment be referred for stimulation and educational programs?
a)      As young as possible b)      As soon as they have the ability to communicate in some way c)       At age 3 years, when schools are required to provide services At age 5 or 6 years, when schools are required to provide services


A, The child’s education should begin as soon as possible.  Considerable evidence exists that early intervention programs for children with disabilities are valuable for cognitively impaired children.  (p. 912)
Parents of a child with cognitive impairment ask the nurse for guidance in toilet training.  They have older children who were successfully toilet trained but do no know how to do this with the impaired child.  The nurse’s recommendation should include which of the following?
a)      Accidents cannot be ignored if training is to be successful b)      Determine the child’s readiness to begin toilet training c)       Toilet training should not be initiated the child has sufficient speech A more punitive approach is needed because of the child’s cognitive impairment


B, The child’s capabilities and readiness are essential to success.  Parents must also be able to devote the time to a positive, consistent, individualized, nonpressured style of teaching.  (p. 915)
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