Nursing IV Exam III Study guide

Disabled child 19?’S

 Disability – last @ least 3 months, characterized by a diagnosis of any impairment

 Handicap – term used by society
 Birth Injuries – predisposing factors: uterine dysfunctions, cephelopelvic disproportion, maternal
factors, fetal macrosomia, multigestation, abnormal presentation, congenital anomalies, ob.
birthing techniques;
 Soft tissue injury – bruising; petechial, abrasions often caused by vacuum or forceps
 1: Caput succedaneum (cone head) – is serum or blood accumulated over bone that crosses
suture lines, disappears in a few days w/o treatment, nonpathological, no bilirubin change, can
cause neuro impairment,
 2: Subgaleal Hemorrhage – early detection is vital b/c it is the most serious, bleeding in
subgaleal space that crosses the suture line, can cause anemia/hypovolemic shock, in neck area
circumference, monitor blood levels
 3: Cephalhematoma – blood vessels rupture between bone and periosteum , does not cross
suture lines, swelling minimal at first and increases in 2 nd and 3rd day, no tx, absorbed in 2weeks
to 3 months, hyperbilirubin can occur, teach patient to watch for swelling and calcification
 Nursing care for all 3 – usually caused from vaginal canal, look for hypovolemia, increased icp,
infection, blood loss
 Fractures- clavicle/collar are most frequent (common in breach or shoulder dystocia or lga),
crepitus is felt or heard, palpable spongy mass (clavicle), asymmetric moro reflex, reluctance to
move arm, x-rays reveal fracture
 Fracture nursing care – don’t lay on affected side, keep body aligned, careful handling, hold
broken bone, look for neurological problems, let parents practice
 Facial paralysis – pressure on facial nerve during delivery
 Primary facial paralysis clinical manifestations – eye on involved side remains open, loss of
movement, drooping, no forehead wrinkles and deeper wrinkles on affected side, mouth drawn
to unaffected side, no medical intervention, disappears in a few days to several months
 Brachia Palsy – plexus injury from altered normal position and relationship of the arm, shoulder
and neck
 Erbs palsy – morro reflex absent on affected side, damage to the upper plexus, results from
pulling away of the shoulder from the head (shoulder dystocia, vertex or breech delivery,
macrosomia, 2nd stage less than 15 min, obese mom, vacuum, paralysis of affected extremity) ),
can still move finger and wrist
 Manifestations of Erbs palsy affected extremity and muscle – adducted and internally rotated,
elbow extended, forearm prorated w/ wrist and fingers flexed, grasp is present, wrist and finger
move, moro reflex absent
 Klumpke Palsy (lower plexus palsy) – severe stretching of the upper extremity while trunk is less
mobile; tx – prevent contractures, maintain position of arm, recovers 3-6 months, full recovery
common, can have surgery if not healed after 3 months
 Clinical manifestations of Klumpke Palsy – hands are paralyzed, no function, from elbow down,
morro reflex is absent on the affected side
 Phrenic Nerve Palsy – asymmetric movement of lungs, resp. distress, resolves in 6-8 months
 Nursing care for paralysis/palsy – facial damage – aid in sucking, teach feeding technique, soft
rubber nipple w/ large hole, could be on g tube
 Nursing care for paralysis/palsy – eye damage – artificial tears, tape eyes shut, teach eye drop
administration
 Nursing care for paralysis/ palsy – positioning – passive rom, splint keeps affected arm extended,
undress affected 1st, Redress affected 1st,
 Nursing care for paralysis palsy – parents – hold infant in football position, don’t pick up under
arm, stressed & nervous parents, give referrals
 Hypoxic Brain injury – to little blood flow to brain, non-progressive, prenatal, l&d, abruption
placenta, placenta previa, hemorrhage, cord compression
 Hypoxic brain injury clinical manifestations – seizures, hypotonia, poor suck swallow, apnea,
coma
 Hypoxic brain injury nursing management – assess cerebral hypoxia, assess respiratory, manage
seizures, support family, maintain o2
 Syndrome – a pattern of malformations that results from a specific cause
 Trisomy 21 – downs syndrome – special ed programs, functions range, initial development may
appear normal
 Trisomy 21 – appearance - down syndrome clinical manifestations – small square head, upward
eye slant with creases, small ears & nose, mouth & tongue protrude, hypotonic, broad short
hands fingers feet & toes, wide space between big and small toe, simian crease,
 Trisomy 21 – downs syndrome – clinical manifestations – often have; heart defects, mental
retardation, shorter life expectancy, instability in neck, 2-3 year delay in social development,
tracheal esophageal fistulas, eye problems, strabismus, nystagmus, astigmatism, myopia,
cataracts, hearing loss, frequent ear aches, excessive head tilt, mucous, prone to rsv,
 Trisomy 21- downs syndrome – diagnosis – presentation can signal but confirmed with genetics,
cool mist vaporizer, surgery for heart defects, routine med care, screenings, early intervention
 Trisomy 21 – downs syndrome – therapeutic management – evaluate site and hearing, atlanto
axial instability, feed in side and back of mouth, suction nose, humidify
 Trisomy 21 – downs syndrome – nursing care management – support family with dx, prevent
injury, wrap tightly, clear nose before feeds, food in back of mouth, soft skin becomes rough,
specialized growth chart, prenatal dx w/ amniocentesis
 Trisomy 13 – Patau syndrome – multiple anomalies, cleft lip/ palate, ear/nose formation,
microencephely, early death, small eyes, nyastigmas, no tx, needs support
 Klinfelters Syndrome – male, small testes, low androgen, infertile, developed genitalia, sparse
facial hair, girl pubic hair pattern, longer legs, gynecomasia, voice don’t change
 Turners Syndrome – female, ovary dysgenesis, short stature, low estrogen, infertile, delayed
sexual development, neck webbing, low posterior neckline, neonatal lymphedema, cubitus
valgus, short 4th metacarpals (shield)chest, divergent nipples, sex chromatin neg, coarctation of
aorta, Urinary tract abnormality, fetal cyst hygroma, hydrops, normal intellectual development
 Nursing management for Trisomy 13; turners/klinfelters – pregnant woman shldnt take meds
unless ask dr, support symptoms, normal intellectual and social development
 Cerebral palsy – permanent disorder of the development of movement & posture, causes
activity limitation attributed to non-progressive disturbances that occurred in fetal development
or infants brain, effects communication, musco skeletal, is many neurological lesions , caused by
gross malformations of brain, vascular occlusion, atrophy, loss of neurons, degeneration,
hypoxic infarction, hemorrhage, hypoglycemia, intra partum asphyxia ( chord around neck)
 Cerebral palsy – clinical characteristics – hypo/hypertonia, ataxia, athetasis (constant spasms),
hemiplegia, diaplysia (lower extremities are more effected), quadriplegia, delayed gross motor,
 abnormal posture, abnormal reflexes, visual impairment, seizure disorders, drooling, speech,
trouble feeding, hearing impairment may aspirate
 Cerebral palsy – warning signs – poor head control after 3 months, ridged arms/legs/arching
back/pushing away, floppy, preferring one side over other, extreme irritability, high pitch cry,
don’t smile by 3 months, trouble breathing, aspiration, pushing out soft foods w/ tongue @
6months
 Cerebral Palsy – diagnosis – MRI/CT – will show lesions/atrophy, neurologic sx, persistent
morrow reflex beyond 6 months of age
 Cerebral Palsy – therapeutic management – GOAL : early recognition and promotion of optimal
development to enable affected children to attain normalization and their potential w/I the
limits of their existing health problem; 5 broad aims; 1. Locomotion, communication and self-
help skills, 2. Optimal appearance and integration of motor function 3. Correct defects, 4.
Promote socialization w/ other children 5. Medications, manage spasms
 Cerebral Palsy – medications – baclofen pump = meds directly in the intrathecal space, relieves
spasticity, size of puck, in sub q of mid abdomen, fewer s/e than oral baclofen, set rate,
antileptic drugs (carbamazepine “tegretol”, divalproex “valproate sodium & valproic acid,
Depakote”), monitor for therapeutic levels, surgery can help contractures
 Cerebral Palsy – nursing management – more rest periods, tailored diet, feeding modification,
safety precautions, immunizations, recreational activities, support family, individualize POC,
mobilization devices, surgery, reg. dental visits, often have gastrostomy tube.
 Cognitive impairment – IQ 70-75 or lower, 3 components 1. Intellectual functioning, 2.
Functional strengths, weaknesses (dx before age 18). Impairment on 2 or 10 adaptive skills;
communication, self-care, home living, social skills, leisure, health and safety, self-direction,
functional, academics, community use and work (promote rehabilitation for each person).
 Cognitive impairment – dx – suspicion, routine screening, delays extremely below average,
standardized testing
 Cognitive impairment – Etiology – infection, intoxications, congenital rubella, syphilis, maternal
drug use, trauma, physical agent, inadequate nutrition, metabolic disorders, cerebral or cranial
malformations, chromosomal abnormalities, low birth weight, prematurity, psychiatric disorders
(onset during childhood), environmental influences.
 Cognitive impairment – nursing care – prevent regression, help achieve level of development
that can be achieved, prevent secondary disease, protect from abuse, ethical considerations
(marriage/children)
 Cognitive impairment Education – take parents control seriously, can’t discriminate between 2+
stimuli, can learn if cues are presented in an exaggerated manner, concrete form, eliminate all
other stimuli, give control, early intervention, help achieve their full potentials, motivation,
teach self-care, give simple one step directions
 Cognitive impairment – Nursing care – encourage play and exercise (based on developmental
age), means of communication, establish discipline, encourage socialization, teach acceptable
behaviors, provide sexual information in laymen’s terms, help family adjust (in case of parent
death future plan of care),
 Cognitive impairment –caring for a hospitalized child – regimen, ask about toileting, special
needs
 Neural Tube defect – normally closes 3-5 weeks), failed closure of neural tube from drugs,
malnutrition or etc…damage depends on sac location
 Hydrocephaly – imbalance in production/absorption of CSF in the ventricular system
 Communicating hydrocephaly – non obstructive, impaired absorption of csf fluid
 No communicating hydrocephaly – obstructive – obstructed flow of csf through ventricular
system
 Hydrocephaly – clinical manifestations – decreased coordination, confused, poor feeding,
change in loc, extreme spasms, persistent infant reflexes, decreased gag reflex
 Hydrocephaly – dx evaluation – imp TIME OF ONSET, PRE EXISTING STRUCTURAL LESION, head
enlargement, ICP causes symptoms, MRI and CT diagnose it, crosses one or more quad line in 2-
4 weeks, decreased loc, decreased Glasgow, ventricles will be big
 Hydrocephaly – therapeutic management – tx – relive hydrocephalus, tx complication, manage
problems, surgical (remove tumor / place shunt), surgery complication infections 1-2 months
 Post op shunt care – lay on unaffected side, child is flat, (to rapid decrease can cause sub dermal
hematoma), look for abdominal distention, peritonitis or post op ileus, inspect incision for leaks,
bleeds fluid should be tested for glucose, measure head daily
 Spina bifida occulta – mild one- defect in cns, osteous spine doesn’t close L5-s1, neuromuscular
disturbances of gait, bowel and bladder disturbances, not visible, not apparent, port wine stain,
dark tuff of hair
 Spina bifida ccystica miningocele – sac outside of skin, encases meninges and spinal fluid no
nerves
 Spina bifida cystica myelomeningocel – contains meninges, spinal fluid and verves, major
complication of neurogenic bladder, hydrocephalus often seen, occurs during first 28 days of
pregnancy, sac can tear and leak csf
 Spina bifida – clinical manifestations – sensory disturbances , s calosis, kyposos, hip dislocation,
lower (cnt move lower extremities), high (cld have no motor skill, may effect bowel),
 Spina bifida – clearly see sac, mri/CT checks for nerves, could see prenatally in ultrasound, fixed
by surgery, prevent infection, abx tx, prognosis depends on neurological deficit, prevent by folic
acid
 Spina bifida – nursing care assess neurological deficits, observe limb involvement, head
circumference, wet dressing, clean with ns, change dressing 2-4 hrs., assess for leaks, infection is
a high risk if it breaks, no rectal temps, position prone, legs and arms comfortable, rom, no
diapering, need touch.
 Spina bifida post op – frequent vs, signs of infects, follow md tx, look for csf leakage, prone or
side position, can hold infant upright, breastfeeding mom can pump, initiate long term goals
 Microcephaly – small brain from early closure of cranial suture 3times smaller, supportive care,
no tx
 Anencephaly – head end of neural tube fails to close, brain missing, w/o forebrain, born blind
deaf, cannot feel pain, will die.

Stroke 15 ?’s

 Stroke is a episode of neurologic dysfunction caused by a blockage or rupture of vessel to the

brain
 Risk factors for a stroke: pt should exercise 30 min. a day; begin evaluating risk factors at 20yrs
age; Risk factors: prehypertension 120-140/80-90; hypertension over 140/90; contraceptives;
antiphospholi pid antibodies; DM; stress; sleep apnea; cardiac disease; smoking; polycythemia;
sickle cell; cholesterol want ldl below 100 Hdl above 50; triglycerides; homocysteine; obesity;
family hx; age; gender; race; drug abuse; previous stroke/tia; c reactive protein; chagas disease;
migraine aura; alcoholism; pregnancy
 Triggers to stroke: anger, stress
 Thrombotic (ischemic stroke) – due to atherosclerosis (elderly, usually not fatal); usually occurs
at rest; may be TIA’s before; wake up with symptoms; s/s peak at 72hrs
 Anterior thrombotic ischemic stroke – decreased strength; decreased movement; aphasia,
mental confusion; paralysis
 Posterior thrombotic ischemic stroke – dizziness, visual problems; dysarthria; numbness;
headache
 Brain stem thrombotic ischemic stroke – effects vital signs
 Thrombotic stroke had increased edema in area once resolved s/s decrease; there is necrotic
tissue and penumbra surrounds it. The penumbra still gets little blood flow. The goal is to
increase the blood flow to the penumbra.
 Embolic ischemic stroke – bp normally stays normal; occlusion of vessels due to traveling emboli
(usually from the heart, carotids, aortic arch) due to post mi, l ventrical thrombus, decreased
c.o., endocarditis, orthopedic surgery (fat embolism)
 AF (embolic ischemic stroke)- atria contracts irregularly; potential for thrombus; therapy is
Coumadin, or dibigatran (predaxa)
 Embolic ischemic stroke – s/s – effects many ages; sudden onset; unrelated to activity; no
prodromal symptoms; consciousness preserved; h/a where embolus is lodged; usuall effects
MCA ( mca supplies 2/3 of the anterior cerebral hemisphere including lateral portion, frontal,
parietal, and upper half of the temporal regions) s/s may be temporary if clot breaks up; PLAATO
prevents clots therefore prevents emboli from forming
 Intracerebral Hemorrhage - occurs during activity, ruptured cerebral vessel directly to brain;
increased mortality rate; due to elevated bp, brain tumor, trauma, vascular malformation,
coagulation disorder, ruptured aneurysm, oral anticoagulation
 Intracerebral hemorrhage – usually after age 50; during activity; severity depends on amount of
bleeding; thalamus and cerebellar hemispheres are common sites but pons area is the most life
threatening location; severe h/a; n/v; hypertension; impaired LOC; 70 % mortality rate;
 Subarachnoid hemorrhage (thunderclap) – known as the worst h/a ever; hemorrhage w/I the
subarachnoid space; due to ruptured aneurysm, av malformation, trauma, cocaine abuse; may
show prodromal signs/symptoms if an aneurysm; an unruptured anyrism can be treated; if a
rupture occurs rapid neuro changes will progress to parylsis, coma, and death; 85% are in the
circle of willis;
 Subarachnoic hemorrhage (thunderclap) post complications and treatments – vasospasm is a
common and serious complication that occurs in 3-5 days past hemorrhage and causes
narrowing of the vessel; Utilize the triple H therapy , Hypertension, high fluids (500 to 1000),
Hemodilution. This can cause n/v, quickly decreased deteriorates and death.
 TIA’s – transient episode of neuro dysfunction caused by focal brain or retinal ischemia without
acute infarct, caused by micro emboli due to atrial fib or carotid artery stenosis
 Carotid system TIA – loss of motor function, hemiparalysis, difficulty speaking
 Vertebrobasilar system TIA – posterior, darkened blurred vision, dysphagia
 Limb shaking TIA – looks like a seizure activity, stops when they back down
 Hemiplegia – paralysis of one side of the body, shoulder can freeze, luction of joints, everything
adducts
 Aphasia – deficit understanding and using language usually left hemisphere stroke
 Sensory receptive aphasia – pt. not aware of mistakes, temporal lobe damage, they cannot read
or understand words, repeat words and are easily flustered
 Motor Expressive Aphasia – effects speech, pt forgets little words and are aware of errors
 Global anaphasia – combination of both usually with MCA
 Apraxia – can move the affected extremity but cannot use it for purposeful learned movements
 Visual Changes – occur due to lesions in the parietal temporal lobes
 Homonymous Hemianopsia – loss of vision in the same half of the eye, corresponds with the
paralyzed side.
 Amaurosis Fagux – produced by micro-emboli to the retina (monocular blindness) like a window
shade, temporary
 Agnosia – disturbance in the interpretation of visual, tactile, or other sensory info, cannot tell
arm is part of their body
 Dysarthria – slurred speech, trouble chewing and swallowing
 Hemianesthesia – loss of sensation on one side
 Paresthesia – c/o heaviness, numbness, tingling
 Horners syndrome – eye sympather nerve paralysis, sinking of eyeball and droopy eye, pupils
constrict, no tears form.
 Unilateral/left sided neglect – neglect the left side of body, pt with right sided stroke, don’t
recognize the left side of body
 Other s/s of strokes – elimination is altered if infarct is in frontal lobe or bons and bladder
training is needed; central post stroke pain occurs on the affected side of the stroke; should
hand syndrome the hand swells
 Brain stem stroke effects the vitals
 Left sided stroke – right sided weakness; slow cautious behavior; speech language
deficit/aphasia; emotional lability; aware of deficit (left knows they left their speech behind);
memory deficit; lack of automatic and functional speech; short attention span; impaired
comprehension related to language and math; hard to learn; impaired right/left discrimination;
need lots of feedback
 Right sided stroke – lft sided weakness; left sided neglect; quick and impulsive behavioral style;
misjudge distances; spatial perceptual deficits; impaired judgment; impaired time concepts; not
aware of deficits (right always thinks they are right); tends to deny problems; no clutter; good
lighting
 Cerebellar stroke – Balance; coordination; dizzy; posture
 Brain stem stroke – life supporting functions
 Silent stroke – whispering stroke; can be seen on mri; r/t hypertension; no symptoms
 Luncunar – r/t small vessel occlusions; caused by hypertension, smoking and diabetes
 Treatment – admit anyone having Tia symptom; consider using tissue plasma activator; IVs,
blood work, glucometer; cbd, electrolytes, pt, ptt, chem prof, lipids; keep npo; keep NPO;
dysphagia screening/speech consult, swallow study, tongue lip coordination, ekg; NIH stroke
scale; CT scan; mra; mri, dwi, pwi; pet scan; Doppler flow studiens of the carotids; meds,
Thrombolytic therapy;
 NIH stroke scale – measures neuro deficits higher number is worse prognosis
 Ct scan – r/o bleeding
 MRA – see better, dwi detects acute infarcts earlier, pwi is better
 PET scan – chemical activity
 Doppler flow studies of the carotid – greater than 50% blockage surgery is discussed
 Anti platelet agents – given w/I 24-48 hrs, first class, give aspirin, agronox, Plavix
 Anticoagulants – if immobile give sub q heparin to prevent dvt’s
 Steroids
 Dilantin – if there is seizure activity
 Antihypertensives – normally pt is on them before stroke. If it is over 220/120 they will give it
during a stroke
 Ace inhibitors – Ramaqual
 Thrombolytic therapy for acute ischemic stroke – Alteplase – (TPA) bp must be under 185/110 to
give Alteplase. Give 0.9 mg/kg (max 90mg), give 10%as IV bolous; remainder over 1 hour
through iv, pt must be 18 or older, must be less than 3 to 4.5 hrs from the onset of s/s. Ideally
w/I 60 minutes; cannot be a bleed,
 Post tpa care – close neuro assessments q 15 min first 2 hrs then q 30 minutes for the next 6 hrs
look for signs of cereberal hemorrhage, frequent vitals; watch for bleeding, no anticoagulants or
antiplatelet drugs for 24 hrs following TPA
 Intra-arterial thrombolysis with prourokinase or urokinase – direct thrombolytic delivered into
the clot by catheter, good results in the internal carotid, mca, and basilar artery
 Tumor cell research – turning cancerous cells into non cnacerous cells
 Stem cell research – prompts cells to correct damage
 Trans cranial laser therapy – non invasive procedure 2 monutes per site, it can cuase retinal
damage
 Merci retriever – contraindicated w/ contourous vessels, hemorrhage conditions, platelets
below 30,000, hypoglycemic
 Carotid endarterectomy – surgically excise the artery, remove plaque, place a drain in incision,
can only do one side at a time
 Carotid enderectomy post op care – vitals; keep head straight; raise hob after vitals are stable;
maintain systolic bp w/I 20 mmhg of normal; good neuro exam q 2 hr.; check edema; check
resp. compromise; especiall 7,10, 11, 12…7 facial 10 vagus
 Stents are contraindicated with previous endarectomy
 Angioplasty with stent – used in stenosis of vertebrobasilar or carotid arteries, insertion of a
balloon to open up the artery. (risk for emboli)
 Surgery for intracerebral Hemorrhage – evacuation of hematoma, poor survival rate
 Surgery for subarachnoid hemorrhage – interventional neuroradiology combines angiography
with neurosurgery, leaking aneurysm is a clipping (subarachnoid anyrism) or coil procedure
(better outcome than clipping)
 Nursing DX for stroke – alteration in cerebral tissue perfusion r/t decreased cerebral blood flow
aeb decrease in NIH assessment data (pt will have decrease in loc); implementation – monitor
icp, monitor neuro, elevate hob, monitor temp and vitals, maintain head and neck alignment,
avoid hypervolemia (csf drainage, diuretics)
 Impaired physical mobility r/t right side hemiplegia (due to left sided stroke); implementation –
improve gait, posture, strength, hob 30 degree or flat, position to unaffected side, don’t flex
upper thigh at acute angle during side lying position, upright sitting for short periods of time, no
pillow under affected knee (do put pillows between legs), pillow in axillary area, sling on
affected side, trochanter roll (blanket from ileum to thigh affected to arm), prone position if
tolerable, prevent foot drop (chair with feet flat, Oscar boots, high tops), trochanter roll (rolled
blanket illieum to thigh, arms neutral with hands in a functional position, ROM (first day post
stroke), spasticity (uncontrollable muscle tightness), up with good down with pad, bilateral
repetitive rhythmic training intervention, constraint induced movement therapy,
 Self care deficit r/t right sided weakness or paralysis; will be complete care at first, encourage
them to do as much as possible, encourage self care with unaffected hand
 Potential for falls r/t weakness – keep side rails up, visual disturbances will increase risks, bed in
low position
 Risk for ineffective airway clearance, r/t inability to expectorate secretions = assess congestion,
assess cough, check lung sounds, observe amount color consistency of sputum
 Potential for aspiration r/t loss of swallowing reflex – pt is npo till gag reflex is checked
 Checking gag reflex – longer time to eat, speech therapy evaluates, cookie swallow, high fowlers
position to eat, small bites on unaffected side, chen down, head flexed forward stroke throat,
double swallow, check mouth for food, thicket use, avoid milk
 Communication problems – impaired verbal communication, decrease background noise, talk
slow, clear secretions, identify objects, anticipate needs, repeat directions slow and clear
 Disorientation – keep oriented, environmental cues, residual deficit adjustment
 Residual disabilities – need to be treated, give family good education
 Stroke in a newborn – before 28 days, caused by prom, birthing process, seizures, perinatal
cuases
 Stroke in a child – 30 days to 18 yrs ischemic or hemorrhagic
 Stroke in children, neonates – disabilities, posture/movement abnormalities, confusion,
agitation, Infarct sites (basal ganglia, thalamus), problems solving deficit, memory problems,
epilepsy; language problems;
 Considerations with strokes in minors – moya moya (cva base brain arteries don’t develop and
become stinosed and are replaced with collateral circulation), arteriovenous malformation,
sickle cell disease, heart defects, patent foramen ovale (shunting), atrial septal defect,
coagulation defect

Brain Tumors

 Brain tumors are a freq. site for metastisis / leads to death because of increased ICP if not
treated
 Brain tumor – frontal –(symptoms often noticed by pt’s family but not patient)
behavioral/personality changes, judgement changes, lack of emotional control, disorientation,
memory deficit, depression, visual disturbances, seizures (first sign of problem)
 Parietal – disorientation, confusion
 Occipital – speech, visual disturbances, seizure
 Temporal – seizures, dysphagia
 Cerebellum – balance, coordination, fine muscle control
 Brain stem – breathing, blood pressure, heartbeat, swallowing
 Types – primary glioma – glioblastoma multiforme – highly milagnant and invasive, most
devastating
 Primary glioma astrocytoma – low grade to moderate grade malignancy
 Primary gioma medulloblastoma – highly malignant and invasive, metastasizes to spinal cord
and remote areas of brain
 Primary Meningioma – benign or malignant, seen more in woman
 Secondary tumor – metastasized tumor
 Brain tumor clinical manifestations – h/a, seizure, nausea (increased ICP), vomiting, cognitive
dysfunction (esp. w/ metastisis), muscle weakness, sensory losses, aphasia,
 Brain tumor complications – hydrocephalus (vetriculaoatrial or ventriculoperitoneal shunt),
increased ICP (decreasing loc, restlessness, h/a, blurred vision, vomiting w/o nausea), infected
shunt (fever, persistent h/a and stiff neck)
 DX studies – HISTORY and NEURO EXAM, mri, pet, ct, brain scan, icp measurements,
angiography (blood flow to tumor), biopsy (only way to detect type of tumor), with unexplained
seizures they will look for brain tumor.
 Treatment goals of brain tumor: identify type and location, remove or decrease tumor mass,
prevent or manage increasing ICP
 Collaborative care for brain tumors – surgery 1 st choice but doesn’t always work,, radiation,
stereotactic radiosurgery, chemotherapy
 Chemo w/ brain tumors – Nitrosoureas (effective in tx of brain tumors), Methotrexate &
Procarbazine “matulane” (given interthecally), Temozolomide “temodar” (first chemo found to
cross blood brain barrier), chemo can cause increased ICP so prednisone is given to decrease ICP
 Nursing assessment brain tumor – Neuro (loc, motor abilities, sensory perception, bowel and
bladder function, balance, proprioception (eyes closed), coping abilities of family and pt, you can
learn a lot by watching pt do adl’s
 Nursing implementation brain tumor – support family, protect self/patient from harm, minimize
environmental stimuli, create routine, reality orient, approach in calm reassuring manner,
seizure precautions, assist w/ adl’s, encourage self care, establish communication, assess
nutrition, ensure nutrition
 Cranial surgeries – biopsy, radiosurgery, lazer (Carbon dioxide, argon, ND yag) Craniotomy (bone
flap removal)
 Preoperative cranial surgery teaching – allay fears, type of surgery,, what to expect (shaved
head, recovery room, tubes, icu, ventilator
 Post oeperative cranial surgery management – prevent increase of icp, frequent neuro
assessment (good base assessment before surgery), monitor fluid/electrolytes, turn and
position, dressing (3-5 days, assess drainage for color, odor, amount), scalp care (meticulous w/
betadine) sunblock with radiation
 Post cranial surgery home care – rehabilitation after swelling decreases, foster independence,
positioning, skin and mouth care, rom exercise, bowel/bladder care, good nutrition, referrals
SPEECH THERAPY. PHYSICAL THERAPY, DIETICIAN
 Brain tumors in kids – parental work (aircraft, agricultural, paints, solvents, radiation,
electromagnetic fields
 Intfraterntorial child brain tumor – posterior 1/3 of the brain, primarily cerebellum or brainstem,
(medulloblastoma, cerebellar astrocytoma, brainstem glioma, ependymoma), post surgery
position child on side with bed flat
 Supratentorial child brain tumor – anterior 2/3 of brain mainly cerebrum (astrocytoma,
sypothalmic tumor, optic pathway tumor, craniopharyngioma), post surgery position pt w/ hob
20-30 degress on side or back
 Child clinical manifestations – h/a (morning), vomiting, nausea, dizziness, change in vision or
hearing, fatigue, mental status change
 Dx testing same as adult – mri, ct, angiography, eeg, lumbar puncture (may not be done w/
increased icp, cld find abnormal cells in csf)..surgeries can be done on children as well as adults
 Prognosis of any tumor depends on age, tumor type, location and size
 Nursing management – vs, neuro checks, head circumference, h/a, vomiting, seizure activity,
dressing, drainage
 Post surgical do not flex neck, never trendelenburg, complications are : increased icp,
meningitits, Respiratory tract infection, regulate fluids, gavage feeding if needed, iv fluids are
continued, monitor fluids careful, comfort for h/a (quiet, dim, restrict visitors, no jarring, ),
prevent increased ICP (positioning, no straining, defecating, coughing, vomiting) opiods
(morphine, tylenole with codeine, ice to forehead, support child and family
 Discharge planning – teach infection signs, reason for and s/e of chemo, special equipment,
monitor slowed development, incoordination, learning disabilities
Seizures 6 ?’s

 Seizures – proximal uncontrolled electric discharge of neuron, that interrupt the normal
function, a symptoms of an underlying condition
 Causes of Seizures – acidosis (renal disease, or diabetic acidosis), hypoglycemia, hypoxia,
withdrawal, water intoxication, dehydration, disease (heart, lung, liver, kidney), lupus
erythematosus, DM, hypertension, septicemia
 Epilepsy – 2-3 or more Seizures cause by a chronic underlying condition
 Causes of epilepsy – (birth) – birthing injuries, congenital cns defects, infections. (2-20yrs) –
birth injury, infection, trauma, genetic factors. (20-30yrs) – structural lesions from trauma, brain
tumors, vascular disease. (50 & up) – cerebrovascular lesions, metastatic brain tumors
 Recurring seizures – spontaneous firing of neurons that spreads by physiological pathways to
involve adjacent and distant brain areas (often these areas have scar tissue)
 *The longer the patient goes without good seizure control the lower the likelihood that the
seizures will be controlled
 *Benziodiazipine – (valium) IV is the most common way to control a seizure
 Seizure phases – prodromal (what happens to trigger the seizure), Aural (sensory warning), Ictal
(seizure activity), Postictal (after the seizure subsides, often confusion is seen)
 Generalized tonic clonic seizure – “grand mal”, tonic (still body 10-20 sec), clonic (jerking
extremeties 30-40sec), characterized by cyanosis, excessive salivation, tongue or cheek biting,
incontinence, cat call (contraction of diaphragm pushing air out); Postictal phase often shows
muscle soreness, exhaustion, no memory of seizure
 Generalized typical absence seizure – “peti mal or petite mal” only in children, may stop as child
matures or evolve into another seizure type; characterized by brief staring spell, brief loss of
consciousness, can happen 100+ times a day if not treated, EEG 3hz spike and wave pattern is
unique to the typical absence seizure; precipitated by hyperventilation and flashing lights;
 Generalized atypical absence seizure – similar to the typical seizure with staring spell, but has a
eeg spike of above or below 3hz that is specific to the atypical absence seizure, will also see
staring spells, brief warning sign, percular behavior changer, confusion after
 Partial seizures – begin in specific region of the cortex, no loss of consciousness, last 1+ minutes,
involves motor, sensory, or autonomic phenomena (or combination)
 Simple partial seizures – focal motor (motor seizure), focal sensory (sensory seizure), jacksonian
(spasm confined to one part or one group of muscles)
 Partial seizures with complex symptoms – usually temporal lobe, variety of behavioral,
emotional, affective and cognitive functions
 Partial complex temporal lobe seizures – last longer than a minute, postictial confusion,
alteration in consciousness (cloudy or confused), rarely complete loss of consciousness.
 Partial complex psychomotor seizures – lip smacking, repetitive movements
 Complications with seizures - make sure to have suction and o2 available,
 Complications with seizures - status epilepticus can occur (seizures recur in rapid succession
w/o pt regaining normal function between them NEUROLOGICAL EMERGENCY); tonic clonic
status epilepticus is most dangerious b/c can cause ventilator insufficiency, hypoxemia, cardiac
arrhythmias, hyperthermia, systemic acidosis (all can be fatal)
 Psyschosocial effects of epilepsy – cannot drive, huge effect on lifestyle, social stigma,
discrimination, ineffective methods of coping
 Seizure dx studies – complete health hx, ct, eeg, cbc, serum chemistries, liver test, kidney
function test, uranlysis, mri, cerebral angiography, pet, fasting blood glucose
 Drug therapy antiseizure medications – can make patient drowsy, monitor blood levels on a
regular basis, #1 dilantin – long term use in high doses can cause hyperglycemia, it increases
serum glucose levels in diabetics, also used: tegretol, mysoline, Depakote (velpuric acid),
phenobarbital
 Antiseizure medication for absence, akinetic, myoclonic – Zerontin, Depakote, klonopin
 Anti-seizure medication for generalized partial seizures – Neurontin, lamictal, gabatril, topomax
 Anti-seizure medication for disorders that are resistant to other medications – Felbatol (causes
aplastic anemia and liver toxicity),
 Antiseizure medication for status epilepticus – give benzadiazipine (valium or Ativan IV), must
follow with long lasting benzodiazepines or phenobarbital
 Anti-seizure meds s/e – cns (diplopia 2xvision, drowsy, ataxia, mental slowing) Neurological
(nystigmus or wobble eyes, impaired hand gait coordination, impaired cognitive function,
impaired alertness) Skin rash (swelling of gum, decreased bone marrow, lidney and liver
problems, blood discasia
 Surgical therapy epilepsy – must first be dx w/ epilepsy, failure of drug therapies, type of seizure
disorder must be defined
 Complex partial seizure of temporal lobe surgery – resectioning of epileptogenic tissue
 Partial seizures of frontal lobe origin surgery – resectioning of epileptogenic tissue
 Generalized seizure surgery – sectioning of corpus callosum
 Intractable unilateral multifocal epilepsy associated with infantile hemiplegia –
hemispherectomy or callosotomy
 Alternative epilepsy treatments – biofeedback, vegal nerve stimulation
 Nursing dx epilepsy – ineffective breathing pattern r/t neuromuscular impairment (have o2 and
suctioning)
 nursing dx – ineffective airway clearance r/t tracheal bronchio obstruction
 nursing dx – risk for injury r/t seizure activity
 nursing dx – self concept disturbance r/t dx of epilepsy (pt will identify one positive thing about
self)
 nursing outcomes – pt will maintain appropriate rate rhythm and respiration, pt will be absent
of airway obstruction and have clear breath sounds, patient will have no injury
 Interventions seizure – loosen clothes, assess breathing, provide o2, assess airway, suction as
prn, assess for trauma, assist to safe location
 Planning – overall goals: No injury, optimal mental and physical functioning while on meds,
satisfactory psychosocial functioning
 Implementation – safety measures, helmets, improved perinatal labor and delivery, treat high
fevers quickly, observe (what preceded, when did seize occur, how long per phase, what
occurred per phase, body parts involved, Loss of consciousness?), maintain airway 100% o2,
nothing in mouth
 Ambulatory and home care seizure – prevent recurring seizures, meds for life, if missed dose is
remembered w/I 24 hrs take it, educate that employers cannot discriminate, wear med alert
bracelet, avoid excessive alcohol, eat reg meals with snacks
 Myoclonic – arms and legs jerk and hearls pt to ground
 Atonic – drop attack, loss of tone, no jerking
 Akinetic – arrest of movement
 Astatic – loss of balance
 Pseudoseizures – no actual cause, psych consult will be called in
Meningitis, encephalitis and reyes 7 ?’s

 Meningitis – inflammation of pia matter and arachnoid membrane surrounding the brain and
spinal cord (meninges), therefore it is always a cerebrospinal infection, gets in through upper
respiratory track or blood stream, more common in children 6 and under, older adults and
debilitated persons, males more than female, highest morbitidy birth to 4 yrs
 Bacterial meningitis – medical emergency , highest mortality rate, common long term
neurological deficits, entry by direct implantation after entering (wound, skull fracture, sinuses,
lumbar puncture, surgical procedure, spinal bifida, ventricular shunts) once implanted it spreads
to the csf and subarachnoid space, extends to brain(cerebral edema, increased ICP)
 Bacterial meningitis – triad (nuchal ridgity, fever above 38.5 c, neuro deficits), permanent
hearing loss, + brudinskis (child picture flex neck) and kernigs sign ( cant straighten leg),
 meningitis – common causes – neonate (strep b, e coli, baby will behave poorly, high pitched
cry, little movement, poor sucking, fever, projectile vomiting, diarrhea, bulging fontinels),
 2 months and older (miningococcus, influenza b type, streptococcus pneumonia ),
 School aged (provide isolation, meningococcal meningitis, only type transmitted through
droplets, pt will have increased temp and could seize, decrease stimulus by darkening room)
 Manifestations of meningococcal meningitis – (everyone can get) – peticheal/papuric rash,
overwhelming septic shock (waterhouse frederisckson syndrome), dic and adrenal hemorrhage,
this person can die, dic is a serious bleeding disorder that results in uncontrolled hemorrhage,
there is a depletion of platelets and clotting factors, the disease must be treated for dic to stop
 Meningitis dx studies – cbc w/ diff, blood cultures, lumbar puncture with csf culture, cri/ct, gram
a stain (tells whether viral or bacterial)
 Meningitis haimophilus influenza – occurs early autumn or early winter
 Meningitis pneumococcal and meningococcal – any time but more common in late winter and
early spring,
 Meningitis manifestations (in general) – h/a, backache, fever, leukocytosis, change in mental
status, photophobia, nuchal rigidity, positive brudzinski and kerings, coma
 Bacterial meningitis maternal factors – PROM, maternal infection during last week of pregnancy,
 For bacterial meningitis give isolation, abx that cross the blood brain barrier (ampicillian,
penicillin, recephin), hydrate, supply o2, decreased the ICP (no stimuli), manage shock, control
seizure, correct anemia, darken room, quiet environment
 Viral meningitis – Aseptic caused by virus, non infectious insult (blood in subarachnoid space),
associated with other diseases (measles, mumps, herpes, hiv, leukemia)
 Viral meningitis manifestations – fever, h/a, photophobia, back/leg pain, stomach pain, n/v
 Treatment for viral meningitis – strict bed rest, iv fluid, condeine (h/a), aspirin (fever),
hypothermia, clear liquids, Dilantin (IV), Lasix (diaresis), decadron (corticosteroid,
antiiimflammatory) treat symptoms
 Meningitis (general) nursing diagnosis – hyperthermia r/t infectious process and cerebral edema
 Risk for fluid volume deficit r/t fever and decreased intake
 Altered cerebral tissue perfusion r/t infectious process and cerebral edema
 Pain r/t meningeal irritation
 Outcomes meningitis (general) – must be measurable , pt will show a reduction in fever at the
end of day shift, patient will maintain fluid balance, pt will report decreased pain from an 8 to a
2
 Meningitis (general) interventions – abx as ordered, (apticillin, pcn, ceftin, rocephin), monitor
temp, administer iv fluids, monitor I’s and o’s, assist with positioning
 Encephalatis – inflammation of the brain caused by virus, epidemic (ticks, misquitoes), non-
epedemic (complication of measles, chx pox, mumps)
 Encephalitis causes herpes simplex, rabies, cytomegalovirus, manifestations are : GRADUAL
ONSET – h/a, fever, seizures, change of loc, stiffness of neck, tremors, hyperactivity, nausea,
vomiting, coma, death
 Encephalitis nursing considerations – cerebral edema (give osmotic diuretics and corticosteroids,
decadron), control icp, hand heigene, assess loc, meds as ordered, quiet environment,
 Encephalitis diagnostic – MRI, pet, polymerase chain reaction test for hsv dna levels in csf
 Reyes syndrome – common after chx pox and shingles can be caused by aspirin (influenza or
varacells), characterized by cerebral edema and fatty changes of liver, will see encephalopathy,
coma
 Ryes syndrome stages 1: vomiting, lethargy, drowsiness, liver dysfunction, type I eeg, follows
commands, pupillary reaction brisk; 2: disorientation, combative, delirium, hyperventilation,
hyperactive reflexes, appropriate response to painful stimuli, evidence of liver dysfunction, type
I EEG, pupillary reflex sluggish; 3: coma, hyperventilation, decorticate, rigidity, pupillary reaction
sluggish, type II EEG; 4: deeping coma, decerbrate coma, large fixed pupils, minimal liver
dysfunction, type III and IV EEG, evidence of brain stem dysfunction; 5: seizures, loss of deep
tendon reflexes, respiratory arrest, flaccidity, type IV EEG
 Ryes syndrome nursing considerations – monitor I’s and o’s, monitor for impaired coagulation,
teach family not to give otc’s that contain aspirin
 Brain abcess – accumulation of pus in brain tissue from local or systemic infection (sinus
infection, tooth abcess, ear infection, mastoid infection, strep and staph) manifests as h/a, fever,
increased ICP (if not treated can cause death) treat with abx