Johnson J., Keogh J. Pediatric Nursing Demystified: A Self-Teaching Guide

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䊋 Tonic-clonic (grand mal): Abnormal electrical activity simultaneously

occurs in both hemispheres of the brain and then moves from the cortex

to the brainstem. It begins with the tonic phase expressed as uncon-

sciousness, continuous muscle contraction, and sustained stiffness. This

is followed by the clonic phase, which is expressed as alternating mus-

cle contractions in a rhythmic repetitive jerking motion.

䊋 Simple partial seizure: Abnormal electrical activity occurs in one hemi-

sphere of the brain or from an area of the cerebral cortex. There is no loss

of consciousness and lasts <30 seconds.

䊋 Complex partial seizures: Abnormal electrical activity occurs in one

hemisphere of the brain or from an area of the cerebral cortex resulting in

impaired consciousness lasting up to 5 minutes and postseizure confusion.

䊋 Absence seizure (petit mal): Brief loss of consciousness lasting <30 sec-

onds with no postseizure confusion and minimal or no loss of postural tone.

䊋 Atonic seizure: Loss of posture tone causing a drop-and-fall action.

䊋 Myoclonic seizure: Involuntary jerking and loss of body tone resulting

in falling forward, often occurring when falling asleep or awakening.

There is no loss of consciousness or postseizure confusion.

䊋 Akinetic seizure: Brief loss of muscle tone and brief loss of consciousness.

䊋 Infantile spasms: Delays in neurologic development or neurologic

abnormalities result in abrupt jerking and contracting of the head and

neck that begin at 2 months of age and resolve by 2 years of age.

䊋 Febrile seizure: Rapid rise in body temperature of >102.2° F (39°C) in

children 6 months to 6 years of age might result in tonic/clonic seizures

lasting <15 minutes.

䊋 Status epilepticus: Continuous seizure or a series of seizures lasting for

>30 minutes during which there is a loss of consciousness. Postseizure

period can last for up to 2 hours.

Signs and Symptoms

䊋 Tonic:

• Unconsciousness

• Continuous muscle contraction

• Sustained stiffness

䊋 Clonic:

• Alternating muscle contract in a rhythmic repetitive jerking motion

• Syncope

• Incontinence

• Biting of the tongue

• Holding breath

䊋 Tonic-clonic:

• Unconsciousness

• Continuous muscle contraction

• Sustained stiffness

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• Alternating muscle contract in a rhythmic repetitive jerking motion

• Syncope

• Incontinence

• Biting of the tongue

• Holding breath

䊋 Simple partial seizure:

• Continuous muscle contraction and stiffness and jerking motion of

the face, neck, and extremities

• Deviations of the eyes

• Head turning

䊋 Complex partial seizures:

• Impaired consciousness

• Blinking

• Staring

• Lip smacking

• Sleepwalking

• Chewing

• Night terrors

• Sucking

䊋 Absence seizure:

• Brief loss of consciousness

• No or minimal loss of postural tone

• Eye blinking

• Rolling of the eyes

• Drooping eyelid

䊋 Atonic:

• Loss of posture tone

• Drop-and-fall action

䊋 Myoclonic seizure:

• Involuntary jerking

• Loss of body tone

• Falling forward

• Flexing the upper chest

• Infantile spasms

• Pallor

䊋 Akinetic:

• Brief loss of consciousness

• Brief loss of muscle tone

䊋 Abrupt jerking:

• Contraction of the head and neck

• Cyanosis

• Altered consciousness

• Eye rolling

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䊋 Febrile seizure:

• >102.2°F (39°C)

• Unconsciousness

• Continuous muscle contraction

• Sustained stiffness

• Alternating muscle contract in a rhythmic repetitive jerking motion

• Syncope

• Incontinence

• Biting of the tongue

• Holding breath

䊋 Status epilepticus

• Unconsciousness

• Continuous muscle contraction

• Sustained stiffness

• Alternating muscle contract in a rhythmic repetitive jerking motion

• Syncope

• Incontinence

• Biting of the tongue

• Holding breath

Test Results

䊋 Blood glucose level because a low glucose level might precipitate a

seizure.

䊋 Electrolytes level because an abnormal sodium level might precipitate a

seizure.

䊋 Blood level of anticonvulsant medication to determine if medication is

at a therapeutic level and not nearing the toxic level.

䊋 Computed tomography (CT) scan to identify lesions on brain that might

be causes of the seizure.

䊋 Magnetic resonance imaging (MRI) scan to identify lesions on brain that

might be causes of the seizure.

䊋 Lumbar puncture to rule out meningitis.

䊋 Electroencephalogram (EEG) to differentiate between nonepileptic and

epileptic seizures.

Treatment

䊋 Seizures lasting 5 minutes are self-limiting.

䊋 Seizures lasting 5 to 10 minutes: administer Ativan (lorazepam), Dilantin

(phenytoin), or Fosphenytoin as ordered.

䊋 Administer single medication to reduce adverse effects of multiple

medications.

䊋 Transfer the patient to the intensive care unit after 45 minutes.

䊋 Surgery might be necessary to remove portion of the brain that is causing

the seizure.

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Nursing Intervention

䊋 Maintain airway.

䊋 Place patient in a side laying position to prevent aspiration.

䊋 Slightly elevate the head of bed to prevent aspiration.

䊋 Administer 100% oxygen using a face mask if the patient is hypoxic.

䊋 Monitor for depressed respiratory rate because this might indicate

increase intracranial pressure.

䊋 Monitor vital signs.

䊋 Monitor pulse oximetry continuously.

䊋 Monitor level of consciousness.

䊋 Pad the side rails of the bed or crib to prevent injury.

䊋 Document seizure activity.

䊋 Determine the child’s weight because the dose of medication is calcu-

lated by the patient’s weight.

䊋 Explain to parents that the child should wear a medical identification

bracelet stating that the child is prone to seizures. Parents should also tell

the school and caregivers about the child’s seizures and explain that they

should lay the child on his side, protect him from injuring himself dur-

ing the seizure, and not place anything in the child’s mouth.

Nursing alert Never place anything in the patient’s mouth during a seizure.

Maintain airway by placing the patient on his side.

MENINGITIS

What Went Wrong?

The meningeal covering of the brain and spinal cord becomes inflamed, which

is commonly caused by bacteria or a virus but can also be caused by fungus,

protozoa, or toxic exposure.

Bacterial meningitis is most common and typically due to Streptococcus

pneumoniae (pneumococcal), Neisseria meningitides (meningococcal), or

Haemophilus influenzae. The incidence of H. influenzae meningitis infections

has decreased since the routine use of vaccine against H. influenzae began to

be used in infants in the early 1990s. Other organisms that can cause bacterial

meningitis include Staphylococcus aureus, Escherichia coli, and Pseudomonas.

Organisms typically travel through the bloodstream to the CNS or enter by

direct contamination (skull fracture, extension from sinus infections).

Bacterial meningitis is more common in colder months when upper res-

piratory tract infections are more common. People living in close living

conditions, such as prisons, military barracks, or college dorms, are at

greater risk for outbreaks of bacterial meningitis due to the likelihood of

transmission.

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205

Viral meningitis may follow other viral infections such as mumps, herpes

simplex or zoster, enterovirus, or measles. Viral meningitis is often a self-limiting

illness.

Patients with immunocompromise have an increased risk for contracting a

fungal meningitis. This may travel from the bloodstream to the CNS or by

direct contamination. Cryptococcus neoformans may be the causative organ-

ism in these patients.

Bacterial meningitis still has a significant mortality rate, and these patients

need to be managed in the hospital. Some patients will have permanent neuro-

logic effects following the acute episode. Viral meningitis is typically self-limited.

Fungal meningitis often occurs in patients who are immunocompromised.

Nursing alert Always isolate a patient who is suspected of having bacterial

meningitis until bacterial meningitis is ruled out.

Signs and Symptoms

䊋 Stiff neck due to meningeal irritation and irritation of the spinal nerves.

䊋 Nuchal rigidity (pain when flexing chin toward chest) due to meningeal

irritation and irritation of the spinal nerves.

䊋 Headache due to increased intracranial pressure.

䊋 Nausea and vomiting due to increased intracranial pressure.

䊋 Photophobia (sensitivity to light) due to irritation of the cranial nerves.

䊋 Fever due to infection.

䊋 Malaise and fatigue due to infection.

䊋 Myalgia (muscle aches) due to viral infection.

䊋 Petechial rash on skin and mucous membranes with meningococcal

infection.

䊋 Seizures due to irritation of brain from increased intracranial pressure.

䊋 Bulging anterior fontanel in infants.

䊋 Kerning sign where the child lies flat with legs flexed at hips and knees.

The child resists positioning and experiences pain indicating a positive

Kerning sign.

䊋 Brudzinski sign where the head is flexed while in the supine position. A

positive sign is if the child experiences pain or if the child’s hips and

knees are flexed.

Test Results

䊋 Lumbar puncture for CSF analysis, glucose (bacterial low), protein (bac-

terial elevated), cell counts (bacterial elevated neutrophils), and culture.

䊋 Increased CSF pressure noted.

䊋 Polymerase chain reaction (PCR) test of CSF to test for organisms:

Results within a few hours (not all labs).

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䊋 Culture and sensitivity: Results may take up to 72 hours.

䊋 Blood cultures to identify the microorganism that is causing the infection.

䊋 CT brain to rule out space-occupying lesion as cause of symptoms.

Treatment

䊋 Administer antibiotics as soon as possible to improve outcome for bac-

terial meningitis:

• Penicillin G

• Ceftriaxone

• Cefotaxime

• Vancomycin plus ceftriaxone or cefotaxime

• Ceftazidime

䊋 Fungal infections are typically treated with

• Amphotericin B

• Fluconazole

• Flucytosine

䊋 Administer corticosteroid to decrease inflammation in pneumococcal

infection:

• Dexamethasone

䊋 Administer osmotic diuretic for cerebral edema:

• Mannitol

䊋 Administer analgesics for headache if needed:

• Acetaminophen

䊋 Administer anticonvulsant if necessary:

• Phenytoin, phenobarbital

䊋 Administer Decadron (IV) every 6 hours for 4 days to reduce hearing

loss and severe neurologic damage.

䊋 Bed rest until neurologic irritation improves.

䊋 Administer D5/0.22 NSS IV plus potassium (two thirds of maintenance

fluids requirements) to reduce intracranial pressure.

䊋 No oral fluids.

䊋 Fluid restriction.

Nursing Intervention

䊋 Monitor intake and output to check fluid balance.

䊋 Keep room darkened due to photophobia.

䊋 Keep room quiet. Place Quiet sign on the door.

䊋 Monitor neurologic function at least every 2 to 4 hours, changes in men-

tal status, level of consciousness, pupil reactions, speech, facial move-

ment symmetry, signs of increased intracranial pressure.

䊋 Seizure precautions per institution policy.

䊋 Isolation per policy depending on organism (meningococcal).

䊋 Cluster care activities.

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䊋 Elevate head of bed 30 degrees to decrease intracranial pressure.

䊋 Keep suction and oxygen available at bedside.

䊋 Administer cooling blanket if the patient’s temperature rises >101.3°F

(38.5°C).

䊋 Assess the anterior fontanel in infant to determine if it is bulging due to

increase intracranial pressure.

䊋 Measure the patient’s head circumference per shift to detect increase

intracranial pressure.

䊋 Assess motor skills.

䊋 Assess vital signs for indication of increase intracranial pressure.

䊋 Assess the patient’s level of consciousness.

䊋 Explain to the patient why restrictions such as bed rest are necessary and

that a vaccine is available for meningococcal meningitis. The two differ-

ent types are meningococcal polysaccharide vaccine (MPSV4) and con-

jugate vaccine (MCV4).

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You are the triage RN in the Emergency Department (ED). A parent and 5-year old

walk into the ED. The parent says that the child has a fever and a stiff neck. What

would you do?

a. Ask the parent to sign in and take a seat until they are called since the child is

ambulatory.

b. Take the child immediately to an isolation room.

c. Ask the parent how long the child has had the fever.

d. Ask the parent to take the child to his family health-care provider.

Answer:

✔ ROUTINE CHECKUP 1

ENCEPHALITIS

What Went Wrong?

Encephalitis is the inflammation of the brain tissue most often caused by a

virus but also can be caused by bacteria, fungus, or protozoa. In viral

encephalitis, the patient typically has had viral symptoms prior to the current

illness because the virus enters the CNS via the bloodstream and begins to

reproduce. Inflammation in the area follows, causing damage to the neurons.

Demyelination of the nerve fibers in the affected area and hemorrhage,

edema, and necrosis occur, which creates small cavities within the brain

tissue. Herpes simplex virus 1, cytomegalovirus, echovirus, coxsackie virus,

and herpes zoster can all cause encephalitis. Some causes of encephalitis can

be transmitted by insects (such as mosquitoes or ticks) to humans, such as

West Nile virus, St. Louis encephalitis, or equine encephalitis.

Identification of the organism is important to individualize the treatment for

the patient. The earlier symptoms are recognized and the patient enters the

health-care system, the better. Some patients incur permanent disability from

the irreversible damage that occurs to the brain. These patients may be in need

of long-term custodial care.

Signs and Symptoms

䊋 Fever due to infection

䊋 Nausea and vomiting due to increased intracranial pressure

䊋 Stiff neck due to meningeal irritation

䊋 Drowsiness, lethargy, or stupor due to increased intracranial pressure

䊋 Altered mental status: irritability, confusion, disorientation, personality

change

䊋 Headache due to increased intracranial pressure

䊋 Seizure activity possible due to irritation of brain tissue

䊋 Bulging fontanels in infant

Test Results

䊋 Blood cultures used to help identify organism when patient febrile

䊋 CT scan

䊋 MRI

䊋 Analysis of CSF for microorganism that is causing the infection

Treatment

䊋 Monitor respiratory status for compromise.

䊋 Monitor vital signs for widened pulse pressure and bradycardia, signs of

increased intracranial pressure.

䊋 Monitor neurologic function for change.

䊋 Administer corticosteroid to decrease inflammation:

• Dexamethasone

䊋 Administer antipyretics to reduce fever:

• Acetaminophen

䊋 Administer anticonvulsants to decrease chance of seizure activity:

• Phenytoin, phenobarbital

䊋 Administer diuretics to decrease cerebral edema if indicated:

• Furosemide

• Mannitol

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Nursing Intervention

䊋 Range of motion exercises—active or passive.

䊋 Turn and position patient.

䊋 Monitor neurologic status for changes; typically use the Glasgow Coma

Scale or similar tool to grade response to stimuli (highest score: 15):

• Eye opening response:

䊊

Spontaneous 4

䊊

To sound 3

䊊

To pain 2

䊊

None 1

• Motor responses:

䊊

Obeys commands 6

䊊

Localizes pain 5

䊊

Withdrawal (normal) 4

䊊

Abnormal flexion 3

䊊

Extension 2

䊊

None 1

• Verbal responses:

䊊

Oriented 5

䊊

Confused conversation 4

䊊

Inappropriate words 3

䊊

Incomprehensible sounds 2

䊊

None 1

䊋 Provide a quiet environment to decrease unnecessary stimulation.

䊋 Monitor fluid input and output.

䊋 Explain to the family that home care is needed and that the patient must

be turned and positioned every 2 hours. Also alert the family to adverse

reactions and side effects of medication and interactions with other med-

ications.

REYE SYNDROME

What Went Wrong?

During the urea cycle, ammonia is changed to urea in the liver. Urea is then

excreted by the kidneys. In Reye syndrome, there is a disruption in the urea

cycle resulting in an increase in ammonia levels in the blood and increased

fatty acids that infiltrate the kidneys, muscles, and neuronal cells. Reye syn-

drome occurs within 3 days from a viral infection and is linked to the use of

aspirin in children.

Recovery is related to the degree of cerebral edema. If the patient is diag-

nosed and treated in the early stages, recovery is excellent; otherwise the

patient may die within a few days. The prognosis is poor for a patient who has

lapsed into a coma.

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There are five stages of Reye syndrome:

1. Viral infection

2. Recovery period

3. Intractable vomiting, confusion, agitation

4. Coma

5. Seizures, decreased respiration, decreased tendon reflexes

Nursing alert Children <15 years who exhibit fever and flulike symptoms

should be administered acetaminophen rather than aspirin. Alka Seltzer, Anacin,

Ascriptin, Bufferin, Pamprin, Pepto-Bismol, and Vanquish all contain aspirin.

Signs and Symptoms

䊋 Stage 1:

• Fever

• Flulike symptoms

䊋 Stage 2:

• No symptoms

䊋 Stage 3:

• Persistent and recurring nausea and vomiting

• Listlessness

• Irritability

• Combativeness

• Disorientation

• Confusion

• Increased blood pressure

• Increased pulse

• Hyperactive reflexes

䊋 Stage 4:

• Loss of consciousness

䊋 Stage 5:

• Decreased tendon reflexes

• Respiratory failure

• Delirium

• Convulsions

• Seizures

Test Results

䊋 Increased serum liver enzyme

䊋 Increased serum ammonia levels

䊋 Decreased serum glucose level

䊋 Liver biopsy to confirm liver damage

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