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experience altered sensory perception in the same areas, such as the sensa-

tion of crawling, tingling, burning, or pain. The progression of symptoms may

take hours or days.

Descending Guillain-Barré begins with muscles in the face, jaw, or throat

and travels downward. Respiratory compromise is a concern as the paralysis

reaches the level of the intercostal muscles and diaphragm. Breathing can

become compromised more quickly in patients with descending disease. Level

of consciousness, mental status, personality, and pupil size is not affected.

Patient support and monitoring are important during symptom progression.

Involvement of respiratory muscles may result in respiratory compromise or

failure. Involvement of ocular areas may cause blindness.

If the nerve cell body is damaged during the acute phase, there may be per-

manent deficits for the patient in the involved area. Otherwise, the axons of

the nerves may be able to repair the damage over several months.

Signs and Symptoms

䊋 Burning or pickling feeling due to demyelination of the nerve axons.

䊋 Symmetric weakness or flaccid paralysis, typically ascending in pattern.

䊋 Absence of deep tendon reflexes due to changes within the nerves: Reflexes

are a sensory-motor response that happen at the spinal level, not the brain.

䊋 Recent infection or other acute illness.

䊋 Facial weakness, dysphagia, visual changes in descending disease.

䊋 Labile blood pressure and cardiac dysrhythmias due to autonomic nerv-

ous system response.

Test Results

䊋 Lumbar puncture shows CSF with increased protein; may not be pres-

ent initially.

䊋 Nerve conduction studies show slowed velocity.

䊋 Pulmonary function tests show diminished tidal volume and vital capacity.

Treatment

䊋 Monitor respirations and support ventilation if necessary.

䊋 Plasmapheresis for plasma exchange to remove the antibodies in the cir-

culation.

䊋 Administer immunoglobulin IV after drawing labs for serum immunoglob-

ulin A.

䊋 Nasogastric tube feeding if swallowing is a problem.

Nursing Intervention

䊋 Monitor for progression of change of sensation.

䊋 Monitor respiratory status for change in effort or rate, use of accessory

muscles, cyanosis, change in breath sounds, breathlessness when talking,

irritability, decreased cognitive awareness.

Pediatric Nursing Demystified

222

䊋 Call physician for respiratory changes or decrease in pulse oximeter reading.

䊋 Monitor gag reflex.

䊋 Monitor for visual changes.

䊋 Monitor for communication ability; may need special method to commu-

nicate with staff; may not be able to use call bell system.

䊋 Turn and reposition.

䊋 Consult with social worker or chaplain for support services available to

patient.

䊋 Explain to the family the importance of turning and positioning the

patient every 2 hours and the proper care of the plasmapheresis access

site. Also explain that the patient will require home care.

CHAPTER 10 / Neurologic Conditions

223

Enlarged head

Brain with

normal ventricles

Brain with

enlarged ventricles

FIGURE 10-2

HYDROCEPHALUS

What Went Wrong?

Hydrocephalus occurs when there is disruption of circulation and absorp-

tion of CSF resulting in an accumulation of CSF in ventricles of the brain

causing ventricles to dilate and increase intracranial pressure. There are two

types of hydrocephalus:

䊋 Noncommunicating hydrocephalus: Caused by an obstruction of CSF flow.

䊋 Communicating hydrocephalus: Caused by disruption of CSF absorption.

Signs and Symptoms

䊋 Rapidly increasing head circumference in infants

䊋 Bulging and widening of fontanels in infants

䊋 Underdeveloped neck muscles

䊋 Shiny thin scalp

䊋 Distended scalp veins

䊋 Setting-sun sign where the sclera is above the iris

䊋 Irritability

䊋 Projectile vomiting

䊋 Shrill cry

䊋 Anorexia

䊋 Weak sucking

䊋 Nuchal rigidity

䊋 Arnold-Chiari malformation

Test Results

䊋 Measure head circumference to detect enlargement.

䊋 CT scan: Visualizes the ventricles to determine if the ventricles are dilated.

䊋 MRI scan: Visualizes the ventricles to determine if the ventricles are dilated.

䊋 Radiograph: Determines if the skull is thinning or widening

Treatment

䊋 Surgical removal of or bypass the obstruction using a ventriculoperi-

toneal (VP) shunt that connects the ventricles to the peritoneal cavity or

to the right atrium of the heart.

䊋 Administer Tylenol as needed for postoperative pain.

䊋 VP shunt infection or malfunction:

• Administer vancomycin IV.

• Administer Tylenol if the temperature is >101.3°F (38.5°C).

Nursing Intervention

䊋 Before surgery:

• Measure the head circumference daily and report increases of 0.5 cm

to the health-care provider.

• Monitor for increase intracranial pressure.

Pediatric Nursing Demystified

224

• Monitor vital signs every 4 hours.

• Maintain strict intake and output measurement.

• Provide small feedings due to the risk of vomiting.

• Burp frequently during feedings.

• Support the child’s head during feedings.

䊋 After surgery:

• Position the patient flat on the nonoperative side to prevent the CSF

from rapidly draining.

• Assess the level of consciousness.

• Monitor for vomiting.

• Assess for infection and VP shut malfunction:

䊊

Severe headaches

䊊

Irritability

䊊

Vomiting

䊊

Redness along the shunt

䊊

Fluid around the VP shunt valve

䊊

Fever

䊊

Lethargy

• Assess for abdominal distention resulting from paralytic ileus due

to the VP shunt.

• The child should not participate in contact sports.

• Explain the disorder and treatment to the family and explain that VP

shunt may have to be replaced periodically to accommodate the

child’s growth. Also explain how to identify infection or malfunc-

tioning of the VP shunt and to call the health-care provider immedi-

ately if it should occur.

CONCLUSION

There are three divisions of the neurologic system. These are the central nerv-

ous system (CNS), peripheral nervous system, and the autonomic nervous

system (ANS).

When an abnormal discharge of neurons in the CNS occurs, the patient

experiences involuntary movement referred to as a seizure.

The brain and spinal cord is covered by a meningeal covering that can

become inflamed by invading bacterial, virus, fungus, or other microorganism.

This is called meningitis. A microorganism can also infect the brain tissue that

results in inflammation called encephalitis. Encephalitis can lead to the

demyelination of nerve fibers in the affected brain tissue.

The brain is surrounded by cerebral spinal fluid (CSF). CSF circulates

throughout the brain and becomes absorbed to maintain balance pressure. A

disruption of this circulation or absorption results in a buildup of CSF referred

to as hydrocephalus.

CHAPTER 10 / Neurologic Conditions

225

The brain can also be adversely affected by the disruption of the urea cycle

in the liver. The liver changes ammonia to urea that is excreted in urine. The

disruption causes ammonia levels to build in the blood and cross the blood-

brain barrier, causing neurologic problems and problems with muscles and

kidneys. This disorder is called Reye syndrome.

Neurologic disorders can stem from genetic and development abnormali-

ties such as neural tube defects. A neural tube defect occurs when the neural

tube, which later develops into the brain and spinal cord, fails to close within

28 days after conception.

Cerebral palsy is another disorder that can occur during fetal development,

a difficult birth, or trauma. This is where the portion of the brain that controls

motor functions becomes disabled, resulting in partial paralysis and uncon-

trolled movement.

Down syndrome and Duchenne muscular dystrophy are both genetic disor-

ders that affect children. Down syndrome is a genetic disorder resulting in retar-

dation most commonly caused by three instead of two chromosomes 21.

Duchenne muscular dystrophy is a sex-linked recessive genetic degenerative

muscular disease where muscle fibers are replaced by connective tissue and fat.

A child might develop Guillain-Barré syndrome following a viral infec-

tion, surgery, or from immunization. This disorder is an acute, progressive

autoimmune condition that affects the peripheral nerves where the myelin sur-

rounding the axon on the peripheral nerves is damaged.

An abnormal growth of cells in the brain might develop. This called a brain

tumor. A brain tumor might consist of brain tissue or tissues from a secondary

site that has metastasized to the brain. As a result, the brain tumor can interfere

with normal neurologic activities and might increase intracranial pressure.

Pediatric Nursing Demystified

226

FINAL CHECKUP

1. What is the disorder called where there is a brief loss of consciousness lasting

<30 seconds with no postseizure confusion and minimal or no loss of postural tone?

a. Myoclonic seizure

b. Complex partial seizure

c. Absence seizure

d. Tonic-clonic seizure

2. What would you do for a patient diagnosed with encephalitis?

a. Monitor for increased intracranial pressure.

b. Encourage family and friends to visit at all times a day and night to support the child.

c. Avoid administering corticosteroid.

d. All of the above.

CHAPTER 10 / Neurologic Conditions

227

3. What stage of Reye syndrome would you suspect if the patient lost consciousness?

a. Stage 2

b. Stage 3

c. Stage 4

d. Stage 5

4. How would you care for the sac in a patient who has spinal bifida occulta?

a. Keep the patient on his side to remove pressure from the sac.

b. Place a sterile dress soaked in warm saline solution to prevent the sac from dehydration.

c. Place a strip of plastic below the sac to prevent contamination from urine and stool.

d. None of the above.

5. You notice a child having a scissor-like gait. What disorder would you suspect?

a. Cerebral palsy spastic

b. Cerebral palsy athetoid

c. Cerebral palsy ataxic

d. Duchenne muscular dystrophy

6. A patient diagnosed with Guillain-Barré syndrome has difficulty swallowing.

What would you expect the health-care provider to order?

a. Peg tube feeding

b. Nasogastric tube feeding

c. Nothing by mouth (NPO)

d. Only fluids by mouth

7. The parent of a 3-year-old who has been treated for hydrocephalus at birth calls

saying that the child has severe headaches and is irritable and vomiting. What

would you tell the parent?

a. Bring the child to the health-care provider’s office immediately.

b. Give the child an aspirin.

c. Give the child acetaminophen.

d. This is a reaction to the medication administered for hydrocephalus.

8. What would you do if the health-care provider diagnosed a newborn with

anencephaly?

a. Teach the family how to care for infant’s sac.

b. Make an appointment with the social worker to explain services that are available

to parents of a child who is paralyzed.

c. Explain to the family that the child will likely develop hydrocephalus.

d. Prepare the family for the child’s death.

9. Increased intracranial pressure can cause which of the following?

a. Seizure

b. Nausea

c. Vomiting

d. All of the above

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228

10. What could occur if the child’s temperature is 103°F?

a. Falling forward

b. Drop-and-fall action

c. Febrile seizure

d. Night terror

ANSWERS

Routine checkup 1

1. b

Routine checkup 2

1. b

Routine checkup 3

1. c

Final checkup

1. c 2. a 3. c 4. d

5. a 6. b 7. a 8. d

9. d 10. c

CHAPTER

Gastrointestinal

Conditions

Learning Objectives

At the end of the chapter, the student will be able to

1 Understand the effects of a ruptured appendix.

2 Identify signs of celiac disease.

3 Know the interventions for a cleft palate and cleft lip.

4 Explain the treatment for Crohn disease.

5 Care for a patient who is diagnosed with hepatitis.

6 Assess a patient who has Hirschsprung disease.

7 Teach families about intussusception.

8 Intervene with a patient who has pyloric stenosis.

9 Discuss transmission tracheoesophageal fistula and esophageal atresia.

10 Recognize a patient who has ulcerative colitis.

11 Respond to a patient who has volvulus.

Pediatric Nursing Demystified

230

Borborygmi

Cardiac sphincter

Cheiloplasty

Gluten

Ileocecal valve

Lower esophageal

sphincter (LES)

McBurney point

Megacolon

Palatoplasty

Pyloric sphincter

Radiopaque catheter

Rebound pain

Upper esophageal

sphincter (UES)

KEY WORDS

Esophagus

Stomach

Pancreas

Jejunum

Ileum

Colon

Liver

Duodenum

FIGURE 11-1

OVERVIEW

The two major components of the gastrointestinal (GI) system are the alimen-

tary canal and the accessory organs. The alimentary canal is commonly

referred to as the GI tract and consists of the following

䊋 Oral cavity

䊋 Pharynx

䊋 Esophagus

䊋 Stomach

䊋 Small intestine

䊋 Large intestine

THE ESOPHAGUS

Digestion involves mechanical and chemical processes, both of which begin

in the mouth. Chewing, movement through the GI tract, and churning within

the stomach are parts of the mechanical process. Saliva, hydrochloric acid,

bile, and other digestive enzymes all contribute to the chemical process of

digestion.

The esophagus extends from the oropharynx to the stomach. At the top of

the esophagus is the upper esophageal sphincter (UES) to prevent the influx

of air into the esophagus during respiration. At the bottom of the esophagus

is the lower esophageal sphincter (LES) that prevents the reflux of acid from

the stomach into the esophagus.

THE STOMACH

The contents of the esophagus empty into the stomach through the cardiac

sphincter. The stomach has three parts: the fundus, body, and pylorus. The

fundus is the upper portion of the stomach that connects to the lower end of

the esophagus. The body is the middle portion of the stomach where gastrin

secretes. Gastrin promotes secretion of pepsinogen and hydrochloric acid,

pepsin, and lipase, all of which aid digestion, and mucus formation, which

helps protect the stomach lining. The pylorus is the lower portion of the stomach

that connects to the duodenum by the pyloric sphincter.

THE LIVER

The liver is a very vascular organ located in the right upper quadrant of the

abdomen under the diaphragm. It has two main lobes that are comprised of

smaller lobules. The liver stores a variety of vitamins and minerals. It metab-

olizes proteins; synthesizes plasma proteins, fatty acids, and triglycerides; and

stores and releases glycogen. The liver detoxifies foreign substances such as

alcohol, drugs, or chemicals.

The liver forms and secretes bile to aid in digestion of fat. Bile will release

into the gallbladder for storage or into the duodenum if needed for digestion

CHAPTER 11 / Gastrointestinal Conditions

231