NEURO (A lot of neuro questions on test)
-
-
-
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LOC (#1 Assessment)
o 1.) Fully Conscious
o 2.) Confusion
 Impaired decisions
o 3.) Disorientation
 To time and place
o 4.) Lethargy
 Sluggish speech and movement
o 5.) Obtundation
 Arouse with stimulation
o 6.) Stupor
 Responds to vigorous and repeated stimulation (sternal rub)
 Worse than obtundation
o 7.) Coma
 No motor or verbal response to stimuli
o 8.) Veggie
S/S = Non-stop headache, n/v, seizure activity
Make sure to not overload sensory
Glascow Coma Scale =
o 15 = Unaltered LOC (perfect)
o 3 = Extreme decreased LOC (dead)
o 7-8 = CALL MD
 Be able to identify patient based on their number!
Can you give Codeine to a neuro patient?
o NO
Care for a patient with increased cranial pressure
o Positioning – use pillows (30 degrees)
o Avoid activity
o No noise
o NO deep suction – can increase ICP
o Do you give fluids?
o Do you give supplemental oxygen?
Decorticate (IN) & Decerebrate (OUT) – ATIVAN DRUG OF CHOICE!!
o Know posture differences: decerebrate and decorticate
Increased Intracranial Pressure (ICP)
-
Early signs and symptoms may be subtle
As pressure increases, signs and symptoms become more pronounced
-
-
Loss of Consciousness is first sign of cerebral edema
o When you do neuro assessment, first thing you assess is LOC
Signs and symptoms in infants:
o Irritability
o Poor feeding
o High-pitched cry, difficult to soothe
o Fontanels – BULGING
 May feel it pulsing to heart beat
o Cranial sutures separated
o Eyes- setting sun signed
 If they turn their head one way, their eyes go the other way
o Scalp veins distended
o Headache & Vomiting –FIRST TWO SIGNS OF SHUNT FAILURE
o Seizures
o Diplopia, blurred vision
o Drowsiness, decrease in physical activity and motor skills
o Diminished physical activity
o Inability to follow commands
o Memory loss lethargy
LATE signs of Increasing ICP
o Decreased LOC
o Decreased motor responses to commands
o Decreased sensory response to painful stimuli
o Alteration in pupil size and reactivity – Pupils go up
o Decerebrate or Decorticate posturing
o Eyes swelling (papilledema)
Unconscious Child
-
Airway
Reduction of ICP
Treatment of shock (Monitol)
Nutrition
-
Watch for fluid overload
G-tube
Cerebral Trauma:
-
#1 = Stabilize neck and spine if any trauma
CT scan first!
Near Drowning:
-
First 24 hours after incident cause by “drowning”, after 24 hours after incident is caused
by “near drowning”
-
Death occurs due to NO OXYGEN to the brain!!!!
Expected findings = HYPOXIA (brain lacked O2, aspiration, and hypothermia)
IF child is brought into ER and parents suspect issues due to coughing and CT is negative
in lungs for water……..KEEP CHILD OVER NIGHT BECAUSE CHILD COULD
HAVE FURTHER PROBLEMS
Epilepsy:
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Two or more seizures with unknown cause
Bad diagnoses for Adolescents because they can’t get their license unless they haven’t
had a seizure in last 6 months
Febrile Seizure – seizure activity due to sudden increase in temperature
-
Kids can grow out of this disorder (rare after age 5)
TX = Acetaminophen or Motrin (for fever)
Hydrocephalus:
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Build-up of cerebrospinal fluid in the brain
Tx = Insertion of a VP Shunt
 Shunt can cause dysrhythmias
o If patient has VP shunt and is experiencing N/V what do you assess first?
 LOC
o S/S of shunt infection:
 Change in LOC
 GIVE LARGE DOSES OF ANTIBIOTICS OR REMOVE
SHUNT
Cerebral Palsy:
-
-
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Caused by a lack of OXYGEN to the brain (hypoxic event) (in-utero, at birth, or during
life)
Could be a result of shaken baby syndrome
Three different tyes:
o Spastic
o Dyskinetic
o Ataxic
S/S =
o Arching back
o Stiff posture
o Not meeting milestones (ex. Head control, sit without support)
Feeding difficulty = usually die from aspiration (G-tube)
Goals = Communication, self-help skills, education opportunities, and socialization
Rx:
o Baclofen = reduce tension in joints and muscles
-
Therapeutic Management:
o Ankle/Foot Braces
o Orthopedic surgery to correct spastic deformities
o Pharmalogical agents to treat pain related to spasms and seizures
o Bot. A injections
o Dental hygiene
o PT/OT
Neuro Tube Defects
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-
How can a mother prevent her child from having a neural tube defect?
o Take folic acid supplement
o Question option was a full-term breast-fed baby
Can see in first ultrasound
Infection is number 1 killer in NTD babies
Trouble with elimination and spina bifida
Myelomeningocele:
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Neural tube fails to close
Diagnosed prenatally and at birth
Sacs contain meninges, spinal fluid and nerves
Interchangeable with spina bifidia
Main Task = Protect the sac (prevention of infection)
o Inspect every 2-4 hours
o Keep moist to prevent cracking
o Cover it
o Lay prone to avoid pressure on sac
o Child will endure many surgeries
ADHD:
-
-
ADHD children have to go to doctor once a month
o Weight loss and blood pressure checks
 If within good standing = prescription is refilled
PROVIDE ENVIROMENTAL SAFETY
Autism:
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Kids like to be in safe zone
Will not make eye contact
Down Syndrome:
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Only have one line across hand instead of 3 (SIMIAN CREASE)
Major complication = heart anomalies
Reyes Syndrome:
-
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Toxicity to organs most commonly the brain and liver (jaundice) (associated with
aspirin)
Fever, impaired consciousness, disordered hepatic function, swelling of brain, N/V,
jaundice, rash
No aspirin under 12 years
Children need quiet, dim atmosphere with no stimulation (NEVER OVERLOAD)
Most cases follow:
o Viral Illness such as Influenza or Varicella
o Association between aspirin therapy and RS
SWELLING OF BRAIN & LIVER
SYMPTOMATIC TREATMENT ONLY
HEMATOLOGY
Iron Deficiency Anemia
-
Adolescents at risk because of rapid growth and poor eating habits and females more at
risk because they have periods
Caused by inadequate supply of dietary iron
Polyglycol is the supplement and you have to wipe teeth off after
Sickle Cell Anemia:
-
-
Dx = Newborn Screening
Autosomal recessive- Both parents have to have traits= ¼ chance
SCA with pain= Patient having extreme leg or abdominal pain = Give Morphine
SCA with fever= Patient with pain and fever = Blood culture to test for infection
NO CURE, but possible bone marrow transplants
Cold air is a trigger for sicklers
If a patient with sickle cell is in pain and has had pain med but still has a
headache….CALL MD… patient could be having a stroke and needs a CT scan
Management = KEEP HYDRATED and TREAT PAIN
o No strenuous exercise, no high altitudes, get annual vaccines, and take folic acid
supplement
Give morphine (hydromorphone), Acetaminophen with Codeine, Toradol (Ketorolac) 
Don’t pick the other choice* You give pain meds
Hemophilia:
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Bleeding
Absence of a protein in coagulation
Management = Joint pain or swelling... COLD COMPRESS/constricts the blood
Leukemia:
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-
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Most common form of childhood cancer
o Acute Lymphoid Leukemia (ALL)
 Most common
 80% survivability
 Protocol: come in and do chemo to put in remission, can do up to 3 times.
If it comes back after that you have to look for bone marrow transplant
 Peaks at age 2-4 years
 White males
o Acute non-lymphoid leukemia (AML)
 50% survivability
 Protocol: look for bone marrow transplant immediately
 Across ethnic groups equally
 Older kids
o Consequences of Leukemia
 Anemia from decreased RBC’s
 Infection from neutropenia
 Decreased platelet production
o Symptoms
 Joint pain is cardinal sign of bone marrow failure
o Identifying factors for determining prognosis
 Initial WBC count
 Age at time of diagnosis
 Type of cell involved
 Gender
 Karyotype analysis
What should you do for a child with leukemia? Allow them to play with other kids that
do not experience fear? You wouldn’t want them in isolation.
Most common childhood cancer
Acute lymphoid = Young children
o Chemo and radiation …. If child fails to stay in remission, they become candidate
for bone marrow transplant
Expected findings = low O2, low energy level, low WBC, low platelet
S/S = petechia, joint pain, and headache that won’t go away due to increased ICP
Teachings:
o Chemo
 Vesicants: sclerosing agents even in the minute amounts
 If you’re a chemo nurse and you’ve given chemo to a patient and they’re
nauseous and want a drink you give them cool, clear liquids or ice chips.
 Ginger ale
 No milk or coffee
 Use soft sponge toothbrush
 Watch for ulcers and monitor blood pressure


IF reaction to chemotherapy… first STOP the pump, then flush the line
and call the MD
Child may take Zofran for n/v
Infection Control:
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Best way to prevent spread of infection...HAND WASHING
Wilms Tumor:
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Tumor in the kidney (usually unilateral, encapsulated); Kidney cancer “nephroblastoma”
S/S = Weight loss, abdominal swelling, hypertension; left more than right
NEVER PALPATE THE ABDOMEN WHEN THIS IS SUSPECTED
Tx = Removal of kidney
o POST OP
 Priority Assessment = I/O’s
 Chemo and Radiation
 Monitor Blood Pressure (hypertension)
May occur in lungs
Osteosarcoma:
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Bone cancer
Most common in long bones of the lower extremities (femurs)
Bones such as the femur? This was an answer option
Tx = Limb Salvage Procedure
o According to the book after an amputation a prosthesis is put on immediately
Retinoblastoma:
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Cancer on the retina of the eye
S/S = white eyed reflex “cats eye reflex- whitish “glow” of the pupil”, pain, loss of vision
Tx = Chemo, removal of lens
CNS Tumors:
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Cortex = Chemo (better prognosis)
Glyoma = Chemo & Radiation (poor prognosis)
Biggest S/S = Consecutive headache accompanied with nausea
o Neuroblastoma
 Chemo/Radiation
 Surgery to remove
 Known as the“SILENT TUMOR”
 After you have found it, it has already metastasized
 Usually comes back

Patients with a brain tumor that have sudden increase ICP = CALL
NEUROSUREGON
GRIEF AND LOSS (5 questions)
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First year it is okay for people to feel depressed and as if the deceased is still with us
(dreams)
Everyone grieves their own; cannot put a time limit on grief
A dying child needs = HONESTY AND ACCURECY OF INFORMATION
Concepts of death:
o Infant =
 6 months or older they will know someone is gone; they don’t know why
o Toddler =
 Thinks about death in their terms (little understanding)
 Egocentrism makes them not understand death but be more affected by
change in lifestyle (they feel the absence of person)
o Pre-school =
 May see death is temporary/reversible
 Be patient with these children regression
 Explain death at their level
 They don’t have a great understanding of death
o School Age =
 Deeper understanding; be honest
 Personify death as a monster and fear punishment associated with death
 FEAR OF THE UNKNOWN IS GREATER THAN FEAR OF KNOWN
o Adolescents =
 Understand death in irreversible, inevitable
 Have most difficulty coping with death: answer option on test
 Child feels death is barbaric
o Parental Grief =
 If a parent still hears or sees her dead child 6 months after death = Normal
 If the parent still sees/hears child after 1 year = Not normal, get parent
help
ENDOCRINE
Meningitis:
-
#1 S/S = Kernig Sign
o Child not able to extend leg when thigh is flexed anteriorly at the hip
Why is a baby put in an incubator?
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Increase temperature
Diabetes 1:
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Autoimmune, insulin dependent (pancreas not working)
Onset: childhood/adolescent (but can occur at any age)
Complications = vision loss and blindness, kidney failure, cardiovascular disease, nerve
damage/amputation, ulcers/sores
S/S = weight loss
Never store insulin too cold or too hot
Dx:
o Fasting = <126 mg/dl
o Random >200 mg/dl
o A1C = <7%
Hypoglycemia: (cold and clammy = need some candy) (HYPO/HIPPO)
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BS less than 70mg/dl
Nurse Alert: Hypoglycemic episodes most commonly occur before meals
o The insulin effect is peaking
PRIORITY PATIENT (HYPO IS WORSE)
S/S = shaky, sweating, tachycardia, irritable (cry for no reason), nervous, difficulty
concentration, hunger, pallor, headache, shallow respirations
Nurse Alert: Never store insulin at very cold (under 36 F) or very hot (over 86 F)
o Extreme temperatures destroy insulin.
Ex: little boy playing sports was experiencing hypoglycemia what should the boy do?
Eat a snack before playing, take an extra dose of insulin before the game, skip a dose of
insulin, etc.
Hyperglycemia: (hot and dry = sugar high)
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BS greater than 150 mg/dl
o S/S = polyuria, polydipsia, polyphagia, irritability, headache, weight loss,
nocturia, shortened attention, fatigue, dry skin, blurred vision, headache, frequent
infections, Deep Rapid Kussmaul Respirations
PKU:
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Metabolic disorder- autosomal recessive gene (find out at newborn screening)
Toxic levels of phenylalanine
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Accumulations of phenylalanine that eventually causes developmental delays, mental
retardation, and seizures  death if not controlled
NO CURE- can only treat by what they eat
Need to know that PKU pt’s should decrease their intake of phenylalanine
Causes = developmental delays, mental retardation, and seizures
Blood test
o Test at least 24 hours after initial ingestion of milk
o If early discharge, obtain 2nd sample before 2 weeks of age
Tx: Diet low in phenylalanine soon after birth
o Vegetables, Fruits, Juices, Cereals, Breads, Starches
Tyrosine supplementation
Avoid PROTEINS, Eat more veggies, fruits, and juices
Hyperthyroidism:
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Breast and testicular development occur early
o Dress appropriately
Hypothyroidism:
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Dry skin, slowing body and mind, constipation, depression
Rx: levothyroxine (Synthroid) – must crush and put in small amount of liquid
Precocious Puberty:
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IN girls
o Breast development
o Pubic/axillary hair
 Acne, oily skin & hair, voice, mood behavior
o Menarche
IN boys
o Testicular enlargement
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o Penile enlargement
o Public/axillary hair
 Acne, muscle mass, voice, mood behavior
Adverse consequences
o Body image/selfesteem, depression, earlier sexual activity, conduct problems,
delinquency, substance abuse, developed body without equal brain development
THREATS TO SKIN INTEGRETY
PREVENT SPREAD OF INFECTION WITH GOOD HANDWASHING
Impetigo:
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Most common bacterial skin infection in children; caused by a staph infection
EXTREMELY CONTAGIOUS – Child should not go back to school until scab crust is
gone; no draining lesions
o Wash crust with warm water
o Ex: What is a priority intervention? To prevent further spreading
Cellulitis:
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S/S = warm, red, painful area of skin
Tx = WARM COMPRESS
Pediculosis (Head Lice):
-
Apply pediculicides and let sit for 8 hours (kills adult lice)
Therapeutic Management: application of pediculicides & manual removal of nits.
o MUST COMB OUT BABY LICE
Nursing Considerations : Caution against cutting child’s hair or shaving (causes distress)
Dermatitis:
-
Rash from anything
Stop itching
Use topical ointment
o Diaper Rash:
 ABX
o Eczema:
 Oil based cream, steroid (oral and topical)
Lyme Disease:
-
Stages:
o Stage 1- consists of tick bite at time of inoculation, followed in 3 to 31 days by
development of erythema migrans at site of bite
o Stage 2- most serious stage characterized by systemic involvement of neurologic,
cardiac, and musculoskeletal systems; appears several weeks after cutaneous
phase is complete
o Stage 3- late stage; musculoskeletal pain that involves tendons, bursae, muscles,
and synovia; arthritis may occur; deafness, chronic encephalopathy
Bug Bites:
-
What is your first action after a bug bite?
o Irrigate wound; clean it out
What bites are the most dangerous?
o HUMAN is the priority patient
Acne:
-
Rx:
-
o Accutane- reserved for severe cystic acne that has not responded to any other tx
(for severe acne that scars)
 Must watch SE
 Dry skin and mucous membranes; nasal irritation, ha, mood changes
 Monitor for depression and suicidal ideation
o Must be off Accutane for 6 months to try to conceive (99.5% still born or defect
baby with mother on Accutane)
Never pop the pimple
THREATS TO MOBILITY (5-6 questions)
You lose 33% of muscle mass if you are flat off your feet for 24 hours
Immobilized Child:
-
PRIORITY: DO NOT touch weights on traction beds!!!
If a patient has weights after surgery… is it in the nurses scope of
practice to move the weights?
-
NO! Call surgeon
Assessment of fractures (5 P’s):
o
o
o
o
o
Pain and point of tenderness (PRIORITY)
Pulse: distal to the fracture site
Pallor
Paresthesia: sensation distal to the fracture site
Paralysis: movement distal to the fracture site
Child in a Cast:
-
-
All fractures swell
o PREFORM NEUROVASCULAR CHECKS
 Teach parent
If hot spot occurs, cut out spot and check it for compartment syndrome
Hip Dysplasia:
-
-
Assessment = Push knees to chest. Legs SHOULD come out like frog. Put 2 fingers on
the hip, if it clicks (+) DDH
o (+) Barlow Test
o Ortolani test
S/S = Shortened leg, restricted abduction
Management:
o Pavlik Harness = 0 – 6 months
 Ex: “I will have to keep it on for 6-12 weeks” Is this right?
 Teaching =
 Can take it off for bathing and diapering.
 Teach to reset gears if they take it off.
 Also massage where shoulder straps sit due to high pressure
 Worn for 24 hours a day
 Due to infant’s rapid growth
 Wraps should be checked every 1-2 weeks for possible adjustments
 For skin care and bathing, you may or may not be able to remove
 Follow up involves frequent adjustments because of growth
 Parents should not adjust harness without supervision
 Used for hip click and hip dysphasia
o Spica Cast = 6 months – 2 years
 After this, the limp is permanent
Clubfoot:
-
Tx = Serial Casting
o New cast q. 1-2 weeks; continues for 8-12 weeks
o Question asked what would require further intervention… “I will need to change
my cast every month”
Scoliosis:
-
-
Tx = Brace (10-20 degree curve)
o Don’t take off or curve will worsen
o Check skin
POST OP
o Log roll first 48 hours (twice a day)
o PCA pump (break through pain)

Reminder: Nurse can’t press but can remind child or parent to press button
Juvenile Idiopathic Arthritis (JIA):
-
-
-
15 or younger = Juvenile (JRA)
o Tx – Methotrexate
16 or older = Adult (Rheumatoid arthritis)
o Tx – Methotrexate + Humira
Methotrexate Substitution = Plaqenil
o Side effect: blindness; EYE EXAMS ANNUALLY
Goal= remission
Twice as many girls as boys affected
Symptoms may burn out and become inactive
Only 30% go into adult RA
Symptoms:
o Stiffness – especially in the morning
o Swelling
o Loss of mobility in affected joints
Warm to touch, usually without erythema
o Tender to touch in some cases
o Symptoms increase with stressors
o Growth retardation – can cause major damage to joints
o Sudden onset – 24-48 hrs
o Pain even at rest – may disturb sleep
o Pronounced weakness
o Emotional depression
NO cure- remission is goal
Elevated sedimentation rate
Knees would be warm to touch or very cool
Methotrexate to treat, also NSAIDS
Long term NSAID use can cause GI problems and Liver function problems
Number one priority is pain relief
Firm mattress, hot water bottle, electric blanket, and rest
Duchenne Muscular dystrophy:
-
Degeneration of skeletal muscle
Progressive weakness
Osteomyelitis
-
Infection in the bone
Foot, femur, tibia, pelvis
Tx:
o Gentamycin, vancomycin, clindamycin