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Nclex & Cgfns Review Bullets 5

Nclex & Cgfns Review Bullets 5

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Published by: blazegomez on Jan 09, 2010
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SOURCE: http://www.nursereview.org
The harness should be worn 23 hours a day and should be removedonly to check the skin, and for bathing. The hips and buttocks shouldbe supported carefully when the infant is out of the harness. Theharness does not need to be removed for diaper changes orfeedings.
A complication after surgical treatment of scoliosis is superior mesentericartery syndrome. This disorder is caused by mechanical changes in theposition of the child’s abdominal contents, resulting from lengthening of thechild’s body. It results in a syndrome of emesis and abdominal distentionsimilar to that which occurs with intestinal obstruction or paralytic ileus.Postoperative vomiting in children with body casts or those who haveundergone spinal fusion warrants attention, because of the possibility of superior mesenteric artery syndrome.
The most serious complication associated with skeletal traction isosteomyelitis, an infection involving the bone. Organisms gainaccess to the bone systemically or through the opening created bythe metal pins or wires used with the traction. Osteomyelitis canoccur with any open fracture. Clinical manifestations includecomplaints of localized pain, swelling, warmth, tenderness, anunusual odor from the fracture site, and an elevated temperature.
 The primary legal nursing responsibility when child abuse is suspected is toreport the case. All 50 states require health care professionals to report allcases of suspected abuse. It is not appropriate for the nurse to file chargesagainst the father or mother. It is also inappropriate to ask the mother toidentify the abuser, because the abuser may be mother. If so, the possibilityexists that the mother may become defensive and leave the emergency roomwith the child.
Late signs of increased ICP include tachycardia leading to bradycardia,apnea, systolic hypertension, widening pulse pressure, and posturing. Analtered level of consciousness is an early sign of increased ICP.
Hydrocephalus is a condition characterized by an enlargement of the craniumdue to an abnormal accumulation of cerebrospinal fluid within the cerebralventricular system. This characteristic causes the increase in the weight of the infant’s head. The infant’s head becomes top heavy. Supporting theinfant’s head and neck when picking the infant up will preventhyperextension of the neck area and keep the infant from falling backward.1
Hyperextension of the infant’s head can put pressure on the neck vertebrae,causing injury.
Intracranial pressure and encephalopathy are major symptoms of Reye’ssyndrome.
Safety with all activities is a priority in planning activities with the child. Thechild with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions,verbal communications, and providing familiarity with activities andorientation are also appropriate interventions, the priority is safety.
The adolescent should not stop taking antiepileptic medicationssuddenly or without discussing it with a physician or nurse. Acne oroily skin may be a problem for the adolescent, and the adolescent isadvised to call a physician for skin problems. Alcohol will lower theseizure threshold and it is best to avoid the use of alcohol. Birthcontrol pills may be less effective when the client is takingantiepileptic medication.
Decerebrate posturing is an abnormal extension of the upper extremities withinternal rotation of the upper arm and wrist and extension of the lowerextremities with some internal rotation.
 The progression from decorticate to decerebrate posturing usually indicatesdeteriorating neurological function and warrants physician notification.
Cushing’s response is a late sign of ICP and consists of an increased systolicblood pressure with widening pulse pressure, bradycardia, and a change inthe respiratory rate and pattern. Cushing’s response is usually apparent justbefore or when the brain stem herniates.
 The hallmark symptoms of children with brain tumors are headache andmorning vomiting related to the child’s getting out of bed. Headaches worsenon arising but improve during the day. Fatigue can occur but is a vaguesymptom. Visual changes might occur, including nystagmus, diplopia, andstrabismus, but these signs are not the hallmark of symptoms with a braintumor.
Following amputation, phantom limb pain is a temporary condition that somechildren may experience. This sensation of burning, aching, or cramping inthe missing limb is most distressing to the child. The child needs to bereassured that the condition is normal and only temporary.
If a child is severely thrombocytopenic, with a platelet count less than20,000/mm3, precautions need to be taken because of the increased risk of 2
bleeding. The precautions include limiting activity that could result in headinjury, using soft toothbrushes or toothettes, checking urine and stools forblood, and administering stool softeners to prevent straining withconstipation. Additionally, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000/ mm3.
Once the marrow is infused, nursing care focuses on preventing theimmunocompromised child from developing a life-threatening infection untilthe child engrafts and produces his or her own white blood cells with which tofight infections.
Sun protection is essential during radiation treatments. The child should notbe exposed to sun during these treatments.
Orchiopexy (or orchidopexy) is a surgery to move an undescended testicleinto the scrotum. The most common complications associated withorchiopexy are bleeding and infection. Discharge instructions should includedemonstrating proper wound cleansing and dressing and teaching the motherto identify signs of infection, such as redness, warmth, swelling, or discharge. The testicles will be held in a position to prevent movement, and great careshould be taken to prevent contamination of the suture line.
Cryptorchidism is the absence of one or both testes from the scrotum. Thisusually represents failure of the testis to move, or "descend. When a childreturns from surgery, the testicle is held in position by an internal suture thatpasses through the testes and scrotum and is attached to the thigh. It isimportant not to dislodge this suture, and this body area should beimmobilized for 1 week. The most common complications are bleeding andinfection.
Epispadias is a congenital malformation with the absence of the upper wall of the urethra. The urethral opening is located anywhere on the dorsum of thepenis. This anatomical characteristic leads to the easy access of bacterialentry into the urine.
In bladder exstrophy, the bladder is exposed and external to the body. Thehighest priority is impaired tissue integrity related to the exposed bladdermucosa.
 The “huff” maneuver (forced expiratory technique) is used to mobilizesecretions. This technique reduces the likelihood of bronchial collapse. Thechild is taught to cough with an open glottis by taking a deep breath, thenexhaling rapidly whispering the word “huff.”
Removal of foreign bodies from the respiratory tract may need to beperformed by direct laryngoscopy or bronchoscopy. After the procedure the3

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