PEDIATRIC NURSING

NEUROLOGIC DISORDERS OF PEDIA

ABNORMAL
INCREASED ICP
- (n) 5 – 15 mmhg
- Cushing’s Triad: (hyper brady brady)
- Widened pulse pressure (difference between systole and diastole)
o 120 / 80 (subtract) = 40 (n) 30 – 40

S / Sx:
 Bulging fontanels (2) aggravated by CRYING = inc ICP
 Anterior: diamond (ADi) = closes 12 – 18 mos
 Posterior: triangular (PoT) = closes 2 – 3 mos

 High pitched cry / shrill cry

 Early sign
 Early sx of inc. ICP per age group
o Infant: high pitched cry
o Child: irritability and agitation
o Adult: restlessness
o Geria: confusion

 Increased head circumference

 Bed side: tape measure
 Measure every shift or 8 hours

 Headache: initial sx (pinakaunang symptom)

 Projectile vomiting: compression of MEDULLA (CTZ – chemoreceptor

trigger zone) = cerebral edema

 Diplopia (double vision)

 Naduduling
 Inc. ICP = Inc. IOP (intraocular pressure) leads to OPTIC NERVE
DAMAGE = blurring of vision or blindness

 Pupillary Changes: (n) PERRLA

 Anisocoria: uneven pupils = brain damage
 Dilated: two dilated = presence of SHOCK
 Constricted: two constricted = narcotic overdose

 Sunset Eyes

 Anorexia, nausea, weight loss

 Seizures
 Inc. neuronal impulses = erratic transmission
 Vomiting = dec. fluid levels = dehydration = inc. temp (convulsions /
seizures)
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MANAGEMENT
a. Position: semi – fowlers (HOB): dec. ICP by gravity
b. Avoid coughing and sneezing
c. Limit fluid intake (1200 – 1500ml / day)

“Where Na goes, HO2 follows” = INC FLUID – INC PRESSURE

PHARMACOTHERAPY
a. Diuretics: K – wasting
 Lasix: loop diuretics (loop of henle): localized
 Mannitol: osmotic (osmosis) pulling pressure: generalized
 Monitor for hypokalemia

b. Decadron: Dexamethasone (corticosteroids)

 Prevent cerebral edema (anti – inflammatory)

c. Anticonvulsants

d. Antacids
 Due to use of decadron (GI irritant)
 Mg: diarrhea = Mag Tae
 Al: constipation = Alang Tae

e. Anticoagulants: prevents clumping of bloods

 Heparin: IV / Subq
 Check for PTT (partial thromboplastin time)

 Warfarin: oral
 Check for PT (prothrombin time)

REMEMBER: Opiates and Sedatives are CONTRAINDICATED in inc. ICP

Depressants

*cushing’s triad*: hyper brady brady = respiratory and cardiac depression

SEIZURE DISORDER
- Aka epilepsy
- Erratic transmission of electrical impulses

Types
A. Grand mal
 Generalized seizure (head to toe)

o Tonic (mild) clonic (severe) – mild gradually inc. to severe: “during”

dyspnea, salivation, urination
o Position: flat / supine and support head

o Post ictal – exhaustion phase “after”

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o Position: side lying / recovery position = prevent

aspiration

B. Petite mal / Absent seizure

 Lips smacking
 Automatisms – repeated purposeless movement
 Blank facial expression

C. Jacksonian
 Tonic clonic of a group of muscle progressing to grand mal
 “One part to generalized”
 “Michael Jackson”

D. Psychomotor Seizure
 Geriatrics: delirium first then seizure
 Mental clouding
 Intoxication

E. Febrile Seizure
 Under 5 seizure
 Common in children under 5: Immature hypothalamus
(thermoregulatory of body)
 38.5 – 40 degree Celsius = convulsions (seizure)

F. Status Epilepticus
 Most DANGEROUS
 Last for 30 mins
 Brain damage could occur
 On and off / continuous

MANAGEMENT
Medical:
1. Hydantoins: Phenytoin (Dilantin)

Watch Out For:

- Gingival hyperplasia (inflamed gums)
o Soft bristle brush
o Meticulous oral care

- Pinkish red urine

o Inform SO (significant other)

2. Benzodiazepines: “pam / lam”

- Minimizes seizure episodes

3. Iminostilbenes: Carbamazepine (tegretol)

- For REFRACTORY SEIZURE (pabalik balik)
- Prevent seizure reoccurrence

4. Valproates: Valproic Acid

- Last resort due to its S/E
- HEPATOTOXIC
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- NEVER GIVEN IN PREGNANT (especially in 1st trimester) =

NTD

Surgical:
 Neurectomy – surgical resection of CN involve

MENINGITIS
Brain Stem
 Midbrain – pupil and arousal (ICP)

 Pons – pneumotoxic: stop over distention of lungs

 Apneutic: depth of respiration

 Medulla – respiratory center: detect level of CO2 in CSF

 Vomiting
 Cough: defense mechanism
 HR
Inc. ICP – brain herniation
Blood supply – circle of willies

MANIFESTATION
- Meningal Irritation

 Irritability – early sx of hypoxia

 Nuchal rigidity – stiff neck
 Opisthotonic / opisthotonus position – exaggerated back arching
o Intervention: SIDE LYING position
 (+) Kernig’s – knee: supine and flex knee produces hamstring, back and
Hallmark
neck pain sx
 (+) Brudzinki’s – batok (neck sx): supine
 Flexion of nape produces flexion of knees, neck and back
pain
 Cycling feet
 Seizure

DIAGNOSTIC TEST

A. Lumbar Puncture

- L3 , L4, L5 (confirmatory dx)

- Avoid L1 – conus medullans “terminal end of spinal cord”
- CSF analysis (n. color) CLEAR

Position:
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 C
 Shrimp
 Knee chest
 Fetal
 Genupectoral

CSF ANALYSIS:

VIRAL CSF BACTERIAL

 Cloudy
 Clear  Inc. WBC – neutrophils
 Inc. WBC – Protein  Inc. CHON: byproduct
lymphocytes (n): g = 2 / 3 of serum of bacteria
 (n) CHON  Low glucose: bacteria
 (n) glucose food

CAUSATIVE AGENT

 N. Meningitides

Incubation Period: Based on Syllables

Ex:

 Co - vid = 2 weeks
 Chic – ken - Pox = 3 weeks
 Me-nin-gi-tis = 4 weeks

Sx of Bacterial Meningitis IMPROVEMENT

 Inc. glucose
 Dec. CHON

MANAGEMENT

 Isolation: droplet 3 – 6 ft w/ surgical face mask

 Antibiotic therapy: DOC ceftriaxone
o Finish duration of antibiotic = prevent drug resistance
 IVF: PNSS
 Seizure precaution – inc. side rails, dim light
o Bright = trigger inc. BMR = less O2
 Inc. ICP = diuretic: mannitol
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 MVS
 MUO – measure effectiveness of diuretics
 Assess LOC: GCS

3rd GENERATION: Ceftriaxone

- Increase penetration to blood brain barrier

PENICILLIN CEPHALOSPORIN

Cross reaction
both beta lactam

BEFORE ADM  Don’t adm w/ calcium

True penicillin allergy
containing IVR
 Fever  D5LR
 Rash
 Wheezing

Co – Amoxi Clav
- Enzyme for penicillin resistace
- Clovulamic acid + amoxicillin
- B lacatamase inhibitor
MRSA – vancomycin
- Adm slowly over 60 mins and inc. fluid
- Red man syndrome
VRSA – linecolid (last defense)

HEAD TRAUMA
- Common in pedia (not stable balance)
Types:
1. Concussion – jarring of brain (naalog); sudden forceful contact in a rigid skull
- Transient loss of consciousness

2. Contusion – brain is bruised / damaged (nauntog); structural alteration –

extravasations of blood (hematoma)

MANAGEMENT
- PRIORITY: safety
- Bike helmets, seat belts, safe driving, infant car seat
- Assess for cervical neck injury
 (+): do not move the patient – IMMOBLIZE = prevent further damage
 (–): HOBE 30 degrees = dec. ICP by gravity
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- Assess for cerebral functioning: GCS, PERRLA

Most Important Prognostic Indicator: LOC

Chances of survival = the higher the LOC / GCS, the higher the
surviving rate

Infant Car Seat

- Below 3 y/o: rear facing (likod) – protect spine
- Above 3 y/o: front / forward facing booster seat

CARDIOVASCULAR DISORDERS OF PEDIA

LAYERS OF HEART
 Endocardium – inner
 Myocardium – muscle (contraction / CO) amount of blood ejected by blood q
1min
 Pericardium – outer
o Visceral – inner pericardium
 Pericardial space – fluid (prevent friction rub)
o Parietal – outer pericardium

CHAMBERS OF HEART (4)

- Flow of blood is only ONE WAY (n):
- TWO WAY – regurgitation = vulvular problems
- RA – RV – LUNGS – LA – LV – AORTA
- Pedia and adult circulation is the SAME except FETAL

CONGENITAL HEART DISORDERS

 Acyanotic: absence of cyanosis = 1 problem
 Cyanotic: presence of cyanosis = 2 or more problems

PATENT DUCTUS ARTERIOSUS (PDA)

- Acyanotic
- Failure of DA to close
S / Sx
- Machinery like murmur (pathognomonic / hallmark sx)
- Heart failure (s / sx)
- Poor feeding (sucking) – in order to suck you need enormous amount of O2 =
poor O2 leading to fatigue
- Poor weight gain
 6 mos – birth weight is DOUBLED
 12 mos - birth weight is TRIPLED
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- Irritability: cerebral hypoxia (first sx of hypoxia)

MANAGEMENT
 DOC – indomethacin (inhibits prostaglandin): facilitates closure of PDA
 Secondary Drug: Ibuprofen

SEPTAL DEFECTS
 Acyanotic (1 problem only)
 Asymptomatic upon birth
 Failure to Close

Types:
 ASD (atrial septal defect): top hole
 VSD (ventricular septal defect): bottom hole

S / Sx
 Fatigue
 DOE – diff. of breathing on activity (activity intolerance)
 Failure to thrive: delayed milestones / development
 Heart failure s / sx

MANAGEMENT
 Surgery by suture (by pass): used only for small hole

 (Dac)ron Patch – for large hole: DAKS

o Tissue: made up of cardiac tissue (not foreign)
 Dec. rejection rate because it’s a normal flora (favorable)
o Plastic:
 Inc. rejection rate (inc. inflammatory response)

COARCTATION OF AORTA
- NARROWING of aorta (descending)
- Acyanotic (1 problem only)
- Inc. pressure = Dec. output

S / Sx
UE LE
BP Inc Dec
PULSE Pounding Weak / absent

Rib Notching – rib deformity because of inc. blood pressure due to decrease
cardiac output (compensatory mechanism)

MANAGEMENT
Surgery
 Balloon angioplasty w/ coronary stenting
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Scaffold / support
Made of mesh: superfine screen which is
specifically made for BV
Aorta Repair

- Insertion of a deflated balloon that’s guided by camera towards narrowed

aorta. Balloon is inflated to dilate aorta (stent was left behind) while balloon
was removed.

- STENT is capable of expanding (lifetime)

TETRALOGY OF FALLOT
- Cyanotic (4 problems)

Problems: PROV
 Pulmonary stenosis
 Right Ventricular Hypertrophy
 Overriding of aorta (anatomical defect): hole is in the middle (n) edge of LV
 VSD

Questions
What is:
1. Primary problem? Pulmonary Stenosis (narrowing)
2. Compensatory mechanism? Right Ventricular Hypertrophy
3. Allows mixing of blood? Overriding of aorta
4. Keeps the patient alive? VSD – shunts blood to the left to relieve pressure

S / sx
 Cyanosis: ineffective tissue perfusion

 Squatting:
o Decrease venous return - Dec cardiac workload = promoting cardiac
rest
o Conserve O2 in upper body area (vital organs)

 Tet spells – group of s / sx that presents dec .oxygenation (pathognomonic

sx)
o Irritability
o Convulsions sx of hypoxia
o Black outs
o Pallor (hypoxemia)
o Cardiomegaly
o Clubbing of nails = chronic hypoxia
o Pan systolic murmur in every contraction

DIAGNOSTIC
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2D – echo: boot shaped heart

MANAGEMENT
 Allow child to squat: promote cardiac rest, conserve O2 in upper body
Surgery
 Palliative: relieves s / sx (Goal: inc. O2 in blood compared to UnO2 blood)
o Blalock Tausig Shunt: anastomosis of pulmonary artery and aorta
(subclavian artery)

 Curative: cures and resolve problems

o Intracardiac Surgery / Brocks Procedure:

 Balloon  Dacron Patch

angioplasty

TRANSPOSITION OF THE GREAT ARTERIRES

- TGA / TOGA
- Nagkabaliktad ang two major arteries
- Cyanotic

CONDITION that starts w/ LETTER T = Cyanotic

MECHANISM
 RV – Aorta
 LV – PA
 PDA: keeps the patient alive (point of intersection between artery and aorta)

S / Sx
 Severe respiratory depression and cyanosis
 Failure to thrive
 Fatigue
 No murmur

MANAGEMENT
 Prostaglandin E: maintains PDA – keeps PDA open
Surgery
 Arterial Switch / Jatene Surgery – done during the FIRST WEEK of life
(pagpalit two major artery)

RHEUMATIC HEART FEVER

- Infectious heart disease
Cause: GAHBS (group a betahemolytic streptococcus)
 Sore throat
 Acute Glomerulonephritis (AGN)
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JONES CRITERIA
 2 Major + Hx
 1 major + 2 minor + Hx

MAJOR SX MINOR SX

 Carditis  Low grade fever

 Polyarthritis – multiple joint  Arthralgia – w/ o swelling
inflammation  Elevation of ASO titers
 Chorea – st. vitusdance (worm like (antistreptolysin – O titer)
movement of arms and fingers)  Elevation of inflammatory markers
 Sub - q nodules (bony a. ESR
prominences) b. CRP – C reactive protein
 Erythema marjinatum (redness in
trunk)

MANAGEMENT
 DOC: penicillin ( 5 – 10 days); if allergic (clindamycin / erythromycin)
 Exacerbation (worsening) and remission (rebound): treatment is
continued up to 10 years
 Salicylates (ASA) for pain and swelling
o 4As of Aspirin
 Anti platelet – monitor for bleeding
 Anti pyretic
 Analgesic
 Anti inflammatory

 Corticosteroids: anti inflammatory to relieve CARDITIS

HEART FAILURE
- Insufficient cardiac output = the lesser the CO the lesser the oxygenation
Types
 RHF (systemic sx)
 LHF (pulmonary sx)

Concept of Backflow
RA – RV – LUNGS – LA – LV – AORTA

RHF LHF P
S  Peripheral, pitting or dependent  DOE – activity intolerance
edema  Orthopnea – diff. of breathing when U
Y
 Weight gain lying down L
S  JVD  Crackles / rales
M
T  Hepatomegaly  Cough
 Portal HPN (Inc. pressure in central O
E body) N
M  Esophageal varices (bleeding)
 Ascites A
I
 Hemorrhoids R
C  Body weakness Y
 Anorexia, nausea
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Tachycardia
(early sx)

DIAGNOSTICS
 Chest X – ray: cardiomegaly  PCWP (pulmonary capillary
wedge pressure)
 2D Echo : hypokinetic heart  LHF (n) 4 – 12 mmhg
 slow beating: late sx
 CVP (central venous pressure)
 Pulse O2: dec. O2 saturation  RHF (n) 8 – 12 mmhg
 concentration of O2 in
blood) (n) 95 – 100

MANAGEMENT (FAILURE / HEART)

F – Fowlers – maximize lung expansion = onc. O2
A – Adm high O2 (venturi: precise / accurate)
I – Inotropic drugs: strengthens contraction = inc. CO
L – Lanoxin (digoxin): toxicity (DIGIBIND: antidote)
 N – nausea
 A – anorexia
 V – visual disturbances / vomiting
 D – diarrhea
 A – abd cramps
U – Urine output and intake monitoring
R – Record daily weight
Same time
Same clothes
Same weighing scale
Same patient
E – Edminister Diuretics

H – HOBE / fowlers
E – Encourage diuretics
A – Adm digoxin
R – Record daily weight
T – Teaching: digibind at bed side

KAWASAKI DISEASE
 Mucocutaneous lymph node syndrome
- Altered immune response
 Multisystemic vasculitis
- BV inflammation

S / Sx
 High spiking fever (hyperpyrexia)
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 Strawberry red tongue (pathognomic sx)

 Photophobia - due to hyperemia of conjucntiva (blood pooling)
o Dark color glasses
o Large hats
o Sun visors
 Polymorphous rash (rashes in different shapes)
 Palmar desquamation

DIAGNOSTIC
- Elevated ESR (inflammatory marker)

MANAGEMENT
- Immunoglobulin’s as ordered (enhance / stimulate immune response)

- ASA as ordered
 Anti pyretic
 Analgesic
 Anti inflammatory

 Clear liquid diet (blood in stool monitoring)

- Light can pass through

 CPR: coronary artery disease

HYDROCEPHALUS
- Accumulation of CSF

Adult: 400 – 600 ml

Infant: 100 – 200 ml vary in age / day
CSF produced in: Choroid Plexus

CHOROID PLEXUS
2 Lateral Ventricles
|
foramen of monro
|
rd
3 lateral ventricles
|
aqueduct of sylvius
|
th
4 lateral ventricles
|
foramen of lushka and magendie
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|
arachnoid villi (absorb CSF)

TYPE:
A. Non communication –w/out obstruction in ventricles
B. Communication – dec. absorption or over production

LATE SYMPTOMS
 Frontal enlargement
 Sunset eyes
 Lethargy
 Brief, shrill, high pitched cry
 Head ache (older child)

MANIFESTATION
a. Head enlargement
b. Bulging fontanels
c. Separated suture lines
d. Dilated scalp vein
e. Irritability (early sx of hypoxia)

DIAGNOSTIC EVALUATION
ELECTRO
o CT – Scan
o MRI – safe in pregnant
 claustrophobic = sedate
 metals that contain iron
 humming / clicking sound
 tattoo – there’ll be burning sensation
o X – ray

GRAM / GRAPHY
- Uses dye
- Excepts starts w/ electro
- Check for S – creatinine for dye damages kidney
- Inc. OFI
- Seafood allergies / gelatin
- (n) bluish urine
- Upon dye injection: warmth

MANAGEMENT
 Removal of obstructing mass
 VP Shunting: catheter for sterility
Check for: kink / obstruction (sx: inc. sleepiness I inc. ICP)
 Spinal tap: 50 ml at a time
o Bawal in inc. ICP for it may lead to brain herniation
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o Short term mgt only

o Short relief

 Support head
o Position: un-operated side
o Flat on bed

NUERAL TUBE DEFECT

- Dec. VIT B9: folic acid
- Exposure to valproic acid: mood stabilizer and anti – seizure
- Brain to spinal cord
 Anencephaly – no skull
 Spina bifida – spine failed to fuse
a. Occulta – hidden: rufts of hair with dimpling (sx: foot weakness)
b. Csytica – with sac
B1: minongocele sac w/ csf meninges
B2: myelomeningocele: sac, CSF, meninges, spinal cord = inc.
risk for paralysis (mas mahaba, mas damo content)
Cystica – below C2
 Flaccidity
 Paralysis
 Urine dribbling
 Rectal prolapsed
B2
- below S3 the higher the affection
- no sx
DIAGNOSTIC EVALUATION
 Amniocentesis