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Information

  1. BACTERIAL MENINGITIS
    1. Assessment:
      1. Abrupt onset: initial sign may be a seizure, following an episode of upper respiratory infection (URI)/acute otitis media.
      2. Chills and fever.
      3. Vomiting; may complain of headache, neck pain (older children).
      4. Photophobia.
      5. Alterations in level of consciousness: delirium, stupor, increased intracranial pressure.
      6. Nuchal rigidity (older children).
      7. Opisthotonos position: head is drawn backward into overextension; bulging fontanel (most significant finding in infants).
      8. Hyperactive reflexes related to CNS irritability.
    2. Analysis/nursing diagnosis:
      1. Risk for infection related to communicability of meningitis.
      2. Risk for injury related to CNS irritability and seizures.
      3. Pain related to nuchal rigidity, opisthotonos position, increased muscle tension.
      4. Sensory/perceptual alterations related to seizures and changes in level of consciousness.
      5. Altered nutrition, less than body requirements, related to fever and poor oral intake.
      6. Knowledge deficit regarding diagnostic procedures, condition, treatment, prognosis.
    3. Nursing care plan/implementation:
      1. Goal: prevent spread of infection.
        1. Institute standard precautions.
        2. Enforce strict hand washing.
        3. Institute and maintain respiratory isolation for minimum of 24 hours after starting IV antibiotics, at which time child is no longer considered to be communicable and can be removed from isolation.
        4. Supervise all visitors in isolation techniques.
        5. pillImageIdentify family members and others at high risk: do cultures ( Haemophilus influenzae, Escherichia coli, etc.); possibly begin prophylactic antibiotics (e.g., rifampin). Lumbar puncture (LP) is the definitive diagnostic test.
        6. pillImageTreat with IV antibiotics (as ordered) as soon as possible after admission (after cultures are obtained); continue 10 to 14 days (until cerebrospinal fluid [CSF] culture is negative and child appears clinically improved).
        7. Anticipate large-dose IV medications only—administer slowly in dilute form to prevent phlebitis.
        8. Restrain as needed to maintain IV.
      2. Goal: promote safety and prevent injury/seizures.
        1. pillImageMaintain seizure precautions. Give anticonvulsants, as ordered (e.g., phenytoin).
        2. Place child near nurses' station for maximum observation; provide private room for isolation.
        3. Minimize stimuli: quiet, calm environment.
        4. infoImageRestrict visitors to immediate family.
        5. Position: Head of bed (HOB) slightly elevated to decrease intracranial pressure. (If opisthotonos: side-lying, for comfort and safety.)
      3. Goal: maintain adequate nutrition.
        1. foodImageNPO or clear liquids initially; supplement with IVs, because child may be unable to coordinate sucking and swallowing.
        2. Offer diet for age, as tolerated—child may experience anorexia (due to disease) or vomiting (due to increased intracranial pressure).
        3. Monitor I&O, daily weights.
    4. Evaluation/outcome criteria:
      1. No spread of infection noted; immunize all children against H. influenzae type B
      2. Safety maintained.
      3. Adequate nutrition and fluid intake maintained.
      4. Child recovers without permanent neurological damage (e.g., seizure disorders, hydrocephalus).
  2. REYE SYNDROME
    1. Introduction: Reye syndrome, first described as a disease entity in the mid-1960s, is a multisystem disorder primarily affecting children between 6 and 12 years of age. Although not truly a "communicable disease," studies have confirmed a relationship between aspirin administration during a viral illness (e.g., chickenpox, flu) and the onset of Reye syndrome. The exact cause remains unknown. Reye syndrome is characterized by acute metabolic encephalopathy and fatty degeneration of the visceral organs, particularly the liver. Earlier diagnosis, more sophisticated monitoring equipment, and more aggressive treatment have greatly improved the survival rate of children with Reye syndrome. Recovery is generally rapid in those children who do survive, though they may suffer certain deficits.
    2. Assessment:
      1. Onset typically follows a viral illness, just as child appears to be recovering.
      2. Early signs and symptoms:
        1. Rapidly progressing behavioral changes: irritability, agitation, combativeness, hostility, confusion, apathy, lethargy.
        2. Vomiting, which becomes progressively worse.
      3. Rapidly progressive neurological deterioration:
        1. Cerebral edema and increased intracranial pressure.
        2. Alteration in level of consciousness from lethargy through coma, decerebrate posturing, and respiratory arrest.
      4. Liver biopsy reveals liver dysfunction, necrosis, and failure:
        1. Elevated serum alanine aminotransferase (ALT) (serum glutamic-pyruvic transaminase [SGPT]), aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]), lactate dehydrogenase (LDH), serum ammonia levels.
        2. Severe hypoglycemia.
        3. Increased prothrombin time, coagulation defects, and bleeding.
    3. Analysis/nursing diagnosis:
      1. Altered cerebral tissue perfusion related to cerebral edema and increased intracranial pressure.
      2. Altered hepatic tissue perfusion related to fatty degeneration of the liver.
      3. Risk for injury related to coagulation defects and bleeding.
      4. Knowledge deficit related to diagnosis, course of disease, treatment, and prognosis.
    4. Nursing care plan/implementation:
      1. Goal: reduce intracranial pressure.
        1. Child is admitted to pediatric intensive care unit (PICU) for intensive nursing care, continuous observation, and monitoring.
        2. Monitor neurological status and vital signs continuously.
        3. Assist with/prepare for numerous invasive procedures, including endotracheal (ET) tube/mechanical ventilation and intracranial pressure (ICP) monitor.
        4. Monitor closely for the development of seizures; institute seizure precautions.
        5. infoImagePosition: elevate HOB 30 to 45 degrees.
        6. pillImageAdminister medications as ordered:
          1. Osmotic diuretics (e.g., mannitol) to decrease ICP.
          2. Diuretics (e.g., Lasix) to decrease CSF production.
          3. Anticonvulsants (e.g., Dilantin, phenobarbital).
          4. Vitamin K, fresh frozen plasma, or platelet transfusions for overt or covert bleeding.
      2. Goal: restore and maintain fluid and electrolyte balance, including perfusion of liver.
        1. pillImageAdminister IV fluids per physician's order—usually 10% glucose (or higher).
        2. Strict I&O.
        3. Prepare for/assist with Foley catheter placement, central venous pressure (CVP) monitor, ICP monitor, nasogastric (NG) tube, etc.
        4. Monitor serum electrolyte laboratory values.
      3. Goal: prevent injury and possible bleeding.
        1. Observe child for petechiae, unusual bruising, oozing from body orifices or tubes, frank hemorrhage.
        2. Check all urine and stool for occult blood.
        3. Monitor laboratory values, including prothrombin time (PT), partial thromboplastin time (PTT), platelets.
        4. pillImageAdminister blood products per physician's order.
      4. Goal: provide parents with thorough understanding of Reye syndrome.
        1. Primary nurse assigned to provide care and follow through with teaching.
        2. Encourage parents' presence, even in PICU—explain all equipment and procedures in simple, direct terms.
        3. Provide factual, honest, and complete information regarding disease, diagnosis, and prognosis.
    5. Evaluation/outcome criteria:
      1. Intracranial pressure is reduced and normal neurological functioning is restored.
      2. Fluid and electrolyte balance is restored.
      3. No clinical evidence of bleeding is found.
      4. Parents express understanding of Reye syndrome.
  3. HYDROCEPHALUS
    1. Introduction: Hydrocephalus, known to the layperson as "water on the brain," is actually a syndrome resulting from disturbances in the dynamics of CSF. The accumulation of this fluid causes enlargement and dilation of the ventricles of the brain and increased ICP. If untreated, severe brain damage will result; treatment is a surgical shunting procedure that allows CSF to drain from the ventricles of the brain to another, less harmful area within the body: most commonly the peritoneal cavity, less often the jugular vein or right atrium of the heart. Hydrocephalus can develop as the result of a congenital malformation (e.g., Arnold-Chiari malformation); can be associated with other congenital defects (e.g., spina bifida); or can be acquired secondary to infection (e.g., meningitis), trauma, or neoplasm.
    2. Assessment:
      1. Head: increased circumference—earliest sign of hydrocephalus in the infant (more than 1 inch/mo).
      2. Fontanels: tense and bulging without head enlargement.
      3. Veins: dilated scalp veins.
      4. "Setting sun" sign: sclera visible above pupil; pupils are sluggish, with unequal response to light.
      5. Cry: shrill, high pitched.
      6. Developmental milestones: delayed.
      7. Reflexes: persistence of neonatal reflexes; hyperactive reflexes.
      8. Feeds poorly.
      9. Signs of increased ICP:
        1. Vomiting.
        2. Irritability.
        3. Seizures.
        4. Decreased pulse.
        5. Decreased respirations.
        6. Increased blood pressure.
        7. Widened pulse pressure.
      10. History may reveal other CNS defects (e.g., spina bifida), infection (e.g., meningitis), trauma, or neoplasm.
    3. Analysis/nursing diagnosis:
      1. Altered cerebral tissue perfusion related to increased intracranial pressure.
      2. Impaired skin integrity related to enlarged head size and lack of motor coordination.
      3. Altered nutrition, less than body requirements, related to anorexia and vomiting.
      4. Anxiety related to diagnosis and uncertain outcome.
      5. Knowledge deficit regarding care of the child with a shunt and follow-up care.
    4. Nursing care plan/implementation:
      1. Goal: monitor neurological status.
        1. Measure head circumference daily, and note any abnormal increase.
        2. Perform neurological checks at least every 4 hours to monitor for signs of increased ICP.
        3. Report signs of increased ICP STAT to physician.
        4. Assist with diagnostic procedures/treatments: ventricular tap, computed tomography (CT) scan, etc.
      2. Goal: health teaching to reduce parental anxiety.
        1. Do preoperative teaching regarding the shunt procedure: stress need to remove excessive CSF to relieve pressure on brain; done as soon as possible after diagnosis is established.
        2. Stress early diagnosis and prompt shunting procedure to minimize the risk of long-term neurological complications.
        3. Offer realistic information regarding prognosis:
          1. Surgically treated, with continued followup care: 80% survival rate.
          2. Of these survivors, 50% are completely normal and 50% have some degree of neurological disability (such as inattentiveness or hyperactivity).
      3. Goal: provide postoperative shunt care.
        1. infoImagePosition:
          1. Flat in bed for 24 hours to prevent subdural hematoma.
          2. Gradually increase the angle of elevation of HOB, as ordered by surgeon.
          3. On the nonoperative side, to prevent mechanical pressure and obstruction to shunt.
        2. Monitor head circumference daily to note any abnormal increase that might indicate malfunctioning shunt.
        3. Monitor vital signs; monitor for signs of increased ICP.
        4. Monitor for possible complications:
          1. Infection.
          2. Malfunction of shunt: increased ICP.
      4. Goal: provide discharge teaching to parents regarding home care of the child with a shunt.
        1. Stress need for long-term follow-up care.
        2. Discuss feeding techniques, care of skin (especially scalp), need for stimulation.
        3. Prepare parents for shunt revisions to be done periodically as child grows.
        4. Teach parents signs and symptoms of shunt malfunctioning (i.e., of increased ICP or infection) and to report these promptly to physician.
        5. Encourage parents to enroll infant in "early infant stimulation" program to maximize developmental potential.
        6. Stress need to monitor development at frequent intervals, make referrals prn.
    5. Evaluation/outcome criteria:
      1. Neurological functioning is maintained or improved.
      2. Adequate nutrition is maintained.
      3. No impairment of skin integrity occurs.
      4. Parents' anxiety is relieved; they verbalize understanding of how to care for child after discharge.
  4. FEBRILE SEIZURES
    1. Introduction: Febrile seizures are transient neurological disorders of childhood, affecting perhaps as many as 3% of all children. Although the exact cause of febrile seizures remains uncertain, they seem to be a relatively transient problem that occurs exclusively in the presence of high, spiked fevers. Children in the infant and toddler stages (6 months to 3 years) appear to be most susceptible to febrile seizures, and they are twice as common in boys as in girls. There also appears to be an increased susceptibility within families, suggesting a possible genetic predisposition. Note: Epilepsy is discussed in Chapter 6. Physiological Integrity.
    2. Assessment:
      1. History usually reveals presence of URI or gastroenteritis.
      2. Occurs with a sudden rise in fever: often spiked and quite high (102°F or higher) vs. prolonged temperature elevation.
    3. Analysis/nursing diagnosis:
      1. Risk for injury related to seizures.
      2. Knowledge deficit related to prevention of future seizures, care of child having a seizure, and possible long-term effects.
    4. Nursing care plan/implementation:
      1. Goal: reduce fever/prevent further elevation of fever.
        1. pillImageAdminister antipyretics, as ordered: acetaminophen only ( not aspirin).
        2. Use cool, loose, cotton clothes to decrease heat retention.
        3. Avoid shivering, which increases metabolic rate and temperature.
        4. Encourage child to drink cool fluids.
        5. Monitor temperature hourly.
        6. Minimize stimulation, frustration for child.
      2. Goal: teach parents about care of child who experiences febrile seizure.
        1. Discuss how to prevent seizures from recurring: best method is to prevent temperature from rising over 102°F (see Goal 1).
        2. Discuss how to handle seizures if they do recur: prevent injury, maintain airway, etc.
        3. Answer questions simply and honestly:
          1. 25% of children with one febrile seizure will experience a recurrence.
          2. 75% of recurrences occur within 1 year.
          3. Reassure parents of the benign nature of febrile seizures; 95% to 98% of children with febrile seizures do not develop epilepsy or neurological damage.
    5. Evaluation/outcome criteria:
      1. Fever is kept below 102°F; additional seizures are prevented.
      2. Parents verbalize their understanding of how to care for child at home.