Meningitis in Children

Meningitis is an infection in the nervous system. It can be caused by bacteria and virus or complication from neurosurgery, trauma, and infection in sinus or ears.

Meningococcal meningitis occurs in epidemic form and transmitted by droplet infection from nasopharyngeal sections. Viral meningitis is associated with viruses such as mumps, paramyxovirus, herpes virus, and enterovirus.

The diagnoses of meningitis is made by testing cerebrospinal fluid that shows increased pressure, cloudy, high of protein, and low glucose.

Signs and Symptoms:

• There are no classic signs and symptoms. It depends on the type, child age, and duration of illness.
• Vomiting and diarrhea
• Fever, chills
• Nuchal rigidity
• Poor feeding or anorexia
• Alter level of consciousness
• Bulging anterior fontanel in infant
• Muscle or joint pain
• Kernig's sign and Brudzinski's sign

Nursing Intervention:

• Isolation for at least 24 hours after antibiotic initiated
• Administer antibiotics as prescribed
• Assess neurological and cardiovascular system
• Monitor intake and output

Reye's Syndrome

Reye's syndrome is acute encephalopathy follows a viral illness. It is characterized by cerebral edema and fatty changes in the liver. The disease is associated with administration of aspirin. The main goal of treatment is to maintain effective cerebral perfusion and control increasing Intra Cranial Pressure.


Signs and Symptoms:

• History of viral illness 4-7 days before the onset of symptoms
• Nausea and vomiting
• Progressive neurological deterioration
• Malaise

Nursing Intervention:

• Assess and monitor neurological status
• Monitor LOC and signs of increased ICP
• Provide rest and decrease stimulation
• Monitor intake and output
• Monitor liver function
• Monitor for signs of bleeding and impaired coagulation

Spina Bifida

Spina bifida is a defect in central nervous system. It occurs as a result from neural tube failure to close during embryonic development.

Type of Spina Bifida
1. Spina Bifida Occulta:
Posterior vertebral arches fail to close in the lumbosacral area. Spinal cord remains intact and usually is not visible. Meninges are not exposed on the skin surface and neurological deficit are not usually present.

2. Spina Bifida Cystica
The vertebra and neural tube close incomplete resulting in a saclike protrusion in the lumbar or sacral area. The defect includes meningocele, myelomeningocele, lipomeningocele, and lipomeningomyelocele.

3. Meningocele
The protrusion involves meninges and a saclike cyst that contains CSF in the midline of the back. Spinal cord is not involved and neurological deficits are usually not present.

4. Myelomeningocel
The protrusion involves meninges, CSF, nerve roots, and spinal cord. The sac is covered by a thin membrane that is prone to leakage or rupture. Neurological deficit are evident.


Signs and Symptoms:

• Visible spinal defect
• Flaccid paralysis of the legs
• Hip and joint deformities
• Altered bladder and bowel function
• Specific signs and symptoms depend on the spinal cord involvement

Nursing Intervention:

• Assess the sac and measure the lesion
• Assess neurological system
• Assess and monitor for increasing ICP
• Measure head circumferences
• Protect the sac, cover with a sterile, moist (normal saline), nonadherent dressing and change the dressing every 2-4 hours
• Place patient in prone position and head to one side
• Use antiseptic technique
• Assess and monitor the sac for redness, clear or purulent drainage, abrasions, irritation, and signs of infection
• Assess for hip and joint deformities
• Administer medication: antibiotics, anticholinergics, and laxatives as prescribed

Hydrocephalus

Hydrocephalus is a condition marked by an excessive accumulation of cerebrospinal fluid resulting in dilation of the cerebral ventricles and raised intracranial pressure; may also result in enlargement of the cranium and atrophy of the brain.

There are two types of hydrocephalus: communicating and non-communicating.

Communicating Hydrocephalus:

• It occurs as a result of impaired absorption within the subarachnoid space
• Interference of the cerebrospinal fluid within the ventricular system does not occur

Non-communicating Hydrocephalus:

• It is an obstruction of cerebrospinal flow within the ventricular system.

Signs and Symptoms Hydrocephalus in Infant:

• Increased head circumference
• Macewen’s sign: thin, widely separated bones of the head that produce a cracked-pot sound on percussion
• Dilated scalp vein
• Frontal bossing
• Sunsetting eyes
• Anterior fontanel tense, bulging, and non pulsating

Signs and Symptoms Hydrocephalus in Child:

• Changes of behavior: irritability and lethargy
• Nausea and vomiting
• Headache on awakening
• Ataxia
• Nystagmus

Surgical Intervention:
Surgical intervention of Hydrocephalus is to prevent further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where it can be reabsorbed. There are two types of surgical intervention: Ventriculoperitoneal Shunt and Atrioventricular Shunt.

1. Ventriculoperitoneal Shunt: the CSF drains from the lateral ventricles into the peritoneal cavity.
2. Atrioventricular Shunt: the CSF drains into the right atrium of the heart from the lateral ventricle, bypassing the obstruction. It is mostly used in older children and in children with pathological conditions of the abdomen.

Nursing Intervention (post-op)

• Monitor and assess vital signs and neurological signs
• Position client on the un-operated side to prevent pressure on the shunt valve
• Keep the child flat: to avoid rapid reduction of intracranial fluid
• Observe for increased ICP, if ICP is increased, elevate the head of the bed to 15-30 degrees
• Monitor for signs of infections
• Assess dressings for drainage
• Monitor intake and output
• Measure head circumference
• Administer medications as prescribed
• Teach parents how to recognize shunt infection and shunt malfunction

Head Injury in Children

Head injury is pathological result of any mechanical force to the skull, scalp, meninges, or brain. The manifestations of head injury depend on the type of injury and the amount of increased intracranial pressure (ICP).


Sign and Symptoms of Head Injury:

Early Signs:

• Headache
• Nausea and vomiting
• Visual disturbances and diplopia
• Slight changes in vital signs
• Dizziness or vertigo
• Change in pupillary response and equality
• Slight change in level of consciousness
• Signs in infants: bulging fontanel, wide sutures, increased head circumference, high pitched cry, and dilated scalp vein

Late Signs:

• Cushing’s triad: increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respiration
• Significant decrease in level of consciousness
• Decorticate posturing (see picture)
  
• Decerebrate posturing (see picture)
  
• Fixed and dilated pupils

Nursing Intervention in Head Injury:

1. Monitor and assess the airway, breathing, and circulations
2. Assess the injury and immobilize the neck if a cervical injury is suspected
3. Monitor vital signs and neurological function
4. Monitor level of consciousness
5. Initiate seizure precaution
6. Keep patient a nothing by mouth status until determined that vomiting will not occur
7. Administer oxygen and intravenous fluid as prescribed
8. Elevate the head of bed at 15-30 degrees if not contraindicated
9. Keep head in midline position to facilitate venous drainage and avoid jugular vein compression
10. Monitor for nose or ear drainage which could indicate leakage of cerebrospinal fluid (CSF) as a sign of skull fracture
11. Avoid suctioning through the nares
12. Administers acetaminophen (Tylenol) for headache, anticonvulsants for seizures, antibiotic, and tetanus toxoid as prescribed
13. Monitor for signs of brainstem involvement: deep, rapid, or intermittent and gasping respirations; wide fluctuations or noticeable slowing of the pulse; widening pulse pressure or extreme fluctuations in blood pressure
14. Monitor for epidural hematoma: asymmetric pupils

Children's Fear of Hospitalization

Children's Reaction to Hospitalization may vary depend on child growth and development.

5 month – 3 years

Fear of separation from mother or usual caregiver.

Nursing Intervention:
Encourage rooming in and bring familiar object from home e.g. toys and blanket.


3-6 years

• A toddler views hospitalization as punishment.
• A school age or adolescent will fear of harm and mutilation

Nursing Intervention:

• Kindly explain nursing procedure in simple terms and do not inform child of painful far in advance.
• Nurse can demonstrate procedures with dolls.
• Do not discourage crying and allow parents to be with child during painful procedures.
• Nurse should be honest regarding pain experienced during procedures.

6-18 years

Separation from parents, peers and lost of control

Nursing Intervention:

• Allow child to be visited by family and friends.
• Allow child to use the telephone to maintain family and peer contact.
• Give child choices when it is possible.
• Explain procedures in simple terms.
• Do not discourage child to cry.
• Restrain can be applied for a procedure if necessary and tell that this will help him / her hold still.

Immunization Schedule

Immunization is the process by which an individual's immune system becomes fortified against an agent (known as the immunogen).

Recommendations of immunization schedules are issued by the Center for Disease Control (CDC) and are subject to change. The schedule may vary from state to state, so please always check current recommendations of the CDS and your local board of health.

The current recommended routine administration of immunization licensed childhood vaccines as of December 2007 for children age ) through 6 years may be accessed HERE.
For adolescent and adult immunization schedule may be accessed HERE.


Just to be remembered for nurses giving immunization schedule that :

• Moderate or severe acute illness, with or without fever, is a contraindication to immunization.
• Previous severe reaction to the vaccine or any of its components is a contraindication to immunization
• The common cold without fever is NOT a contraindication to immunization

Pediatric : Deciduous Teeth

Deciduous teeth also known as milk teeth, baby teeth, temporary teeth, primary teeth, lacteal dentition are the first set of teeth in the growth development of humans. They develop during the embryonic stage of development and erupt during infancy. They are usually lost and replaced by permanent teeth, but in the absence of permanent replacements, they can remain functional for many years. (www.wikipedia.org)

Deciduous teeth will continue to form until they erupt at age of 6 – 24 months or 33 months of age.

Please click image above to enlarge.

Pediatric : Developmental Milestones (15 months – adolescent)

As a previous post I mentioned pediatric developmental milestones from 0 month till 12 months, here now I continue with pediatric developmental milestone from 15 months till adolescent.

15 Months :

• Can pull or push a toy
• Can walk without assistance
• Can build tower of 2 blocks
• Can throw ball overhanded
• Can scribble with crayon or pencil

18 Months :

• Can run clumsily
• Can build tower of 3-4 blocks
• Can jump in lace with both feet
• Can control anal and urinary sphincter
• Can control about 10 words

2 Years :

• Climbs stair
• Runs with wide stance
• Says names some familiar objects
• Says combine 2-3 words meaningful
• Can attain bladder and bowel control
• Weight about 4 times birth weight
• Average weight gain is 4-6 lb/year during ages 2-6 years
• Attains about a half of expected adult height

2.5 Years :

• Able to jump from chair or step, and
• Can stand on one foot briefly

3 Years :

• Climbs stairs by alternating feet on steps
• Can ride tricycle
• Turn doorknobs
• Can dress self
• Says or speaks in short sentences
• All 20 deciduous teeth have erupted

4 Years :

• Catches ball
• Recognizes colors
• Hops on one foot
• At this time, birth length has doubled

5 Years :

• Can skip well and jump rope
• Says contain all parts of speech
• Maintain balances with eyes closes
• Vocabulary of 2100 words can be built

6-12 years :

• Can tie shoes
• Can learn to how to swim, skate, and ride bicycle
• Forms clubs or gangs
• Uses pencil and crayon well
• Strong sense of what is fair
• Can read and count
• At this time, average weight gain will be 4-6 lb/year during age 6-12 years

Adolescent :
At this time, he/she can learn to care for self independently while learning to effectively interact with society.

As mentioned on previous post that Pediatric developmental milestones are difficult to memorize, but at least as a Nurse should have knowledge about that. NCLEX - CGFNS examination will ask some questions in relation with pediatric developmental milestones.

Pediatric : Developmental Milestones ( 0 - 12 Months)

Pediatric developmental milestones are based on averages, means that each child progresses at his or her own rate.

Birth - 1st month :

* Maintains eye contact
* Demonstrates reflex activities
* Lies in flexed position
* Using communication technique by crying
* Average weight gains is 3-5 oz weekly during first 6 month

2 Months :

* Can lifts head for short periods when prone
* Smiles and frowns
* Coos
* Will visually follows moving objects

3 Months :

* Sits with support
* Will turn from back to side
* Can recognizes parent
* Demonstrates pleasure by squealing
* Focusing on win hands

4 Months :

* Can lift head and chest about 90 degrees and bearing weight on forearms
* Turning from back to prone position
* Holing head erect while in siting position
* Can reach for objects and grasps objects with both hands
* Plays with fingers
* Carries objects to mouth
* Makes consonant sounds and laughs aloud

5 Months :

* Turning from abdomen to back
* Playing with toes and puts feet into mouth
* Can hold objects in one hand and reaches for another objects with other hand

6 Months :

* Can sit alone leaning forward on both hands
* Reaches for and grasps objects
* Extends arm when he or she wishes to be picked up
* Briefly looks for dropped objects
* Fear to strangers
* Enjoying to play peekaboo
* Begins to produce world like sound
* Birth weight has doubled
* Weekly weight gain is 3-5 oz during 6-18 months


7 Months :

* Bears weight on feet
* Transfers object from one hand to other hand
* Begins to crawl

8 Months :

* Sits alone without support
* Pull to standing position
* Can release object intentionally
* Uses pincer grasp
* Say "DADA" without meaning
* Stranger anxiety

9 Months :

* Can crawl well
* Will walk sideways while holding on
* Bangs 2 blocks together
* Searches for hidden object
* Can drink from cup and attempts to feed self

10 Months :

* Begins to walk and climb
* Neat pincer grasp
* Playing pat-a-cake and initiates peekaboo game
* May say 1-2 words with meaning

11 Months :

* Will cooperate with dressing activities
* Attempts to feed self with spoon
* Follows simple direction
* Will understand "no" and shakes head to indicate "no"

12 Months :

* Will walk alone or with one hand held
* Frequently falls while walking
* Can drink well from a cup
* Can pull off socks
* Points with one finger
* Birth weight has tripled
* Birth length has increased by 50%
* Head and chest circumference are equal

Pediatric developmental milestones are difficult to memorize, but at least as a Nurse should have knowledge about that. NCLEX - CGFNS examination will ask some questions in relation with pediatric developmental milestones.

NCLEX-CGFNS : Developmental Theories

There are common Development theories always come in NCLEX - CGFNS test.

ERIKSON'S PSYCHOSOCIAL DEVELOPMENT
This theory is based on the belief that each stage is the result of the child's need to adapt to the social environment and must be resolved before the next stage can be successfully achieved. As the nurse, you should know pediatric developmental theories well.

Erikson's Psychosocial Developments are :

• Birth - 1 years : Trust vs mistrust
• 1-3 years : Autonomy vs shame and doubt
• 4-5 years : Initiative vs guilt
• 6-11 years : Industry vs inferiority
• 12-18 years : Identity vs identity confusion

FREUD'S PSYCHOSEXUAL DEVELOPMENT
Freud's psychosexual development emphasize the importance of sex and control over aggresive impulses in the child's development. These are :

• Birth-2 years : Oral Stage
• 2-3 years : Anal Stage
• 3-6 years : Phallic Stage
• 6-12 years : Latent Stage
• 12-18 years : Genital Stage

PIAGET'S COGNITIVE DEVELOPMENT THEORY
This is a Intellectual thought development.

• Birth-2 years : Sensorimotor, senses and motor activity
• 2-7 years : Preoperational or preconceptual, Intellectual development
• 7-11 years : Concrete operation, reasoning and organizing thoughts
• 11 years - adulthood : Formal operation, abstract thinking and deductive reasoning