Neuro & Musculoskeletal Clinical Judgment Concept Map PDF 2024

Neuro and Musculoskeletal Clinical Judgment Concept Map Diagnosis/Concep Clinical Therapeutic Important Clinical t Manifestations: Interventions: Considerations Judgment...

Neuro and Musculoskeletal Clinical Judgment Concept Map Diagnosis/Concep Clinical Therapeutic Important Clinical t Manifestations: Interventions: Considerations Judgment : Connections! What does a child What are your look like with this priority Important What is the diagnosis? Know your interventions? details to big picture? assessment findings remember and Can I put the understand info together that affect to care for this status/care child? Increased Intra- Infant – Poor Frequent VS q1 Important early +Degree of cranial Pressure – feeding/vomiting hour with sign? Changes injury is Slide #11 Irritability/restlessnes continuous pulse ox in levels of related to the s Neuro Checks – consciousness force of Lethargy wake them up one impact Bulging Fontanel – two hours Changes in LOC High Pitched Cry Keep close to the may initially be Why do Increased HC nurses station irritability, infants do Separation Cranial NPO agitation – better than Sutures QUIET Progression of children/adult Distended scalp veins ENVIRONMENT – ICP then to s with ICP? Setting sun sign minimize focal neuro Cranium is still Increased/decreased visitors/lights signs movable. response to pain Elevate head of bed Seizure Precautions Monitor I/O Goal is to Child – Headache Pain Management risk for fluid maintain Diplopia volume cerebral Mood swings ? Intubate – do we overload and perfusion and Slurred speech have a safe airway cerebral edema control ICP to Papilledema ? Oxygen preserve brain Nausea and vomiting ? Circulation =brain function! especially early in the perfusion! morning Most minor Mannitol – what is head injuries it? Why do we use can be it? managed at Anti-Seizure Meds home with a Barbiturate Coma? reliable care Why giver Concussion Most common How would you Understand Assess for Transient, reversible manage a child with Coup Contra- signs of ICP neuronal dysfunction a concussion- Coup Injury: LOC possibly minimize lights, no coup- forward Understand Nausea and vomiting screens, rest hit due to and risks of Second All ICP assessment acceleration Impact findings could present injury, coup (returning to contra- the play before second completing backwards hit healing)and Post- Concussive Syndrome (lasts several days to months with headaches, lethargy, difficulty concentrating, memory loss, learning difficulties, visual disturbances, balance issues, personality changes) Brain Injury Behavioral changes, Initiate rehab School Re- Sequelae emotional lability, services integration; Poor concentration, usually slowed responses, Parental education alterations in inappropriate school behavior, physical performance disabilities, memory loss, communication deficits Contusion Tearing and bruising Symptoms get of cerebral tissue worse with peak swelling at 72 hours Skull fractures Regular What are Overall, must A lot of force interventions? manage any to fracture the Depressed – Bone signs of ICP! skull! pushes in towards Look for brain Surgical associated intervention if injuries and/or cerebral  Basilar – Posterior displacement is injuries/tears base of skull >33% = dura tear and bleeds Battle sign Raccoon Eyes Basilar – watch for How do you signs of CSF leakage know it is CSF from nose and ears leaking?- test with UA strip Epidural Blood clot between Will bleed a lot Increased ICP Hematoma the skull and dura signs Subdural Blood clot between Slow leak- more Increased ICP Hematoma the dura and dangerous signs cerebrum Intracerebral Diffuse bleeding into Increased ICP hemorrhage the brain signs Trauma Multi-system Airway/C-spine Consider the Management assessment stabilization mechanism of injury Hydrocephalus Imbalance between Know both pre-op Shunt How would the production and and post-op care complications you know if absorption of CSF – so the shunt what would you see in Nursing Care – Shunts may stopped the infant or child? Preoperatively malfunction or working? Vital Signs, head to become What are your toe assessment, infected S/s of ICP and expected assessment focused neuro increased findings? ICP assessment, small Needs head symptoms frequent feeds due immediate circumference to N/V, I/O, attention Enlarged Head positioning of large Circumference with head for comfort Signs of enlargement of the infection skull Monitor for signs of include fever, Increased Intra- lethargy, cranial Pressure: irritability, Headache, redness along increased head shunt device circumference, system, bulging fontanel, abdominal lethargy, irritability, discomfort, poor feeding, symptoms of distended scalp peritonitis veins, setting sun sign, frontal bone Signs of shunt enlargement, early malfunction in morning vomiting, infants: mimic high pitched cry, the symptoms pupil changes that prompted the initial Medical/Surgical shunting Management: Signs of Ventriculoperitonea increased ICP! l Shunt insertion or Irritability, surgical anatomical vomiting, correction bulging fontanels, VP shunt bypasses lethargy, the blockage and sunset eyes, takes the CSF to the seizures peritoneum to be Increased head reabsorbed. Valves circumference prevent backflow of Toddlers/older fluid; allow only a child: certain amount of Similar as fluid to be drained above but at a time. includes headache Lie flat in bed un- operated side for approximately 24 hours, gradually elevate HOB; VS & Neuro checks X2 hours, head circumference, I/O Monitor for signs of infection: febrile, irritability, pain, N/V, abdominal distention and signs of peritonitis Monitor for signs of Increased Intra- cranial Pressure Do not pump the shunt Pain Management Parental education for home going care: lifelong care Instructions about VP shunt, signs of infection and  increased ICP; signs of gastric ileus, when to call the doctor and emotional support Don’t allow child to lie on shunt side continuously = skin breakdown No contact sports Spinal Cord Injury Airway/C-spine Transition to Extent and stabilization rehab as soon severity may as possible not be known What are the for months ongoing priorities? Safety, Bowel, Bladder, ADLs etc. Spina Bifida Clinical Know both pre-op Folic Acid Always manifestations and post-op care understand maintain depend on the level interventions importance: integrity of the of the lesion may be sac! Pre-Op prevented if Usually include: Assessment: Vital women Loss of bowel Signs, Head to Toe consume 0.4 Loss of bladder and Neuromuscular mg of folic acid Flaccid Watch for bulging daily, prior to paralysis/partial fontanel, irritability and during the paralysis of or changes in early weeks of extremities below the mental status, conception lesion increased head circumference; all Measure HC – signs of increased why? Increased intracranial association pressure and with potential developing development of Hydrocephalus hydrocephalus Fever, signs of infection Prevent rupture of sac and infection!*** Prone position with hips slightly flexed to minimize tension on the sac, or side lying if necessary No clothing or diaper to avoid pressure on sac Heated isolette – maintain temperature – no clothing or cover Sterile moist saline non-adherent dressing to sac; change q 2-4 hrs. Document appearance of sac with each dressing Small frequent feedings maintaining prone position – mom must use breast pump (usually NPO with IV hydration as surgery happens in 24 – 72 hours) Measure head circumference every shift to identify developing hydrocephalus Encourage family bonding Post-Op Assess surgical site for S&S of infection, CSF leakage Fever, incision site for redness, drainage Position prone or side lying Administer antibiotics Strict sterile technique to dressings Avoid contamination of dressing w/stool or urine Keep diaper away from incision site Assess Neurological Status – Signs of increased intra- cranial pressure and measure head circumference every shift Pain Management Assess for motor function – gentle range of motion Monitor skin integrity Assess bowel and bladder function – neurogenic bladder Does not feel the urge to urinate or feeling of full rectum and unable to control urinary and anal sphincter Prevent urinary retention and UTI – urinary catheter q 3-4 hours Establish bowel routine; fiber, fluids, laxatives, daily timing program Parental education and support – Complex discharge planning NO latex gloves due to increased risk for latex allergy Cerebral Palsy Typically, an anoxic Early diagnosis with Chronic non- Start to miss event during early intervention is progressive developmenta pregnancy or at birth best outcomes disorder, but l milestones we don’t Variable presentation always know Promote from mild to severe the degree of optimum disability with development Both Spasticity and an infant Floppy muscle tone Muscular Progressive, Safety/Mobility Start to see Tremendous Dystrophies degenerative, loss of grief and loss inherited diseases previously had function and/or weakness usually by 3-5 years of age Suspicion for MD: losing function previously attained and change in functional patterns Waddling gait, clumsiness, difficulty climbing stairs Meningitis Bacterial vs Viral As the RN –what Brudzinski’s Bacterial diagnostic tests sign and Viral Know symptoms and must be done? Kernig’s sign – assessment findings – ***Lumbar What are they what symptoms puncture definitive and why do would a child present diagnostic test we see them with that had LP sample includes in Meningitis meningitis? culture (to identify Infant: Fever of the causative + Kernig’s sign: unknown origin, poor agent), Gram stain, Severe feeding, vomiting, blood cell count, stiffness of the irritability, seizures, glucose and protein hamstrings high pitched cry, levels. causes an bulging anterior Bacterial shows inability to fontanel – signs of WBCs, glucose, straighten the leg when the  increased intra-cranial protein, (+) gram hip is flexed to pressure stain, cloudy fluid 90 degrees Child or Adolescent: Viral shows slightly + Brudzinski Fever, severe WBCs, normal or sign: Severe headache, slightly protein, neck stiffness photophobia, stiff normal glucose, (-) causes a neck, altered LOC, gram stain, clear patient’s hips lethargy, irritability, fluid and knees to decreased appetite, Blood Cultures*** flex when the vomiting, agitation, Nose and throat neck is flexed. drowsiness. Late sign cultures*** joint pain and purpura Urine Cultures*** rash, seizures, LOC Potentially brain MRI/CT What are the priority treatments? Isolation precautions, broad spectrum antibiotics right away, IV hydration, monitor for septic shock, reduce ICP, seizure management, control temperature and pain, may need mechanical ventilation Reyes Syndrome Toxic metabolic Aspirin is encephalopathy – NEVER given to fever, cerebral children with edema, liver virus dysfunction Seizures Understand the Dilantin – Why seizure nursing priorities mouth care for precautions? and be able to gingival Why oxygen? implement them overgrowth Why glucose check? How do you Regular Why do we manage a child who monitoring of administer the is actively seizing? blood levels to  Seizure Precautions make sure medications Pad the bed rails levels are we do? and keep them up therapeutic X2 and in normal Brain need Active Seizing Child: range to oxygen and Yell first for help! mitigate side glucose- can Observe & effects cause breath document If complete death without, TIMING! Onset, seizure control meds to duration, body is maintained decrease movements, on medication metabolic behavior, color, for 2 years, it demand respiratory effort, may be safe to incontinence, post- slowly ictal phase discontinue the During a seizure- do drug for not restrain, protect children with the patient from no risk factors injury Ease to floor Remove anything hazardous in the environment Place child on side to reduce aspiration (swallowing reflex impaired-increased salivation) O2 and Suction Glucose check NO padded tongue blade at the bedside Treatment - lorazepam or diazepam IV or rectal (diazepam) within 2 minutes of seizure activity Dilantin or Phenobarbital may be used if benzodiazepine doesn’t stop seizure Administer IVF D5NS to replace  used glucose during the seizure Resume previously used seizure medication Attempt to identify cause for breakthrough seizures Guillain-Barre Possibly Autoimmune Treatment is Typically What is my Syndrome Demyelinating symptomatic – function priority polyneuropathy with what are priority returns top to concern? progressive paralysis interventions? bottom- Maintaining recovery airway and Begins in lower Steroids? Suppress usually beings respiratory extremities and immune system within 2-3 function – ascends bilaterally that is attacking weeks why? It can IVIG? Suppress take out the What does a child immune system diaphragm look like with GBS? Heparin? Prevent blood clots from Initially, muscle prolonged tenderness, immobility paresthesia, muscle weakness Paralysis rapidly ascends from the lower extremities Flaccid paralysis; loss of reflexes Intercostal and phrenic nerve involvement Respiratory compromise – may need ventilator support Frequently have urinary incontinency and retention and constipation Fractures How do we assess? Immobilize, elevate, Epiphyseal Inspect, Observe and ice, frequent NV plate fractures Palpation checks, pain can affect Note point tenderness management growth – reliable indicator of (because its fracture  Circulation: extremity involving the color, warm, capillary growth plate) refill, quality of pulses Neurovascular: motion, sensation – Pins and needles? Edema, Ecchymosis Increased pain on extension of fingers, toes Neuro checks every 2 hours, apply ice Assess pain for changes every 2 hours Swelling will increase until 48-72 hours post injury! Compartment Pain Notify provider Pain/Burning/ Worry if pain Syndrome Pallor immediately 5 P = tissue not relieved Pulselessness ischemia! by medication Paresthesia Paralysis Prolonged cap refill time Skeletal Traction Weights off floor When call the 90-90 – Why use Body aligned and up Ortho it? in bed surgeon? Signs NEVER release of Epiphyseal plate traction compartment fractures can syndrome affect growth Why Neurovascular checks? Infection can lead to osteomyelitis Pin care What should the pins How do you clean What are you look like. When are them? concerned you concerned? ½ strength about? Skin – tenting, pulling, hydrogen peroxide, Associated risk drainage, redness, normal saline for tenderness, pain, Sterile q-tips, clean Osteomyelitis edema, crustiness = skin around pin infection with circular, rolling Pin – bending or motion shifting Rinse with normal saline Cast Care Assess Neuro vascular Elevate casted Parent What am I checks extremity always education always assessing for? Comfort modalities Compartment  Assess cast for rough Syndrome – edges/skin why? breakdown Osteomyelitis Infected bone – Priority treatments multiple reasons IV broad spectrum antibiotics What does an osteomyelitis look like Pain management, clinically? antibiotics, I/O, Pain, tenderness, note drainage from redness, fever, site, wound care, swelling, decreased limited weight mobility of the joint bearing SCFE Obese pre-adolescent Priority treatment or adolescent child and nursing following growth interventions pre- spurt and post op. Slip of the femoral Diagnosis confirmed neck from the femoral with x-ray – frog leg head position Treatment Goals: What does the child Prevent further look like clinically with slipping of the SCFE? How do they femoral epiphysis present? Avoid further complications such Limp on affected side, as avascular pain in hip, groin and necrosis decreased hip ROM Maintain hip Vague complaints of function hip or knee pain that may be continuous or Nursing intermittent- easily Considerations: overlooked Pre/post op care Pain management Education and emotional support Maintain activity limitations Club Feet Complex deformity of Treatment started Repeated Pain the ankle and foot immediately after casting is Management birth – parent attempted first and Cast Care! What does it look education like? Foot can not be manipulated into a Post op care neutral position.  Pre-Op/Post-op care Apply ice to foot Elevate foot/feet Neuro checks every 2 hours Hip Dysplasia Head of the femur is Pavlick Harness: Minimize Maintain improperly seated in know how to care isolation if non- abduction the acetabulum of the for a child in the ambulatory pelvis. Mild – severe. harness and important info to What would you educate parents. expect to see clinically? Spica Cast: know how to care and Ortolani Click educate parents Galezzi sign Shortening of the affected limb Limitation of abduction on the affected side Asymmetry of gluteal and thigh fat folds Limited range of motion in the affected hip Uneven knee height Legg-Calve Young school age Bed rest, activity Long term Perthes Painful limp, pain in limitation education treatment hip, thigh, knee for child and with bed rest, parents activity Avascular necrosis of restrictions, the femoral head limited weight bearing, sometimes abduction bracing. Even with surgery the femoral head can take several years to regenerate. Scoliosis What are the clinical Treatment options? How long do manifestations of Mild: exercises they need to scoliosis? : Moderate: bracing wear the Truncal asymmetry, 23 hours a day brace? uneven shoulder and  hip height, a one- Severe: surgery 23 hours a sided rib hump, with spinal fusion day, curvature of spine, discontinue prominent scapula when they Typically, no pain reach skeletal maturity [[c Osteogenesis What are the clinical Support trunk and Must be Imperfecta manifestations of OI? extremities when handled very Bone fragility and moving gently deformity, multiple fractures, blue sclera, discolored teeth, thin skin, short stature, deafness, joint contractions, enlarged anterior fontanel, weak muscles