Chapter 23 Pediatrics.pdf

UNIT V The Child Needing Nursing Care The Child With a Sensory or Neurological Condition 23 http://evolve.elsevier.com/Leifer Objectives 1. Define each key term listed. 2. Discuss the prevention and treatment of ear infections. 3. Outline the nursing approach to serving the hearingimpaired child...

UNIT V The Child Needing Nursing Care The Child With a Sensory or Neurological Condition 23 http://evolve.elsevier.com/Leifer Objectives 1. Define each key term listed. 2. Discuss the prevention and treatment of ear infections. 3. Outline the nursing approach to serving the hearingimpaired child. 4. Discuss the cause and treatment of amblyopia. 5. Compare the treatment of paralytic and nonparalytic strabismus. 6. Review the prevention of eye strain in children. 7. Discuss the functions of the 12 cranial nerves and nursing interventions for dysfunction. 8. Describe the components of a “neurological check.” 9. Discuss neurological monitoring of infants and children. 10. Outline the prevention, treatment, and nursing care for the child with Reye’s syndrome. 11. Describe the symptoms of meningitis in a child. 12. Describe signs of increased intracranial pressure in a child. 13. Discuss the various types of seizures and the relevant nursing responsibilities. 14. Describe four types of cerebral palsy and the nursing goals involved in care. 15. Formulate a nursing care plan for the child with a decreased level of consciousness. 16. Prepare a plan for success in the care of a child with intellectual disabilities. 17. Describe three types of posturing that may indicate brain damage. 18. State a method of determining level of consciousness in an infant. 19. Identify the priority goals in the care of a child who experienced near drowning. Key Terms amblyopia (ăm-blē-Ō-pē-ă, p. 545) athetosis (ăth-ĕ-TŌ-sĭs, p. 559) aura (ĂW-ră, p. 554) barotrauma (p. 543) clonic movement (p. 553) cognitive impairment (p. 562) concussion (p. 564) conjunctivitis (p. 547) encephalopathy (ĕn-sĕf-ă-LŎP-ăthē, p. 550) enucleation (ē-nū-klē-Ā-shŭn, p. 547) epicanthal folds (p. 544) extensor posturing (p. 565) flexor posturing (p. 565) generalized seizures (p. 554) grand mal (p. 554) hyperopia (hī-pŭr-Ō-pē-ă, p. 545) idiopathic (ĭd-ē-ō-PĂTH-ĭk, p. 554) intellectual disability (p. 562) intracranial pressure (ICP) (p. 550) intellectual impairment (p. 561) ketogenic diet (p. 556) myringotomy (mĭr-ĭng-GŎT-ŏ-mē, p. 542) neurological check (p. 549) nystagmus (nĭs-TĂG-mŭs, p. 552) opisthotonos (ō-pĭs-THŎT-ō-nŏs, p. 551) papilledema (păp-ĭl-ă-DĒ-mă, p. 552) paroxysmal (păr-ŏk-SĬZ-mŭl, p. 554) THE EARS The ear, which can be considered a part of the nervous system, contains the receptors of the eighth cranial (acoustic) nerve. The fetus can hear at 20 weeks’ gestation, and the auditory nerve function has matured by 5 months of age. The ear performs two main functions: hearing and balance. Fig. 23.1 summarizes ear, eye, and neurological differences between children and adults. The three partial seizures (p. 554) petit mal (p. 554) postictal lethargy (pōst-ĬK-tăl lethargy, p. 554) posturing (p. 565) second impact syndrome (SIS) (p. 564) sepsis (SĔP-sĭs, p. 550) shaken baby syndrome (p. 564) sign language (p. 543) status epilepticus (p. 558) strabismus (stră-BĬZ-mŭs, p. 545) tonic-clonic seizure (p. 554) tonic movement (p. 553) divisions of the ear are the external ear, the middle ear, and the inner ear (Fig. 23.2). In the newborn, the tympanic membrane is almost horizontal and is more vascular than in the adult. It has a dull and opaque appearance and an inconsistent light reflex. The eustachian tube is shorter and straighter in the infant than in the adult. Three functions of the eustachian tube are ventilation of the middle ear, protection from nasopharyngeal secretions and sound pressure, and drainage. Middle-ear infections are common during early childhood. 539 UNIT V The Child Needing Nursing Care 540 EARS • The eustachian tube in infants is shorter, wider, and straighter than in older children and adults, and this may contribute to infections. • In newborns and young infants, the walls of the ear canal are pliable because of underdeveloped cartilage and bony structures. EYES • Infants’ eyes may occasionally cross until about 6 weeks of life. • Tears are scant or absent for the first 2 to 4 weeks of life. NERVOUS SYSTEM • Brain and nerve cell growth and specialization are most rapid from birth until about 4 years of age. • The suture lines and fontanelles of the infant allow for molding during birth and also help compensate for increases in intracranial pressure. • By the end of the first year, the brain has increased in weight about 2½ times. Brain growth is almost complete by 2 years of age. Measuring head circumference in infants helps determine neurological growth. • Myelinization of nerve tracts in the central nervous system accelerates after birth and follows the cephalocaudal and proximodistal sequence. This allows for progressively more complex neurological and motor functions. Fig. 23.1 Summary of the ear, eye, and neurological differences between the child and adult. (Art overlay courtesy Observatory Group, Cincinnati, OH.) Antihelix Pinna Helix Auricle Triangular fossa Ossicles Malleus Semicircular canals Incus Stapes Facial nerve (VII) Tragus Cochlea Antitragus A Lobule Intertragal notch External auditory canal B Mastoid bone Facial nerve (VII) Cranial nerve (VIII) Tympanic membrane Eustachian tube Fig. 23.2 Anatomy of the ear. (A) The normal external ear—the auricle (pinna) and tragus—is shown with common landmarks labeled. (B) There are three divisions of the ear: outer ear, middle ear, and inner ear. In the newborn, the mastoid process and the bony part of the external canal are not fully developed, leaving the tympanic membrane vulnerable to injury. Newborns can hear as soon as amniotic fluid is drained by the first sneeze. The eustachian tube connects the middle ear and the pharynx, and it serves to vent the middle ear. In infants, the eustachian tube is shorter, wider, and straighter than in adults. Pooling of fluids (e.g., milk) in the throat of an infant who falls asleep with a bottle of milk can contribute to ear infections. The external auditory canal is more angulated (curved) in infants; therefore pulling the pinna (auricle) is required to straighten the canal for an accurate tympanic temperature. (From Zitelli BJ, McIntire SC, Nowalk AJ: Zitelli and Davis’ atlas of pediatric physical diagnosis, ed 7, St Louis, 2018, Elsevier.) When nurses examine the ear, they observe both the exterior and the interior. Ear alignment is observed. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput (see Fig. 12.6). Low-set ears may be associated with kidney disorders and intellectual or developmental disabilities. The outer ear and the area around it are inspected for cleanliness and drainage. The inner ear is examined with an otoscope. One method of restraint used when assisting with the examination of the inner ear is to lay The Child With a Sensory or Neurological Condition the child on a table with the arms held alongside the head, which is turned to the side. Another method of positioning a child for an ear examination is to place the child in the lap of the adult (see Fig. 22.5). Nursing Tip Before instilling ear drops in infants, gently pull the pinna of the ear down and back. In children, gently pull the pinna of the ear up and back to straighten the external auditory canal. DISORDERS AND DYSFUNCTION OF THE EAR Otitis Externa An acute infection of the external ear canal is called otitis externa and is often referred to as swimmer’s ear because prolonged exposure to moisture is often the precipitating factor. Pain and tenderness on manipulating the pinna or tragus of the ear are specific signs of this type of infection. The ear canal may be erythematous, but the tympanic membrane is normal. A foreign body, cellulitis, diabetes mellitus, and herpes zoster should be ruled out. Irrigation and topical antibiotics or antivirals are the treatments of choice. The health care provider may insert a loose cotton gauze (wick) into the outer third of the ear canal. The wick is kept moist with frequent drops of the appropriate medicated solution. Prevention should be aimed at keeping the ear dry during and after exposure to moisture. This is especially important when swimming in lakes, creeks, or streams where many organisms are often present. Acute Otitis Media Pathophysiology. Otitis media (ot, “ear,” itis, “inflammation of,” and media, “middle”) is an inflammation of the middle ear. The middle ear is a tiny cavity in the temporal bone. Its entrance is guarded by the sensitive tympanic membrane, or eardrum, which transmits sound waves through the “oval window” to the inner ear, which contains the organs of hearing and balance. The middle ear opens into air spaces, or sinuses, in the mastoid process of the temporal bone. It is also connected to the throat by a channel called the eustachian tube. These structures—the mastoid sinuses, the middle ear, and the eustachian tube—are lined by mucous membranes. As a result, an infection of the throat can easily spread to the middle ear and can lead to mastoiditis. The eustachian tube also protects the middle ear from nasopharyngeal secretions, provides drainage of middle ear secretions into the nasopharynx, and equalizes air pressure between the middle ear and the outside atmosphere. These protective functions are diminished when the tubes are blocked. Unequalized air pressure within the ear creates a negative pressure that allows organisms to be swept up into the eustachian tube. Otitis media (OM) occurs most often after an upper respiratory tract infection and usually affects children CHAPTER 23 541 between 6 and 24 months of age and those in early childhood. It is caused by various organisms, of which Streptococcus pneumoniae and Haemophilus influenzae are the most common. Polyvalent pneumococcal polysaccharide vaccines have reduced the incidence of pneumococcal OM, but these vaccines are not effective in children less than 2 years of age because they are not capable of producing an antibody response. Infants are more prone to middle ear infections than older children and adults because their eustachian tubes are shorter, wider, and straighter. When infants lie flat for long periods, microorganisms have easy access from the eustachian tube to the middle ear. Feeding methods may have a bearing on middle ear infection; for instance, the pooling of fluids (e.g., milk) in the throat of an infant who falls asleep with a bottle of milk provides a source for growth of organisms. The infant’s humoral (humor, “body fluid”) defense mechanisms are immature. Children in passive smoking environments have more respiratory infections because of the effect of secondary smoke on the protective cilia that line the nose. Day care attendance can contribute to the risk of upper respiratory infections and OM because of increased exposure to ill children. Upper respiratory infections are discussed in detail in Chapter 25. Nursing Tip Signs and symptoms of ear infection can include: • Rubbing or pulling at the ear • Rolling the head from side to side • Hearing loss • Loud speech • Inattentive behavior • Articulation problems • Speech development problems Manifestations. The symptoms of OM are pain in the ear, which is often very severe, irritability, and diminished hearing. Fever, which may be as high as 40°C (104 °F); headache; vomiting; diarrhea; and febrile seizures may also occur. Earaches in infants may be manifested by general irritability, frequent rubbing or pulling at the ear, and rolling of the head from side to side. The older child can point to the place that is tender. Visualization of the tympanic membrane via otoscope shows a reddened and bulging membrane. If an abscess forms, a rupture of the eardrum may result, and drainage from the ear may be evident. When this happens, the pressure is relieved and the child is more comfortable. Some amount of hearing loss may result from the rupture. OM is considered chronic if the condition persists for more than 3 months. Recurrent attacks can lead to serious complications. Chronic OM can lead to cholesteatoma (chole, “bile,” steato, “fat,” and oma, “tumor”), a cystlike sac filled with keratin debris. This may occlude the 542 UNIT V The Child Needing Nursing Care middle ear and erode adjacent ossicle bones, causing hearing loss. This condition is best treated by an otolaryngologist. Complications of repeated attacks of acute OM can include the development of chronic OM with effusion (fluid accumulation). Hearing loss can result. Treatment may be indicated because hearing loss may impair cognitive and language development that can hamper the education and communication abilities of developing children. Treatment. The first-line antimicrobial medication prescribed is oral amoxicillin, which is given for 10 days, with follow-up scheduled after 2 weeks. The nurse should instruct the parent on techniques of administering medications to children. It is essential that the nurse have a knowledge and understanding of the medications prescribed for his or her patient. Nursing Tip Instruct caregivers that the child’s condition may improve dramatically after antibiotics are taken for a few days. To prevent recurrence, caregivers must continue to administer the medication until the prescribed amount has been completed. Surgical Treatment. Surgical intervention may be necessary when medical treatment is unsuccessful. The health care provider may incise the tympanic membrane to relieve pressure and to prevent a tear by spontaneous rupture. This is called a myringotomy (myringa, “eardrum,” and otomy, “incision of”). A tympanic membrane button or tympanostomy ventilating tube (pressure equalizer [PE]) may be inserted if the condition becomes chronic, lasts more than 3 months, or causes hearing difficulties that impair school performance. The PE tube may fall out spontaneously within 6 to 12 months. In some children, the tubes may have to be reinserted to continue ventilation. Care no longer needs to be taken to avoid getting water in the ears while bathing or showering, and the use of earplugs is no longer required when PE tubes are in place (Kerschner and Preciado, 2020). All children should be followed up to make sure that the condition is resolved and to evaluate any hearing loss that may have occurred. Comfort Measures. Antipyretics may be given to reduce fever, and a warm compress may be applied locally for comfort. If the eardrum has ruptured, the child is placed on the affected side. Cold may also be beneficial. An ice pack may be prescribed to reduce edema and pressure. The skin around the ears must be kept clean and protected from any drainage to prevent tissue breakdown. Parents are instructed not to insert cotton swabs into the ears. Hearing Impairment Hearing-impaired children present special challenges to the health care team. Hearing loss can affect speech, language, social and emotional development, and behavior, in addition to academic achievement. The nurse should have a basic understanding of how to approach and work with a hearing-impaired child. Pathophysiology. Hearing loss can be central or peripheral and is classified according to where the problem is. Congenital hearing loss in the newborn may be hereditary or may result from in utero infection, a low birth weight, prolonged resuscitative measures, or specific anomalies or syndromes. Sensorineural hearing loss occurs when the hair cells along the cochlea and acoustic nerve may be damaged, which can occur from exposure to environmental toxins, genetic anomalies, or exposure to loud noise—some rattles and squeaky toys can emit sounds exceeding 100 decibels (dB) and should not be placed near the ear of an infant. Conductive hearing loss occurs when the tympanic membrane prevents sound from entering the middle ear. Common causes of conductive hearing loss in older children include impacted cerumen (ear wax), perforation of the tympanic membrane, and some types of ear infections. Teens who use earphones or ear buds at high volumes and those who attend loud rock concerts, are near fireworks, or work with power equipment are at risk for developing conductive hearing loss. Hearing loss is expressed in terms of decibels, which are units of loudness and are the basis for rating the severity of a hearing loss. A hearing loss greater than the 15 dB threshold requires some intervention to prevent developmental problems, and a hearing loss greater than 70 dB is considered legal deafness (Haddad et al., 2020). The American Academy of Pediatrics (AAP) recommends universal hearing screening at birth or before 3 months of age, with interventions no later than 6 months of age. Testing for hearing loss is possible even in the very young infant or child. An initial screening is done for a newborn before discharge. If hearing loss is complete, the child misses all the pleasures of sound and has difficulty in communication (children learn to talk by imitating what they hear). Behavior problems may arise because these children do not understand verbal directions. They may become aggressive with other children in their attempt to communicate. If playmates ridicule them, personality development will be affected. Unless these children are helped early in life, they may become socially isolated. Nursing Tip When addressing a hearing-impaired child, the nurse should: • Be at eye level with the child. • Be face-to-face with the child. • Establish eye contact. • Talk in short sentences. • Avoid using exaggerated lip or face movement. The Child With a Sensory or Neurological Condition Diagnosis and Treatment. The American Academy of Pediatrics recommends a goal of universal detection of hearing impairment in infants before 3 months of age, with interventions started no later than 6 months of age to minimize problems with growth and development (Haddad & Dodhia, 2020). The evoked otoacoustic emissions (OAE) test is a preferred method for neonatal testing. The auditory brainstem response (ABR) test records brain wave responses generated by the auditory system. These tests are easily administered to the newborn infant, and many hospitals routinely screen newborns for hearing ability before discharge. Lack of response by the infant to sounds or music or lack of the startle reflex in infants less than 4 months of age is the first sign that may alert the parents or nurse to the possibility of hearing impairment. Early diagnosis and prompt treatment are primary requisites, regardless of the child’s age. Tympanometry measures ear pressure but is difficult to perform adequately on an active infant or small child. A tuning fork is used to evaluate for air conduction (Rinne test) or bone conduction (Weber test). These types of tests require the child to be cooperative and able to communicate what is heard or felt. A diagnosis of hearing loss can be confirmed by visual reinforcement audiometry (VRA), which identifies sensitivity to sounds in young infants. Many hearing defects are amenable to medical or surgical treatment. Hearing aids can amplify sound waves and can be used with infants as young as 2 months of age. They are fitted by a pediatric audiologist. Surgically placed cochlear implants are used for some children as young as 2 years of age. All children with cochlear implants must be immunized with pneumococcal vaccine before surgery to avoid complications related to bacterial infection (Haddad et al., 2020). Children who suffer a severe loss of hearing need more extensive help from personnel at an auditory training center. These children must begin treatment as soon as the hearing loss is discovered. Nursing Care. Various methods are used to bring the child into the world of sound. Lip reading, sign language, writing, visual aids, and amplified sound are but a few examples. The parents are instructed in means of communication that correspond with those used by the teachers. The nurse must be aware of the symptoms of deafness in the child. Newborns are observed for their responses to auditory stimuli. The Brazelton Neonatal Behavioral Assessment Scale evaluates the infant’s orientation response to the sound of a voice. The nurse enquires into the facilities that are available in the community for hearing-impaired children. The hearing-impaired child in the hospital needs the same opportunities to communicate as the child who does not have this disability. The nurse smiles when approaching the child. Body language communicates a lot, especially if there is a severe communication problem. The nurse faces the child when speaking and is CHAPTER 23 543 positioned at eye level with the child. The nurse must ensure that the child sees him or her before touching to avoid startling the child. Sign language is the use of hand signals that correspond to words and assist in communication with a deaf child. Previously developed speech patterns may regress during hospitalization. Visual aids, writing, or drawing can be used to enhance communication. A hearing aid is expensive and invaluable to the child. When the child goes to surgery, it is given to the parents or placed in the hospital safe. The pockets of hospital gowns are checked before the gowns are placed in the laundry. The National Hearing Center provides information about hearing aids. Hearing aids are designed to fit in the ear, behind the ear, on eyeglass frames, or on the body with wires to the ear. The nurse should check ear hygiene and be sure hairs are not caught on the end of the hearing aid to ensure a proper fit and to minimize noise and whistling problems. Teaching safe battery handling and storage and promoting self-care are important nursing responsibilities. Home care of the hearing-impaired child should include speech therapy. Flashing lights should be installed in the home to alert the child to doorbells and other sound-based devices. Telecommunication devices for the deaf (TDD) are available to enable telephone communication. Closed captioning devices for television are available to the child who can read. The school nurse can help the family nurture socialization skills. Some hearing-impaired children attend special schools for the deaf, and some are mainstreamed into the general school population. The multidisciplinary health care team should follow each hearing-impaired child and each family unit to provide individualized care. Nursing Tip Emphasize to parents the need to supervise the care and storage of hearing aid batteries to prevent accidental ingestion. When inserting the earpiece of a hearing aid, be sure that the ear canal is free of hair. Barotrauma Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment. An example of barotrauma would be the painful obstruction of auditory tubes when in a pressurized cabin of an airplane. Today many children travel with their families via airplanes and may react to a change in altitude and barometric pressure. During airplane descent, children should be encouraged to yawn or chew on gum to promote swallowing. Infants should be bottle-fed juice or water to promote swallowing, which produces autoinflation UNIT V The Child Needing Nursing Care 544 and relief of symptoms. Systemic decongestants can be taken before air travel and timed so that their peak effectiveness occurs during airplane descent. Adolescents may participate in recreational underwater diving that can cause barometric pressure stress to the ear and result in severe earaches and other serious problems. Underwater diving should be slow during the descent phase to minimize negative pressure buildup. Sensory hearing loss and vertigo with nausea and vomiting may be early signs of decompression sickness when it occurs during the ascent phase of diving. The diver should be referred for medical care. Upper respiratory infections or tympanic membrane perforation are contraindications to diving because vertigo, nausea, vomiting, and disorientation can occur, with dangerous results. eyes to follow people or objects that may be 1.8 meters (6 feet) away. By 4 to 5 months their eyes are open most of the day, and tears, when the infant cries, can be seen to overflow on to the face (visible tears). Eyehand coordination develops. The nurse should document this because the ability to transfer objects from one hand to another is partially dependent on the ability to see the object. The development of the ability to crawl is also partially dependent on the ability to see an object at a distance and attempt to reach it. Depth perception is not developed until 9 months of age. When the child walks or runs, visual depth perception influences the child’s ability to run without falling. The AAP recommends that all children undergo preschool visual screening during well-child visits between 2 and 3 years of age. THE EYES The eye is the organ of vision. The anatomy of the eyeball is depicted in Fig. 23.3. The eyes begin to develop as an outgrowth of the forebrain in the 4-week-old embryo. The retinal vessels vascularize (develop) at 40 weeks of gestation; therefore infants born prematurely often have vision problems throughout their lives. At birth, the eye is 65% of adult size. The newborn’s sight is not mature, but the newborn can see. Visual acuity is estimated to be in the range of 20/400. This improves rapidly and may reach 20/40 to 20/30 by 2 or 3 years of age and 20/20 by 6 or 7 years of age. The shape of the newborn’s eye is less spherical than the adult’s eye. Newborns keep their eyes closed most of the day, can focus and fixate on objects 12 to 30 cm (8 to 12 inches) away for only a few seconds at a time, and cannot coordinate or follow without turning their heads. By 2 to 4 months, infants can move their Upper eyelid Sclera Caruncle Lateral canthus Medial canthus Health Promotion Healthy People 2030 A goal of Healthy People 2030 is to increase the number of children who have visual screening before 5 years of age. On physical examination, the nurse observes the eyes to see if they are symmetrical and are an equal distance from the nose. Epicanthal folds (epi, “upon,” Ciliary muscle Iris muscle Retinal artery Retinal vein Optic nerve Cornea Lower eyelid Iris Anterior chamber Conjunctiva Lateral rectus muscle B Central retinal artery and vein Optic disc (“blind spot”) Pupil Macula Lens Limbus A At birth, the quiet, alert infant will respond to visual stimuli by ceasing to move. Visual responsiveness to the mother during feeding is noted. The infant’s ability to focus and follow objects in the first months of life should be documented. Coordination of eye movements should be achieved by 3 to 6 months of age. Medial rectus muscle Vitreous body Palpebral fissure Pupil Nursing Tip Sclera Choroid Retina Fig. 23.3 The normal eye. (A) External view. (B) Internal view showing relationship of the optic nerve, eye muscles, and chambers of the eye. (A from Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 10, St Louis, 2015, Mosby; B from Seidel HM, et al: Mosby’s guide to physical examination, ed 9, St Louis, 2019, Elsevier.) The Child With a Sensory or Neurological Condition and canthus, “angle”) are folds of skin that extend on either side of the bridge of the nose and cover the inner eye canthus. Some folds are broad and cover a large portion of the inner eye, causing the eye to appear crossed. Large epicanthal folds occur as part of some chromosomal factors. Pupils are observed for size, shape, and movement. Shining a penlight into the eye and then quickly removing it allows observation of the eye’s reaction to light. The healthy pupil constricts (gets smaller) as the light approaches and dilates (gets larger) as it disappears (see Fig. 23.14). Older children are given explanations concerning the examination. The nurse should assess and document the general appearance of the child, and also the achievement of developmental milestones. This includes observing for symmetry of the eye orbit and eyelids, excessive tearing, squeezing of the eyelids, and strabismus (crossed eyes). Nursing Tip The achievement of developmental milestones, such as transferring objects from hand to hand, is partially dependent on seeing the object. Therefore assessment of visual ability is part of the assessment of growth and development. VISUAL ACUITY TESTS The ability of an infant to fixate and focus on an object can be demonstrated by 6 weeks of age. In tests for this ability, the object should not emit a sound, so it is certain the infant is turning toward a sight stimulus rather than a sound stimulus. There are a variety of visual acuity charts (Fig. 23.4A). The Snellen alphabet chart and the Snellen E version for preschoolers who have not learned the alphabet are commonly used to assess the ability to see near and far objects. Picture cards are also useful for children who do not know letters. Visual acuity can be tested by 2½ to 3 years of age (Fig. 23.4B). The Titmus machine is often used for school-age children and adolescents. Directions for testing are standardized and must be carefully adhered to for proper results. Computerized tests, such as the random-dot stereogram, are also useful in the visual screening of children. Visual acuity is important in the learning process. (Retinopathy of prematurity [ROP] is discussed in Chapter 13.) DISORDERS AND DYSFUNCTION OF THE EYE Amblyopia Pathophysiology. Amblyopia (lazy eye) is a reduction in or loss of vision that usually occurs in children who strongly favor one eye. If both retinas do not receive a clearly defined image, bilateral amblyopia may result. However, it is more common for one eye to be affected. When abnormal binocular interaction CHAPTER 23 545 occurs (e.g., crossed eyes or strabismus), the prognosis depends on how long the eye has been affected and the age of the child when treatment begins. The earlier the treatment is given, the better the results. One commonly accepted diagnostic sign is that vision in the normal eye is at least two Snellen lines (E charts) better than that in the affected eye. There are various types of amblyopia. Strabismus is the most common; however, dissimilar refractory errors can also result in this condition. Because amblyopia occurs as a result of sensory deprivation of the affected eye, children are at risk for developing the problem until visual stability occurs, usually by 9 years of age. Treatment and Nursing Care. Early detection and prompt treatment are essential. The goal of treatment is to obtain normal and equal vision in both eyes. Treatment consists of eyeglasses for significant refractive errors, such as hyperopia (farsightedness) or myopia (nearsightedness), and patching (occlusion) of the good eye. The good eye is patched to force the use of the affected eye. Daytime patching may be tried first, since part-time occlusion is sufficient in some cases. Occlusion therapy is often difficult to maintain. The nurse can help by explaining the importance of the procedure and by offering support, but the child is often subjected to teasing by peers. Providing a safe place to express feelings is important to promoting a healthy self-image. In some cases atropine eye drops are given to blur the vision in the better eye (Olitsky and Marsh, 2020). Strabismus Pathophysiology. Strabismus (cross-eye), also known as squint, is a condition in which the child is not able to direct both eyes toward the same object. There is a lack of coordination between the eye muscles that direct movement of the eye. When the eyes cannot coordinate sight together, the brain will disable one eye to provide a clear image. The disabled eye can develop permanent visual impairment because of sensory deprivation (amblyopia). Normal binocular vision is the goal and must be accomplished by intervening early, before the eye matures. There are several types of strabismus. Nonparalytic strabismus (concomitant) is most common and involves a constant deviation in the gaze. One eye always looks crossed. The extraocular muscles are normal. Paralytic strabismus (incomitant) involves a paralysis or weakness in the extraocular muscle. Double vision is experienced. Deviation of the gaze occurs with movement, when the eye attempts to focus. To prevent double vision (diplopia), the child will tilt his or her head or squint when focusing on an object. Visual exercises or surgery may be required to restore muscle balance. Strabismus may be present at birth or may manifest after a disease or injury. Strabismus that occurs after a head trauma may indicate that cranial nerve damage has occurred. 546 UNIT V The Child Needing Nursing Care A Fig. 23.4 (A) Various types of visual acuity charts. The E chart is often used for young children, who can show which way the fingers of the E are pointing. (B) A 4-year-old child responds to a detailed vision assessment. Nursing Tip Symptoms of strabismus include: • Eye “squinting” or frowning to focus • Reaching for objects and missing them • Covering one eye to see • Tilting the head to see • Dizziness and/or headache In nonparalytic strabismus, the refractory error is usually corrected with eyeglasses. When paralytic strabismus is seen during early infancy, the health care provider may recommend that a patch cover the unaffected eye until the infant is old enough to wear glasses. The affected eye may improve through use and often becomes normal. Eye exercises and glasses are effective ways of treating the condition medically. If they do not help, surgery is considered. It is generally performed when the child is 3 or 4 years of age. Early correction is necessary to prevent amblyopia. If strabismus is left untreated, blindness in the affected eye may result because the brain tends to obliterate the confusing double image by disabling the eye. Nursing Care. The child undergoing surgery for strabismus might be hospitalized for only a brief period. The surgery involves structures outside the eyeball; therefore the child is allowed to be up and about postoperatively. Eye dressings are kept at a minimum, and elbow restraints may be sufficient to keep the child from touching the dressings. Prevention of Eyestrain. Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height. Symptoms that may indicate eyestrain include inflammation, aching or burning of the eyes, squinting, a short attention span, frequent headaches, difficulties with schoolwork, or an inability to see the blackboard. The Child With a Sensory or Neurological Condition Edema Crusting of eyelids Itching Inflamed, pink conjunctiva Tearing and purulent drainage Fig. 23.5 Acute bacterial conjunctivitis. Signs of conjunctivitis are evident in this highly contagious infection. (From Newell FW: Ophthalmology: principles and concepts, ed 7, St Louis, 1992, Mosby.) It is important for the nurse to observe the child for eyestrain, to teach proper eye care, to prevent complications of eyestrain or strabismus, to refer as needed for follow-up care, and to assist in rehabilitation. Conjunctivitis Conjunctivitis (conjungere, “to join together,” and itis, “inflammation”) is an inflammation of the conjunctiva, which is the mucous membrane that lines the eyelids (Fig. 23.5). A wide range of bacterial and viral agents, allergens, irritants, toxins, and systemic diseases can cause conjunctivitis. Conjunctivitis that occurs with viral exanthems (e.g., measles) is usually self-limiting. It is common in childhood and may be infectious or noninfectious. The acute, infectious form is commonly referred to as pinkeye. Pinkeye is considered no longer contagious after 24 hours of appropriate antimicrobial therapy. Conjunctivitis can also result from an obstruction of the lacrimal duct. In general, the common forms of conjunctivitis respond to warm compresses and topical antibiotic eye drops or eye ointments. Ointments blur vision and are not generally used during daytime hours in the ambulatory child. The nurse instructs parents to administer the eye medication for the prescribed time to prevent recurrence. Parents and older children are taught to wipe secretions from the inner canthus downward and away from the opposite eye. Because conjunctivitis spreads easily, affected children should use separate towels and should be instructed to wash their hands frequently. Ophthalmia neonatorum, an acute conjunctivitis in the newborn, is discussed in Chapter 6. Allergic conjunctivitis is often associated with allergic rhinitis (rhin, “nose,” and itis, “inflammation”) in children with hay fever. Symptoms include itching, tearing of one or both eyes, and edema of the eyelids and periorbital tissues. The child may appear distracted and irritable. Periorbital Cellulitis An infection of the eyelid and tissues surrounding the eye sometimes occurs in school-age children as a CHAPTER 23 547 complication of bacterial sinusitis (inflammation of the sinus). Pain and swelling around the eye are common symptoms of periorbital cellulitis. Intravenous antibiotics may be required to prevent spread of the infection to the brain. Hyphema Hyphema, the presence of blood in the anterior chamber of the eye, is one of the most common ocular injuries. It can occur from either a blunt or a perforating injury. Blows from flying objects (e.g., baseballs, snowballs) and forceful coughing or sneezing can cause this condition. These accidents are common among active school-age children. Hyphema appears as a bright red or dark red spot in front of the lower portion of the iris. Treatment includes bed rest and topical medication. The head of the bed is elevated 30 to 45 degrees to reduce intraocular pressure (and also intracranial pressure if there is an associated head injury). The use of ibuprofen or nonsteroidal antiinflammatory drugs (NSAIDs) are contraindicated. The condition generally resolves itself without residual problems, although patients should be monitored for the development of glaucoma later in life (Olitsky and Marsh, 2020). Retinoblastoma Pathophysiology. Retinoblastoma is a malignant tumor of the retina of the eye. There are hereditary and spontaneous forms. The average ages at diagnosis is 2 years of age with 90% of cases diagnosed by 5 years of age (Tarek and Herzog, 2020). The risk of retinoblastoma is increased in children conceived by in-vitro fertilization. Manifestations. A yellowish-white reflex is seen in the pupil because of a tumor behind the lens. This is called the cat’s eye reflex or leukokoria (leuk, “white,” and kore, “pupil”). It is most suspected when the normal red reflex is not seen on normal newborn or child eye examination. This may be accompanied by loss of vision, strabismus, hyphema and, in advanced tumors, pain. Metastasis to the unaffected eye is common in unilateral tumors. When retinoblastoma is suspected in children, an examination is performed using an anesthetic so the pediatric ophthalmologist may carefully examine the fundus of the eye. Treatment and Nursing Care. The standard treatment for unilateral disease is enucleation (removal) of the eye if there is no possibility of saving the vision. Small tumors are treated with laser photocoagulation to destroy the blood vessels supplying the tumor. Larger tumors can be treated with systemic chemotherapy followed by laser therapy, cryotherapy, and brachytherapy (Tarek and Herzog, 2020). On return from enucleation surgery, the child has a large pressure dressing on the eye. Elbow restraints may be necessary to prevent removal of the dressing. The bandage is observed for bleeding, and the 548 UNIT V The Child Needing Nursing Care vital signs are assessed. After a few days the surgeon removes the dressing and applies an eye patch. Other structures of the eye, such as the lids, lashes, and tear glands, are not affected. An eye prosthesis is fitted when the socket has healed. Instructions for care of the prosthesis are provided at the time of final fitting. Providing education and emotional support for the child and family and referral to the multidisciplinary health care team is essential. THE NERVOUS SYSTEM The nervous system is the body’s communication ­center; it receives and transmits messages to all parts of the body. It also records experiences (memorization) and integrates certain stimuli (learning). The anatomy of the nervous system is depicted in Fig. 23.6. Neural tube development occurs during the third to fourth week of fetal life. This eventually becomes the central Fig. 23.6 (A) Functional areas of the brain. Each area of the brain has a specific function. Damage to the local area can cause loss of that function. (B) The nervous system and the innervation of target organs by the autonomic nervous system. The sympathetic pathways are shown in orange, and the parasympathetic pathways are shown in green. (A from Patton KT, Thibodeau GA: Anatomy & physiology, ed 9, St Louis, 2015, Mosby; B from Thibodeau GA, Patton KT: Structure and function of the body, ed 15, St Louis, 2016, Mosby.) CHAPTER 23 The Child With a Sensory or Neurological Condition nervous system (CNS). The fusing process of the neural tube is critical. Its failure to fuse may lead to congenital conditions, such as spina bifida (see Chapter 14). Most neurological disabilities in childhood result from congenital malformation (birth defects), brain injury, or infection. The 12 cranial nerves and their functions are shown in Fig. 23.7. Skull x-ray films, electroencephalography (EEG), computed tomography (CT), magnetic resonance imaging (MRI), electromyography, and other methods, including a neurological check, may detect CNS dysfunction (see Box 23.6 and Table 23.6). The reflexes of the newborn are good indicators of neurological health. A decreased level of consciousness in the ill child may be an indication of a neurological problem. Box 23.1 describes the causes of altered levels of consciousness. In the finger-nose test (used to determine coordination), the child is asked to extend the arm and then to touch his or her nose with the index finger. This is done with the eyes opened and closed. The inability to balance on one foot in a school-age child necessitates follow-up. The 12 cranial nerves, selected forms of dysfunction, and nursing interventions are described in Table 23.1. Safety Alert! The sudden appearance of a fixed and dilated pupil is a neurological emergency. Box 23.1 Causes of Altered Level of Consciousness (LOC) • A fall in the partial pressure of arterial oxygen (Pao2) to 60 mm Hg or below. • A rise in the partial pressure of arterial carbon dioxide (Paco2) above 45 mm Hg. • Low blood pressure, causing cerebral hypoxia • Fever (1 °F rise in fever increases oxygen need by 10%) • Drugs (sedatives, antiepileptics) • Seizures (postictal state) • Increased intracranial pressure (ICP) Hypoglossal • Head rotation • Shoulder movement Spinal Accessory 11 Vagus • Voice • Visceral nerve function 12 Olfactory 1 10 • Smell Optic 2 • Sight Oculomotor Glossopharyngeal 9 • Swallow • Taste 3 • Dilation of pupil • Single vision, open eye Acoustic • Hearing 4 8 Facial 7 6 5 Abducens • Wrinkle forehead • Close eyes • Facial muscles Fig. 23.7 The 12 cranial nerves and their functions. 549 • Eye movement • Single vision Trigeminal Trochlear • Rotation of eyeball • Single vision • Sensation of face • Chewing 550 UNIT V The Child Needing Nursing Care Table 23.1 The 12 Cranial Nerves: Selected Dysfunctions and Nursing Interventions CRANIAL NERVE I—Olfactory II—Optic III—Oculomotor IV—Trochlear V—Trigeminal VI—Abducens VII—Facial VIII—Acoustic IX—Glossopharyngeal X—Vagus XI—Spinal accessory XII—Hypoglossal DYSFUNCTION Inability to smell Inability to control pupil reflex Double vision Inability to move eyes Difficulty in chewing Inability to control corneal reflex Inability to close eye Inability to hear Inability to taste or to control gag and cough reflexes Difficulty talking or swallowing; visceral malfunction Controls head, turns, and shrugs shoulders Controls tongue movement, thick speech States of Consciousness Consciousness is the awareness of environmental stimuli, the ability to react to stimuli, and the cognitive ability to respond to the stimuli either verbally or physically in an age-appropriate manner. Altered levels of consciousness include: Confusion—disoriented to time, place, or person; unable to answer simple or complex questions Delirium—disorientation involving fear and agitation Lethargy—sleepy, difficult to arouse Stupor—deep sleep, responds only to vigorous or painful stimuli Coma—unconscious, unresponsive to any external stimuli; may include posturing (see Fig. 23.13). Some causes of altered consciousness include infection, trauma, hypoxia, poisoning, electrolyte imbalance, metabolic disturbances, increased intracranial pressure (ICP), and head injury. (Congenital pathology is discussed in Chapter 14.) The effect of head injuries on the state of consciousness and nursing care during altered levels of consciousness are discussed throughout this chapter. DISORDERS AND DYSFUNCTION OF THE NERVOUS SYSTEM Reye’s Syndrome Pathophysiology. Reye’s syndrome is an acute, noninflammatory encephalopathy (pathology of the brain) and hepatopathy (pathology of the liver) that follow a viral infection in children. There may be a relationship between the use of aspirin (acetylsalicylic acid) during a viral flu or illness (e.g., chickenpox [varicella]) and the development of Reye’s syndrome. For this reason, aspirin use is generally contraindicated NURSING INTERVENTIONS Appetite may be suppressed; present food attractively. Protect eyes from glaring lights. Cover eyes. When communicating, remain in child’s view. Provide soft foods. Have eye ointment or eye patch on hand to protect cornea. Protect eyes with moist dressing. Maintain body language for communication. Provide visually attractive food. Keep tracheotomy tray and suction at bedside. Provide means of communication. Assess for aspiration. Assess body system functions and vital signs. Provide position change and support. Have suction ready; observe ability to chew and swallow. Provide method of communication. in the pediatric population. Some studies show that a genetic metabolic defect may also trigger Reye’s syndrome. This condition has become uncommon in recent years mainly due to the decreased use of aspirin for children (Johnston, 2020). Medication Safety Alert! Discourage the use of aspirin and other medications that contain salicylates in children with flu-like symptoms. Advise parents to read medication labels carefully to determine their ingredients. Sepsis Sepsis is the systemic response to infection with bacteria; it can also result from viral and fungal infections. Sepsis causes a systemic inflammatory response syndrome (SIRS) because of the endotoxin of the bacteria that causes tissue damage. Untreated sepsis results in septic shock, multiorgan dysfunction syndrome (MODS), and death. Children who are immune compromised, who have neutropenia, or who are in intensive care receiving invasive therapy are at increased risk for developing sepsis. Manifestations. Manifestations of sepsis include fever, chills, tachypnea, tachycardia, and neurological signs, such as lethargy. Septic shock is not diagnosed by a decrease in blood pressure because the infant’s body initially compensates for the poor circulation and tissue perfusion by increasing the heart rate and vasoconstriction of peripheral blood vessels. Hypotension is an ominous sign that may indicate that the body is unable to compensate adequately and cardiorespiratory arrest is about to occur. The Child With a Sensory or Neurological Condition Laboratory test results may include positive blood cultures, reduced fibrinogen and thrombocyte levels, and the presence of immature white blood cells. Neutropenia (a neutrophil count below 1000/mm3) is an ominous sign. Nursing responsibilities include monitoring neurological status and vital signs, observing for shock, and maintaining strict standard and expanded precautions. Intravenous antibiotics are prescribed. To prevent sepsis, immunization against H. influenzae type B (Hib) and administration of the pneumococcal conjugate vaccine (PCV) are recommended for all children 2 months to 4 years of age. These vaccines may prevent some cases of sepsis, but sepsis also can be caused by other bacterial sources. Meningitis Pathophysiology. Meningitis is an inflammation of the meninges (the covering of the brain and spinal cord). Various organisms can cause bacterial meningitis. Group B streptococcus is the main cause of the infection in newborns. Organisms may invade the meninges indirectly, by way of the bloodstream (sepsis) or from centers of infection (e.g., the teeth, sinuses, tonsils, or lungs), or directly, through the ear (OM) or from a fracture of the skull. Bacterial meningitis is often referred to as purulent (i.e., pus forming) because a thick exudate surrounds the meninges and adjacent structures. This can lead to certain sequelae, such as subdural effusion and, less frequently, hydrocephalus. The peak incidence for bacterial meningitis is between 6 and 12 months of age. Meningococcal meningitis is readily transmitted to others. The H. influenzae type B vaccine and pneumococcal vaccines PCV-13 and PCV-23 have reduced the incidence of bacterial meningitis. The approaches to nursing care for all types of meningitis are similar. Manifestations. The symptoms of purulent meningitis result mainly from intracranial irritation. They may be preceded by an upper respiratory infection and several days of gastrointestinal symptoms, such as poor feeding. Severe headache, drowsiness, delirium, irritability, restlessness, fever, vomiting, and stiffness of the neck (nuchal rigidity) are other significant symptoms. Often the infant is resistant to cuddling and rocking because these increase discomfort from the inflamed meninges. A characteristic high-pitched cry is noted in infants. Seizures are common. Coma may occur fairly early in the older child. In severe cases, involuntary arching of the back caused by muscle contractions is seen (Fig. 23.8). This condition is called opisthotonos (opistho, “backward,” and tonos, “tension”). The presence of petechiae (small hemorrhages beneath the skin) suggests meningococcal infection. The diagnosis is confirmed by examination of the cerebrospinal fluid (CSF). CHAPTER 23 551 Fig. 23.8 Opisthotonos Position. An involuntary arching of the back and extension of the neck are seen in children with brain injury or meningeal irritation. Note that the back is arched so that the head is on an even level with the heels. (From Behrman R, Kliegman R, Jenson HB: Nelson textbook of pediatrics, ed 20, Philadelphia, 2016, Saunders.) Safety Alert! The acutely ill and lethargic child who develops a rash with petechiae must be referred for immediate follow-up care. Treatment. At the first indication of meningitis, the health care provider performs a spinal tap (lumbar puncture—see Chapter 22) to obtain a specimen of CSF for laboratory testing. The spinal fluid may be clear in the early stages of the illness, but it rapidly becomes cloudy. The CSF pressure is increased, and further laboratory analysis indicates a high white cell count, an increase in protein, and a decrease in glucose. The child is placed in isolation until 24 hours after antibiotic therapy has been initiated. An intravenous (IV) line is established for the administration of antibiotics and to restore the fluid and electrolyte balance. Antibiotics are selected on the basis of culture and sensitivity laboratory results. Antibiotics are usually administered for a minimum of 10 to 21 days. A sedative may be provided to reduce the child’s restlessness. An anticonvulsant, such as phenytoin (Dilantin), may also be required to reduce the risk of seizure activity. Steroids (e.g., dexamethasone) reduce the complications of bacterial meningitis but are not used in nonbacterial meningitis. Nursing Care. The single room is prepared in accordance with hospital protocol. Nursing responsibilities include performing frequent neurological checks and maintaining an accurate recording of the child’s vital signs and intake and output. The nurse should also organize care so that the child is disturbed as little as possible. The child with meningitis may be overly sensitive to stimuli; therefore the room should be dimly lit and noise kept to a minimum. The nurse carefully raises and lowers the sides of the crib to avoid jarring the 552 UNIT V The Child Needing Nursing Care bed. The nurse avoids startling the child and so uses a soft voice and gentle touch. These precautions are also explained to the parents. Frequent monitoring of the child’s vital signs is necessary. A slowed pulse rate, irregular respirations, and increased blood pressure are reported immediately because they could indicate increased ICP. Antipyretics, sponge baths, or a hypothermia (cooling) mattress may control fever. The nurse observes the child for additional or subtle signs of increased ICP, especially a change in alertness or twitching muscles. The joints are also observed for swelling, pain, and immobility. Oxygen is given as needed. The child’s intake and output are carefully observed and recorded. Careful attention is given to maintaining the IV line. Good oral hygiene is essential during this stage, when the child is receiving nothing by mouth. As the child’s condition improves, the diet progresses from clear fluids to an age-appropriate diet. A special formula may be given when nasogastric feedings are necessary. During the convalescent period, oral fluids are encouraged unless contraindicated. The nurse promptly reports a decrease in the output of urine (oliguria), which could signal urinary retention. Bowel movements are recorded each day to detect constipation and prevent fecal impaction (an accumulation of feces in the rectum). The nurse continues to monitor the child’s neurological status and to record and report findings such as weakness of the limbs, speech difficulties, mental confusion, and behavior problems. The child should be assessed for developmental deficiencies. When recovery is uneventful, the child may be discharged home. The parents are taught the principles of intermittent IV therapy that can be accomplished in the home setting with visits from a home health agency nurse. The nurse should discuss the concerns of the parents and help them meet the needs of their child in recovery. Nursing Tip When a spinal tap is planned, the infant can be sedated and eutectic mixture of local anesthetics (EMLA) cream applied to the area to reduce discomfort during needle insertion. Safety Alert! A child diagnosed with meningitis remains on transmissionbased droplet precautions until 24 hours after appropriate antimicrobial therapy has been started. Encephalitis Pathophysiology. Encephalitis (encephalo, “brain,” and itis, “inflammation”) is an inflammation of the brain. The condition is known as encephalomyelitis (myelo, “spinal cord”) when the spinal cord is also infected. This condition can occur as a complication of disorders such as upper respiratory tract infections, German measles (rubella), or measles (rubeola), and it may also result from lead poisoning. Nursing Tip Encephalitis may occur as a complication of childhood diseases such as measles, mumps, or chickenpox. It is crucial that children receive the immunizations available for the diseases that are preventable. Manifestations. The symptoms of encephalitis result from the CNS response to irritation. Characteristically, the history is that of a headache followed by drowsiness that may proceed to coma. Seizures are seen, particularly in infants. Fever, cramps, abdominal pain, vomiting, stiff neck (nuchal rigidity), delirium, muscle twitching, and abnormal eye movements are other manifestations of the disease. Treatment and Nursing Care. The treatment is supportive and aimed at providing relief from specific symptoms. Sedatives and antipyretics may be prescribed. Seizure precautions are taken. Adequate nutrition and hydration are maintained. The nurse provides a quiet environment, good oral hygiene, skin care, and frequent changes of position. Oxygen is administered as ordered, and the mouth and nose are kept free of mucus by gentle aspiration. Bowel movements are recorded daily because the child may be constipated from the lack of activity. Preventing the secondary effects of immobilization is paramount. The nurse closely observes the child for neurological changes. Fatality rates and residual effects are higher among infants than among older children. Speech, mental processes, and motor abilities may be slowed, and permanent brain damage and intellectual or developmental disabilities can result. Growth and development and hearing evaluations should be monitored. Parents are encouraged to help with the care of the child as soon as the condition is stable. They are instructed in the nursing procedures for home care and any required follow-up care. Brain Tumors Pathophysiology. Brain tumors are the second most common type of neoplasm in children (the first is leukemia). The majority of childhood tumors occur in the lower part of the brain (cerebellum or brainstem). The etiology of these tumors is unknown. They occur most commonly in school-age children. Manifestations. The signs and symptoms are directly related to the location and size of the tumor. Most tumors create increased ICP, with the hallmark symptoms of headache, vomiting, drowsiness, and seizures (Fig. 23.9). Nystagmus (constant jerky movements of the eyeball), strabismus, and decreased vision may be evident. Papilledema (edema of the optic nerve) The Child With a Sensory or Neurological Condition Confusion 553 Loss of consciousness Bulging fontanelle Asymmetrical pupil response Blurred vision High-pitched cry Vomiting Cries when moved or rocked Lethargy Decreased motor sensory responses CHAPTER 23 Irritability Decrease in pulse and respirations Posturing Increase in blood pressure Seizures Fig. 23.9 Signs of increased intracranial pressure (ICP) in infants and children. may occur. Other symptoms include ataxia, head tilt, behavioral changes, and cerebral enlargement, particularly in infants. Deviations in vital signs are noticeable when the tumor presses on the brainstem. Treatment and Nursing Care. Clinical manifestations, laboratory tests, CT, MRI, and EEG confirm the diagnosis. Angiography is used to assist in the surgical approach by identifying the tumor’s blood supply. Radiotherapy, chemotherapy, or surgery may be indicated. Preoperative emphasis is placed on carefully explaining various procedures and on familiarizing the child and family with the recovery room, intensive care unit (ICU), and hospital personnel. The nurse explains that the child will have part or all of his or her head shaved. The size of the postoperative dressing is carefully explained. Applying a similar dressing to a doll may be helpful to the child. The Trendelenburg position is avoided because it increases ICP. Postoperative care is usually provided in the ICU. Adjuncts to care may include using a hypothermia (cooling) blanket or a mechanical res