Post on 22-Dec-2015
Course Objective #36
• Describe the cause and symptoms in the child suffering from the following types of malnutrition:– Kwashiorkor– Marasmus
KwashiorkorOccurrence
World -Wide
• Famine• Limited food
supply• Low levels of
education
U.S.A.
• Weaning
Kwashiorkor
• When kwashiorkor does occur in the United States, it is usually a sign of …
• child abuse and severe neglect
Kwashiorkor
Severe• infections • Irritability• Hepatomegaly Ascites• Lethargy• Dermatitis• Edema
Mild• △ skin pigment• h muscle mass• Diarrhea• i grow• Fatigue• Hair △
KwashiorkorDx test
• BUN• CBC• Creatinine clearance• Serum creatinine• Serum potassium• Total protein
KwashiorkorPrognosis
• “Children who have had this condition will never reach their full potential for height and growth”
• May be permanent– Mental & physical problems
Course Objective #37
• Differentiate between the following forms of cerebral palsy:– Spastic– Dyskinetic– Ataxic– Mixed
Cerebral Palsy
• Disorder of movement, balance and posture
• Results from a non-progressive lesion in the– Cerebellum
Causes of CP:Prenatal:-infections -exposure to teratogens -maternal-fetal blood incompatibilities-faulty implantation of ovum
Spastic CP• -#1• lesion located in pyramidal tract• “spasticity”• movement is slow, effortful,
restricted• occasionally jerky and explosive
Spastic CPFurther sub-typed by limbs affected:-all four limbs = quadriplegia-two like limbs, mostly legs = diplegia-three limbs = triplegia-legs only = paraplegia-limbs on one side only = hemiplegia-one limb = monoplegia
Spastic CPclassified by severity
• Mild: May lack only fine motor movements, have awkward gait, arms out for balance
• Moderate: problems with fine and gross motor and speech
• Severe: unable to walk, use hands, or speak
Extrapyramidal CP
-AKA Dyskinetic CP- Refers to one of the two nerve tracts in
the brain that control movement - Impairment in muscle tone and a variety
of abnormal motor patterns and postures
Extrapyramidal CP
--movements are uncontrolled and without purpose
-movements disappear with sleep and increase with stress
Extrapyramidal CP
Types of movement:• Athetosis*
– slow, wormlike, writhing. – If movements are jerky
• choreic & choreoathetoid
Ataxic CP
-hand movements awkward with tendency to under or over reach
-difficulty with repetitive finger movements or rapid turning
Atonic (Hypotonic) CP
-Usually hypotonic at birth and persists beyond 2-3 yrs.
-usually develops incoordination, ataxia, difficulty with rapid movements
-cognitive impairment can be severe-can also develop into athetoid form by age 3
Mixed Form CP
-combination of movement disorders-most common mix is spasticity and
athetosis-less common is ataxia and athetosis
CP Associated Disorders1) Speech Impairment may be the most disabling aspect of the disorder~ 2/3 of people with CP are speech impaired
CP Associated Disorders
2) Intellectual Impairment-assessment of intelligence is difficult due
to impairment in movement -ataxia & athetoid types less affected-spastic type more affected-mixed type greatest affected
CP Associated Disorders
3) Perceptual Disorders• visual, visual-motor, tactile, auditory• ADD / ADHD
CP Associated Disorders
4) Health Problems• seizures • orthopedic deformities• UTI• Respiratory difficulties• Eye abnormalities• hearing loss
Treatment of CP
2) Surgery-lengthen or release muscles and
tendons-correct bone deformities-Botox injections with muscle building
exercises
Treatment of CP
5) Supported Employment & Living-sheltered workshops, independent living
facilities-in adults: 1/3-1/2 will achieve
independence
What do these people have in common?
Alexander the Great Danny GloverAristotle Agatha ChristieJulius Caesar Margaux HemingwayCharles Dickens Richard BurtonNapoleon Truman CapoteSt. Paul the Apostle Socrates Vincent Van Gogh
Epilepsy
- “epilepsy” from the Greek word meaning “condition of being overcome, seized or attacked”
- not a disease;
Epilepsy
-it IS a condition-characterized by sudden, brief seizures
whose nature and intensity vary from person to person
What is a seizure?
It may appear as:a brief starean unusual movement of the bodya change in awarenessa convulsion
What is a seizure?-the type depends on which part of the brain is
affected by the abnormal electrical impulse-divided into two major types: generalized
seizures and partial seizures
What is a seizure?-many different types of seizures-people may experience one type or more than
one type of seizure
Seizures– Partial
– Seizure that begins in one part of the brain• Simple
– Repetitive purposeless behavior– Dreamlike state– No loss of consciousness– Duration: < 1 minute– I.e. talking unintelligibly, dizziness, hand shake,
picking at clothes, chewing, smacking lips, spitting, fondling self
Seizures
• Classification– Partial
• Simple• Complex
– Repetitive purposeless behavior– Loss of consciousness– Lasts 2-15 minute– Not aware of behavior
Seizures
• Classification– Generalized
– Seizure that involves electrical discharges in the whole brain
• Absence Seizure– Occurs must often in children– Period of staring– Duration: several seconds
• Tonic-Clonic Seizure
Absence Seizure
• < 10 sec• ‘staring’• -usually begin between 4-14 yrs. age• -70% stop by age 18 yrs.• -may also have eye blinking, eyes roll-up• -no warning, no awareness of seizure, alert
immediately after
Atypical Absence Seizure
-usually last 5-30 seconds; usually more than 10 with gradual beginning and end
-stare, somewhat responsive, eye blinking, jerking of lips
-usually begin before 6 yrs.; continue into adulthood-most have < IQ and other types of seizures
Seizures
• Classification– Generalized
• Tonic-Clonic Seizure–(grand mal seizure)–Tonic – rigidity–Clonic – contraction and relaxation of all
muscles jerky, rhythmic
Seizures
• Possible Etiology– Underlying cause is electrical disturbance
emitting of abnormal, recurring, uncontrolled electric discharge
• Idiopathic origin• Head injury• Hypoglycemia• Brain tumor• Infection • Anoxia
Seizures
• Clinical manifestations– Prodromal phase– Aura
• Brief sensory experience• Precedes seizure by a few seconds• Usually the same aura each time
Seizures
• Clinical manifestations–Prodromal phase–Aura–Loss of consciousness
• May or may not occur–Seizure activity
Seizures
• Seizure activity– Tonic Phase
• Duration: 30-60 sec• Rigidity fall• Pupils fixed & dilated• Hands and jaws clenched• Stop breathing
– Clonic phase
Seizures
• Seizure activity– Clonic phase
• Contraction & relaxation of all muscles, jerky rhythmic fashion
• Incontinent• Frothing at the mouth• Dyspnea• Epileptic cry• Tongue chew• Lasts 1-2 minutes subsides
Seizures
• Medical management– Anticonculsants
• Caramazepine / Tegretol– S/E
» Blood dyscrasias» Hepatitis
• Clonazepam / Klonopin– S/E
» Hepatotoxicity» Behavioral changes
Seizures– Anticonculsants
• Phenytoin / Dilantin– S/E
» Gum hyperplasia» Nystagmus» Blood dyscrasias» PG cleft palate
Seizures
– Anticonculsants• Valproate / Depakene
– S/E» Hepatotoxicity» Blood dyscrasias
• Diazepam / Valium• Phenobarbital / Luminal
– S/E» Rash» h pain
Seizures
• Nrs Management w/ anticonvulsants– Do not stop abruptly seizures– Monitor levels– Take regularly– Inform of all meds– Alcohol only in moderation
Seizures
• Before Seizure– At risk for injury
• Padded side rails• Suction machine in room• Loose clothing• Know aura
Seizures
• Fear r/t possibility of a seizure– Take meds routinely– ID triggers
• Stress• New environment• Menstruation• Fever• Sleep deprivation• Alcohol
Seizures
• Fear– Avoid photic stim
• Bight flickering lights• TV• Wear dark glasses
– Regular routine– Wear ID band
Seizures
• Ineffective coping– Embarrassed– Feel rejected, avoided, discriminated– Frequently lonely psych problems– Driving restrictions
Seizures
• Knowledge deficit– Take meds daily– records of meds & seizures– Drug levels routine– Avoid activities requiring alertness after meds– Showers or bath?
• Shower!
– Exercise– Sleep
Seizures
– Do not • pry open mouth• Insert anything in mouth• restrain
– Stay with pt
• Support patient– Privacy
During a seizure• Safety
– Ease to floor– Protect the head– Turn to side– Loosen clothing– In bed?
• Remove pillow• Side rails up
Seizures
– Duration– Unconsciousness– Weakness– Dysphasia– Post seizure behavior
• Observe & document– Circumstance (before) – Aura?– 1st – Movement– Area– Pupils– Automatisms– Incontinent
Seizures
• Recovery position• After a seizure
– Document– At risk for
• Hypoxia• Vomiting• Aspiration
Seizures
• Post Seizure Nursing care– Side lying– Bed low– Padded side rails– i stimulation
• Dim lights• Noise i
– VS– Check mouth– Clean pt– Allow to “sleep it off”
Status Epilepticus
• Defines– Prolonged seizure activity– Series of generalizes seizures
w/o full recovery btw attacks
– Medical emergency
Status Epilepticus
• Medical Management– Goal
• Stop seizure activity• Airway
• Rx of choice– Diazepam
• Valium
What is an AURA?
-some people experience an aura; a sensation or warning before a seizure starts
-varies from person to person-may occur enough in advance that person
can protect self from injury-seizure dogs help
What is an AURA?
-may manifest as a change in body temp, tension/anxiety, musical sound, strange taste, or odor
-precise description of aura helps diagnose the region of brain involved
-not always followed by full scale seizure -aura is a simple-partial seizure
Myoclonic Seizure
-brief, shock-like jerks of a muscle or muscle group-last 1-2 seconds; just one, or many in a row-usually both sides of body at once-seen in several epilepsy syndromes-many people have ‘normal’ myoclonus w/o having
epilepsy
Atonic Seizure
-AKA drop attacks or drop seizures-usually last < 15 seconds-sudden loss muscle strength-eyelids may droop, head may nod, drop items,
falls to ground-usually remains conscious-often begins in childhood; continues into
adulthood
Tonic-Clonic Seizure
-when massive bursts of electrical energy sweep through the whole brain at once, causing loss of consciousness, falls, convulsions, massive muscles spasms
Tonic-Clonic Seizure
-AKA Grand Mal-usually lasts 1-3 minutes-sudden onset, some preceded by aura-characteristics: immediate loss of consciousness two phases: Tonic and Clonic
Tonic-Clonic Seizure
Tonic Phase:-sudden contraction of all muscle groups-lasts 10-30 seconds, at times, loud cry-if standing, forcibly fall-pupils dilate, face is pale or flushed-eye roll up to one side or to the back-stops breathing!
Tonic-Clonic Seizure
Clonic Phase:-spasmodic jerking of all muscles-lasts 1-5 minutes or longer-breathing resumes, but labored-profuse sweating, salivation-tongue may be bitten-involuntary bowel/bladder-gradually becomes less violent and finally ceases
Tonic-Clonic Seizure
-may have quick recovery to consciousness with no effects, if episode is short
-often followed by stuperous state (postictal phase) and sleep
-upon waking; headache, fatigue, restlessness, agitation, sadness
Partial SeizuresTwo forms: Simple Partial and Complex Partial -difference is whether or not there is a change in level
of consciousness
Causes: head trauma, serious infections, tumors of any kind, brain surgery, strokes, Alzheimer’s disease, arteriosclerosis
Simple Partial
-usually last < 2 minutes-do not lose consciousness-remain awake and aware-may talk normally-can remember what happened-can affect movement, emotions, sensation,
feelings in unusual and sometimes frightening ways
Complex Partial Seizures
-usually lasts 30 seconds to 2 minutes-affects larger area of the brain and affects
consciousness-cannot interact normally during-can’t remember what happened-will be in dreamlike, trancelike state-may talk, but unlikely to make sense-often takes place in temporal lobes-AKA “psychomotor epilepsy”
Secondarily Generalized Seizure
-starts as a partial seizure, then spreads and becomes a generalized seizure
Status Epilepticus
-condition in which there are continual seizures or a tonic/clonic seizure is barely finished before another begins and the person does not regain consciousness
-can produce exhaustion, severe anoxia leading to brain damage and cardiac arrest, brain hemorrhage and DEATH
Status Epilepticus
-can quickly become a LIFE-THREATENING situation!
-treated with IM or IV Diazepam and/or IV Phenobarbital
Treatment of Seizures
1) Medications:-single or combination of drugs-drugs control seizures – no cure!-partial seizures are more difficult to
control-meds must be taken consistently
Treatment of Seizures
2) Surgery:-when meds don’t work and seizures are
frequent and affect quality of life-remove small portion of the brain-or if coming from many sites on one side and
spreading, will cut connections between two sides (corpus callosotomy)
Treatment of Seizures
3) Vagus Nerve Stimulation (VNS)-electrical stimulation of the brain via the vagus nerve
in the neck-a small battery is implanted in the chest wall and
programmed to deliver short bursts of energy to the brain via the vagus nerve
-interrupts abnormal electrical impulses triggering seizures
Treatment of Seizures
4) Ketogenic Diet:-an option for children with hard to control
seizures-high in fat, low in carbohydrates, no sugar,
restricted calories-must be closely monitored by MD, RD, family-being used more often when other methods
fail
Nursing Actions During
-never leave them alone-if upright, lower to floor and side-lying safety
position to aid respirations-clear area of hazards, loosen tight clothing-do not restrain-padded tongue blade, if possible-padded bed rails, no pillows-accurate observations and documentation
Nursing Observations
-aura-presence or absence; if present, ability of patient to describe it
-cry-presence or absence-onset-initial sounds, movements, body parts
involved; chewing and salivation; posture; sensory changes
-tonic and clonic phases- movements, progression, duration of each
-skin color, respirations, pupillary changes, incontinence
Nursing Observations
-relaxation (sleep)-duration and behavior-postictal phase-duration, general behavior, ability to
remember, orientation, headache, injuries present-duration of seizure-from aura to relaxation-level of consciousness-changes and duration-presence of injury-to mouth, lips, tongue, soft tissue,
injury to extremities
Patient Education
-use of meds, including side effects, dose, timing, reporting side effects to Dr.
-importance of avoiding alcohol and illegal drugs
-safety measures top prevent injury during seizures
-good oral hygiene if taking Phenytoin-importance of adequate rest and diet