Shared Flashcard Set

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Neuro/MuscSkel
Denise K
84
Nursing
Undergraduate 3
10/09/2013

Additional Nursing Flashcards

 


 

Cards

Term
Skeletal system growth
Definition
•Ends of long bones (epiphyses) remain cartilaginous - growth occurs here
•Skeletal maturation: About 20 years of age
•Calcium is needed for new bone growth
Term
Metatarsus Adductus
Definition
•Most common congenital foot disorder
•Forefoot turns inward (“intoeing”)
•Probable cause: Genetic; intrauterine positioning
•Treatment: Exercise, casting, braces, orthopedic shoes
Term
Metatarsus Adductus Nursing care
Definition
•Parental teaching
–Condition is correctable
–How to exercise foot
–Cast care if child requires casting
Term
Clubfoot
Definition
•Congenital anomaly: Foot is twisted - involves muscles, bones, and tendons
•Occurs in boys more than girls - bilateral in half of cases
•Cause unknown - many theories
•Treatment 
–Cannot be corrected by exercise
–Serial casting if done early
–Surgical correction (3 to 12 months of age)
Term
Clubfoot nursing care
Definition
•Provide emotional support
•Cast and brace care
•Postsurgical care
•Home care teaching
Term
Genu Varum and Genu Valgum
Definition
•Genu varum: “Bowlegs,” Blount’s disease, rickets
•Genu valgum: “Knock-knees”
•Normal unless persists beyond 4 to 5 years of age
•Treatment: Braces, surgery
Term
Genu Varum and Genu Valgum: Nursing Care
Definition
•Parental reassurance if child is less than 4 years of age
•Parental teaching - brace wear
Term
Developmental Dysplasia of the Hip (DDH)
Definition
•Femoral head and acetabulum improperly aligned
•May include hip instability, dislocation, subluxation, or dysplasia
•Occurs in girls more than boys - unilateral in 80% of cases
•Cause: Unknown - genetic factors likely
Term
DDH: tx
Definition
•Pavlik harness (younger than 3 months of age)
•Skin traction (older than 3 months of age)
•Spica cast, surgery (older than 18 months of age)
Term
DDH: nursing care
Definition
•Assessment of hip during well-child visits
•Nursing care depends on the treatment
–Maintain traction
–Provide cast care
–Prevent complications from immobility
Term
Legg-Calve-Perthes Disease
Definition
•Avascular necrosis of the femoral head - blood supply to femoral epiphysis is interrupted
•Occurs in boys more than girls
•Average age of onset: 7 years
•Cause unknown - may be genetic or coagulation system disorder
•Occurs in four distinct stages of 1 to 4 years
•Treatment: Traction, casting, bracing - goal is to keep hip abducted
Term
Legg-Calve-Perthes Disease: Nursing Care
Definition
•Assessment: Hip discomfort plus limp - pain
•Promote normal growth and development
•Brace care
Term
Slipped Capital Femoral Epiphysis (SCFE)
Definition
•Femoral head displaced from femoral neck
•Occurs during adolescent growth spurt
•Occurs in boys more than girls
•Cause: Unknown - likely related to obesity, endocrine disorders
•Symptoms: Acute or chronic - limp, pain, loss of hip motion
Term
SCFE: Treatment and Nursing Care
Definition
•Treatment: Surgical most common
•Address obesity if present
•Provide emotional support
•Home care teaching
Term
Scoliosis
Definition
•Lateral S- or C- shaped curvature of the spine
•More than 10 degrees is abnormal
•Types 
–Idiopathic (most common)
–Congenital
–Acquired
•Most common in girls around adolescent growth spurt
Term
Scoliosis: Causes
Definition
•Idiopathic - cause unknown
•Congenital
–Related to spinal structure
–Examples: Spina bifida, cerebral palsy, muscular dystrophy
•Acquired: Injury to spinal cord
Term
Scoilosis: tx
Definition
•Observation, serial x-rays
•Mild (10 to 20 degree curve): Exercise
•Moderate (20 to 40 degree curve): Brace (worn 23 hours a day)
•Severe (greater than 40 degree curve): Surgery (spinal fusion)
Term
Scoliosis: nursing care
Definition
•Screening (usually during fifth and seventh grades)
•Promote acceptance of care plan
•Post-op care
•Home care teaching
Term
Torticollis
Definition
•Head tilt caused by rotation of the spine
•Treatment
–Stretching exercises
–Surgical correction
Term
Kyphosis and Lordosis
Definition
•Kyphosis: Convex curvature of spine (“hunchback”): Treatment - exercise, bracing, surgery
•Lordosis:  Concave curvature of spine (“swayback”): Treatment - exercise, postural awareness
Term
Osteomyelitis
Definition
•Infection of the bone, usually a long bone in lower extremity
•Acute or chronic
•Occurs at any age - boys more than girls (due to trauma)
•Cause: Microorganism, usually bacterial
•Symptoms: Pain, swelling, decreased mobility, fever
•Treatment: Antimicrobials (oral or IV) for 3 to 6 weeks
Term
Osteomyelitis: Nursing Care
Definition
•Immunization status (tetanus)
•Obtain cultures and blood work
•Administer fluids and medications
•Protect from spread of infection
•Encourage well-balanced diet
•Home care teaching - considerations for home IV therapy
Term
Skeletal Tuberculosis
Definition
•Rare infection that affects spine and other joints
•Antimicrobial therapy
Term
Septic Arthritis
Definition
•Joint infection
•Most common sites: Knee, hip, ankle, elbow
•Joint drained via aspiration, then IV antibiotics for 3 to 4 weeks
Term
Achondroplasia (Dwarfism)
Definition
•Genetic condition
•Head, torso are normal size - arms and legs are short
•Treatment:  None (gene therapy in the future) - limp lengthening may be palliative
•Nursing care 
–Genetic counseling for parents
–Positive self-image
–Modifications to adjust for size
Term
 Marfan Syndrome
Definition
•Genetic condition that affects the connective tissue
•Common problems
–Cardiac: Mitral valve prolapse, aortic regurgitation, and abnormal aortic root dimensions
–Skeletal: Pectus excavatum, long arms and digits, scoliosis, elongated head, high arched palate
–Ocular: Lens subluxation
–Respiratory: Pneumothorax
Term
Marfan Syndrome: Treatment
Definition
•None specific
•Surgery to prevent aortic dissection (most common cause of death)
Term
Marfan Syndrome: Nursing Care
Definition
•Identification of disease
•Monitoring
•Surgical care
•Genetic counseling
•Medication management
Term
OsteogenesisImperfecta
Definition
•“Brittle bone disease”
•Genetic condition affecting collagen production
•Manifestations
–Frequent fractures
–Blue sclerae
–Thin, soft skin
–Short stature
Term
OsteogenesisImperfecta:  Treatment
Definition
•Fracture prevention, treatment
•Prevention of deformity
•Maximize mobility
•Support for family, child
Term
Muscular Dystrophy
Definition
•Group of inherited diseases - Duchenne most common
•Muscle fibers degenerate
•Onset varies (birth to late in life)
•Progression varies (few years to many years)
•All are terminal
Term
Muscular Dystrophy: Treatment
Definition
•None specific
•Gene therapy in the future?
•Preserve muscle function:  Steroids, deflazacort
•Prevent complications (infection, spinal deformities)
Term
Muscular Dystrophy: Nursing Care
Definition
•Promote independence and mobility
•Psychosocial support and acceptance
•Referral to resources for support
Term
Care of the Child in a Cast
Definition
•Elevation
•Drainage, bleeding
•Neurovascular checks - pulses, capillary refill, warmth, edema
•Itching
Term
Care of the Child in a Brace
Definition
•Brace should be comfortable
•Skin care
•Wear clothes beneath brace
Term
Care of the Child in Traction
Definition
•Types of traction
–Skin
–Dunlop
–Bryant
–90-90
–Skeletal
–Halo
–Russell
Term
Post-Surgical Care: External Fixator
Definition
•Neurovascular checks
•Pin care
•Drainage
Term
Fractures
Definition
•Occur at any age
•Result from trauma to bones or diseases that weaken bones
•Types
•Signs and symptoms
•Treatment:  Closed versus open reduction
Term
Fractures: Nursing Care
Definition
•Maintain proper alignment
•Monitor neurovascular status
•Pain control
•Promote mobility
•Discharge teaching
Term
Sports Injuries
Definition
•Most common type of injury in youths 13 to 19 years
•Football, wrestling, soccer, gymnastics
Term
Risk Factors for Injury in Childhood
Definition
•Vulnerability of growth plates
•Increased joint mobility leads to joint injuries
•Softer bones lead to fractures
•Lack of experience, training
•Not wearing protective gear
•Impatience with healing process
Term
Prevention of Injury
Definition
•Proper training and instruction
•Protective gear
•Supervision
•Warm up before activity
Term
Neuro Developmental Considerations
Definition
•Nervous system complete but immature at birth
•Infant born with all nerves he or she will have
•Myelination of nerves incomplete until age 4
•Development proceeds in cephalocaudal direction
Term
Level of Consciousness (LOC)
Definition
•Most important indicator of neurologic dysfunction
•Describing LOC
–Conscious versus unconscious
–Alertness: Ability to react to stimuli
–Cognitive power: Processing of data
Term
Causes of Altered LOC
Definition
•Trauma and/or injury
•Hypoxia
•Infection
•Poisoning
•Seizures
•Endocrine or metabolic disturbances
•Electrolyte or acid-base imbalance
•Congenital structural defect
Term
Assessment of LOC: Monitoring
Definition
•Responsiveness to environment or stimuli
•Pupil size and reactivity
•Movement of extremities
•Ability to maintain an airway
•Changes in vital signs
•Changes in breathing patterns
•Status of the cranial nerves
Term
Deterioration of LOC: A Sequential Pattern
Definition
•Awake and alert - responds appropriately
•Slight disorientation to time, place, or person
•Restless, fussy, or irritable
•Drowsy but responds to loud commands, painful stimuli
•Nonpurposeful response
•Posturing
•No response
Term
Long-Term Management of Seizures
Definition
•Most are treated with monotherapy medication - successful in 60% to 70% of children
•Ketogenic diet
•Family teaching
–Management of seizure at home, school
–Blood levels may be needed to monitor anticonvulsant dosing
Term
Bacterial Meningitis
Definition
•Inflammation of the meninges
•Newborns and infants at greatest risk
•Higher morbidity and mortality than viral meningitis
•Common bacterial causes
–Haemophilusinfluenzae type B
–Neisseria meningitides
–Streptococcus pneumoniae
–Group B Streptococcus
Term
Bacterial Meningitis: Signs and Symptoms (Infants)
Definition
•Fever
•Changes in feeding pattern
•Vomiting, diarrhea
•Anterior fontanelle bulging or flat
•Alert, restless, lethargic, or irritable
•Difficult to console
Term
Bacterial Meningitis: Signs and Symptoms (Children)
Definition
•Fever
•Confusion, delirium, irritable, lethargic
•Vomiting
•Muscle or joint pain
Term
Bacterial Meningitis: Signs and Symptoms (Children) (cont’d)
Definition
•Hemorrhagic rash (meningococcal meningitis)
•Meningeal irritation
–Headache
–Photophobia
–Nuchal rigidity
Term
opisthotonic position
Definition

The child with bacterial meningitis assumes an opisthotonic position, with the neck andthe head hyperextended, to relieve discomfort.

Term
Kernig sign
Definition
raise the child’s leg with the knee flexed. Then extend the child’sleg at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig sign.This is a common finding in meningitis
Term
Brudzinski sign
Definition

flex the child’s head while in a supine position. If this action makesthe knees or hips flex involuntarily, a positive Brudzinski sign is present. This is a commonfinding in meningitis.

Term
Progression of Symptoms of meningitis
Definition
•Seizures
•Apnea
•Cerebral edema
•Subdural effusion
•Hydrocephalus
•Disseminated intravascular coagulation (DIC)
•Shock
•Increased intracranial pressure
Term
Bacterial Meningitis: Treatment
Definition
•Labs and cultures (blood, urine, cerebrospinal fluid)
•Intravenous antibiotics
•Steroids, anticonvulsants, antipyretics
•IV fluids, fluid resuscitation
•May be left with severe neurologic deficits
Term
Viral (Aseptic) Meningitis
Definition
•Inflammatory response of meninges
•Most common cause: Enterovirus
•Child not as ill-appearing as child with bacterial meningitis
Term
Viral Meningitis: Signs and Symptoms
Definition
•Irritable or lethargic - general malaise
•Fever
•Headache
•Photophobia
•Upper respiratory symptoms
•Positive Kernig and Brudzinski signs - indicate meningeal irritation
•Seizures are rare
Term
Viral Meningitis: Treatment
Definition
•Labs and cultures (blood, urine, cerebrospinal fluid)
•Intravenous antibiotics until cultures are negative - treat as bacterial meningitis until proven otherwise
•Treatment of symptoms is supportive
•Symptoms usually resolve in 3 to 10 days
•Neurologic deficits are uncommon
Term
Encephalitis
Definition
•Inflammation of the brain
•Meninges may be inflamed as well
•Viruses most common cause (herpes simplex type I)
Term
Encephalitis: Signs and Symptoms
Definition
•Depend on causative organism
•Classic presentation
–Acute onset of febrile illness
–Neurologic signs (disoriented, confused)
–Severe headache, nausea, vomiting
–Meningeal signs
–Seizures
Term
Encephalitis: Treatment
Definition
•Diagnosis by history, lab findings
•Acyclovir (for herpes infections)
•Supportive care
•Many children left with severe neuralgic deficits
Term
Reye Syndrome
Definition
•Acute encephalopathy
•Associated with use of aspirin and a mild viral illness
•With decreased aspirin use, condition is now rare
•Condition develops over five stages
Term
Reye Syndrome: Treatment
Definition
•Diagnosis by history, lab findings
•Treatment is supportive
•Often require treatment for increased intracranial pressure
•Mortality is high
Term
Guillain-Barré Syndrome
Definition
•Acute inflammatory demyelinating polyneuropathy
•Motor function deteriorates, causing paralysis
•Ascending pattern (legs to head)
•Cause: Autoimmune response to infectious organism
Term
Guillain-Barré Syndrome: Signs and Symptoms
Definition
•History of infectious illness about 10 days prior to onset of symptoms
•Infants: Severe hypotonia, respiratory distress, poor feeding
•Children 
–Progressive symmetric weakness
–Legs to upper extremities, head
–Difficulty swallowing
–Respiratory failure
Term
Guillain-Barré Syndrome: Treatment
Definition
•Supportive care for respiratory failure
•Intravenous immunoglobulin (IVIG)
•Plasmapheresis
•Condition is rarely fatal
Term
Myelodysplasia: Pre-op Nursing Care
Definition
•Cover sac with sterile dressing (warm saline)
•Monitor for CSF leakage
•Place infant in prone position with knees slightly flexed
•Assess bowel, bladder function
•Monitor for signs of infection
•Feed with head turned to one side
•Avoid latex products
Term
Myelodysplasia: Post-op Nursing Care
Definition
•Monitor for wound healing
•Monitor for signs of infection
•Monitor for signs of hydrocephalus, increased ICP
•Place in prone or side-lying position
•Measure head circumference daily
•Assess intake and output
•Avoid latex products
Term
Hydrocephalus: Nursing Care
Definition
•Measure head circumference daily
•Observe for signs of increased ICP
•Neurologic assessment
•Signs of shunt malfunction
•Positioning: usually supine - head of bed is raised gradually
Term
Cerebral Palsy (CP): Background Information
Definition
•Cerebral palsy caused by insult to central nervous system
–Congenital
–Hypoxic
–Ischemic
–Infectious
•Very premature infants at high risk
•Birth asphyxia accounts for only 9% of cases
Term
Nurses in the Community: Care of the Child with CP
Definition
•Continuous support
•Coordination of care - referrals
•Working with schools to individualize education plan
•Adaptive devices
•Transition to adult living
Term
Assessment Findings: Mild Brain Injury
Definition
•No loss (or very brief loss) of consciousness
•Mild headache that will not go away with medications
•Memory problems
•Fatigue and irritability
•Change in appetite
•Changes in school performance
•Sensitivity to lights and sounds
Term
Assessment Findings: Moderate Brain Injury
Definition
•Glasgow Coma Scale: 9 to 12
•Loss of consciousness
•Headache
•Nausea and vomiting
•Amnesia for 1 to 24 hours
Term
Assessment Findings:  Severe Brain Injury
Definition
•Glasgow Coma Scale:  Less than 8
•Amnesia for more than 24 hours
•Signs of increased ICP
•Prolonged period of unconsciousness
Term
Nursing Management: Mild Brain Injury
Definition
•Monitor level of consciousness
•Signs of increased ICP
•Home teaching
•Restrictions on activities
•May take 6 weeks for full healing - may affect school performance
Term
Nursing Management: Severe Brain Injury
Definition
•Airway, breathing, and circulation: Hyperventilation - prolonged use causes cerebral ischemia
•Assess neurologic status frequently
•Elevate head of bed 30 degrees if no neck injury present
•Keep head midline to promote venous drainage
Term
Nursing Management: Severe Brain Injury (cont’d)
Definition
•Minimal stimulation
•Monitor vital signs, intake and output, and intracranial pressure
•Skin care, range of motion
Term
Medications Common with Severe Brain Injury
Definition
•Diuretics (furosemide, mannitol)
•Opthalmic lubricants to protect cornea
•Stool softeners
•Sedatives, paralytics if needed
Term
Glascow Coma Scale
Definition
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Term
Anticonvulsansts used to tx seizures
Definition
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Term
Stages of Reye Syndrome
Definition
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